1
|
Canver B, Liptak A, Clark K, Tetrault JM, Holt SR. Preparing Physicians to Treat Addiction: Inclusion of Dedicated Addiction Training During Internal Medicine Residency. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:408-414. [PMID: 38254274 DOI: 10.1177/29767342231224978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Physicians in internal medicine lack comfort and skills required to diagnose and treat substance use disorder (SUD). Formal training in substance use treatment within primary care training has traditionally been inconsistent and sparse. The purpose of this study is to assess the impact of a longitudinal experiential addiction curriculum on the attitudes and experiences of graduates from a primary care/internal medicine residency program that included formal addiction didactics, rotations in an outpatient addiction clinic embedded within the resident primary care clinic, and exposure to addiction medicine faculty across treatment settings. METHODS A survey was emailed to all graduates from a single academic primary care residency program who graduated between 2016 and 2018 (n = 53). The survey assessed pharmacotherapy for SUD prescribing patterns, comfort with SUD pharmacotherapy, overall comfort treating SUD, experience correcting stigmatizing language, and providing guidance to colleagues on the care of patients with SUD. A subset of respondents (n = 14) were interviewed regarding their experience with the residency program's addiction medicine curriculum and its impact on their current clinical practice. RESULTS Sixty percent (n = 28) of graduates responded to the survey. All respondents felt comfortable using medications to treat SUD. Eighty-four percent perceived themselves as more comfortable using pharmacotherapy to treat SUD than their colleagues. Qualitative interviews revealed that this addiction medicine training shaped participants' attitudes toward patients with SUD and imparted them with the skills to address stigmatizing language. Participants described how they have become ambassadors of addiction medicine in their workplace and a resource to colleagues with less comfort in the management of SUD. CONCLUSION Graduates of a primary care/internal medicine residency with a dedicated addiction medicine curriculum are comfortable prescribing pharmacotherapy for SUD, taking an active role in reducing SUD-related stigma, and serving as a resource for colleagues.
Collapse
Affiliation(s)
- Bethany Canver
- Department of Internal Medicine and Addiction Medicine, Cooper Medical School of Rowan University and Cooper University Health Care, Camden, NJ, USA
| | - Alayna Liptak
- LifeLong West Berkeley Health Center, Berkley, CA, USA
| | - Katie Clark
- Program in Addiction Medicine and Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jeanette M Tetrault
- Program in Addiction Medicine and Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephen R Holt
- Program in Addiction Medicine and Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
2
|
Campopiano von Klimo M, Nolan L, Corbin M, Farinelli L, Pytell JD, Simon C, Weiss ST, Compton WM. Physician Reluctance to Intervene in Addiction: A Systematic Review. JAMA Netw Open 2024; 7:e2420837. [PMID: 39018077 PMCID: PMC11255913 DOI: 10.1001/jamanetworkopen.2024.20837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/07/2024] [Indexed: 07/18/2024] Open
Abstract
Importance The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low. Objective To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions. Data Sources A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021. Study Selection Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included. Data Extraction and Synthesis Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons. Main Outcomes and Measures The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria. Results A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug. Conclusions and Relevance In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.
Collapse
Affiliation(s)
| | - Laura Nolan
- JBS International, Inc, North Bethesda, Maryland
| | - Michelle Corbin
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Lisa Farinelli
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Jarratt D. Pytell
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Caty Simon
- National Survivors Union, Greensboro, North Carolina
- NC Survivors Union, Greensboro, North Carolina
- Whose Corner Is It Anyway, Holyoke, Massachusetts
| | - Stephanie T. Weiss
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Wilson M. Compton
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| |
Collapse
|
3
|
Callister C, Porter S, Vatterott P, Keniston A, McBeth L, Mann S, Calcaterra SL, Limes J. The Impact of Completing X-Waiver Training and Clinical Addiction Exposure on Internal Medicine Residents Treating Patients With Opioid Use Disorder. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:356-366. [PMID: 38258815 DOI: 10.1177/29767342231221004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Treating opioid use disorder (OUD) with buprenorphine or methadone significantly reduces overdose and all-cause mortality. Prior studies demonstrate that clinicians and residents reported a lack of preparedness to diagnose or treat OUD. Little is known about how clinical exposure or buprenorphine X-waiver training impacts OUD care delivery by resident physicians. OBJECTIVE Distinguish the effects of X-waiver training and clinical exposure with OUD on resident's knowledge, attitudes, feelings of preparedness, and practices related to OUD treatment provision. METHODS From August 2021 to April 2022, we distributed a cross-sectional survey to internal medicine residents at a large academic training program. We analyzed associations between self-reported clinical exposure and X-waiver training across 4 domains: knowledge about best practices for OUD treatment, attitudes about patients with OUD, preparedness to treat OUD, and clinical experience with OUD. RESULTS Of the 188 residents surveyed, 91 responded (48%). A majority of respondents had not completed X-waiver training (60%, n = 55) while many had provided clinical care to patients with OUD (65%, n = 59). Most residents had favorable attitudes about OUD treatment (97%). Both residents with clinical exposure to treating OUD and X-waiver training, and residents with clinical exposure without X-waiver training, felt more prepared to treat OUD (P < .0008) compared to residents with neither clinical exposure or X-waiver training or only X-waiver training. CONCLUSIONS Residents with clinical exposure to treating OUD are more prepared to treat patients with OUD than those without clinical exposure. Greater efforts to incorporate clinical exposure to the treatment of OUD and education in internal medicine residency programs is imperative to address the opioid epidemic.
Collapse
Affiliation(s)
| | - Samuel Porter
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Phillip Vatterott
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Angela Keniston
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Lauren McBeth
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Sarah Mann
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Susan L Calcaterra
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado, Aurora, CO, USA
| | - Julia Limes
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| |
Collapse
|
4
|
Bolshakova M, González JL, Thompson T, Schneberk T, Sussman S, Unger JB, Bluthenthal RN. A qualitative analysis of internal medicine residents' experience with substance use disorder education and training: a pilot study. J Addict Dis 2024; 42:63-70. [PMID: 36330994 DOI: 10.1080/10550887.2022.2139580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Lack of education and training on caring for patients with substance use disorder (SUD) is common among healthcare providers, often resulting in clinicians feeling unprepared to treat patients with SUD. OBJECTIVES This study explored resident physicians' experiences with SUD education throughout medical school and residency and qualitatively evaluated whether a SUD initiative improved resident's knowledge and efficacy of treating various SUDs. METHODS We implemented a brief (seven hours total) educational initiative focused on treating SUDs virtually over the course of an academic year for residents enrolled in the University of Southern California Internal Medicine Residency program. Semi-structured interviews were conducted with residents after completion of the initiative. A thematic analysis was conducted to identify common themes that emerged from the qualitative data. RESULTS Every resident noted receiving insufficient training for the treatment of SUDs prior to the initiative. The initiative was viewed favorably, and participants particularly appreciated having an introduction to prescribing medication for the treatment of SUD such as buprenorphine. Despite the perceived success of the initiative in increasing awareness of treatment modalities for SUD, residents expressed a lack of comfort in handling SUD cases and desired additional practical lectures and application of knowledge through increased experiential training. CONCLUSIONS SUD education and training appears to be a useful constituent of resident training and should be included in the standard curriculum and rotations. Residency programs should consider including formal education, hands-on practice, and providing adequate resources for residents to develop their capabilities to care for patients with SUD.
Collapse
Affiliation(s)
- Maria Bolshakova
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - José Luis González
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- LAC + USC Medical Center, Los Angeles, CA, USA
| | - Tiana Thompson
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Steve Sussman
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jennifer B Unger
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ricky N Bluthenthal
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| |
Collapse
|
5
|
Marshall KF, Carney PA, Bonuck KJ, Riquelme P, Robbins J. Preparing fourth year medical students to care for patients with opioid use disorder: how this training affects their intention to seek addiction care opportunities during residency. MEDICAL EDUCATION ONLINE 2023; 28:2141602. [PMID: 36333902 PMCID: PMC9645269 DOI: 10.1080/10872981.2022.2141602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND & OBJECTIVES In 2021, the USA recorded 100,000 annual deaths from drug overdose, representing the most frequent cause of death in adults under age 55. The integration of care for substance use disorders (SUDs) into undergraduate medical education is not well established. It is unclear whether a short course on management of opioid use disorder (OUD) offered to fourth year medical students could increase graduating students' knowledge and preparedness to treat these disorders. METHODS We designed a 2-hour interactive case-based session on patient care for OUD and delivered it virtually as part of a Transition to Residency course. A retrospective pre-/post-test assessment instrument determined the impact of this session on students' perceived knowledge, confidence, and intention to seek further educational opportunities for OUD. RESULTS Of 144 participants, 58 students (40.3%) completed the retrospective pre-/post- survey. There were statistically significant improvements in perceived knowledge and attitudes on the 12-item survey. The largest gains in perceived knowledge on a 5-point scale occurred in the categories regarding buprenorphine induction (pre 2.9; post 4.22; p < 0.001), managing inpatient opioid withdrawal (pre 2.84; post 4.27; p < 0.001), and the role of methadone in treating withdrawal (pre 3.16; post 4.29; p < 0.001). All (n = 58) survey respondents would recommend the training to a colleague and felt that the session would benefit their professional practice. Over 90% (93.1%) of respondents planned on seeking additional SUD learning opportunities during residency. CONCLUSIONS A 2-hour interactive case-based teaching session delivered to medical students improved perceived knowledge, attitudes, and future interest in obtaining education around OUD. As the opioid epidemic shows no sign of abating, we would advocate for the inclusion SUD education as part of Transition to Residency courses.
Collapse
Affiliation(s)
- Katharine F. Marshall
- Division of General Internal Medicine & Geriatrics, Section of Addiction Medicine, Wise Fellow in General Internal Medicine, Portland, OR, USA
| | - Patricia A. Carney
- Division of General Internal Medicine & Geriatrics, Section of Addiction Medicine, Wise Fellow in General Internal Medicine, Portland, OR, USA
| | - Kathryn J. Bonuck
- Division of General Internal Medicine & Geriatrics, Section of Addiction Medicine, Wise Fellow in General Internal Medicine, Portland, OR, USA
| | - Patricio Riquelme
- Division of General Internal Medicine & Geriatrics, Section of Addiction Medicine, Wise Fellow in General Internal Medicine, Portland, OR, USA
| | - Jonathan Robbins
- Division of General Internal Medicine & Geriatrics, Section of Addiction Medicine, Wise Fellow in General Internal Medicine, Portland, OR, USA
| |
Collapse
|
6
|
Cunningham CO, Starrels JL. Guideline Promoting Buprenorphine for Treatment of Chronic Pain: Transformative Yet Underdeveloped. Ann Intern Med 2023; 176:419-420. [PMID: 36780656 DOI: 10.7326/m23-0229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Affiliation(s)
- Chinazo O Cunningham
- New York State Office of Addiction Services and Supports, New York, and Albert Einstein College of Medicine, Bronx, New York
| | | |
Collapse
|
7
|
Effect of Didactic Training on Barriers and Biases to Treatment of Opioid Use Disorder: Meeting the Ongoing Needs of Patients with Opioid Use Disorder in the Emergency Department during the COVID-19 Pandemic. Healthcare (Basel) 2022; 10:healthcare10122393. [PMID: 36553917 PMCID: PMC9778275 DOI: 10.3390/healthcare10122393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/19/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022] Open
Abstract
In the wake of COVID-19, morbidity and mortality due to Opioid Use Disorder (OUD) is beginning to emerge as a second wave of deaths of despair. Medication assisted treatment (MAT) for opioid use disorder MAT delivered by Emergency Medicine (EM) providers can decrease mortality due to OUD; however, there are numerous cited barriers to MAT delivery. We examined the impact of MAT training on these barriers among EM residents in an urban, tertiary care facility with a large EM residency. Training included the scripted and standardized content from the Provider Clinical Support System curriculum. Residents completed pre- and post-training surveys on knowledge, barriers, and biases surrounding OUD. We performed Wilcoxon matched-pairs signed-ranks test to detect statistical differences. Of 74 residents, 49 (66%) completed the pre-training survey, and 34 (69%) of these completed the follow-up survey. Residents reported improved preparedness to treat aspects of OUD across all areas queried, reported decreased perception of barriers to providing MAT, and increased comfort prescribing naloxone, counseling patients, prescribing buprenorphine, and treating opioid withdrawal. A didactic training on MAT was associated with residents reporting improved comfort providing buprenorphine and naloxone. As the wake of morbidity and mortality from both COVID and OUD continue to increase, programs should offer dedicated training on MAT.
Collapse
|
8
|
Robles M, Mortazavi L, Vannerson J, Matthias MS. How a Medication for Opioid Use Disorder Curriculum Translates into Experiences and Internal Medicine Residents' Understanding of Patients with Opioid Use Disorder. TEACHING AND LEARNING IN MEDICINE 2022; 34:514-521. [PMID: 33974460 DOI: 10.1080/10401334.2021.1897597] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PROBLEM The number of people with an Opioid Use Disorder (OUD) continues to outpace access to associated medication. Ninety-six percent of states report higher rates of OUD than access to medications, and, despite being the standard of care, only 3% of physicians currently prescribe medication for opioid use disorder (MOUD). Prior studies have shown that decreasing barriers, such as a lack of knowledge about MOUD, increased physicians' willingness to prescribe. However, most internal medicine residency programs do not have a required addiction curriculum. As a result, we created a curriculum and conducted qualitative interviews with residents to better understand experiences with the curriculum. INTERVENTION In an effort to overcome physician-centered barriers associated with prescribing MOUD, we developed and implemented a week-long curriculum, Addiction Week, for second and third year Internal Medicine Residents at Indiana University School of Medicine in a safety-net clinic. The curriculum included the following: didactics on substance use disorder (SUD), including OUD and alcohol use disorder, and MOUD (mostly buprenorphine), and mostly web-based, peer-reviewed and guideline based readings about addiction, direct observation of addiction counselors, direct discussion with people receiving MOUD, observation of a group therapy session, informal discussion with providers who prescribe MOUD, and, for some residents, observation of a physician prescribing MOUD. After completing the curriculum, the residents participated in an hour long audio-recorded interview to better understand their experiences with the curriculum. CONTEXT This study was completed at a residency program where residents were not previously exposed to outpatient MOUD prescribing. Due to limited availability of faculty treating patients with MOUD, residents spent the majority of their time shadowing a social worker. IMPACT Residents described gaining a deeper understanding of OUD by having the opportunity to interact with patients in a stable outpatient setting, which for many led to increased confidence and willingness to prescribe MOUD for people with OUD. LESSONS LEARNED The greater understanding of addiction and willingness to prescribe MOUD described by residents in this study indicate that this type of curriculum may be a promising way to increase MOUD prescribing. Further studies are needed to evaluate whether this intervention can change prescribing behaviors. UNLABELLED Supplemental data for this article is available online at https://doi.org/10.1080/10401334.2021.1897597.
Collapse
Affiliation(s)
- Maria Robles
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Leila Mortazavi
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Julie Vannerson
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Marianne S Matthias
- VA HSRD Center for Health Information and Communication, Roudebush VAMC, Roudebush, Indiana, USA
| |
Collapse
|
9
|
Martin CE, Thakkar B, Cox L, Johnson E, Jones HE, Connolly A. Beyond opioid prescribing: Evaluation of a substance use disorder curriculum for OBGYN residents. PLoS One 2022; 17:e0274563. [PMID: 36107914 PMCID: PMC9477269 DOI: 10.1371/journal.pone.0274563] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 08/30/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Amidst the current opioid crisis, there is a need for better integration of substance use disorder screening and treatment across specialties. However, there is no consensus regarding how to best instruct OBGYN trainees in the clinical skills related to opioid and other substance use disorders (SUD). Study objectives were (1) to assess the effectiveness a SUD curriculum to improve self-reported competence among OBGYN residents and (2) to explore its effectiveness to improve attending evaluations of residents' clinical skills as well as its feasibility and acceptability from the resident perspective. METHODS A pilot 3-session curriculum was developed and adapted to SUD screening and treatment which included readings, didactics, and supervised outpatient clinical experiences for OBGYN post-graduate year 1 (PGY-1) residents rotating through an integrated OBGYN-SUD clinic. Eighteen residents completed pre and post clinical skills self-assessments (SUD screening, counseling, referring, Motivational Interviewing) using an adapted Zwisch Rating Scale (range 1-5). Scores were compared between time points using paired t-tests. Sub-samples also (a) were evaluated by the attending on three relevant Accreditation Council for Graduate Medical Education Milestones (ACGME) milestone sets using the web-based feedback program, myTIPreport (n = 10) and (b) completed a qualitative interview (n = 4). RESULTS All PGY-1s (18/18) across three academic years completed the 3-session SUD curriculum. Clinical skill self-assessments improved significantly in all areas [SUD Screening (2.44 (0.98) vs 3.56 (0.62), p = <0.01); Counseling (1.81 (0.71) vs 3.56 (0.51), p = < .01; Referring (2.03 (0.74) vs 3.17 (0.71), p = < .01; Motivational Interviewing (1.94 (1.06) vs 3.33 (0.69), p = < .01)]. Milestone set levels assigned by attending evaluations (n = 10) also improved. Qualitative data (n = 4) revealed high acceptability; all curriculum components were viewed positively, and feedback was provided (e.g., desire for more patient exposures). CONCLUSION A pilot SUD curriculum tailored for OBGYN PGY-1 residents that goes beyond opioid prescribing to encompass SUD management is feasible, acceptable and likely effective at improving SUD core clinical skills.
Collapse
Affiliation(s)
- Caitlin E. Martin
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
- Institute of Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Bhushan Thakkar
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Lauren Cox
- Department of Obstetrics and Gynecology, Virginia Commonwealth University School of Medicine, Richmond, VA, United States of America
| | - Elisabeth Johnson
- Department of Obstetrics and Gynecology, UNC Horizons, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - Hendrée E. Jones
- Department of Obstetrics and Gynecology, UNC Horizons, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| | - AnnaMarie Connolly
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, Chapel Hill, NC, United States of America
| |
Collapse
|
10
|
Training in Safe Opioid Prescribing and Treatment of Opioid Use Disorder in Internal Medicine Residencies: a National Survey of Program Directors. J Gen Intern Med 2022; 37:2650-2660. [PMID: 34729698 PMCID: PMC8562932 DOI: 10.1007/s11606-021-07102-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 08/13/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Training future clinicians in safe opioid prescribing (SOP) and treatment of opioid use disorder (OUD) is critical to address the opioid epidemic. The Accreditation Council on Graduate Medical Education requires all programs to provide instruction and experience in pain management and will mandate addiction medicine clinical experiences for internal medicine trainees. OBJECTIVE Assess residents' training in SOP and treatment of OUD and identify training barriers. DESIGN Cross-sectional nationally representative survey was emailed in 2019. PARTICIPANTS Four hundred twenty-two Association of Program Directors in Internal Medicine members in US internal medicine residency programs. MAIN MEASURES Program opportunities and challenges to developing or implementing training in SOP, treatment of OUD, and buprenorphine waiver training, and perceived curricular effectiveness. KEY RESULTS The response rate was 69.4% (293/422). Most programs required didactics in SOP (94.2%) and treatment of OUD (71.7%). Few programs required clinical experiences including addiction medicine clinics (28/240, 11.7%), inpatient consult services (11/240, 4.6%), or offsite treatment rotations (8/240, 3.3%). Lack of trained faculty limited developing or implementing curricula (61.5%). Few respondents reported that their program was "very effective" in teaching SOP (80/285, 28.1%) or treatment of OUD (43/282, 15.3%). Some programs offered buprenorphine waiver training to residents (83/286, 29.0%) and faculty (94/286, 32.9%) with few mandating training (11.7% (28/240) and 5.4% (13/240) respectively). Only 60 of 19,466 (0.3%) residents completed buprenorphine waiver training. Primary care programs/tracks were more likely to offer waiver training to residents (odds ratio [OR], 3.07; 95% CI, 1.68-5.60; P < 0.001) and faculty (OR, 1.08; 95% CI, 1.01-3.22; P = 0.05). CONCLUSIONS In this nationally representative survey, few internal medicine residency programs provided clinical training in SOP and treatment of OUD, and training was not viewed as very effective. Lack of effective training may have adverse implications for patients, clinicians, and society.
Collapse
|
11
|
Gugala E, Briggs O, Moczygemba LR, Brown CM, Hill LG. Opioid harm reduction: A scoping review of physician and system-level gaps in knowledge, education, and practice. Subst Abus 2022; 43:972-987. [PMID: 35426772 DOI: 10.1080/08897077.2022.2060423] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: Harm reduction includes treatment and prevention approaches rather than abstinence, as a public health strategy for mitigating the opioid epidemic. Harm reduction is a new strategy for many healthcare professionals, and gaps in knowledge and practices may lead to barriers to optimal treatment. Our objective was to identify and describe gaps in physicians' knowledge, education, and practice in harm reduction strategies related to opioid overdose. Methods: We searched the PubMed, CINAHL, and Web of Science databases for articles published between 2015 and 2021, published in English, containing empirical evidence, addressing opioid harm reduction, and identifying gaps in physicians' knowledge, education, or practice. Results: Thirty-seven studies were included. Studies examined how physicians' perceptions or stigma influenced harm reduction efforts and addressed clinical knowledge gaps in overdose treatment and prevention and OUD treatment. Less than half of the studies addressed access issues at the system level, above the individual healthcare professional. Conclusion: Individual-level interventions should be addressed with professional continuing education and curricular-based changes through experiential and interprofessional education. System-level gaps can be remedied by increasing patient access to care, creating policies favorable to harm reduction, and extending resources to provide harm reduction strategies.
Collapse
Affiliation(s)
- Emma Gugala
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Owanate Briggs
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Leticia R Moczygemba
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Carolyn M Brown
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| | - Lucas G Hill
- TxCORE and PhARM Program, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
| |
Collapse
|
12
|
Robbins JL, Bonuck K, Thuillier P, Buist C, Carney PA. Differences in perceived clinical knowledge uptake among health profession students and licensed clinicians receiving buprenorphine waiver training in Oregon. Subst Abus 2022; 43:825-833. [DOI: 10.1080/08897077.2021.2010260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Jonathan L. Robbins
- Internal Medicine, Division of General Internal Medicine & Geriatrics, Section of Addiction Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Kathryn Bonuck
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Philippe Thuillier
- Department of Dermatology, School of Medicine, Knight Cancer Institute, Portland, OR, USA
| | - Catriona Buist
- Department of Anesthesiology and Perioperative Medicine & Psychiatry, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Patricia A. Carney
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| |
Collapse
|
13
|
Garcia-Vassallo G, Edens EL, Heward B, Auerbach MA, Wong AH, Camenga D. Management of Adolescents With OUD: A Simulation Case for Subspecialty Trainees in Addiction Medicine and Addiction Psychiatry. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2021; 17:11147. [PMID: 33889724 PMCID: PMC8056775 DOI: 10.15766/mep_2374-8265.11147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 02/22/2021] [Indexed: 06/12/2023]
Abstract
Introduction The opioid epidemic impacts all ages, yet few published medical education curricula exist to train physicians on how to care for opioid use disorder (OUD) in adolescents, a developmental stage where confidentiality protection is appropriate and contributes to quality health care. We developed a simulation-based educational intervention to increase addiction medicine and addiction psychiatry trainees' confidence in managing adolescents with OUD. Methods Trainees completed a confidence survey and viewed an educational video covering state-specific confidentiality laws pertinent to treating adolescents with OUD. One week later, trainees participated in a simulated encounter where they described the scope of confidentiality to a trained actor, used the Clinical Opiate Withdrawal Scale to assess symptoms of opioid withdrawal, and explained adolescent-specific OUD medication treatment options. Immediately afterward, trainees completed a self-reflection and satisfaction survey and participated in a debriefing session with a faculty member where they identified learning goals. One month later, they completed the confidence survey to quantify changes in confidence. Results Thirty-five fellows (21 male, 14 female) completed the simulation-based educational intervention between 2016 and 2019. When asked to answer yes or no, 96% of participants described the exercise as effective and 100% (n = 26) would recommend it to peers. In addition, learners identified future learning goals, including researching specific topics and seeking out additional opportunities to evaluate adolescents with OUD. Discussion Based on our participants' report, this simulation-based educational intervention is an effective teaching method for increasing trainee confidence in managing adolescents with OUD.
Collapse
Affiliation(s)
| | - Ellen Lockard Edens
- Associate Professor and Associate Fellowship Director for Addiction Psychiatry, Department of Psychiatry, Yale School of Medicine
| | - Brady Heward
- Assistant Professor, Department of Psychiatry, Robert Larner, M.D., College of Medicine at the University of Vermont; Clinical Instructor, Department of Psychiatry, Yale School of Medicine
| | - Marc A. Auerbach
- Associate Professor, Departments of Emergency Medicine and Pediatrics, Yale School of Medicine
| | - Ambrose H. Wong
- Assistant Professor, Department of Emergency Medicine, and Associate Fellowship Director, Medical Simulation, Yale School of Medicine
| | - Deepa Camenga
- Associate Professor, Departments of Emergency Medicine and Pediatrics, Yale School of Medicine
| |
Collapse
|
14
|
Logan AA, Jack HE, Darnton J, Klein JW. "It's that longitudinal relationship that pays off": A qualitative study of internal medicine residents' perspectives on learning to prescribe buprenorphine. Subst Abus 2021; 42:944-950. [PMID: 33797320 DOI: 10.1080/08897077.2021.1900990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The opioid use disorder (OUD) epidemic is a national public health crisis. Access to effective treatment with buprenorphine is limited, in part because few physicians are trained to prescribe it. Little is known about how post-graduate trainees learn to prescribe buprenorphine or how to optimally train them to prescribe. We therefore aimed to explore the experiences and attitudes of residents learning to prescribe buprenorphine within two primary care-based opioid treatment models. Methods: We performed semi-structured interviews with second- and third-year internal medicine residents at an urban academic residency program. Participating residents practiced in clinics providing buprenorphine care using either a nurse care manager model or a provider-centric model. Subjects were sampled purposively to ensure that a diversity of perspectives were included. Interviews were conducted until theoretical saturation was reached and were analyzed using principles of thematic analysis. The research team developed a consensus code list. Each transcript was then independently coded by two researchers. The team then summarized each code and generated a set of themes that captured the main ideas emerging from the data. Results: We completed 14 interviews. Participants reported learning to prescribe buprenorphine through didactics, longitudinal outpatient prescribing, mentorship, and inpatient experiences. We characterized their attitudes toward patients with OUD, medication treatment of OUD, their own role in buprenorphine care, and future prescribing. Participants practicing in both clinical models viewed learning to prescribe buprenorphine as a normal part of their training and demonstrated positive attitudes toward buprenorphine prescribing. Conclusions: Longitudinal outpatient experiences with buprenorphine prescribing can prepare residents to prescribe buprenorphine and stimulate interest in prescribing after residency. Both nurse care manager and provider-centric clinical models can provide meaningful experiences for medical residents. Educators should attend to the volume of patients and inductions managed by each trainee, patient-provider continuity, and supporting trainees in the clinical encounter.
Collapse
Affiliation(s)
- Alexander A Logan
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
| | - Helen E Jack
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - James Darnton
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jared W Klein
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
15
|
Fujita AW, LaRosa A, Carter A. Treating Withdrawal and Pain in Inpatients With Opioid Use Disorder: A Brief Educational Intervention for Internal Medicine Residents. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2021; 17:11123. [PMID: 33768154 PMCID: PMC7970646 DOI: 10.15766/mep_2374-8265.11123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 01/10/2021] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Despite the effectiveness of opioid agonist therapy (OAT) for treating patients with opioid use disorder (OUD), insufficient education remains a barrier to prescribing. Internal medicine (IM) residents are optimally positioned to facilitate use of OAT, especially in the inpatient setting. We implemented an educational intervention aimed at increasing IM residents' knowledge and confidence regarding prescribing OAT to inpatients with OUD. METHODS We created a 35-minute, case-based presentation highlighting the management of opioid withdrawal using OAT and treating pain in inpatients on maintenance OAT. It was presented to IM residents beginning their general medicine ward rotations from November 2019 through January 2020. We developed a survey to measure participants' knowledge (mean number of questions correct out of five) and confidence (mean Likert-scale score, 1 = Not at all confident, 5 = Extremely confident, on each of five items) regarding prescribing OAT in the inpatient setting. We compared knowledge and confidence before versus 1 month after the intervention using paired Student t tests, with p < .05 indicating significance. RESULTS Of 103 unique residents completing ward rotations, 29 (28%) completed both the pre- and 1-month postsurveys and were included in the analysis. The mean number of knowledge questions correct increased from 3.1 pre- to 4.3 postintervention, and mean confidence scores increased from below 2 pre- to over 3 postintervention in four of five items (ps < .001). DISCUSSION A brief, generalizable, educational intervention significantly increased residents' knowledge of and confidence in prescribing OAT in inpatients with OUD.
Collapse
Affiliation(s)
- Ayako Wendy Fujita
- Fellow, Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine
| | - Anna LaRosa
- Fellow, Department of Medicine, Division of Cardiology, University of Pittsburgh School of Medicine
| | - Andrea Carter
- Assistant Professor, Department of Medicine, Division of General Internal Medicine, University of Pittsburgh School of Medicine; Associate Program Director, Internal Medicine Residency Training Program, University of Pittsburgh Medical Center
| |
Collapse
|
16
|
Fine DR, Herzberg D, Wakeman SE. Societal Biases, Institutional Discrimination, and Trends in Opioid Use in the USA. J Gen Intern Med 2021; 36:797-801. [PMID: 32556873 PMCID: PMC7947135 DOI: 10.1007/s11606-020-05974-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
History has demonstrated cyclical trends in opioid use in the USA, alternating between high rates of prescribing driven by compassion and marketing and restrictive prescribing driven by stigma and fear of precipitating addiction and other harms. Two under-recognized yet powerful forces driving these trends are societal biases against individuals who use and are addicted to drugs, as well as a recognized social determinant of health, institutional discrimination. In the context of these influential forces, which are often based on racist and classist ideologies, we examine the history of opioid use in the USA from the 1800s when the vast majority of those addicted to opioids were middle- to upper-class women to the present-day white-washed narrative of the opioid crisis. As the demographics of those affected by opioid use and addiction has started to shift from white communities to communities of color, we cannot allow the preliminary success observed in white communities to obscure rising mortality rates from opioids in black and Latinx communities. To do so, we highlight ways to prevent racist and classist ideologies from further shaping responses towards opioid use. It is important to acknowledge the long history that has influenced responses to opioid use in the USA and take active steps towards promoting a sense of compassion towards all individuals who use and those who are addicted to drugs.
Collapse
Affiliation(s)
- Danielle R Fine
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital , Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - David Herzberg
- Department of History, University at Buffalo College of Arts and Sciences, Buffalo, NY, USA
| | - Sarah E Wakeman
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital , Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| |
Collapse
|
17
|
Lai S, Li E, Silverio A, DeBates R, Kelly EL, Weinstein LC. "It's a place that gives me hope": A qualitative evaluation of a buprenorphine-naloxone group visit program in an urban federally qualified health center. Subst Abus 2021; 42:858-864. [PMID: 33492204 DOI: 10.1080/08897077.2021.1876202] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Medication for opioid use disorder (MOUD) with buprenorphine is effective in treating opioid use disorder yet remains underutilized. Scant research has examined the experience of patients, clinic staff, and providers in a "low-threshold" group-based MOUD program. This study evaluates a "low-threshold" MOUD program at a federally qualified health center (FQHC) in Philadelphia, Pennsylvania through the perspectives of its key stakeholders. Methods: This qualitative study involved focus groups of patients, providers, and clinic staff. Focus groups were conducted between October 2017 and June 2018. Grounded theory was used for analysis. Results: There were a total of 10 focus groups, including 20 patient participants and 26 staff members. Program participants noted that a strength of the program is its person-centered harm reduction approach, which is reflected in the program's policies and design. Program participants discussed the programmatic design choices that facilitated their participation and engagement in the program: ease of access, integration into primary care, and group-based visit model. Challenges in program implementation included varying acceptance and understanding of harm reduction among staff, the unpredictability of clinic volume and workflow, and the need to balance access to primary care and MOUD. Conclusion: This group-based MOUD program's philosophy of person-centered harm reduction, low-barrier approach, the structure of group-based visits, and integrated care contributes to increased patient access and retention. Understanding the strengths and challenges of the program may be useful for other safety-net clinics considering a MOUD program.
Collapse
Affiliation(s)
- Sunny Lai
- Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Erica Li
- Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Alexis Silverio
- Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robin DeBates
- Project HOME Health Services, Philadelphia, Pennsylvania, USA
| | - Erin Lee Kelly
- Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Lara Carson Weinstein
- Department of Family and Community Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| |
Collapse
|
18
|
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.
Collapse
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.
| |
Collapse
|
19
|
Kennedy-Hendricks A, Barry CL, Stone E, Bachhuber MA, McGinty EE. Comparing perspectives on medication treatment for opioid use disorder between national samples of primary care trainee physicians and attending physicians. Drug Alcohol Depend 2020; 216:108217. [PMID: 32810837 PMCID: PMC7609519 DOI: 10.1016/j.drugalcdep.2020.108217] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Most people with opioid use disorder (OUD) are not treated with FDA-approved medications methadone, buprenorphine, or naltrexone. Expanding capacity for evidence-based OUD medication in primary care is a national priority. No studies have examined primary care trainee physicians' attitudes about these medications. This study surveyed a national sample of primary care trainee physicians and compared their views with those of primary care attending physicians (i.e., those who have completed training). METHODS Random samples of 1,000 trainee physicians and 1,000 attending physicians specializing in family, internal, or general medicine were selected from the American Medical Association Masterfile. Surveys were mailed February-August 2019. 45 % of eligible trainee physicians and 54 % of eligible attending physicians responded. Chi-square tests were used to compare responses between the groups. RESULTS Trainee physicians were more likely than attending physicians to agree that treating OUD with medication is more effective than treatment without medication (76 % versus 67 %, p = 0.03). Half of trainee physicians (51 %) expressed interest in treating patients with OUD compared to 20 % of attending physicians. Trainee physicians expressed greater support than attending physicians for policies that loosen restrictions on prescribing OUD medications. CONCLUSIONS Relative to attending physicians, the emerging cohort of primary care physicians may be more receptive to working with patients with OUD and prescribing medication. Enhancing medical training on OUD and its treatment, exposing clinicians to individuals in recovery from OUD, and increasing support for clinicians that provide medication treatment for OUD may strengthen this group's capacity to respond to the opioid crisis.
Collapse
Affiliation(s)
- Alene Kennedy-Hendricks
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, United States; Johns Hopkins Center for Mental Health and Addiction Policy Research, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, United States.
| | - Colleen L. Barry
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, United States,Johns Hopkins Center for Mental Health and Addiction Policy Research, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, United States
| | - Elizabeth Stone
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, United States,Johns Hopkins Center for Mental Health and Addiction Policy Research, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, United States
| | - Marcus A. Bachhuber
- Section of Community and Population Medicine, Louisiana State Health Sciences Center – New Orleans, Department of Medicine, Clinical Sciences Research Building, 533 Bolivar Street, New Orleans, LA 70112, United States
| | - Emma E. McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, United States,Johns Hopkins Center for Mental Health and Addiction Policy Research, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, United States
| |
Collapse
|
20
|
Evaluation of Resident Physicians' Knowledge of and Attitudes Towards Prescribing Buprenorphine for Patients With Opioid Use Disorder. J Addict Med 2020; 15:219-225. [PMID: 33079729 DOI: 10.1097/adm.0000000000000750] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine internal medicine (IM) residents' knowledge of, attitudes towards, and barriers to prescribing buprenorphine for opioid use disorder (OUD). METHODS We conducted a cross-sectional study of IM residents across all 35 Accreditation Council for Graduate Medical Education (ACGME) accredited Florida IM residency programs. We used an online survey to collect information about resident demographics, substance use curriculums, career interests, content knowledge about diagnosing and managing OUD, and attitudes about and barriers to prescribing buprenorphine for OUD. We used Chi-square test to explore differences in interest in prescribing buprenorphine. We created a composite knowledge score and investigated distribution of knowledge among characteristics via Mann-Whitney U test. RESULTS There were 161 participants (response rate 16.0%, n = 1008) across 35 programs Seventy-seven percent of residents provided care for patients with OUD more than once per month. Seventy-four percent report no buprenorphine prescribing training. Higher knowledge scores, interest in primary care, being an intern, and caring for patients with OUD more than monthly were associated with interest in obtaining a buprenorphine waiver (P < 0.05). Limited knowledge about OUD was the most important barrier to prescribing buprenorphine. Eighty-nine percent support legislation to deregulate buprenorphine. CONCLUSIONS Knowledge about managing OUD was poor and represented the most commonly cited barrier to prescribing buprenorphine. Residents want to expand their role in treating OUD. Our findings warrant incorporating addiction medicine into residency curriculum standards. Legislation removing the buprenorphine waiver requirement may increase the number of resident buprenorphine prescribers and improve treatment options for patients with opioid addiction.
Collapse
|
21
|
Sweeney S, Coble K, Connors E, Rebbert-Franklin K, Welsh C, Weintraub E. Program development and implementation outcomes of a statewide addiction consultation service: Maryland Addiction Consultation Service (MACS). Subst Abus 2020; 42:595-602. [PMID: 32814004 PMCID: PMC7892630 DOI: 10.1080/08897077.2020.1803179] [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: 10/23/2022]
Abstract
Background: As the opioid epidemic continues, there is a mounting sense of urgency to improve access to high-quality early identification and treatment services. However, the need is outpacing capacity in many states and effective solutions to support primary care and specialty prescribers to identify and treat more patients with opioid use disorders are still emerging. This paper describes one state's approach to increase access to medication for opioid use disorders (MOUD) through development and implementation of a statewide addiction consultation service: Maryland Addiction Consultation Service (MACS). Methods: Program components include a warmline, outreach and training, and resource and referral linkages for prescribers based on related consultation service models and documented barriers to prescribing MOUDs. Results: Initial implementation outcomes indicate service components are being adopted as intended and by the target audience; many prescribers who engaged with the service have their buprenorphine waiver (44%) but do not have any additional formal addiction training (57%). Also, statewide penetration is promising with prescriber engagement in 100% of counites, however only 33% of counties in engaged in all four types of MACS services. Most calls (61%) originated from urban counties. Conclusions: The MACS program increases access to specialty addiction medicine consultation and training through use of technology. MACS can serve as a model for other states looking to bridge the gap in access to addiction treatment.
Collapse
Affiliation(s)
- Sarah Sweeney
- Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Kelly Coble
- Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Elizabeth Connors
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Christopher Welsh
- Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| | - Eric Weintraub
- Department of Psychiatry, School of Medicine, University of Maryland, Baltimore, Maryland, USA
| |
Collapse
|
22
|
Kirk JK, Yount T, Boyd CT, Cassidy-Vu L, Koehler AN, Spangler JG. Launching a Medication-Assisted Treatment in an Outpatient Office-Based Practice. J Prim Care Community Health 2020; 11:2150132720940723. [PMID: 32644863 PMCID: PMC7350034 DOI: 10.1177/2150132720940723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Opioid use and overdose are escalating in the United States. Primary care providers are in a strategic position to assess patients for medication-assisted treatment (MAT). Objectives: To describe the implementation of MAT in an integrated primary care residency clinic and assess provider comfort levels with evaluating patients for high-risk opioid use, conduct crucial conversations about MAT treatment options and referral to MAT for evaluation and treatment. Methods: As part of a Primary Care Training and Enhancement grant through Health Resources and Services Administration, we used an implementation process to allow for optimal clinic flow. The process included assessment of patient populations, identifying a provider champion, organizing multidisciplinary team, engaging a practice facilitator, designing clinic model and infrastructure, creating the electronic health record order sets along with provider and staff training. Providers responded to brief questions to evaluate comfort levels in 3 domains: identifying high-risk opioid use, conducting crucial conversations about treatment options and referral to MAT for evaluation and treatment. Discussion: Incorporating MAT within an integrated primary care clinic and residency program with waiver training for residents was a successful and innovative program. The availability of MAT provided a solution for patients that could benefit from this type of treatment. MAT presence gave providers the opportunity to refer these patients for treatment that had not previously been as accessible. Conclusion: An integrated primary care practice with an embedded MAT can be successful with an organized structure to optimize clinic flow.
Collapse
Affiliation(s)
- Julienne K Kirk
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Tamela Yount
- Northwest Area Health Education Center, Wake Forest School of Medicine, Winstons Salem, NC, USA
| | - Charlotte T Boyd
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Lisa Cassidy-Vu
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Aubry N Koehler
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - John G Spangler
- Wake Forest School of Medicine, Wake Forest Baptist Health, Winston-Salem, NC, USA
| |
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
Pytell JD, Buresh ME, Graddy R. Outcomes of a novel office-based opioid treatment program in an internal medicine resident continuity practice. Addict Sci Clin Pract 2019; 14:46. [PMID: 31856915 PMCID: PMC6921403 DOI: 10.1186/s13722-019-0175-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 12/11/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The integration of opioid use disorder (OUD) care and competencies in graduate medical education training is needed. Previous research shows improvements in knowledge, attitudes, and practices after exposure to OUD care. Few studies report outcomes for patients with OUD in resident physician continuity practices. METHODS A novel internal office-based opioid treatment (OBOT) program was initiated in a resident continuity clinic. Surveys of resident and staff knowledge and attitudes of OBOT were administered at baseline and 4 months. A retrospective chart review of the 15-month OBOT clinic obtained patient characteristics and outcomes. RESULTS Twelve patients with OUD were seen in the OBOT clinic. Seven patients (58%) were retained in care at the end of the study period for a range of 9-15 months. Eight patients demonstrated a good clinical response. Surveys of residents and staff at 4 months were unchanged from baseline showing persistent lack of comfort in caring for patients with OUD. CONCLUSIONS OBOT can be successfully integrated into resident continuity practices with positive patient outcomes. Improvement in resident and staff attitudes toward OBOT were not observed and likely require direct and frequent exposure to OUD care to increase acceptance.
Collapse
Affiliation(s)
- Jarratt D. Pytell
- Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Mason Lord Building, East Tower, 2nd Floor, Baltimore, MD 21224 USA
| | - Megan E. Buresh
- Division of Addiction Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Mason Lord Building, East Tower, 2nd Floor, Baltimore, MD 21224 USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Ryan Graddy
- Division of Addiction Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Mason Lord Building, East Tower, 2nd Floor, Baltimore, MD 21224 USA
| |
Collapse
|
25
|
Ari M, Kisielewski M, Osman NY, Szauter K, Packer CD, Pincavage AT. Teaching Safe Opioid Prescribing During the Opioid Epidemic: Results of the 2018 Clerkship Directors in Internal Medicine Survey. J Gen Intern Med 2019; 34:2812-2817. [PMID: 31367866 PMCID: PMC6854155 DOI: 10.1007/s11606-019-05203-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Educating medical trainees across the continuum is essential to a multifaceted strategy for addressing the opioid epidemic. OBJECTIVE To assess the current state of internal medicine clerkship content on safe opioid prescribing and opioid use disorder, and barriers to curriculum implementation. DESIGN National Annual (2018) Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey. PARTICIPANTS One hundred thirty-four clerkship directors at all Liaison Committee of Medical Education accredited US medical schools with CDIM membership as of October 1, 2018. MAIN MEASURES The survey section on safe opioid prescribing and opioid use disorder education in the internal medicine clerkship addressed assessment of current curricula, perceived importance of curricula, barriers to implementation, and plans to start or expand curricula. Descriptive statistics were used to summarize responses, and Pearson's chi-square and Fisher's exact tests for statistical comparisons. KEY RESULTS The survey response rate was 82% (110/134). Overall 54.1% of responding institutions reported covering one or more topics related to safe opioid prescribing or opioid use disorder in the internal medicine clerkship. A preponderance of clerkship directors (range 51-86%) reported that various opioid-related topics were important to cover in the internal medicine clerkship. Safe opioid prescribing topics were covered more frequently than topics related specifically to opioid use disorder. The main barriers identified included time (80.9%) and lack of faculty expertise (65.5%). CONCLUSIONS Clerkship directors agreed that incorporating safe opioid prescribing and opioid use disorder topics in the internal medicine clerkship is important, despite wide variation in current curricula. Addressing curricular time constraints and lack of faculty expertise in internal medicine clerkships will be key to successfully integrating content to address the opioid epidemic.
Collapse
Affiliation(s)
- Mim Ari
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA.
| | | | - Nora Y Osman
- Department of Medicine, Brigham & Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Karen Szauter
- Department of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Clifford D Packer
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA.,Department of Medicine, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Amber T Pincavage
- Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| |
Collapse
|
26
|
Beetham T, Saloner B, Wakeman SE, Gaye M, Barnett ML. Access to Office-Based Buprenorphine Treatment in Areas With High Rates of Opioid-Related Mortality: An Audit Study. Ann Intern Med 2019; 171:1-9. [PMID: 31158849 PMCID: PMC7164610 DOI: 10.7326/m18-3457] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Improving access to treatment for opioid use disorder is a national priority, but little is known about the barriers encountered by patients seeking buprenorphine-naloxone ("buprenorphine") treatment. OBJECTIVE To assess real-world access to buprenorphine treatment for uninsured or Medicaid-covered patients reporting current heroin use. DESIGN Audit survey ("secret shopper" study). SETTING 6 U.S. jurisdictions with a high burden of opioid-related mortality (Massachusetts, Maryland, New Hampshire, West Virginia, Ohio, and the District of Columbia). PARTICIPANTS From July to November 2018, callers contacted 546 publicly listed buprenorphine prescribers twice, posing as uninsured or Medicaid-covered patients seeking buprenorphine treatment. MEASUREMENTS Rates of new appointments offered, whether buprenorphine prescription was possible at the first visit, and wait times. RESULTS Among 1092 contacts with 546 clinicians, schedulers were reached for 849 calls (78% response rate). Clinicians offered new appointments to 54% of Medicaid contacts and 62% of uninsured-self-pay contacts, whereas 27% of Medicaid and 41% of uninsured-self-pay contacts were offered an appointment with the possibility of buprenorphine prescription at the first visit. The median wait time to the first appointment was 6 days (interquartile range [IQR], 2 to 10 days) for Medicaid contacts and 5 days (IQR, 1 to 9 days) for uninsured-self-pay contacts. These wait times were similar regardless of clinician type or payer status. The median wait time from first contact to possible buprenorphine induction was 8 days (IQR, 4 to 15 days) for Medicaid and 7 days (IQR, 3 to 14 days) for uninsured-self-pay contacts. LIMITATION The survey sample included only publicly listed buprenorphine prescribers. CONCLUSION Many buprenorphine prescribers did not offer new appointments or rapid buprenorphine access to callers reporting active heroin use, particularly those with Medicaid coverage. Nevertheless, wait times were not long, implying that opportunities may exist to increase access by using the existing prescriber workforce. PRIMARY FUNDING SOURCE National Institute on Drug Abuse.
Collapse
Affiliation(s)
- Tamara Beetham
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts (T.B.)
| | - Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (B.S.)
| | - Sarah E Wakeman
- Massachusetts General Hospital, Boston, Massachusetts (S.E.W.)
| | - Marema Gaye
- Brigham and Women's Hospital, Boston, Massachusetts (M.G.)
| | - Michael L Barnett
- Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital, Boston, Massachusetts (M.L.B.)
| |
Collapse
|
27
|
Blanco C, Volkow ND. Management of opioid use disorder in the USA: present status and future directions. Lancet 2019; 393:1760-1772. [PMID: 30878228 DOI: 10.1016/s0140-6736(18)33078-2] [Citation(s) in RCA: 252] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 11/15/2018] [Accepted: 11/26/2018] [Indexed: 02/06/2023]
Abstract
Opioid use disorder is characterised by the persistent use of opioids despite the adverse consequences of its use. The disorder is associated with a range of mental and general medical comorbid disorders, and with increased mortality. Although genetics are important in opioid use disorder, younger age, male sex, and lower educational attainment level and income, increase the risk of opioid use disorder, as do certain psychiatric disorders (eg, other substance use disorders and mood disorders). The medications for opioid use disorder, which include methadone, buprenorphine, and extended-release naltrexone, significantly improve opioid use disorder outcomes. However, the effectiveness of medications for opioid use disorder is limited by problems at all levels of the care cascade, including diagnosis, entry into treatment, and retention in treatment. There is an urgent need for expanding the use of medications for opioid use disorder, including training of health-care professionals in the treatment and prevention of opioid use disorder, and for development of alternative medications and new models of care to expand capabilities for personalised interventions.
Collapse
Affiliation(s)
- Carlos Blanco
- National Institute on Drug Abuse, Bethesda, MD, USA.
| | | |
Collapse
|
28
|
Morris NP, Bentzley BS. Requiring Buprenorphine Waivers for Psychiatry Residents. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2019; 43:131-134. [PMID: 30414072 DOI: 10.1007/s40596-018-1005-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 11/05/2018] [Indexed: 06/08/2023]
|