The lived experience of Australian opioid replacement therapy recipients in a community-based program in regional Victoria

Banging My Head Against a Brick Wall! Enablers and Barriers to Nurse Practitioners Delivering Opioid Agonist Treatments in Regional/Rural Victoria, Australia

The Victorian government's Alcohol and other drugs (AOD) workforce policy calls for greater recruitment of alcohol and other drugs nurse practitioners (AODNPs). However, frontline organisations in Victoria report several systemic barriers to their recruitment and retention. Additionally, there is scant Australian literature that examines the experiences of AODNP in opioid agonist treatment (OAT) provision in regional/rural areas. This research aims to address this gap by examining the AODNP workforce issues in delivering pharmacotherapy treatments in regional/rural areas of Victoria. Using an interpretative phenomenological approach, we conducted qualitative, in-depth interviews with 11 OAT prescribing AODNP's working in regional or rural Victoria. We analysed transcripts using reflective thematic analysis and generated three themes: (1) Professional motivations and values, (2) Enablers to professional role and (3) Barriers to professional role. The findings suggest that AODNPs in regional/rural areas are a dedicated workforce who provide holistic and integrated care for OAT clients. AODNPs play an important role in reducing and providing timely and subsidised health care for OAT clients living in regional/rural locations. AODNPs face many systemic and organisational barriers. These include inadequate funding for AODNP positions to prescribe pharmacotherapy treatments, lack of understanding of the AODNP professional role at the executive/management level within organisations and irregular access to supervision, mentoring, training and education. Also, endemic stigma in the health system acts as a barrier in recruiting and supporting AODNP positions that focus on care for OAT clients.

Patient experience of opioid use disorder treatment medications: a systematic review of contemporary qualitative research

OBJECTIVES

Opioid agonist, partial agonist and antagonist medications are used to treat opioid use disorder (OUD). This was the first omnibus narrative systematic review of the contemporary qualitative literature on patient experiences of receiving these medications.

DESIGN

Narrative systematic review using the sample, phenomenon of interest, design, evaluation and research framework.

DATA SOURCES

PubMed, Embase and APA PsycINFO were searched between 1 January 2000 and 14 June 2023, with the addition of hand searches.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Qualitative and mixed methods studies among adults with experience of receiving OUD treatment medication in community and criminal justice settings.

DATA EXTRACTION AND SYNTHESIS

One reviewer conducted searches using the pre-registered strategy. Two independent reviewers screened studies and assessed quality using the Consolidation Criteria for Reporting Qualitative tool. Identified reports were first categorised using domains from the addiction dimensions for assessment and personalised treatment (an instrument developed to guide OUD treatment planning), then by narrative synthesis.

RESULTS

From 1129 studies, 47 reports (published between 2005 and 2023) were included. Five major themes (and nine subthemes) were identified: (1) expectations about initiating treatment (barriers to access; motivations to receive medication); (2) responses to medication induction and stabilisation; (3) experience of the dispensing pharmacy (attending; medication dispensing); (4) experiences of maintenance treatment (services; dose adjustment; personal and social functioning); and (5) social factors (integration and stigma) and experiences of discontinuing treatment. Together these themes reflected and endorsed the importance of patient-centred care and clinically integrated services. Further qualitative research in real-world settings is needed on extended-release buprenorphine given the relative novelty of this medication option.

CONCLUSIONS

A narrative systematic review of the qualitative studies of medications for OUD endorsed the importance of patient-centred care and clinically integrated services.

PROSPERO REGISTRATION NUMBER

CRD42019139365.

'It's not just a matter of taking the drug. It's about changing the way you function in your society too': Narratives of power and resistance in the lived experiences of opioid agonist therapy consumers in regional Victoria, Australia

Opioid Agonist Therapy (OAT) has initiated extensive discussion regarding its efficacy, cost-effectiveness and best practice delivery. Although this discussion has been dominated by pharmacologists, clinicians, pharmacists and public policy-makers, there is increasing interest in examining OAT consumer experience and voice, particularly regarding consumers' navigation and experience of the social field of their treatment. Concerned with the expression and circulation of power and resistance, Michel Foucault's work offers rich resources for examining OAT consumers' experience and navigation of the social field of their treatment, including the administration of OAT as a harm reduction and social welfare intervention and consumers' efforts to shape their relationships with medical and allied health professionals and other stakeholders. In the case of this study, Foucault's conceptions of power provide a productive means to critically interrogate the experience of 16 OAT consumers participating in pharmacotherapy treatments within a community pharmacy model in regional Victoria, Australia. Through the application of Foucauldian analyses of subjects and power to OAT participant accounts, precisely what the participant responses in our study have shown is that the relationship between OAT practitioners and consumers is neither always oppositional nor binary. Findings suggest that practitioners must pay attention to the everyday interactions they have with consumers (and others)-to how they communicate, listen, understand, present and provide solutions. Interactions with consumers should be treated as sites that produce complex power relations with moral and ethical implications for subjects, including consumers, practitioners and other stakeholders. Both practitioner and consumers need to remember that they are both productive subjects locked in a complex assemblage of practices and social discourses that circumscribe the social field of opioid treatments.

The Therapeutic Potential of Cannabidiol in Revolutionising Opioid Use Disorder Management

Opioid use disorder (OUD) is a significant cause of morbidity and mortality worldwide and is linked to a complex interplay of biopsychosocial factors as well as the increasing overprescription and availability of opioid medications. Current OUD management relies on the controlled provision of opioid medications, such as methadone or buprenorphine, known as opioid replacement therapy. There is variable evidence regarding the long-term efficacy of these medications in improving the management of OUD, thereby necessitating an exploration into innovative approaches to complement, or even take the place of, existing treatment paradigms. Cannabidiol (CBD), a non-psychoactive compound derived from the cannabis plant, has garnered attention for its diverse pharmacological properties, including anti-inflammatory, analgesic, and anxiolytic effects. Preliminary studies suggest that CBD may target opioid withdrawal pathways that make CBD a potential therapeutic option for OUD. This narrative review synthesises current literature surrounding OUD and offers a nuanced review of the current and future role of CBD in managing this condition. In doing so, we highlight the potential avenues to explore with respect to CBD research for the guidance and development of further research opportunities, framework and policy development, and clinical considerations before medicinal CBD can be integrated into evidence-based clinical guidelines.

Changes to methadone maintenance therapy in the United States, Canada, and Australia during the COVID-19 pandemic: A narrative review

INTRODUCTION

In response to the COVID-19 pandemic, countries across the world made adaptations to policies regulating the provision of methadone maintenance therapy (MMT) to facilitate social distancing for health care providers and people in treatment. Many countries issued guidance about increasing take-home methadone doses after the onset of the pandemic.

METHODS

In this review, we compare the regulation of MMT prior to the pandemic in the United States, Canada, and Australia, analyze changes to treatment policy in the context of COVID-19, and review emerging data on treatment outcomes.

RESULTS

The United States only permits the prescription and disbursement of methadone for MMT treatment at federally designated opioid treatment programs (OTPs). Conversely, Australia and Canada operate on a community pharmacy-based distribution model, where patients can access methadone doses either in participating pharmacies or in some methadone clinics.

CONCLUSION

Given reports of similar treatment outcomes and increased patient satisfaction since the pandemic-related policy changes, some changes including increased receipt of take-home doses should be considered for incorporation into post-pandemic treatment policies and regulations.

The Lived Experience of Medication for Opioid Use Disorder: Qualitative Metasynthesis

PURPOSE OF THE STUDY

Buprenorphine and methadone, when used as maintenance therapy in opioid use disorder (OUD), can significantly reduce the risk of death after an opioid overdose. Despite the many benefits, medication for OUD (MOUD) remains controversial and underutilized. The aim of this study was to (a) identify studies that explicate the lived experience of MOUD, (b) conduct a methodologically sound critical quality assessment, (c) conduct a metasynthesis of identified qualitative studies, and (d) analyze the results through the lenses of critical social justice, feminist standpoint, and social theories to inform a more culturally responsive, effective, and holistic approach to treatment to increase the utilization of and receptivity to MOUD in the treatment of OUDs.

DESIGN AND METHODS

Metasynthesis is the deliberate process of synthesizing data from multiple qualitative studies to create a new interpretation of previously published research. Our metasynthesis focused on forming a new interpretation of the lived experience of MOUD. Of the 292 studies identified, eight met inclusion criteria. The overall quality of the studies was variable. The study population included adults aged ≥ 18 years with OUD or dependency.

RESULTS

Metasynthesis produced three overarching themes: (a) The duplexity of MOUD creates ambivalence in how a person experiences MOUD; (b) the structure of treatment and systemic influences matter, and (c) MOUD as a stepping-stone with multiple meanings in recovery.

IMPLICATIONS

Understanding experiential dualities allows professionals to see from other perspectives and can inform interventions and treatment structures as well as serve as a backdrop for social change. The synthesized new meaning of MOUD was an ambivalent experience influenced by intersectionality.

[Opioid agonist therapy and the German Narcotic Drugs Prescription Ordinance from the pharmacist's perspective]

BACKGROUND

Opioid agonist therapy (OAT) has been established to be the most important therapy option for improving health and social burdens of people with opioid dependence. Pharmacies provide drug substitutes to substitution practices or outpatient clinics and administer drugs to substituted patients (medication under visual control) or supply prescriptions for unsupervised, at-home use by patients. Given the gaps in medical care, the relevance of pharmacies for the comprehensive treatment of opioid-dependent patients will become even more important in the future. The 3^rd Revision of the Narcotic Drugs Prescription Ordinance (NDPO) adopted sweeping reforms to the framework of OAT in 2017. This paper examines the impact of this reform from the pharmacist's perspective.

METHODS

Between November 2020 and March 2021, pharmacists in the German federal states of Hamburg, North-Rhine Westphalia, Saxony, and Bavaria were informed by their State Chambers of Pharmacists about participation in this online study. A total of 480 questionnaires were evaluated. The analysis differentiates between pharmacists who are currently involved in the substitution of opioid-dependent patients (54.2%), pharmacists who were involved in the past (21.4%), and those who have never been involved in opioid substitution (24.4%).

RESULTS

Pharmacists involved in OAT have not seen any positive changes resulting from the 3^rd Revision of the NDPO. According to 97.9% of the pharmacists, remuneration for administering medication under visual control should be analogous to remuneration in doctors' practices. Mixed prescriptions (prescription of take-home dose and intermediate medication under visual control) increase the administrative workload and have been rejected by a quarter of the pharmacists. Non-involved pharmacists significantly overestimated the occurrence of critical situations with substituted patients in the pharmacy. While only 2.7% of pharmacists involved in OAT reported drug emergencies, 23.1% of non-involved pharmacists expressed such concerns. 39.3% of the pharmacists felt they could be motivated to participate in OAT if they were approached directly, and 73.9% of the pharmacists who are currently involved in OAT said they could provide substitution medication under visual control to additional opioid-dependent patients.

CONCLUSIONS

The 3^rd Revision of the NDPO has no influence on the situation and willingness of pharmacists to be involved in OAT. However, to ensure that pharmacists continue to be actively involved in OAT and attract new substituting pharmacies, their importance for comprehensive OAT must be upgraded. This includes, and not least, the funding of pharmacists' administration of substitution drugs under visual control. In addition, knowledge about OAT, attitudes toward opioid-dependent patients, and contact anxiety could be addressed by promoting educational awareness and training.

The Impact of Stigma on People with Opioid Use Disorder, Opioid Treatment, and Policy

Illicit drug use disorders are the most stigmatised health conditions worldwide, and stigma acts as a meaningful barrier to treatment entry and treatment provision. In the context of dramatically rising opioid-related harms, it is critical that we understand the drivers of stigma and how it affects opioid use disorder treatment and policy. The aim of this narrative review is to discuss how opioid-related stigma impacts treatment provision and harm reduction, and provide potential strategies to reduce stigma at a social and structural level. We used the Framework for Integrating Normative Influences on Stigma (FINIS) to identify sources of opioid-related stigma at the macro (structural stigma), meso (public stigma) and micro (internalised stigma) levels. Reducing stigma requires strategies that target multiple levels, however addressing inequity in the laws, regulations, and rules that segregate people with opioid and other substance use disorders from mainstream society is essential.

A prospective, multisite implementation-efficacy trial of a collaborative prescriber-pharmacist model of care for Medication Assisted Treatment for Opioid Dependence: Protocol for the EPIC-MATOD study

BACKGROUND

Medication Assisted Treatment for Opioid Dependence (MATOD) is clinically effective and cost effective, yet a lack of MATOD prescribers in the community limits access to this treatment in Australia. These shortages are often greatest in regional and rural areas.

OBJECTIVE(S)

The Enhancing Pharmacist Involvement in Care (EPIC)-MATOD study will evaluate clinical and implementation outcomes among people with opioid dependence receiving MATOD through a collaborative pharmacist-prescriber model of care across multiple sites in a regional location (encompassing a mix of metropolitan and non-metropolitan areas) of Victoria, Australia.

METHODS AND ANALYSIS

The EPIC-MATOD study is a prospective, multisite, implementation trial of collaborative MATOD care. Pharmacists and prescribers will be recruited through the local network of opioid pharmacotherapy providers. Patients will be recruited through participating healthcare providers. After induction into the collaborative care model, patients and healthcare professionals will be followed up over 6- (patients) and 12-months (pharmacists and prescribers) in a hybrid implementation-efficacy study, with outcomes mapped to the RE-AIM framework. The primary clinical efficacy endpoint is patient retention in treatment at 26 weeks. The primary implementation outcome is treatment capacity, based on prescriber time required to provide treatment through collaborative care compared with traditional care. Secondary clinical endpoints include attendance for dosing and clinical reviews, substance use, mental and physical health and overall well-being. Implementation costs, acceptability, and provider engagement in collaborative care will be used as secondary implementation outcome indicators. Time and costs associated with collaborative care, and health service utilisation, will also be estimated.

PROJECT IMPACT

The study will provide important information on outcomes and acceptability of collaborative care for MATOD, as well as the cost and key considerations in delivering a collaborative model of care in Australia and other countries where similar treatment barriers exist.

Experiences of Opioid Use Disorder Patients Receiving Buprenorphine Through a Telehealth Program

BACKGROUND

Opioid use disorder (OUD) continues to be a growing and major public health issue in the United States. In an effort to increase OUD treatment access, medication-assisted treatment with buprenorphine via telehealth is emerging as the leading treatment option.

OBJECTIVE

This study sought to describe the experiences of adults with OUD receiving medication-assisted treatment buprenorphine in a nurse-practitioner-facilitated telehealth program.

METHODS

Using a descriptive qualitative design, convenience sampling was used to recruit participants who were currently receiving OUD treatment in one telehealth program with locations in California and Michigan. Participants were invited to participate in the study via an email flyer sent to all clients of the telehealth program. Participants completed demographic data and took part in individual, semistructured interviews that were conducted online.

RESULTS

The study sample included 15 largely White, married, college-educated men (n = 8, 53%) and women (n = 7, 47%). Qualitative content analysis of interview data revealed three overall themes and associated subthemes: (a) improved access to care, (b) isolation, and (c) feeling normal on buprenorphine.

CONCLUSION

Our findings support a nurse-practitioner-facilitated telehealth treatment program for OUD. However, in a program that offers patient-centered care that does not have a one-size-fits-all approach to service, goals of care must be reevaluated throughout treatment. Moreover, given the increased risk of patients feeling isolated with telehealth appointments and the lack of physical face-to-face interactions, healthcare providers should explore ways to engage patients in meaningful support resources and reduce stigma.

U.S. student pharmacist perceptions of the pharmacist's role in methadone for opioid use disorder: A qualitative study

BACKGROUND

Of the over 20 million Americans reporting an opioid use disorder, only around 3 million report receiving treatment of any kind. The gold standard for opioid use disorder treatment is medication in combination with psychosocial support, but despite robust evidence supporting treatment, barriers are substantial and include limited insurance coverage, patient beliefs, ease of access, regulatory hurdles, and stigma. Although trained as medication experts, U.S. pharmacists are not routinely involved in opioid use disorder treatment and may represent an underutilized care team member.

OBJECTIVE

To explore U.S. pharmacy students' perspectives on pharmacists as providers of methadone-based medications for opioid use disorder treatment.

METHODS

A qualitative design with focus groups of student pharmacists in a U.S. college of pharmacy in the Southeastern United States.

RESULTS

Over 2 months in 2020, three focus groups were conducted with 15 students in each group participating, and including second-, third-, and fourth-year student pharmacists. Three overarching themes emerged from the data: (1) student pharmacists desire exposure to therapeutic knowledge and lived experiences related to opioid use disorder and methadone treatment, (2) students perceive stigmatizing views held by practicing pharmacists toward opioid use disorder and methadone treatment, (3) pharmacists should play a role in methadone treatment.

CONCLUSION

Student pharmacists desire an active and larger role in the care of patients managing opioid use disorder. Findings indicate these students perceive less stigma toward opioid use disorder than currently practicing pharmacists. Pharmacy curricula should emphasize stories of lived experiences of patients with opioid use disorder, therapeutic knowledge and guidelines related to medications for opioid use disorder, and the regulatory environment surrounding opioid use disorder treatment.

"Before the training I just assumed they've done something bad": Reporting on professional training for pharmacy assistants and pharmacy dispensary technicians on medically assisted treatment of opioid dependence

BACKGROUND

A study that examined the lived experiences of Medically Assisted Treatment of Opioid Dependence (MATOD) consumers suggested that they had experienced discrimination and stigma in pharmacies in regional Victoria, Australia. To address this, the need for professional training opportunities for Pharmacy Assistants (PAs) and Pharmacy Dispensary Technicians (PTDs) had been emphasised. A research project was undertaken to develop training modules using Social Determinants of Health (SDH) for PAs and PDTs involved in providing MATOD pharmacy services in regional Victoria, and to evaluate their effectiveness.

OBJECTIVES

The study aimed to examine and evaluate changes in attitudes and practices amongst PAs and PDTs involved in MATOD services in regional Victoria, Australia and who had undertaken the training modules.

METHODS

The paper reports primarily on the in-depth qualitative interviews that were completed after the training with PAs and PTDs. Thematic analysis was employed to code the data.

RESULTS

Thematic analysis generated five themes: understanding of the professional role of PAs and PTDs, initial judgements concerning MATOD consumers, reflection on the SDH, training content analysis, and the post-training impact upon Professional Practice. These themes reflected participants' insights with regards both to MATOD consumers and the impact the training itself had had on their professional practice.

CONCLUSION

"Consciousness-raising" from participation in the training can positively influence the development of participants' professional attitudes and practices with regards to MATOD service delivery. This development supports that training informed by SDH and ideas of critical reflection can help facilitate the creation of knowledge around the social construction of health and increased understanding of the impacts of language-use, attitudes and behaviour.