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Oldfield BJ, Chen K, Joudrey PJ, Biegacki ET, Fiellin DA. Availability of Specific Programs and Medications for Addiction Treatment to Vulnerable Populations: Results from the Addiction Treatment Locator, Assessment, and Standards (ATLAS) Survey. J Addict Med 2023; 17:477-480. [PMID: 37579115 DOI: 10.1097/adm.0000000000001158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
OBJECTIVES This study aimed to describe addiction treatment facilities by their offerings of medications for alcohol use disorder (MAUD) and/or for opioid use disorder (MOUD), and by their offering services to groups with barriers to care: uninsured and publicly insured, youth, seniors, individuals preferring to receive care in Spanish, and sexual minority individuals. METHODS We examined addiction treatment facility survey data in 6 US states. We performed bivariate analyses comparing facilities that offered MAUD, MOUD, and both (main outcomes). We then constructed a multivariable model to identify predictors of offering MAUD, MOUD, or both, including exposures that demonstrate programming for special populations. RESULTS Among 2474 facilities, 1228 (50%) responded between October 2019 and January 2020. Programs were offered for youth (30%), elderly (40%), Spanish-speaking (37%), and sexual minority populations (39%), with 58% providing MAUD, 67% providing MOUD, and 56% providing both. Among those providing MAUD, MOUD, or both, a majority (>60% for all exposures) offered programming to vulnerable populations. With Delaware as reference, Louisiana (adjusted odds ratio [aOR], 0.28; 95% confidence interval [CI], 0.12-0.67) and North Carolina (aOR, 0.33; 95% CI, 0.15-0.72) facilities had lesser odds of offering both MAUD and MOUD. All exposures identifying facilities offering treatment to vulnerable groups were associated with offerings of MAUD and/or MOUD except for offerings to youth; these facilities had less odds of offering MOUD (aOR, 0.31; 95% CI, 0.31-0.62). CONCLUSIONS There are facility-level disparities in providing MAUD and MOUD by state, and facilities with youth programming have lesser odds of offering MOUD than other facilities.
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Affiliation(s)
- Benjamin J Oldfield
- From the Fair Haven Community Health Care, New Haven, CT (BJO); Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT (BJO, ETB, DAF); Office of Ambulatory Care and Population Health, New York City Health and Hospitals Corporation, New York, NY (KC); Division of General Internal Medicine and Clinical Innovation, New York University Grossman School of Medicine, New York, NY (KC); Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (PJJ); Department of Emergency Medicine, Yale School of Medicine, New Haven, CT (DAF); and Yale School of Public Health, New Haven, CT (DAF)
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Jawa R, Tin Y, Nall S, Calcaterra SL, Savinkina A, Marks LR, Kimmel SD, Linas BP, Barocas JA. Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics. JAMA Netw Open 2023; 6:e237888. [PMID: 37043198 PMCID: PMC10098970 DOI: 10.1001/jamanetworkopen.2023.7888] [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: 10/16/2022] [Accepted: 02/28/2023] [Indexed: 04/13/2023] Open
Abstract
Importance US primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown. Objective To estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids. Design, Setting, and Participants In this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort. Main Outcomes and Measures Life-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs). Results The simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000. Conclusions and Relevance This modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.
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Affiliation(s)
- Raagini Jawa
- Section of General Internal Medicine, Center for Research on Healthcare, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Yjuliana Tin
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Samantha Nall
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Susan L. Calcaterra
- Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Alexandra Savinkina
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Laura R. Marks
- Division of Infectious Diseases, School of Medicine, Washington University in St Louis, Missouri
| | - Simeon D. Kimmel
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Benjamin P. Linas
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Joshua A. Barocas
- Divisions of General Internal Medicine and Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora
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John WS, Mannelli P, Hoyle RH, Greenblatt L, Wu LT. Association of chronic non-cancer pain status and buprenorphine treatment retention among individuals with opioid use disorder: Results from electronic health record data. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100048. [PMID: 36845986 PMCID: PMC9948869 DOI: 10.1016/j.dadr.2022.100048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/23/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Although chronic non-cancer pain (CNCP) is common among individuals with opioid use disorder (OUD), its impact on buprenorphine treatment retention is unclear. The goal of this study was to use electronic health record (EHR) data to examine the association of CNCP status and 6-month buprenorphine retention among patients with OUD. METHODS We analyzed EHR data of patients with OUD who received buprenorphine treatment in an academic healthcare system between 2010 and 2020 (N = 676). We used Kaplan-Meier curves and Cox proportional hazards regression to estimate risk of buprenorphine treatment discontinuation (≥90 days between subsequent prescriptions). We used Poisson regression to estimate the association of CNCP and the number of buprenorphine prescriptions over 6 months. RESULTS Compared to those without CNCP, a higher proportion of patients with CNCP were of older age and had comorbid diagnoses for psychiatric and substance use disorders. There were no differences in the probability of buprenorphine treatment continuation over 6 months by CNCP status (p = 0.15). In the adjusted cox regression model, the presence of CNCP was not associated with time to buprenorphine treatment discontinuation (HR = 0.90, p = 0.28). CNCP status was associated with a higher number of prescriptions over 6 months (IRR = 1.20, p < 0.01). CONCLUSIONS These findings suggest that the presence of CNCP alone cannot be reliably associated with buprenorphine retention in patients with OUD. Nonetheless, providers should be aware of the association between CNCP and greater psychiatric comorbidity among patients with OUD when developing treatment plans. Research on the influence of additional characteristics of CNCP on treatment retention is needed.
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Affiliation(s)
- William S. John
- Department of Psychiatry and Behavioral Sciences, Division of Social and Community Psychiatry, Duke University Medical Center, Durham, NC, United States
| | - Paolo Mannelli
- Department of Pyschiatry and Behavioral Sciences, Division of Adult Psychiatry and Psychology, Duke University Medical Center, Durham, NC, United States
| | - Rick H. Hoyle
- Department of Pyschiatry and Behavioral Sciences, Division of Adult Psychiatry and Psychology, Duke University Medical Center, Durham, NC, United States
| | - Lawrence Greenblatt
- Department of Psychology and Neuroscience, Duke University, Durham, NC, United States
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Division of Social and Community Psychiatry, Duke University Medical Center, Durham, NC, United States
- Department of Psychology and Neuroscience, Duke University, Durham, NC, United States
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, United States
- Duke Institue for Brain Sciences, Duke University, Durham, NC, United States
- Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, NC, United States
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4
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Gunn CM, Maschke A, Harris M, Schoenberger SF, Sampath S, Walley AY, Bagley SM. Age-based preferences for risk communication in the fentanyl era: 'A lot of people keep seeing other people die and that's not enough for them'. Addiction 2021; 116:1495-1504. [PMID: 33119196 PMCID: PMC8081736 DOI: 10.1111/add.15305] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 04/01/2020] [Accepted: 10/16/2020] [Indexed: 02/03/2023]
Abstract
AIMS To explore how people who use fentanyl and health-care providers engaged in and responded to overdose risk communication interactions, and how these engagements and responses might vary by age. DESIGN A single-site qualitative in-depth interview study. SETTING Boston, MA, United States. PARTICIPANTS The sample included 21 people (10 women, 11 men) who were either 18-25 or 35+, English-speaking, and reported illicit fentanyl use in the last year and 10 health-care providers who worked directly with people who use fentanyl (PWUF) in clinical and community settings. MEASUREMENTS Open-ended, flexible interview questions guided by a risk communication framework were used in all interviews. Codes used for thematic analysis included deductive codes related to the risk communication framework and inductive, emergent codes from interview content. FINDINGS We identified potential age-based differences in perceptions of fentanyl overdose, including that younger participants appeared to display more perceptions of an immunity to fentanyl's lethality, while older people seemed to express a stronger aversion to fentanyl due to its heightened risk of fatal overdose, shorter effects and potential for long-term health consequences. Providers perceived greater challenges relaying risk information to young PWUF and believed them to be less open to risk communication. Compassionate harm reduction communication was preferred by all participants and perceived to be delivered most effectively by community health workers and peers. PWUF and providers identified structural barriers that limited compassionate harm reduction, including misalignment of available treatment with preferred options and clinical structures that impeded the delivery of risk communication messages. CONCLUSIONS Among people who engage in illicit fentanyl use, fentanyl-related risk communication experiences and preferences may vary by age, but some foundational elements including compassionate, trust-building approaches seem to be preferred across the age spectrum. Structural barriers in the clinical setting such as provider-prescribing power and infrequent encounters may impede the providers' ability to provide compassionate harm reduction communication.
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Affiliation(s)
- Christine M Gunn
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
| | - Ariel Maschke
- Department of Medicine, Section of General Internal Medicine, Women's Health Unit, Boston University School of Medicine, Boston, MA, USA
| | - Miriam Harris
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | - Samantha F Schoenberger
- Department of Medicine, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Alexander Y Walley
- Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Grayken Center for Addiction, Boston University School of Medicine, Boston, MA, USA
| | - Sarah M Bagley
- Department of Medicine, Section of General Internal Medicine, Department of Pediatrics, Division of General Pediatrics, Boston University School of Medicine, Boston, MA, USA
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5
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John WS, Zhu H, Greenblatt LH, Wu LT. Recent and active problematic substance use among primary care patients: Results from the alcohol, smoking, and substance involvement screening test in a multisite study. Subst Abus 2021; 42:487-492. [PMID: 33797348 PMCID: PMC9822781 DOI: 10.1080/08897077.2021.1901176] [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] [Indexed: 01/11/2023]
Abstract
Background: Primary care settings provide salient opportunities for identifying patients with problematic substance use and addressing unmet treatment need. The aim of this study was to examine the extent and correlates of problematic substance use by substance-specific risk categories among primary care patients to inform screening/intervention efforts. Methods: Data were analyzed from 2000 adult primary care patients aged ≥18 years (56% female) across 5 clinics in the eastern U.S. Participants completed the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Prevalence and ASSIST-defined risk-level of tobacco use, alcohol use, and nonmedical/illicit drug use was examined. Multinomial logistic regression models analyzed the demographic correlates of substance use risk-levels. Results: Among the total sample, the prevalence of any past 3-month use was 53.9% for alcohol, 42.0% for tobacco, 24.2% for any illicit/Rx drug, and 5.3% for opioids; the prevalence of ASSIST-defined moderate/high-risk use was 45.1% for tobacco, 29.0% for any illicit/Rx drug, 14.2% for alcohol, and 9.1% for opioids. Differences in the extent and risk-levels of substance use by sex, race/ethnicity, and age group were observed. Adjusted logistic regression showed that male sex, white race, not being married, and having less education were associated with increased odds of moderate/high-risk use scores for each substance category; older ages (versus ages 18-25 years) were associated with increased odds of moderate/high-risk opioid use. Conclusions: Intervention need for problematic substance use was prevalent in this sample. Providers should maintain awareness and screen for problematic substance use more consistently in identified high risk populations.
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Affiliation(s)
- William S. John
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - He Zhu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Lawrence H. Greenblatt
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, NC, USA
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Oldfield BJ, Tetrault JM, Berland G. Addiction Screening-The A Star Is Born Movie Series and Destigmatization of Substance Use Disorders. JAMA 2021; 325:915-917. [PMID: 33687448 DOI: 10.1001/jama.2020.25256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Benjamin J Oldfield
- Fair Haven Community Health Care, New Haven, Connecticut
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Gretchen Berland
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
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Saunders EC, Moore SK, Walsh O, Metcalf SA, Budney AJ, Cavazos-Rehg P, Scherer E, Marsch LA. "It's way more than just writing a prescription": A qualitative study of preferences for integrated versus non-integrated treatment models among individuals with opioid use disorder. Addict Sci Clin Pract 2021; 16:8. [PMID: 33499938 PMCID: PMC7839299 DOI: 10.1186/s13722-021-00213-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 01/06/2021] [Indexed: 01/17/2023] Open
Abstract
Background Increasingly, treatment for opioid use disorder (OUD) is offered in integrated treatment models addressing both substance use and other health conditions within the same system. This often includes offering medications for OUD in general medical settings. It remains uncertain whether integrated OUD treatment models are preferred to non-integrated models, where treatment is provided within a distinct treatment system. This study aimed to explore preferences for integrated versus non-integrated treatment models among people with OUD and examine what factors may influence preferences. Methods This qualitative study recruited participants (n = 40) through Craigslist advertisements and flyers posted in treatment programs across the United States. Participants were 18 years of age or older and scored a two or higher on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool. Each participant completed a demographic survey and a telephone interview. The interviews were coded and content analyzed. Results While some participants preferred receiving OUD treatment from an integrated model in a general medical setting, the majority preferred non-integrated models. Some participants preferred integrated models in theory but expressed concerns about stigma and a lack of psychosocial services. Tradeoffs between integrated and non-integrated models were centered around patient values (desire for anonymity and personalization, fear of consequences), the characteristics of the provider and setting (convenience, perceived treatment effectiveness, access to services), and the patient-provider relationship (disclosure, trust, comfort, stigma). Conclusions Among this sample of primarily White adults, preferences for non-integrated versus integrated OUD treatment were mixed. Perceived benefits of integrated models included convenience, potential for treatment personalization, and opportunity to extend established relationships with medical providers. Recommendations to make integrated treatment more patient-centered include facilitating access to psychosocial services, educating patients on privacy, individualizing treatment, and prioritizing the patient-provider relationship. This sample included very few minorities and thus findings may not be fully generalizable to the larger population of persons with OUD. Nonetheless, results suggest a need for expansion of both OUD treatment in specialty and general medical settings to ensure access to preferred treatment for all.
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Affiliation(s)
- Elizabeth C Saunders
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA.
| | - Sarah K Moore
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Olivia Walsh
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Stephen A Metcalf
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Alan J Budney
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Patricia Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Emily Scherer
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
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Motavalli D, Taylor JL, Childs E, Valente PK, Salhaney P, Olson J, Biancarelli DL, Edeza A, Earlywine JJ, Marshall BDL, Drainoni ML, Mimiaga MJ, Biello KB, Bazzi AR. "Health Is on the Back Burner:" Multilevel Barriers and Facilitators to Primary Care Among People Who Inject Drugs. J Gen Intern Med 2021; 36:129-137. [PMID: 32918199 PMCID: PMC7858998 DOI: 10.1007/s11606-020-06201-6] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/27/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND The estimated 2.2 million people who inject drugs (PWID) in the USA experience significant gaps in preventive healthcare and a high burden of infectious, psychiatric, and other chronic diseases. Many PWID rely on emergency medical services, which are costly and not designed to deliver preventive services, manage chronic conditions, or address social needs. OBJECTIVE The objective of this study was to explore barriers and facilitators to primary care utilization from the perspectives of PWID in New England, a region highly affected by the overdose crisis. DESIGN Participants completed semi-structured qualitative interviews exploring substance use and healthcare utilization patterns. PARTICIPANTS We recruited 78 PWID through community-based organizations (e.g., syringe service programs) in 16 urban and non-urban communities throughout Massachusetts and Rhode Island. APPROACH Thematic analysis identified barriers and facilitators to primary care utilization at the individual, interpersonal, and systemic levels. KEY RESULTS Among 78 PWID, 48 described recent primary care experiences; 33 had positive experiences and 15 described negative experiences involving discrimination or mistrust. Individual-level barriers to primary care utilization included perceived lack of need and competing priorities (e.g., avoiding opioid withdrawal, securing shelter beds). Interpersonal-level barriers included stigma and perceived low quality of care for PWID. Systemic-level barriers included difficulty navigating healthcare systems, inadequate transportation, long wait times, and frequent provider turnover. Participants with positive primary care experiences explained how appointment reminders, flexible hours, addiction medicine-trained providers, case management services, and transportation support facilitated primary care utilization and satisfaction. CONCLUSIONS Findings regarding the multilevel barriers and facilitators to accessing primary care among PWID identify potential targets for programmatic interventions to improve primary care utilization in this population. Based on these findings, we make recommendations for improving the engagement of PWID in primary care as a means to advance individual and public health outcomes.
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Affiliation(s)
| | - Jessica L Taylor
- Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | - Ellen Childs
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Pablo K Valente
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Peter Salhaney
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- Center for Health Equity Research, Brown University, Providence, RI, USA
| | - Jennifer Olson
- Center for Health Equity Research, Brown University, Providence, RI, USA
| | - Dea L Biancarelli
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Alberto Edeza
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- Center for Health Equity Research, Brown University, Providence, RI, USA
| | - Joel J Earlywine
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Mari-Lynn Drainoni
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, MA, USA
- Section of Infectious Diseases, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Evans Center for Implementation and Improvement Sciences, Boston University School of Medicine, Boston, MA, USA
- Center for Healthcare Organization and Implementation Research, ENRM VA Hospital, Bedford, MA, USA
| | - Matthew J Mimiaga
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- Center for Health Equity Research, Brown University, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
- Department of Psychiatry and Human Behavior, Brown University Alpert Medical School, Providence, RI, USA
| | - Katie B Biello
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- Center for Health Equity Research, Brown University, Providence, RI, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Fenway Institute, Fenway Health, Boston, MA, USA
| | - Angela R Bazzi
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, 02118, USA.
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Bagchi AD. A Structural Competency Curriculum for Primary Care Providers to Address the Opioid Use Disorder, HIV, and Hepatitis C Syndemic. Front Public Health 2020; 8:210. [PMID: 32582612 PMCID: PMC7289946 DOI: 10.3389/fpubh.2020.00210] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 05/07/2020] [Indexed: 12/26/2022] Open
Abstract
The interrelated epidemics of opioid use disorder (OUD) and HIV and hepatitis C virus (HCV) infection have been identified as one of the most pressing syndemics facing the United States today. Research studies and interventions have begun to address the structural factors that promote the inter-relations between these conditions and a number of training programs to improve structural awareness have targeted physician trainees (e.g., residents and medical students). However, a significant limitation in these programs is the failure to include practicing primary care providers (PCPs). Over the past 5 years, there have been increasing calls for PCPs to develop structural competency as a way to provide a more integrated and patient-centered approach to prevention and care in the syndemic. This paper applies Metzel and Hansen's (1) framework for improved structural competency to describe an educational curriculum that can be delivered to practicing PCPs. Skill 1 involves reviewing the historical precedents (particularly stigma) that created the siloed systems of care for OUD, HIV, and HCV and examines how recent biomedical advances allow for greater care integration. To help clinicians develop a more multidisciplinary understanding of structure (Skill 2), trainees will discuss ways to assess structural vulnerability. Next, providers will review case studies to better understand how structural foundations are usually seen as cultural representations (Skill 3). Developing structural interventions (Skill 4) involves identifying ways to create a more integrated system of care that can overcome clinical inertia. Finally, the training will emphasize cultural humility (Skill 5) through empathetic and non-judgmental patient interactions. Demonstrating understanding of the structural barriers that patients face is expected to enhance patient trust and increase retention in care. The immediate objective is to pilot test the feasibility of the curriculum in a small sample of primary care sites and develop metrics for future evaluation. While the short-term goal is to test the model among practicing PCPs, the long-term goal is to implement the training practice-wide to ensure structural competence throughout the clinical setting.
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Affiliation(s)
- Ann D Bagchi
- Rutgers School of Nursing, The State University of New Jersey, Newark, NJ, United States
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Donroe JH, Bhatraju EP, Tsui JI, Edelman EJ. Identification and Management of Opioid Use Disorder in Primary Care: an Update. Curr Psychiatry Rep 2020; 22:23. [PMID: 32285215 DOI: 10.1007/s11920-020-01149-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs. RECENT FINDINGS The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.
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Affiliation(s)
- Joseph H Donroe
- Yale School of Medicine, 1450 Chapel Street, Office MOB211, New Haven, CT, 06511, USA.
| | | | - Judith I Tsui
- University of Washington School of Medicine, Seattle, WA, USA
| | - E Jennifer Edelman
- Yale School of Medicine, 1450 Chapel Street, Office MOB211, New Haven, CT, 06511, USA.,Yale Schools of Medicine and Public Health, E.S. Harkness Memorial Hall, Building A, 367 Cedar Street, Ste Suite 401, New Haven, CT, 06510, USA
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Abstract
OBJECTIVE We sought to identify optimal strategies for integrating HIV- and opioid use disorder-(OUD) screening and treatment in diverse settings. DESIGN Systematic review. METHODS We searched Ovid MEDLINE, PubMed, Embase, PsycINFO and preidentified websites. Studies were included if they were published in English on or after 2002 through May 2017, and evaluated interventions that integrated, at an organizational level, screening and/or treatment for HIV and OUD in any care setting in any country. RESULTS Twenty-nine articles met criteria for inclusion, including 23 unique studies: six took place in HIV care settings, 12 in opioid treatment settings, and five elsewhere. Eight involved screening strategies, 22 involved treatment strategies, and seven involved strategies that encompassed screening and treatment. Randomized controlled studies demonstrated low-to-moderate risk of bias and observational studies demonstrated fair to good quality. Studies in HIV care settings (n = 6) identified HIV-related and OUD-related clinical benefits with the use of buprenorphine/naloxone for OUD. No studies in HIV care settings focused on screening for OUD. Studies in opioid treatment settings (n = 12) identified improving HIV screening uptake and clinical benefits with antiretroviral therapy when provided on-site. Counseling intensity for OUD medication adherence or HIV-related risk reduction was not associated with clinical benefits. CONCLUSION Screening for HIV can be effectively delivered in opioid treatment settings, yet there is a need to identify optimal OUD screening strategies in HIV care settings. Strategies integrating the provision of medications for HIV and for OUD should be expanded and should not be contingent on resources available for behavioral interventions. REGISTRATION A protocol for record eligibility was developed a priori and was registered in the PROSPERO database of systematic reviews (registration number CRD42017069314).
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John WS, Zhu H, Mannelli P, Subramaniam GA, Schwartz RP, McNeely J, Wu LT. Prevalence and patterns of opioid misuse and opioid use disorder among primary care patients who use tobacco. Drug Alcohol Depend 2019; 194:468-475. [PMID: 30513477 PMCID: PMC6329633 DOI: 10.1016/j.drugalcdep.2018.11.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/11/2018] [Accepted: 11/13/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Current data suggest that opioid misuse or opioid use disorder (OUD) may be over represented among tobacco users. However, this association remains understudied in primary care settings. A better understanding of the extent of heterogeneity in opioid misuse among primary care patients who use tobacco may have implications for improved primary care-based screening, prevention, and intervention approaches. METHODS Data were derived from a sample of 2000 adult (aged ≥18) primary care patients across 5 distinct clinics. Among past-year tobacco users (n = 882), we assessed the prevalence of opioid misuse and OUD by sociodemographic characteristics and past-year polysubstance use. Latent class analysis (LCA) was used to identify heterogeneous subgroups of tobacco users according to past-year polysubstance use patterns. Multinomial logistic regression was used to examine variables associated with LCA-defined class membership. RESULTS Past-year tobacco use was reported by >84% of participants who reported past-year opioid misuse or OUD. Among those reporting past-year tobacco use, the prevalence of past-year opioid misuse and OUD was 14.0% and 9.5%, respectively. The prevalence of opioid misuse or OUD was highest among tobacco users who were male or unemployed. Three LCA-defined classes among tobacco users were identified including a tobacco-minimal drug use group (78.0%), a tobacco-cannabis use group (10.1%), and a tobacco-opioid/polydrug use group (11.9%). Class membership differed by sociodemographic characteristics. CONCLUSIONS Results from this study support the benefit of more comprehensive assessment of and/or monitoring for opioid misuse among primary care patients who use tobacco, particularly for those who are male, unemployed, or polydrug users.
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Affiliation(s)
- William S. John
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA,Corresponding authors: William S. John, Ph.D., Department of Psychiatry and Behavioral Sciences, Division of Social and Community Psychiatry, Duke University Medical Center, Durham, NC 27710, Phone: (336) 624-7212,
| | - He Zhu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Paolo Mannelli
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | | | | | - Jennifer McNeely
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA; Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA; Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, NC, USA.
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Sofuoglu M, DeVito EE, Carroll KM. Pharmacological and Behavioral Treatment of Opioid Use Disorder. PSYCHIATRIC RESEARCH AND CLINICAL PRACTICE 2018. [PMCID: PMC9175946 DOI: 10.1176/appi.prcp.20180006] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Objective: Opioid use disorder (OUD) in the United States has surged, with an estimated 2.5 million needing treatment. The aim of this article is to provide a clinical overview of the key pharmacological and behavioral treatments for OUD. Methods: A nonsystematic review of the literature was conducted to investigate OUD treatments, including their mechanism of action, efficacy, clinical guidelines in the United States, and consideration of frequently occurring comorbid conditions. Results: Food and Drug Administration (FDA)–approved pharmacotherapies for OUD include methadone, buprenorphine, and naltrexone, each of which has different actions on opioid receptors. Although these medications all show efficacy in some dosages and formulations, barriers to accessibility may be most pronounced for methadone, whereas treatment retention poses greater challenges for naltrexone and, to a lesser extent, buprenorphine. Lofexidine, an α2‐adrenergic agonist, has recently been approved by the FDA for treatment of opioid withdrawal symptoms. OUD is commonly treated with medication‐assisted treatment (MAT), which offers pharmacotherapy in the context of counseling and/or behavioral treatments. Behavioral therapies, rarely offered as stand‐alone treatments for OUD, are generally used in the context of MAT, in structured settings or to prevent relapse after detoxification and stabilization. The aim of behavioral interventions is to improve medication compliance and target problems not addressed with medication alone. Individuals with OUD commonly have other comorbid psychiatric and substance use conditions, which are not exclusionary for initiating MAT but should be carefully evaluated and monitored because they may reduce treatment effectiveness. Conclusions: MAT is the first‐line treatment for patients with OUD and should be provided in combination with behavioral interventions. Treatment retention remains challenging in this population. Future studies should focus on approaches that will serve the complex needs of patients with OUD, including those with comorbid psychiatric and substance use conditions.
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Affiliation(s)
- Mehmet Sofuoglu
- Yale University School of MedicineDepartment of Psychiatry
- VA Connecticut Healthcare SystemWest HavenCT
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