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Ivasiy R, Madden LM, DiDomizio E, Johnson KA, Machavariani E, Ahmad B, Oliveros D, Ram A, Kil N, Altice FL. The cascade of care for commercially-insured persons with opioid use disorder and comorbid HIV and HCV infections. Drug Alcohol Depend 2024; 263:112410. [PMID: 39159600 DOI: 10.1016/j.drugalcdep.2024.112410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 07/17/2024] [Accepted: 08/06/2024] [Indexed: 08/21/2024]
Abstract
BACKGROUND Opioid use disorder (OUD) significantly impacts individual and public health and exacerbated further by concurrent infectious diseases. A syndemic approach is needed to address the intertwined OUD, HIV, and HCV epidemics, including the expanded use of medications for opioid use disorder (MOUD). METHODS To identify MOUD scale-up opportunities, we conducted a retrospective cohort study, representing commercially insured persons, and created the OUD care continuum, including HIV and HCV influences in adults (18-64 years) newly diagnosed with OUD in 2019 using Merative MarketSan data. RESULTS Among 124,467,633 individuals, the prevalence of OUD was 0.4 % (95 % CI: 0.36 %-0.46 %; N = 497,871), with 327,277 (65.7 %, 95 % CI: 65.60 %-65.87 %) newly diagnosed in 2019. Among these newly diagnosed individuals (54 % men, mean age 44±0.01), 53,568 (27.0 %, 95 % CI: 26.4 %-27.5 %) were prescribed MOUD, with retention rates at 1, 3, and 6 months being 89.0 % (95 % CI: 88.2 %-89.8 %), 66.0 % (95 % CI: 64.8 %-67.2 %), and 50.3 % (95 % CI: 48.3 %-51.6 %), respectively. Buprenorphine was the most prescribed MOUD (79.6 %, 95 % CI: 78.6 %-80.7 %), followed by XR-NTX (14.9 %, 95 % CI:14.0 %-15.8 %) and methadone (5.5 %, 95 % CI: 4.9 %-6.1 %). Six-month retention was highest for methadone (73.4 %, 95 % CI: 73.0 %-73.8 %), however, followed by buprenorphine (55.7 %, 95 % CI: 55.3 %-57.1 %) and substantially lower for XR-NTX (12.6 %, 95 % CI: 10.6 %-14.6 %). Screening for HIV and HCV was low among OUD enrollees (11.1 %, 14.4 %), slightly higher for MOUD initiators (18.0 %, 21.6 %). Being prescribed MOUD was correlated with HCV infection (AOR: 2.54; 95 % CI: 2.41-2.68), HCV/HIV coinfection (AOR: 1.89; 95 % CI: 1.41-2.53), and hospitalization for OUD-related services (AOR: 1.14; 95 % CI: 1.11-1.17), yet hospitalization for OUD-related services was positively correlated with XR-NTX (AOR: 2.72; 95 % CI: 2.56-2.85) prescription and negatively with methadone (AOR: 0.19; 95 % CI: 0.16-0.23) prescription. Having HIV was negatively correlated with being prescribed methadone (AOR: 0.33; 95 % CI: 0.13-0.86). CONCLUSIONS Substantial gaps in the OUD cascade persist, underscoring better implementation opportunities for MOUD prescription in hospital-based settings and expanding access to methadone beyond highly regulated sites given its low coverage yet high treatment retention.
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Affiliation(s)
- Roman Ivasiy
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States.
| | - Lynn M Madden
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States; APT Foundation, New Haven, CT, United States
| | - Elizabeth DiDomizio
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
| | - Kimberly A Johnson
- College of Behavioral and Community Science, Department of Mental Health Law and Policy, University of South Florida, Tampa, FL, United States
| | - Eteri Machavariani
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
| | - Bachar Ahmad
- Yale School of Medicine, New Haven, CT, United States
| | - David Oliveros
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
| | - A Ram
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States; Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT, United States
| | - Natalie Kil
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States; APT Foundation, New Haven, CT, United States; Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States; Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT, United States; Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, CT, United States.
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Ivasiy R, Madden LM, Meteliuk A, Machavariani E, Ahmad B, Zelenev A, Desai MM, Bromberg DJ, Polonsky M, Galvez de Leon SJ, Farnum SO, Islam Z, Altice FL. The impact of emergency guidance to the COVID-19 pandemic on treatment entry, retention and mortality among patients on methadone in Ukraine. Addiction 2024; 119:1585-1596. [PMID: 38807448 DOI: 10.1111/add.16565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/24/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND AND AIMS Ukraine's Ministry of Health released urgent COVID-19 guidelines, allowing for early implementation of take-home dosing (THD) for opioid agonist therapies (OAT) such as methadone. Enrollment in OAT and retention in the program are the most effective HIV prevention strategies for people who inject drugs (PWID). This study aimed to evaluate the impact of Ukraine's COVID-19 emergency guidance on OAT treatment enrollment, retention on treatment and mortality. DESIGN AND SETTING Using Ukraine's national OAT registry for 252 governmental clinics across 25 regions, we conducted a 12-month comparative prospective cohort survival analysis. This study compared newly enrolled methadone patients within the initial 6 months following the COVID-19 guidance (COVID) with patients from the preceding year (pre-COVID) in a country with high adult HIV prevalence (1.2%) that is concentrated in PWID. PARTICIPANTS In the nation-wide sample of newly enrolled PWID in Ukraine, comprising 2798 individuals, 1423 were in the COVID cohort and 1375 were in the pre-COVID cohort. The majority were male (86.7%), with an average age of 39.3 years. MEASUREMENTS Primary outcomes were average monthly enrollment per cohort, treatment retention and mortality, with internal time-dependent predictors, including THD and optimal (> 85 mg) methadone dosing. RESULTS Relative to the pre-COVID period, the monthly average patient enrollment was statistically significantly higher during the COVID period (283.7 versus 236.0; P < 0.0001), where patients were more likely to transition to THD and achieve optimal dosing earlier. Significant differences were observed in the proportions of person-months on THD (41 versus 13%, P < 0.0001) and optimal dosing (38 versus 31%, P < 0.0001) between the COVID and pre-COVID cohorts. Predictors of treatment retention, expressed as adjusted hazard ratios (aHR), included early THD [aHR = 1.90, 95% confidence interval (CI) = 1.47-2.45], early optimal dosing (aHR = 1.71, 95% CI = 1.37-2.13) and prior methadone treatment (aHR = 1.39, 95% CI = 1.15-1.68). These factors persisted, respectively, in the pre-COVID (aHR = 2.28, 95% CI = 1.41-3.70; aHR = 1.84, 95% CI = 1.32-2.56; and aHR = 1.36, 95% CI = 1.06-1.74) and COVID (aHR = 1.91, 95% CI = 1.40-2.59; aHR = 1.61, 95% CI = 1.20-2.16; and aHR = 1.49, 95% CI = 1.08-1.94) cohorts. Survival did not differ significantly between the two prospective cohorts. CONCLUSION Ukraine's prompt adoption of early take-home dosing for opioid agonist therapies, such as methadone, following the emergency COVID-19 guidance appears to have increased enrollment into methadone and improved treatment retention for people who inject drugs without adverse effects on patient survival.
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Affiliation(s)
- Roman Ivasiy
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Lynn M Madden
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- APT Foundation, New Haven, CT, USA
| | | | - Eteri Machavariani
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | | | - Alexei Zelenev
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Mayur M Desai
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA
| | - Daniel J Bromberg
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
| | - Maxim Polonsky
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Frederick L Altice
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- APT Foundation, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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Nguyen T, Bareham J, Halpape K. Barriers and facilitators for family physicians prescribing opioid agonist therapy in Saskatchewan. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2024; 70:e52-e60. [PMID: 38626996 PMCID: PMC11280670 DOI: 10.46747/cfp.7004e52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
OBJECTIVE To explore barriers and facilitators for family physicians in Saskatchewan prescribing opioid agonist therapy (OAT). DESIGN Self-administered postal survey. SETTING Family medicine practices in Saskatchewan. PARTICIPANTS A total of 218 Saskatchewan family physicians who were not authorized to prescribe OAT as of June 2022. MAIN OUTCOME MEASURES Descriptive and inferential statistics of physicians' self-reported barriers to and facilitators of prescribing OAT for opioid use disorder (OUD). RESULTS Most respondents (84.8%) had some comfort with diagnosing OUD. However, more than half (58.3%) did not feel confident or knowledgeable about prescribing OAT. Barriers to OAT prescribing included lack of time, incomplete training requirements, lack of interest, insufficient funding or support, feeling overwhelmed, and perceiving that OAT does not work and thus is not necessary. Physicians working in core neighbourhoods and those receiving fee-for-service compensation reported the least available time to prescribe OAT. Conversely, physicians working in interdisciplinary team settings had increased time for OAT prescribing compared with physicians in other settings. Having a close personal relationship with someone with OUD was correlated with increased comfort in diagnosing OUD as well as with knowledge about and confidence in prescribing OAT. Themes identified as facilitators to increasing OAT prescribing included the addition of resources and supports, increased training, more awareness about OUD and OAT, enhanced compensation, and altered prescribing regulations. CONCLUSION Despite the presence of several real and perceived barriers limiting OAT prescribing by Saskatchewan family physicians, there are family physicians interested in providing this therapy. Increased clinical resources and support, including increased interdisciplinary practice, are actionable steps that should be considered by policy decision makers to address this issue. Additionally, increased OUD and OAT education, which includes the perspectives of those with lived experience of OUD, would help address physician confidence, knowledge, and awareness in this area.
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Affiliation(s)
| | - Julia Bareham
- Pharmacist with the RxFiles Academic Detailing Program at the University of Saskatchewan in Saskatoon
| | - Katelyn Halpape
- Associate Professor in the College of Pharmacy and Nutrition at the University of Saskatchewan
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Bromberg DJ, Machavariani E, Madden LM, Dumchev K, LaMonaca K, Earnshaw VA, Pykalo I, Filippovych M, Haddad MS, Dvoriak S, Altice FL. Integrating methadone into primary care settings in Ukraine: effects on provider stigma and knowledge. J Int AIDS Soc 2024; 27:e26202. [PMID: 38379179 PMCID: PMC10879646 DOI: 10.1002/jia2.26202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 12/08/2023] [Indexed: 02/22/2024] Open
Abstract
INTRODUCTION Stigma has undermined the scale-up of evidence-based HIV prevention and treatment. Negative beliefs influence clinicians' discriminatory behaviour and ultimately have wide-ranging effects across the HIV prevention and treatment continuum. Stigma among clinicians can be mitigated in several ways, including through interpersonal contact. In this study, we test whether interactions with people who inject drugs (PWID) influence attitudes of both direct and indirect providers of opioid agonist therapies (OATs) within the same primary care clinics (PCCs) where OAT is newly introduced. METHODS In a cluster randomized controlled trial integrating OAT and HIV care into PCCs in Ukraine, clinicians at 24 integrated care sites (two sites in 12 regions) from January 2018 to August 2022 completed a structured survey at baseline, 12 and 24 months. The survey included feeling thermometers and standardized scales related to clinician attitudes towards patients and evidence-based care. Nested linear mixed-effects models were used to examine changes in mean scores over three timepoints for both direct and indirect clinicians. RESULTS There were fewer significant changes in any of the scales for direct providers (n = 87) than for indirect providers (n = 155). Direct providers became less tough-minded about substance use disorders (p = 0.002), had less negative opinions about PWID (p = 0.006) and improved their beliefs regarding OAT maintenance (p<0.001) and medical information (p = 0.004). Indirect providers reported improvements in most stigma constructs, including a significant decrease in prejudice (p<0.001), discrimination (p = 0.001), shame (p = 0.007) and fear (p = 0.001) towards PWID. CONCLUSIONS Integrating OAT services within primary settings was associated with significantly reduced stigma constructs and improved attitudes towards PWID, possibly through increased intergroup contact between PWID and general clinical staff. Unlike most stigma reduction interventions, re-engineering clinical processes so that PWID receive their care in PCCs emerges as a multilevel stigma reduction intervention through the integration of specialized services in PCCs. Integration influences different types of stigma, and has positive effects not only on health outcomes, but also improves clinician attitudes and efficiently reduces clinician stigma.
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Affiliation(s)
- Daniel J. Bromberg
- Yale School of Public Health, Yale UniversityNew HavenConnecticutUSA
- Center for Interdisciplinary Research on AIDS, Yale UniversityNew HavenConnecticutUSA
- Yale School of Medicine, Yale UniversityNew HavenConnecticutUSA
| | | | - Lynn M. Madden
- Yale School of Medicine, Yale UniversityNew HavenConnecticutUSA
- APT FoundationNew HavenConnecticutUSA
| | | | | | | | - Iryna Pykalo
- Ukrainian Institute on Public Health PolicyKyivUkraine
| | | | - Marwan S. Haddad
- Center for Key Populations, Community Health Center, Inc.MiddletownConnecticutUSA
| | | | - Frederick L. Altice
- Yale School of Public Health, Yale UniversityNew HavenConnecticutUSA
- Center for Interdisciplinary Research on AIDS, Yale UniversityNew HavenConnecticutUSA
- Yale School of Medicine, Yale UniversityNew HavenConnecticutUSA
- University of DelawareNewarkDelawareUSA
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Owczarzak J, Slutsker JS, Mazhnaya A, Tobin K, Kiriazova T. A mixed methods exploration of injection drug use risk behaviors and place-based norms in Ukraine. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 154:209135. [PMID: 37544509 PMCID: PMC10543465 DOI: 10.1016/j.josat.2023.209135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 04/11/2023] [Accepted: 07/18/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Despite global reductions in HIV incidence and significant investment in local harm reduction services, Ukraine continues to experience high HIV and HCV prevalence among people who inject drugs (PWID). Place-based factors and social norms affect drug use-related risk factors, but research has paid little attention to the relationship between drug use practices and place in Ukraine, including how these factors may contribute to or protect against HIV/HCV risk. METHODS This project used a sequential mixed methods design. Between March and August 2018, we interviewed 30 PWID in Dnipro, Ukraine. Participants completed a single in-depth interview in which they described where and with whom they lived; how they generated income; and where, when, how, and with whom they purchased and used drugs. Between May 2019 and March 2020, we recruited 150 PWID in Dnipro to complete a survey that was designed based on interview findings and consisted of three components: an activity space inventory, an egocentric social network inventory, and an HIV risk behavior assessment. RESULTS Both interview and survey respondents reported consistent use of pharmacies to acquire syringes and nearly universal use of new syringes when injecting. Interview participants reflected that while syringe sharing was previously considered a "common practice," PWID now viewed it as infrequent and unacceptable. However, interview respondents enumerated the contexts in which needle and syringe reuse occurred, including purchasing drugs directly from a dealer and chipping in with other PWID to prepare drugs bought through a stash. CONCLUSION Participants described relatively easy access to new needles and syringes through pharmacies and expressed strong social sanctioning against reusing needles or syringes. However, equipment sharing behaviors and norms persisted in certain contexts, creating an opportunity for further harm reduction campaigns that incorporate changing norms in these situations to "close the gap" and further reduce HIV and other infections among PWID.
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Affiliation(s)
- Jill Owczarzak
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, McElderry Street, 2nd Floor, Baltimore, MD 21205, USA.
| | | | - Alyona Mazhnaya
- Johns Hopkins Bloomberg School of Public Health, 615, N. Wolfe St, Baltimore, MD 21205, USA
| | - Karin Tobin
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, McElderry Street, 2nd Floor, Baltimore, MD 21205, USA.
| | - Tetiana Kiriazova
- Ukrainian Institute on Public Health Policy, 5 Biloruska Street, Kyiv 04050, Ukraine.
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Heidari O, Tormohlen K, Dangerfield DT, Tobin KE, Farley J, Aronowitz SV. Barriers and facilitators to primary care engagement for people who inject drugs: A systematic review. J Nurs Scholarsh 2023; 55:605-622. [PMID: 36480158 PMCID: PMC10635283 DOI: 10.1111/jnu.12863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION People who inject drugs (PWID) have a greater burden of multimorbid chronic diseases than the general population. However, little attention has been paid to the engagement in primary care for services related specifically to injection drug use and management of underlying chronic comorbid diseases for this population. This systematic review identified facilitators and barriers to healthcare engagement in the primary care setting among PWID. DESIGN AND METHODS Studies were identified by a literature search of PubMed, CINAHL, and EMBASE, and by searching the references of retrieved articles. Studies were included if they measured active injection drug use, and outcomes related to primary care engagement characterized by: diagnosis of a health condition, linkage or retention in care, health condition-related outcomes, and reported patient-provider relationship. RESULTS Twenty-three articles were included. Using the behavioral model, factors within predisposing, enabling, need, and health behavior domains were identified. Having co-located services and a positive patient-provider relationship were among the strongest factors associated with healthcare utilization and engagement while active injection drug use was associated with decreased engagement. CONCLUSIONS To our knowledge, this is the only review of evidence that has examined factors related to primary care engagement for people who inject drugs. Most articles were observational studies utilizing descriptive designs. Although the assessment of the evidence was primarily rated 'Good', this review identifies a significant need to improve our understanding of primary care engagement for PWID. Future research and intervention strategies should consider these findings to better integrate the holistic care needs of PWID into primary care to reduce morbidity and mortality associated with injection drug use and chronic disease. CLINICAL RELEVANCE Primary care engagement is important for preventative care, early diagnosis of disease, and management of chronic diseases, including addressing problems of substance use. This review highlights factors nurses can utilize to facilitate primary care engagement of PWID.
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Affiliation(s)
- Omeid Heidari
- University of Washington, School of Nursing, Department of Child, Family, and Population Health Nursing, 1959 NE Pacific Street, Seattle, WA 98195
| | - Kayla Tormohlen
- Johns Hopkins University, Bloomberg School of Public Health, Department of Health Policy and Management, 615 N. Wolfe St, Baltimore, MD 21205
| | - Derek T. Dangerfield
- George Washington University, Milken Institute School of Public Health, Department of Prevention and Community Health, 950 New Hampshire Ave NW #2, Washington, DC 20052
- Us Helping Us, Inc. Georgia Ave. NW. Washington, DC 20010
| | - Karin E. Tobin
- Johns Hopkins University, School of Nursing, 525 N. Wolfe St, Baltimore, MD 21205
| | - Jason Farley
- Johns Hopkins University, Bloomberg School of Public Health, Department of Health, Behavior, and Society, 615 N. Wolfe St, Baltimore, MD 21205
| | - Shoshana V. Aronowitz
- University of Pennsylvania, School of Nursing, Department of Family and Community Health, 418 Curie Blvd, Pennsylvania, PA, 19104
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Ivasiy R, Galvez de Leon SJ, Meteliuk A, Fomenko T, Pykalo I, Bromberg DJ, Madden LM, Farnum SO, Islam Z, Altice FL. Responding to health policy recommendations on managing opioid use disorder during Russia's invasion of Ukraine: Divergent responses from the frontline to the west. Front Public Health 2023; 10:1044677. [PMID: 36711398 PMCID: PMC9880308 DOI: 10.3389/fpubh.2022.1044677] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 12/15/2022] [Indexed: 01/15/2023] Open
Abstract
Russia's invasion of Ukraine on February 24, 2022, followed by Ukraine's Martial law, has disrupted the routine delivery of healthcare services, including opioid agonist treatment (OAT) programs. Directors (chief addiction treatment physicians) of these programs in each region had flexibility with implementing a series of adaptations to their practice to respond to war disruptions like mass internal displacement and legislation updates allowing more flexibility with OAT distribution policies and take-home dosing regulations. We conducted 8 in-depth interviews with directors from seven regions of Ukraine to describe their experiences providing OAT during a specific time during the war and the local crisis-response approach under the emergency policy updates. We categorized their experiences according to the level of exposure to conflict in each region and displacement of patients across the country, which may provide future guidance for OAT provision during the conflict.
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Affiliation(s)
- Roman Ivasiy
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, United States
| | | | - Anna Meteliuk
- International Charitable Foundation Alliance for Public Health, Kyiv, Ukraine
| | - Tetiana Fomenko
- International Charitable Foundation Alliance for Public Health, Kyiv, Ukraine
| | - Iryna Pykalo
- Ukrainian Institute of Public Health Policy, Kyiv, Ukraine
| | - Daniel J. Bromberg
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, United States
| | - Lynn M. Madden
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, United States
- APT Foundation, New Haven, CT, United States
| | | | - Zahedul Islam
- International Charitable Foundation Alliance for Public Health, Kyiv, Ukraine
| | - Frederick L. Altice
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, United States
- Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States
- APT Foundation, New Haven, CT, United States
- Division of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
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Madden LM, Farnum SO, Bromberg DJ, Barry DT, Mazhnaya A, Fomenko T, Meteliuk A, Marcus R, Rozanova J, Poklad I, Dvoriak S, Altice FL. The development and initial validation of the Russian version of the BASIS-24. Addict Sci Clin Pract 2022; 17:65. [PMID: 36435811 PMCID: PMC9701377 DOI: 10.1186/s13722-022-00343-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 10/19/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Efficient and linguistically appropriate instruments are needed to assess response to addiction treatment, including severity of addiction/mental health status. This is critical for Russian-speaking persons in Eastern Europe and Central Asia (EECA) where Medications for Opioid Use Disorder (MOUD) remain underscaled to address expanding and intertwined opioid, HIV, HCV and tuberculosis epidemics. We developed and conducted a pilot validation of a Russian version of the 24-item Behavior and Symptom Identification Scale (BASIS-24), an addiction/mental health severity instrument with six subscales, previously validated in English. METHODS Using the Mapi approach, we reviewed, translated, and back-translated the content to Russian, pilot-tested the Russian-version (BASIS-24-R) among new MOUD patients in Ukraine (N = 283). For a subset of patients (n = 44), test-rest was performed 48 h after admission to reassess reliability of BASIS-24-R. Exploratory principal component analysis (PCA) assessed underlying structure of BASIS-24-R. RESULTS Cronbach alpha coefficients for overall BASIS-24-R and 5 subscales exceeded 0.65; coefficient for Relationship subscale was 0.42. The Pearson correlation coefficients for overall score and all subscales on the BASIS-24-R exceeded 0.8. Each item loaded onto factors that corresponded with English BASIS-24 subscales ≥ 0.4 in PCA. CONCLUSION Initial version of BASIS-24-R appears statistically valid in Russian. Use of the BASIS-24-R has potential to guide MOUD treatment delivery in the EECA region and help to align addiction treatment with HIV prevention goals in a region where HIV is concentrated in people who inject opioids and where healthcare professionals have not traditionally perceived MOUD as effective treatment, particularly for those with mental health co-morbidities.
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Affiliation(s)
- Lynn M. Madden
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Scott O. Farnum
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
| | - Daniel J. Bromberg
- grid.47100.320000000419368710Yale School of Public Health, Laboratory of Epidemiology and Public Health, 60 College St, New Haven, CT 06510 USA
| | - Declan T. Barry
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
- grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06510 USA
- grid.47100.320000000419368710Child Study Center, Yale University School of Medicine, 230 S Frontage Road, New Haven, CT 06519 USA
| | - Alyona Mazhnaya
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
- grid.77971.3f0000 0001 1012 5630School of Public Health, National University of Kyiv-Mohyla Academy, Hryhoriya Skovorody Street, Kiev, 2 04655 Ukraine
| | - Tetiana Fomenko
- grid.511905.9ICF Alliance for Public Health, 24 Bulvarno-Kudriavska Street, Kyiv, 01601 Ukraine
| | - Anna Meteliuk
- grid.511905.9ICF Alliance for Public Health, 24 Bulvarno-Kudriavska Street, Kyiv, 01601 Ukraine
| | - Ruthanne Marcus
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Julia Rozanova
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Iurii Poklad
- Chernihiv Regional Narcological Dispensary, 3 Shchorsa Street, Chernihiv, 14005 Ukraine
| | - Sergii Dvoriak
- European Institute of Public Health Policy, 1 Malopidvalna Street, Office 10, Kiev, 01054 Ukraine
| | - Frederick L. Altice
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
- grid.47100.320000000419368710Yale School of Public Health, Laboratory of Epidemiology and Public Health, 60 College St, New Haven, CT 06510 USA
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
- grid.10347.310000 0001 2308 5949Centre of Excellence On Research in AIDS (CERiA), University of Malaya, Malaysia Level 17, Wisma R&DJalan Pantai Baharu, 59990 Kuala Lumpur, Malaysia
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Pashchenko O, Bromberg DJ, Dumchev K, LaMonaca K, Pykalo I, Filippovych M, Esserman D, Polonsky M, Galvez de Leon SJ, Morozova O, Dvoriak S, Altice FL. Preliminary analysis of self-reported quality health indicators of patients on opioid agonist therapy at specialty and primary care clinics in Ukraine: A randomized control trial. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000344. [PMID: 36962514 PMCID: PMC10021202 DOI: 10.1371/journal.pgph.0000344] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 08/29/2022] [Indexed: 11/07/2022]
Abstract
International agencies recommend integrating addiction treatment into primary care for people who inject drugs (PWID) with opioid use disorder (OUD). Empirical data supporting integration that incorporates comprehensive health outcomes, however, are not known. For this randomized controlled trial in Ukraine, adult PWID with OUD were randomized to receive opioid agonist therapy (OAT) in specialty addiction treatment clinics (SATC) or to primary care clinics (PCCs). For those randomized to PCC, they were subsequently allocated to PCCs where clinicians received pay-for-performance (P4P) incentives (PCC with P4P) or not (PCC without P4P). Participating cities had one of each of the three intervention sites to control for geographic variation. Ongoing tele-education specialty training (OAT, HIV, tuberculosis) was provided to all PCCs. While the primary outcome for the parent trial focuses on patient medical record data, this preliminary analysis focuses on assessment of self-reported achievement of nationally recommended quality health indicators (QHIs) which is summed as a composite QHI score. Secondary outcomes included specialty and primary care QHI subscores. This study occurred from 01/20/2018-11/1/2020 with 818 of 990 randomized participants having complete self-reported data for analysis. Relative to SATC (treatment as usual), the mean composite QHI score was 12.7 (95% CI: 10.1-15.3; p<0.001) percentage points higher at PCCs; similar and significantly higher scores were observed in PCCs compared to SATCs for both primary care (PCC vs SATC: 18.4 [95% CI: 14.8-22.0; p<0.001] and specialty (PCC vs SATC: 5.9 [95% CI: 2.6-9.2; p<0.001] QHI scores. Additionally, the mean composite QHI score was 4.6 (95% CI: 2.0-7.2; p<0.001) points higher in participants with long term (>3 months) experience with OAT compared to participants newly initiating OAT. In summary, PWID with OUD receive greater primary care and specialty healthcare services when receiving OAT at PCCs supported by tele-education relative to treatment as usual provided in SATCs. Clinical trial registration: This trial was registered at clinicaltrials.gov and can be found using the following registration number: NCT04927091.
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Affiliation(s)
| | - Daniel J. Bromberg
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, United States of America
- Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America
| | | | - Katherine LaMonaca
- Yale School of Medicine, Yale University, New Haven, CT, United States of America
| | - Iryna Pykalo
- Yale School of Medicine, Yale University, New Haven, CT, United States of America
- European Institute on Public Health Policy, Kyiv, Ukraine
| | | | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Maxim Polonsky
- Keck Graduate Institute, Claremont, CA, United States of America
| | | | - Olga Morozova
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, IL, United States of America
| | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Frederick L. Altice
- Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America
- Yale School of Medicine, Yale University, New Haven, CT, United States of America
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Altice FL, Bromberg DJ, Klepikov A, Barzilay EJ, Islam Z, Dvoriak S, Farnum SO, Madden LM. Collaborative learning and response to opioid misuse and HIV prevention in Ukraine during war. Lancet Psychiatry 2022; 9:852-854. [PMID: 36244353 PMCID: PMC9806953 DOI: 10.1016/s2215-0366(22)00318-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 09/01/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Frederick L Altice
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA; Division of Epidemiology and Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; APT Foundation, New Haven, CT, USA.
| | - Daniel J Bromberg
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA; Division of Epidemiology and Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Adriy Klepikov
- International Charitable Foundation Alliance for Public Health, Kyiv, Ukraine
| | - Ezra J Barzilay
- Division of Global HIV and TB, Center for Global Health, US Centers for Disease Control and Prevention, Kyiv, Ukraine
| | - Zahedul Islam
- International Charitable Foundation Alliance for Public Health, Kyiv, Ukraine
| | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | | | - Lynn M Madden
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA; APT Foundation, New Haven, CT, USA
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Heidari O, Genberg BL, Perrin N, Dangerfield DT, Farley JE, Kirk G, Mehta SH. Multimorbidity classes indicate differential patterns of health care engagement among people who inject drugs. J Subst Abuse Treat 2022; 142:108806. [PMID: 35643587 PMCID: PMC10544774 DOI: 10.1016/j.jsat.2022.108806] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 03/28/2022] [Accepted: 05/09/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Aging people who inject drugs (PWID) have complex health needs. Health care management could be complicated by persistent substance use, multiple health challenges, and inconsistent access to care. However, we know little about the relationship between chronic multimorbidity and health care engagement in this population. The purpose of this study is to characterize patterns and correlates of chronic disease multimorbidity among PWID. METHODS We conducted a latent class analysis (LCA) using data from the AIDS Linked to the IntraVenous Experience (ALIVE) Study, a community-based observational cohort, to determine classes of multimorbid chronic diseases. We then conducted regressions to determine factors associated with class membership and the impact of each multimorbid class on health events and utilization. RESULTS Of 1387 individuals included, the majority were male (67%) and Black (81%), with a mean age of 53 years. We identified four classes of multimorbidity: Low Multimorbidity (54%), and Low Multimorbidity Including Psychiatric Comorbidity (26%), Multimorbidity (12%), and Multimorbidity Including Psychiatric Comorbidity (7%). Female sex, baseline age, and receipt of disability were factors significantly associated with membership in all three classes compared to the Low Multimorbidity class. Additionally, PWID in these three classes were significantly more likely to utilize emergency room and outpatient health care. Membership in both classes with psychiatric comorbidity was associated with significantly higher adjusted odds of receiving medication for opioid use disorder. DISCUSSION Holistic health care systems can best address the needs of aging PWID with integrated care that provides harm reduction, substance use and mental health treatment together, and wrap around services.
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Affiliation(s)
- Omeid Heidari
- Johns Hopkins University, Bloomberg School of Public Health, Department of Mental Health, 615 N. Wolfe St, Baltimore, MD 21205, United States of America; Us Helping Us, People Into Living, Inc., 3636 Georgia Ave NW, Washington, D.C. 20010, United States of America.
| | - Becky L Genberg
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe St, Baltimore, MD 21205, United States of America
| | - Nancy Perrin
- Johns Hopkins University, School of Nursing, 525 N. Wolfe St, Baltimore, MD, 21205, United States of America
| | - Derek T Dangerfield
- Johns Hopkins University, School of Nursing, 525 N. Wolfe St, Baltimore, MD, 21205, United States of America; Us Helping Us, People Into Living, Inc., 3636 Georgia Ave NW, Washington, D.C. 20010, United States of America
| | - Jason E Farley
- The Center for Infectious Disease and Nursing Innovation, Johns Hopkins University, School of Nursing, 525 N. Wolfe St, Baltimore, MD 21205, United States of America; Johns Hopkins University, School of Nursing, 525 N. Wolfe St, Baltimore, MD, 21205, United States of America
| | - Gregory Kirk
- The Center for Infectious Disease and Nursing Innovation, Johns Hopkins University, School of Nursing, 525 N. Wolfe St, Baltimore, MD 21205, United States of America
| | - Shruti H Mehta
- Johns Hopkins University, Bloomberg School of Public Health, Department of Epidemiology, 615 N. Wolfe St, Baltimore, MD 21205, United States of America
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Alawa J, Muhammad M, Kazemitabar M, Bromberg DJ, Garcia D, Khoshnood K, Ghandour L. Medication for opioid use disorder in the Arab World: A systematic review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 102:103617. [PMID: 35182841 PMCID: PMC9851143 DOI: 10.1016/j.drugpo.2022.103617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/19/2022] [Accepted: 02/06/2022] [Indexed: 01/22/2023]
Abstract
BACKGROUND Opioid use disorder (OUD) is a global public health concern. The standard of care for OUD involves treatment using medications such as buprenorphine, methadone, or naltrexone. No known review exists to assess the contextual factors associated with medication for opioid use disorder (MOUD) in the Arab World. This systematic review serves as an implementation science study to address this research gap and improve the uptake of MOUD in the Arab World. METHODS Systematic searches of Medline, PsycINFO, and EMBASE, and a citation analysis, were used to identify peer-reviewed articles with original data on MOUD in the Arab World. Quality assessment was conducted using the CASP appraisal tools, and main findings were extracted and coded according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. RESULTS 652 research articles were identified, and 10 met inclusion criteria for final review. Four studies considered health-systems aspects of MOUD administration, such as cost-effectiveness, the motivations for and impact of national MOUD policies, the types of social, political, and scientific advocacy that led to the adoption of MOUD in Arab countries, and the challenges limiting its wide-scale adoption in the Arab World. Six papers considered MOUD at individual and group patient levels by evaluating patient quality of life, addiction severity, patient satisfaction, and patient perspectives on opioid agonist therapy. CONCLUSION Despite financial and geographic barriers that limit access to MOUD in the Arab World, this review found MOUD to be cost-effective and associated with positive health outcomes for OUD patients in the Arab World. MOUD can be successfully established and scaled to the national level in the Arab context, and strong coalitions of health practitioners can lobby to establish MOUD programs in Arab countries. Still, the relative novelty of MOUD in this context precludes an abundance of research to address its long-term delivery in the Arab World.
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Affiliation(s)
- Jude Alawa
- Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, United States
| | - Muzzammil Muhammad
- Yale University School of Medicine, 333 Cedar St, New Haven, CT 06510, United States
| | - Maryam Kazemitabar
- Yale University School of Public Health, 60 College St, New Haven, CT 06510, United States
| | - Daniel J Bromberg
- Yale University School of Public Health, 60 College St, New Haven, CT 06510, United States
| | - Danilo Garcia
- Centre for Ethics, Law and Mental Health (CELAM), University of Gothenburg, Box 100, 405 30 Gothenburg, Gothenburg, Sweden; Department of Behavioral Sciences and Learning, Linköping University, SE 581 83, Linköping, Sweden
| | - Kaveh Khoshnood
- Yale University School of Public Health, 60 College St, New Haven, CT 06510, United States
| | - Lilian Ghandour
- Department of Epidemiology and Population Health, Faculty of Health Sciences, American University of Beirut, Van Dyck Building, PO Box 11-0236, Riad El-Solh Beirut, 1107 2020, Lebanon.
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The Advantages and Disadvantages of Integrated Care Implementation in Central and Eastern Europe - Perspective from 9 CEE Countries. Int J Integr Care 2021; 21:14. [PMID: 34824563 PMCID: PMC8588893 DOI: 10.5334/ijic.5632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 09/20/2021] [Indexed: 12/04/2022] Open
Abstract
Introduction: Health and social care systems in Central and Eastern European (CEE) countries have undergone significant changes and are currently dealing with serious problems of system disintegration, coordination and a lack of control over the market environment. Description: The increased health needs related to the ageing society and epidemiological patterns in these countries also require funding needs to increase, rationing to be reformed, sectors to be integrated (the managed care approach), and an analytical information base to be developed if supervision of new technological approaches is to improve. The period of system transitions in CEE countries entailed significant changes in their health systems, including health care financing. Discussion: Large deficits in the public financing of health systems were just one of the challenges arising from the economic downturn of the 1990s, which was coupled with inflation, increasing unemployment, low salaries, a large informal sector and tax evasion in a number of CEE countries. During the communist period, there was universal access to a wide range of health services, proving it difficult to retain this coverage. As a result, many states sought to ration publicly funded health services – for example, through patient cost-sharing or decreasing the scope of basic benefits. Yet, not all of these reform plans were implemented, and in fact, some were rolled back or not implemented at all due to a lack of social or political consensus. Conclusion: CEE health systems had come to practice implicit rationing in the form of under-the-table payments from patients, quasi-formal payments to providers to compensate for lack of funding, and long waiting lists forcing patients to the private sector. All these difficulties pose a challenge to the implementation of integrated care.
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Rozanova J, Zeziulin O, Rich KM, Altice FL, Kiriazova T, Zaviryukha I, Sosidko T, Gulati K, Carroll C, Shenoi SV. An expanding HIV epidemic among older adults in Ukraine: Implications for patient-centered care. PLoS One 2021; 16:e0256627. [PMID: 34591848 PMCID: PMC8483339 DOI: 10.1371/journal.pone.0256627] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 08/12/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction The Eastern Europe and Central Asian (EECA) region has the highest increase in HIV incidence and mortality globally, with suboptimal HIV treatment and prevention. All EECA countries (except Russia) are low and middle-income (LMIC). While LMIC are home to 80% of all older people living with HIV (OPWH), defined as ≥50 years, extant literature observed that newly diagnosed OPWH represent the lowest proportion in EECA relative to all other global regions. We examined HIV diagnoses in OPWH in Ukraine, a country emblematic of the EECA region. Methods We analysed incident HIV diagnoses from 2015–2018 and mortality trends from 2016–2018 for three age groups: 1) 15–24 years; 2) 25–49 years; and 3) ≥50 years. AIDS was defined as CD4<200cells/mL. Mortality was defined as deaths per 1000 patients newly diagnosed with HIV within the same calendar year. Mortality rates were calculated for 2016, 2017, and 2018, compared to age-matched general population rates, and all-cause standardized mortality ratios (SMRs) were calculated. Results From 2015–2018, the proportion of OPWH annually diagnosed with HIV increased from 11.2% to 14.9% (p<0.01). At the time of diagnosis, OPWH were also significantly (p<0.01) more likely to have AIDS (43.8%) than those aged 25–49 years (29.5%) and 15–24 years (13.3%). Newly diagnosed OPWH had the same-year mortality ranging from 3 to 8 times higher than age-matched groups in the Ukrainian general population. Conclusions These findings suggest a reassessment of HIV testing, prevention and treatment strategies in Ukraine is needed to bring OPWH into focus. OPWH are more likely to present with late-stage HIV and have higher mortality rates. Re-designing testing practices is especially crucial since OPWH are absent from targeted testing programs and are increasingly diagnosed as they present with AIDS-defining symptoms. New strategies for linkage and treatment programs should reflect the distinct needs of this target population.
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Affiliation(s)
- Julia Rozanova
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, United States of America
- Yale University School of Public Health: Center for Interdisciplinary Research on AIDS (CIRA), New Haven, CT, United States of America
- * E-mail:
| | | | | | - Frederick L. Altice
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, United States of America
- Yale University School of Public Health: Center for Interdisciplinary Research on AIDS (CIRA), New Haven, CT, United States of America
- Centre of Excellence of Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
- Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, United States of America
| | | | | | - Tetiana Sosidko
- 100%-Life: All-Ukrainian Network for People Living with HIV, Kyiv, Ukraine
| | - Komal Gulati
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States of America
| | - Constance Carroll
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, United States of America
| | - Sheela V. Shenoi
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, United States of America
- Yale University School of Public Health: Center for Interdisciplinary Research on AIDS (CIRA), New Haven, CT, United States of America
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Meteliuk A, Galvez S, Fomenko T, Kalandiia H, Iaryi V, Farnum SO, Islam Z, Altice FL, Madden LM. Successful transfer of stable patients on opioid agonist therapies from specialty addiction treatment to primary care settings in Ukraine: A pilot study. J Subst Abuse Treat 2021; 134:108619. [PMID: 34579978 DOI: 10.1016/j.jsat.2021.108619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/20/2021] [Accepted: 09/02/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION In Ukraine, HIV is concentrated among people who inject drugs (PWID), and opioid agonist therapies (OAT) are the most effective approach to preventing HIV transmission. OAT coverage is well below internationally recommended levels, with OAT provided primarily in specialty addiction treatment clinics. Integrating OAT into primary care settings represents a promising practice for increasing OAT coverage. METHODS The study collected data prospectively from the first 50 stable patients transferred from the largest OAT site to 10 primary care clinics in Kiev; patients had negative urine drug tests for the previous six months. Participants completed the BASIS-24-the 24-item Behaviour and Symptom Identification Scale-to assess symptoms of psychiatric and social function across 6 domains: (1) depression and functioning, (2) relationships, (3) self-harm, (4) emotional lability, (5) psychosis, and (6) substance use before transfer and 6 months after transfer from May through November 2019. RESULTS Participants were on average 36 years old, mostly male (84.0%) and had some employment (64.0%). After six months, some employment increased to 88.0% and BASIS-24 scores significantly improved on four domains: depression (1.09 vs 0.73, p = 0.0005), relationships (2.15 vs 1.7, p < 0.0001), emotional liability (1.30 vs 1.00, p = 0.0209) and substance use (1.23 vs 1.07, p = 0073). CONCLUSIONS Stable OAT patients can be successfully transferred from specialty to primary care clinics without deterioration in mental health symptoms or functioning. Patients transferred to primary care showed significant improvement in their emotional well-being, their substance use, and their employment status.
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Affiliation(s)
- Anna Meteliuk
- Alliance for Public Health of Ukraine, Kyiv, Ukraine
| | - Samy Galvez
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
| | | | - Hela Kalandiia
- Kyiv City Drug Addiction Clinical Hospital 'Sociotherapy', Kyiv, Ukraine
| | - Volodymyr Iaryi
- Kyiv City Drug Addiction Clinical Hospital 'Sociotherapy', Kyiv, Ukraine
| | | | - Zahedul Islam
- Alliance for Public Health of Ukraine, Kyiv, Ukraine
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States; APT Foundation, New Haven, CT, United States; Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, United States.
| | - Lynn M Madden
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States; APT Foundation, New Haven, CT, United States
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Hailemeskal MB, Sereda Y, Latypov A, Kiriazova T, Avaliani N. Perceived quality of HIV care and client satisfaction across different service providers in Ukraine. Eur J Public Health 2021; 30:23-30. [PMID: 31270547 DOI: 10.1093/eurpub/ckz124] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Prior studies have shown that high client satisfaction and quality of services are important drivers of uptake and retention in human immunodeficiency virus (HIV) care. Study objectives were to assess the perceived quality of HIV services, satisfaction and associated factors across different types of health facilities in Ukraine. METHODS We conducted a cross-sectional study among 649 individuals receiving HIV services across 47 health facilities in three regions of Ukraine. Primary outcomes were satisfaction and perceived quality of services measured along five dimensions: accessibility, user-friendliness, privacy and confidentiality, comprehensiveness (separately for testing and treatment services). Quality dimensions were constructed by confirmatory factor analysis. Links between quality dimensions, satisfaction and related factors were measured by structural equation modelling. RESULTS Median scores for accessibility, user-friendliness, privacy and confidentiality, comprehensiveness of services and overall satisfaction ranged from 0.75 to 1 out of 1. User-friendliness was the main determinant associated with satisfaction (total effect: β = 0.515, P < 0.001). Satisfaction was higher at primary healthcare centres (direct effect: β = 0.145, P < 0.001; indirect effect through accessibility: β = 0.060, P < 0.001), narcological/tuberculosis dispensaries (direct effect: β = 0.105, P = 0.006; indirect effect through accessibility: β = 0.060, P < 0.001) and hospitals (indirect effects through user-friendliness and accessibility: β = 0.180, P < 0.001) when compared to acquired immune deficiency syndrome centres. CONCLUSIONS User-friendliness is a key driver of client satisfaction with HIV services in Ukraine. Decentralization of services, together with improved training and supervision for provider-client interactions may provide important levers to improve client satisfaction with HIV services and enrolment and retention in the cascade of HIV services.
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Farnum SO, Makarenko I, Madden L, Mazhnaya A, Marcus R, Prokhorova T, Bojko MJ, Rozanova J, Dvoriak S, Islam Z, Altice FL. The real-world impact of dosing of methadone and buprenorphine in retention on opioid agonist therapies in Ukraine. Addiction 2021; 116:83-93. [PMID: 32428276 PMCID: PMC7674222 DOI: 10.1111/add.15115] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 11/08/2019] [Accepted: 05/12/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Ukraine's HIV epidemic remains concentrated among opioid-dependent people who inject drugs (PWID) where opioid agonist therapies (OAT) like methadone (MMT) and buprenorphine (BMT) maintenance treatments are the most cost-effective HIV prevention strategies, but remain under-scaled. This study aimed to measure the association between dose and type of OAT prescribed and treatment retention. DESIGN Observational longitudinal cohort study. PARTICIPANTS AND SETTING Patients (n = 15 290) prescribed OAT throughout Ukraine from 2004 through 2016. MEASUREMENTS Data were analyzed using time-event strategies to estimate cumulative treatment retention, defined as time to OAT discontinuation. Cumulative retention proportions at 1, 12 and 36 months were assessed for outcomes. Cox regression with log-rank likelihood assessed independent predictors of treatment discontinuation. FINDINGS The proportion prescribed high (MMT: > 85 mg; BMT: ≥ 16 mg), medium (MMT: > 40-85 mg; BMT: > 6-15 mg) and low (MMT: ≤ 40 mg; BMT: ≤ 6 mg) dosages was 25, 43 and 32%, respectively. Retention was significantly higher for BMT than MMT both at 12 (89 versus 75%) and 36 months (80 versus 56%). Although dosing levels for BMT did not influence retention, increasing dosages for MMT were significantly associated with higher retention rates at 1 (90, 96, 99%), 12 (59, 78, 91%) and 36 (34, 59, 79%) months, respectively. Independent predictors associated with 12-month OAT discontinuation were medium [adjusted hazard ratio (aHR) = 2.23; 95% confidence limit (CL) = 1.95-2.54] and low (aHR = 4.96; 95% CL = 4.37-5.63) OAT dosage relative to high dosage, male sex (aHR = 1.27; 95% CL = 1.14-1.41), MMT relative to BMT prescription (aHR = 1.57; 95% CL = 1.32-1.87) and receiving OAT in general (aHR = 1.22; 95% CL = 1.02-1.46) or tuberculosis (aHR = 1.43; 95% CL = 1.10-1.85) hospitals, relative to specialty addiction treatment and AIDS center settings. Lower dosages contributed more to dropout especially at 1 month (aHR 3.12; 95% CL = 2.21-4.41 and aHR 7.71; 95% CL = 5.51-10.79 for medium and low dosages, respectively). Younger age was significantly associated with OAT discontinuation only at 36 months (aHR = 1.08; 95% CI = 1.02-1.15). CONCLUSIONS Higher dosages of opioid agonist therapies, especially for methadone maintenance treatment patients, appear to be associated with higher levels of treatment retention in Ukraine.
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Affiliation(s)
| | | | - Lynn Madden
- APT Foundation, New Haven, CT, USA
- Yale University School of Medicine, Department of Psychiatry, New Haven, CT, USA
| | | | - Ruthanne Marcus
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | | | - Martha J. Bojko
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Julia Rozanova
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | | | - Frederick L. Altice
- APT Foundation, New Haven, CT, USA
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, New Haven, CT, USA
- Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA
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The role of access to integrated services at opioid agonist treatment sites in reaching 90-90-90 cascade in people who inject drugs in Ukraine: Country-level data. Drug Alcohol Depend 2020; 216:108216. [PMID: 32805547 DOI: 10.1016/j.drugalcdep.2020.108216] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 07/21/2020] [Accepted: 07/26/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Opioid agonist treatment (OAT) is an effective means to prevent HIV transmission. Ukraine started integrating HIV services into OAT sites to improve people who inject drugs' (PWID) access to treatment. METHODS Data from the national registry of OAT patients (n = 9,983) were analyzed. These data are collected from all 179 OAT sites countrywide. For the cascade, HIV-positive OAT patients (n = 4,084) were stratified into two categories: OAT alone (received OAT at one site and antiretroviral therapy (ART) at different location, n = 1,789) and integrated care (received OAT and ART at one location, n = 2,295) for comparison. RESULTS Most HIV-positive OAT patients in Ukraine are male (85.6 %) and the mean age is 40.3 years old. The mean length of injecting before OAT is 17.2 years and the mean length on OAT is 4.2 years. All HIV-positive OAT clients are aware of their HIV status. The proportion of HIV-positive clients receiving ART was higher at integrated care sites compared to OAT alone sites (84.2 vs. 73.1 %, p- = 0.012); distribution of viral suppression among those receiving ART across the strata were 79.4 and 59.2 % for 'integrated care sites' vs. 'OAT only sites' respectively (p < 0.001). CONCLUSIONS This analysis clearly demonstrates much better progress towards the 90-90-90 goals among those OAT patients who receive integrated care services (both OAT and ART) at one site at each stage of the HIV care cascade as compared to receiving OAT and ART at different sites. There is an urgent need to further expand the integration of OAT and HIV services in Ukraine.
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Morozova O, Crawford FW, Cohen T, Paltiel AD, Altice FL. Cost-effectiveness of expanding the capacity of opioid agonist treatment in Ukraine: dynamic modeling analysis. Addiction 2020; 115:437-450. [PMID: 31478285 PMCID: PMC7015766 DOI: 10.1111/add.14797] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/24/2019] [Accepted: 08/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Although opioid agonist treatment (OAT) for opioid use disorder (OUD) is cost-effective in settings where the HIV epidemic is concentrated among people who inject drugs, OAT coverage in Ukraine remains far below internationally recommended targets. Scale-up is limited by both OAT availability and demand. This study aimed to evaluate the cost-effectiveness of a range of plausible OAT scale-up strategies in Ukraine incorporating the potential impact of treatment spillover and the real-world demand for addiction treatment. DESIGN, SETTING AND PARTICIPANTS Ten-year horizon (2016-25) modeling study of opioid addiction epidemic and treatment that accommodated potential peer effects in opioid use initiation and supply-induced treatment demand in three Ukrainian cities: Kyiv, Mykolaiv and Lviv, comprising a simulated population of people at risk of and with OUD. MEASUREMENTS Incremental cost per quality-adjusted life-year gained in the simulated population. FINDINGS An estimated 12.2-, 2.4- and 13.4-fold OAT capacity increase over 2016 baseline capacity in Kyiv, Mykolaiv and Lviv, respectively, would be cost-effective at a willingness-to-pay of one per-capita gross domestic product (GDP) per quality-adjusted life-year gained. This result is robust to parametric and structural uncertainty. Even under the most ambitious capacity increase, OAT coverage (i.e. the proportion of people with OUD receiving OAT) over a 10-year modeling horizon would be 20, 11 and 17% in Kyiv, Mykolaiv and Lviv, respectively, owing to limited demand. CONCLUSIONS It is estimated that a substantial increase in opioid agonist treatment (OAT) capacity in three Ukrainian cities would be cost-effective for a wide range of willingness-to-pay thresholds. Even a very ambitious capacity increase, however, is unlikely to reach internationally recommended coverage levels. Further increases in coverage may be limited by demand and would require addressing existing structural barriers to OAT access.
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Affiliation(s)
- Olga Morozova
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Forrest W Crawford
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA
- Department of Statistics and Data Science, Yale University, New Haven, CT, USA
- Yale School of Management, New Haven, CT, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - A David Paltiel
- Yale School of Management, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Frederick L Altice
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- University of Malaya, Kuala Lumpur, Malaysia
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Tan J, Altice FL, Madden LM, Zelenev A. Effect of expanding opioid agonist therapies on the HIV epidemic and mortality in Ukraine: a modelling study. Lancet HIV 2019; 7:e121-e128. [PMID: 31879250 DOI: 10.1016/s2352-3018(19)30373-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 10/14/2019] [Accepted: 10/24/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND As HIV incidence and mortality continue to increase in eastern Europe and central Asia, particularly among people who inject drugs (PWID), it is crucial to effectively scale-up opioid agonist therapy (OAT), such as methadone or buprenorphine maintenance therapy, to optimise HIV outcomes. With low OAT coverage among PWID, we did an optimisation assessment using current OAT procurement and allocation, then modelled the effect of increased OAT scale-up on HIV incidence and mortality for 23 administrative regions of Ukraine. METHODS We developed a linear optimisation model to estimate efficiency gains that could be achieved based on current procurement of OAT. We also developed a dynamic, compartmental population model of HIV transmission that included both injection and sexual risk to estimate the effect of OAT scale-up on HIV infections and mortality over a 10-year horizon. The compartmental population model was calibrated to HIV prevalence and incidence among PWID for 23 administrative regions of Ukraine. Sources for regional data included the SyrEx database, the Integrated Biological and Behavioral Survey, the Ukrainian Center for Socially Dangerous Disease Control of the Ministry of Health of Ukraine, the Public Health Center of the Ministry of Health of Ukraine, and the Ukrainian Census. FINDINGS Under a status-quo scenario (OAT coverage of 2·7% among PWID), the number of new HIV infections among PWID in Ukraine over the next 10 years was projected to increase to 58 820 (95% CI 47 968-65 535), with striking regional differences. With optimum allocation of OAT without additional increases in procurement, OAT coverage could increase from 2·7% to 3·3% by increasing OAT doses to ensure higher retention levels. OAT scale-up to 10% and 20% over 10 years would, respectively, prevent 4368 (95% CI 3134-5243) and 10 864 (7787-13 038) new HIV infections and reduce deaths by 7096 (95% CI 5078-9160) and 17 863 (12 828-23 062), relative to the status quo. OAT expansion to 20% in five regions of Ukraine with the highest HIV burden would account for 56% of new HIV infections and 49% of deaths prevented over 10 years. INTERPRETATION To optimise HIV prevention and treatment goals in Ukraine, OAT must be substantially scaled up in all regions. Increased medication procurement is needed, combined with optimisation of OAT dosing. Restricting OAT scale-up to some regions of Ukraine could benefit many PWID, but the regions most affected are not necessarily those with the highest HIV burden. FUNDING National Institute on Drug Abuse.
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Affiliation(s)
- Jiale Tan
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA; Centre of Excellence on Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
| | - Lynn M Madden
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA; APT Foundation, New Haven, CT, USA
| | - Alexei Zelenev
- Yale University School of Medicine, Section of Infectious Diseases, New Haven, CT, USA.
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21
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Opioid Agonist Treatment and Improved Outcomes at Each Stage of the HIV Treatment Cascade in People Who Inject Drugs in Ukraine. J Acquir Immune Defic Syndr 2019; 79:288-295. [PMID: 30312275 DOI: 10.1097/qai.0000000000001827] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The HIV treatment cascade is a crucial tool to guide HIV prevention and treatment strategies. The extent to which opioid agonist treatments (OATs) such as methadone and buprenorphine influence this cascade was examined in a nationwide study of people who inject drugs (PWID) in Ukraine. SETTING Cross-sectional stratified survey of PWID followed by HIV and hepatitis C virus testing in 5 Ukrainian cities. METHODS Opioid-dependent PWID (N = 1613) were sampled from January 2014 to March 2015. Analysis was confined to 520 participants with HIV, with 184 (35.4%) prescribed OAT. Weighted logistic regression models were used to assess independent factors associated with the 5 steps in the HIV treatment cascade. RESULTS Compared with PWID not on OAT (N = 336), participants who prescribed OAT (N = 184) were significantly more likely to be diagnosed (91% vs. 71%), linked (81% vs. 52%), and retained (69% vs. 35%) in HIV care, and prescribed (56% vs. 31%) and optimally (>95% of doses) adherent to antiretroviral therapy (41% vs. 22%). Receiving OAT contributed most as an independent factor with every step of the cascade. Other steps in the HIV treatment cascade were influenced by age, depression, and geographical variability. CONCLUSIONS OAT remains an essential and effective strategy to not only treat patients with opioid use disorder, but also a crucial strategy to engage PWID in care to meet UNAIDS 90-90-90 targets. Geographical differences suggest local structural impediments. With low OAT coverage prescribed for 2.9% of the estimated 347,000 PWID in Ukraine, OAT expansion requires strategic interventions that target the individual, clinical care settings, policies, and funding.
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Verna EC, Schluger A, Brown RS. Opioid epidemic and liver disease. JHEP Rep 2019; 1:240-255. [PMID: 32039374 PMCID: PMC7001546 DOI: 10.1016/j.jhepr.2019.06.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/27/2019] [Accepted: 06/29/2019] [Indexed: 12/12/2022] Open
Abstract
Opioid use in the United States and in many parts of the world has reached epidemic proportions. This has led to excess mortality as well as significant changes in the epidemiology of liver disease. Herein, we review the impact of the opioid epidemic on liver disease, focusing on the multifaceted impact this epidemic has had on liver disease and liver transplantation. In particular, the opioid crisis has led to a significant shift in incident hepatitis C virus infection to younger populations and to women, leading to changes in screening recommendations. Less well characterized are the potential direct and indirect hepatotoxic effects of opioids, as well as the changes in the incidence of hepatitis B virus infection and alcohol abuse that are likely rising in this population as well. Finally, the opioid epidemic has led to a significant rise in the proportion of organ donors who died due to overdose. These donors have led to an overall increase in donor numbers, but also to new considerations about the better use of donors with perceived or actual risk of disease transmission, especially hepatitis C. Clearly, additional efforts are needed to combat the opioid epidemic. Moreover, better understanding of the epidemiology and underlying pathophysiology will help to identify and treat liver disease in this high-risk population.
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Affiliation(s)
- Elizabeth C. Verna
- Center for Liver Disease and Transplantation, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Aaron Schluger
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Robert S. Brown
- Center for Liver Disease and Transplantation, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY
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Nixon LL, Marlinga JC, Hayden KA, Mrklas KJ. Barriers and facilitators to office-based opioid agonist therapy prescribing and effective interventions to increase provider prescribing: protocol for a systematic review. Syst Rev 2019; 8:186. [PMID: 31345258 PMCID: PMC6657163 DOI: 10.1186/s13643-019-1076-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 06/24/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Opiate agonist therapy (OAT) prescribing rates by family physicians are low in the context of community-based, comprehensive primary care. Understanding the factors that support and/or inhibit OAT prescribing within primary care is needed. Our study objectives are to identify and synthesize documented barriers to, and facilitators of, primary care opioid agonist prescribing, and effective strategies to inform intervention planning and support increased primary care OAT prescribing. METHODS/DESIGN We will systematically search EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, MEDLINE, and gray literature in three domains: primary care providers, opioid agonist therapy, and opioid abuse. We will retain and assess primary studies reporting documented participation, or self-reported willingness to participate, in OAT prescribing; and/or at least one determinant of OAT prescribing; and/or strategies to address determinants of OAT prescribing from the perspective of primary care providers in comprehensive, community-based practice settings. There will be no restrictions on study design or publication date. Studies limited to specialty clinics with specialist prescribers, lacking extractable data, or in languages other than English or French will be excluded. Two reviewers will perform abstract review and data extraction independently. We will assess the quality of included studies using the Joanna Briggs Institute Critical Appraisal Tool. We will use a framework method of analysis to deductively code barriers and facilitators and to characterize effective strategies to support prescribing using a combined, modified a priori framework comprising the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. DISCUSSION To date, no synthesis has been undertaken of the barriers and facilitators or effective interventions promoting OAT prescribing by primary care clinicians in community-based comprehensive care settings. Enacting change in physician behaviors, community-based programming, and health services is complex and best informed by using theoretical frameworks that allow the analysis of the available data to assist in designing and implementing interventions. In light of the current opioid crisis, increasing the capacity of primary care clinicians to provide OAT is an important strategy to curb morbidity and mortality from opioid use disorder. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD86835.
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Affiliation(s)
- Lara L. Nixon
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Room G012 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
| | - Jazmin C. Marlinga
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Room G012 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
| | - K. Alix Hayden
- Libraries & Cultural Resources, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 4N1 Canada
| | - Kelly J. Mrklas
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
- Strategic Clinical Networks™, System Innovation and Programs, Alberta Health Services, 403 - 29th Street NW, Calgary, AB T2N 2T9 Canada
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Makarenko I, Artenie A, Hoj S, Minoyan N, Jacka B, Zang G, Barlett G, Jutras-Aswad D, Martel-Laferriere V, Bruneau J. Transitioning from interferon-based to direct antiviral treatment options: A potential shift in barriers and facilitators of treatment initiation among people who use drugs? THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 72:69-76. [PMID: 31010749 DOI: 10.1016/j.drugpo.2019.04.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/31/2019] [Accepted: 04/04/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Multiple barriers for accessing hepatitis C virus (HCV) treatment were identified during the interferon-based (IFN) treatment era for people who inject drugs (PWID). Whether these barriers persist since the introduction of IFN-free direct-acting antiviral (DAA) agents in Canada remains to be documented. This study examined temporal trends in HCV treatment initiation and associated factors during the transition from INF-based to all-oral DAA regimens. METHODS The study population was drawn from a prospective cohort of PWID in Montreal, Canada. At three-month/one-year intervals between 2011 and 2017, participants with chronic HCV infection completed an interviewer-administered questionnaire on socio-demographic characteristics, drug use and health service utilisation, including HCV treatment. Time-updated Cox multivariate regression models, stratified by DAA + INF (2011-2013) and all-oral DAA (2014-2017) availability periods, were conducted to examine associations between time to HCV treatment initiation and associated barriers and facilitators. RESULTS Of 308 participants (85% male, median age 42 [IQR: 33, 50]), 80 (26%) initiated HCV treatment during 915 person-years (PY). Incidence rates increased from 1.6 /100 PY (95%CI:0.9-2.6) in 2011 to 12.7 (10.6-15.1) in 2017 (p-trend = 0.0012). In multivariate analyses, visiting a primary care physician (2011-2013: aHR = 3.63[1.21-10.9]; 2014-2017: 2.52[1.10-5.77]) and frequent injection (0.23[0.05-0.99] and 0.49[0.24-0.99]) were consistently associated with treatment initiation. Participants aged >40 (2.27[1.24-4.13]), receiving opioid agonist therapy (OAT) (2.17[1.19-3.94]), and reporting prior HCV treatment (3.00[1.75-5.15]) were more likely to initiate treatment in the all-oral DAA period. CONCLUSION Treatment initiation increased between 2011 and 2017, but still remains low among PWID. Primary care visiting was a key facilitator regardless of the period, while engagement in OAT and health services, indicated by prior HCV treatment, increased the likelihood of treatment initiation in the DAA era. These findings suggest that access to health services is essential but not enough to scale up treatment in this population.
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Affiliation(s)
- Iuliia Makarenko
- McGill University, Department of Family Medicine, Montreal, QC, Canada; Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Adelina Artenie
- Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Stine Hoj
- Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Nanor Minoyan
- Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Brendan Jacka
- Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Geng Zang
- Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Gillian Barlett
- McGill University, Department of Family Medicine, Montreal, QC, Canada
| | - Didier Jutras-Aswad
- Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Psychiatry and Addiction, Université de Montréal, Montreal, QC, Canada
| | - Valerie Martel-Laferriere
- Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Microbiology, Infectious Diseases and Immunology, Université de Montréal, Montreal, QC, Canada
| | - Julie Bruneau
- Centre de recherche du Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada; Department of Family and Emergency Medicine, Université de Montréal, Montreal, QC, Canada.
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Ghaddar A, Abbas Z, Haddad R. Opiate agonist treatment to improve health of individuals with opioid use disorder in Lebanon. Harm Reduct J 2017; 14:78. [PMID: 29216892 PMCID: PMC5721516 DOI: 10.1186/s12954-017-0204-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 11/29/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Opioid agonist therapy has been widely used to reduce harms among individuals with opioid use disorder but its effectiveness has not been evaluated in the Middle East North African (MENA) region. This study aims to evaluate the effectiveness of a program using opioid agonist therapy in combination with psychosocial support on improving psychological and social well-being, reducing arrest, and reducing risky behavior in individuals with opioid use disorder in Lebanon. METHODS A one-group pre-test post-test design study was performed at SKOUN Lebanese Addiction Centre between January 2013 and December 2014. Eighty-six out of 181 patients agreed to participate and completed the 3-month assessment and 38 concluded the 12-month assessment. Psychological (depression and anxiety, quality of life), substance dependence/abuse, behavioral (injecting behavior, sharing needles and paraphernalia), and social outcomes were evaluated at baseline, 3, and 12 months post-treatment. RESULTS Remarkable statistical significance improvements were observed 3 months after treatment in most outcome variables including quality of life, anxiety, substance dependence, overdose, employment, and injecting behavior. Improvements were sustained 12 months after treatment. CONCLUSION Results support expanding the access to opioid agonist therapy in other MENA countries to treat substance dependence and reduce harms among individuals with opioid use disorder.
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Affiliation(s)
- Ali Ghaddar
- Department of Biomedical Sciences, Lebanese International University, Beirut, Lebanon. .,Observatory of Public Policies and Health, Beirut, Lebanon.
| | - Zeinab Abbas
- School of Pharmacy, Lebanese International University, Beirut, Lebanon.,Department of Narcotics, Ministry of Public Health, Beirut, Lebanon
| | - Ramzi Haddad
- Department of Psychiatry, Lebanese University, Beirut, Lebanon.,Department of Psychiatry, Saint Joseph University, Beirut, Lebanon
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Marcus R, Makarenko I, Mazhnaya A, Zelenev A, Polonsky M, Madden L, Filippovych S, Dvoriak S, Springer SA, Altice FL. Patient preferences and extended-release naltrexone: A new opportunity to treat opioid use disorders in Ukraine. Drug Alcohol Depend 2017; 179:213-219. [PMID: 28806638 PMCID: PMC5599372 DOI: 10.1016/j.drugalcdep.2017.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/12/2017] [Accepted: 07/15/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND Scaling up HIV prevention for people who inject drugs (PWID) using opioid agonist therapies (OAT) in Ukraine has been restricted by individual and structural factors. Extended-release naltrexone (XR-NTX), however, provides new opportunities for treating opioid use disorders (OUDs) in this region, where both HIV incidence and mortality continue to increase. METHODS Survey results from 1613 randomly selected PWID from 5 regions in Ukraine who were currently, previously or never on OAT were analyzed for their preference of pharmacological therapies for treating OUDs. For those preferring XR-NTX, independent correlates of their willingness to initiate XR-NTX were examined. RESULTS Among the 1613 PWID, 449 (27.8%) were interested in initiating XR-NTX. Independent correlates associated with interest in XR-NTX included: being from Mykolaiv (AOR=3.7, 95% CI=2.3-6.1) or Dnipro (AOR=1.8, 95% CI=1.1-2.9); never having been on OAT (AOR=3.4, 95% CI=2.1-5.4); shorter-term injectors (AOR=0.9, 95% CI 0.9-0.98); and inversely for both positive (AOR=0.8, CI=0.8-0.9), and negative attitudes toward OAT (AOR=1.3, CI=1.2-1.4), respectively. CONCLUSIONS In the context of Eastern Europe and Central Asia where HIV is concentrated in PWID and where HIV prevention with OAT is under-scaled, new options for treating OUDs are urgently needed. FINDINGS here suggest that XR-NTX could become an option for addiction treatment and HIV prevention especially for PWID who have shorter duration of injection and who harbor negative attitudes to OAT. Decision aids that inform patient preferences with accurate information about the various treatment options are likely to guide patients toward better, patient-centered treatments and improve treatment entry and retention.
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Affiliation(s)
- Ruthanne Marcus
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA.
| | | | | | - Alexei Zelenev
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Maxim Polonsky
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | | | | | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Sandra A Springer
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, USA; Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven CT, USA; Centre of Excellence on Research in AIDS (CERiA), University of Malaya, Kuala Lumpur, Malaysia
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