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Yang J, Jung M, Picco L, Grist E, Lloyd-Jones M, Giummarra M, Nielsen S. Pain in people seeking and receiving opioid agonist treatment: A systematic review and meta-analysis of prevalence and correlates. Addiction 2024. [PMID: 38886901 DOI: 10.1111/add.16574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/22/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND AND AIMS People with opioid use disorder (OUD) commonly experience pain including chronic pain. Despite the high prevalence, few studies have systematically examined the prevalence and correlates of pain among people seeking or receiving opioid agonist treatment (OAT) for OUD. This review aimed to determine the prevalence of pain in this population globally, and estimate the association between chronic pain and other demographic and clinical characteristics. METHODS Electronic searches were conducted in three databases (Medline, Embase and PsycINFO) from the inception until October 2022. Eligible studies reported prevalence rates of current and/or chronic pain. Meta-analyses examining the main prevalence estimates were conducted by Stata SE 18.0, and comorbid clinical conditions were analysed by Review Manager 5.4. RESULTS Fifty-six studies (n participants = 35 267) from sixty-seven publications were included. Prevalence estimates of current and chronic pain were reported in 27 (48.2%) and 40 studies (71.4%), respectively. Most studies were conducted in North America (71.4%, n = 40) and used cross-sectional designs (64.3%, n = 36). Meta-analyses revealed a pooled prevalence of 60.0% (95% confidence interval [CI]: 52.0-68.0) for current pain and 44.0% [95% CI: 40.0-49.0] for chronic pain. Chronic pain was positively associated with older age (mean deviation of mean age: 2.39 years, 95% CI: 1.40-3.37; I2 = 43%), unemployment (odds ratio [OR] = 0.57, 95% CI: 0.42-0.76; I2 = 78%), more severe mental health symptoms (e.g. more severe depression (standardised mean difference [SMD] of mean scores: 0.45, 95% CI: 0.20-0.70; I2 = 48%) and anxiety symptoms (SMD: 0.52, 95% CI: 0.17-0.88; I2 = 67%), and hepatitis C (OR = 1.41, 95% CI: 1.03-1.94; I2 = 0%). No association was observed between chronic pain and the onset and type of OAT, geographic location, study design, survey year, participant age or use of specific pain assessment tools. CONCLUSIONS There appears to be a high prevalence of pain among people seeking or receiving opioid agonist treatment for opioid use disorder compared with the general population, with positive associations for older age, unemployment, hepatitis C and the severity of some mental health symptoms.
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Affiliation(s)
- Jie Yang
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Monica Jung
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Louisa Picco
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Elizabeth Grist
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Melita Giummarra
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Richardson C, Daniels K, Confer A, Saxon AJ, Gordon AJ, Liberto J, Albanese AP, Renner J, Edens E, Kennedy AJ. Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements. J Gen Intern Med 2024; 39:1393-1399. [PMID: 38302815 PMCID: PMC11169109 DOI: 10.1007/s11606-024-08639-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites. OBJECTIVE To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites. DESIGN This was a qualitative evaluation based on semi-structured video-based focus groups. PARTICIPANTS Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA. APPROACH Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes. KEY RESULTS Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum. CONCLUSIONS Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.
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Affiliation(s)
- Claire Richardson
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA
| | - Karin Daniels
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrea Confer
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrew J Saxon
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative Patient-Aligned-Care-Team (VIP) Initiative, Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, Salt Lake City Health Care System, Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joseph Liberto
- Office of Mental Health and Suicide Prevention, Substance Use Disorders, Veterans Health Administration, Washington, DC, USA
| | - Anthony P Albanese
- VA Northern California Healthcare System, UC Davis, School of Medicine, Sacramento, CA, USA
| | - John Renner
- VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - Ellen Edens
- VA Connecticut Healthcare System, Yale School of Medicine, New Haven, CT, USA
| | - Amy J Kennedy
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA.
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Turi ER, McMenamin A, Wolk CB, Poghosyan L. Primary care provider confidence in addressing opioid use disorder: A concept analysis. Res Nurs Health 2023; 46:263-273. [PMID: 36611290 PMCID: PMC10033432 DOI: 10.1002/nur.22294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 01/09/2023]
Abstract
Primary care providers (PCPs) are well-positioned to provide care for opioid use disorder (OUD), yet very few address OUD regularly. One contributing factor may be PCPs' lack of confidence in their ability to effectively treat OUD. Evidence demonstrates that clinician confidence in home care and hospital settings is associated with improved care delivery and patient outcomes. However, a conceptual definition of PCP confidence in addressing OUD has yet to be established. The aim of this concept analysis is to enhance conceptual understanding of PCP confidence in addressing OUD and inform future measurement strategies. Following Walker and Avant's method of concept analysis, PubMed, PsycINFO, and Google Scholar were searched in October 2021. Manuscripts were included if they referenced confidence in relation to PCPs who provide care to adult patients with OUD. Studies conducted outside the US and not published in English were excluded. The search resulted in 18 studies which were synthesized to conceptualize PCP confidence in addressing OUD. Defining attributes include self-efficacy, experience, and readiness to address OUD. These attributes may be influenced by organizational culture, training, support, and resources. Consequences of PCP confidence addressing OUD may include improved patient outcomes, improved delivery of and access to OUD care, and PCP attitude changes. This concept analysis-which grounds the concept of PCP confidence in addressing OUD in the theoretical and empirical literature-lays the framework for future measurement of the concept. This represents a critical first step towards developing strategies to enhance PCP confidence in addressing OUD.
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Affiliation(s)
- Eleanor R Turi
- Columbia University School of Nursing, New York, New York, USA
| | - Amy McMenamin
- Columbia University School of Nursing, New York, New York, USA
| | | | - Lusine Poghosyan
- Columbia University School of Nursing, New York, New York, USA
- Columbia University Mailman School of Public Health, New York, New York, USA
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Harder VS, Villanti AC, Heil SH, Smith ML, Gaalema DE, Meyer MC, Schafrick NH, Sigmon SC. Opioid use disorder treatment in rural settings: The primary care perspective. Prev Med 2021; 152:106765. [PMID: 34411588 PMCID: PMC8591995 DOI: 10.1016/j.ypmed.2021.106765] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 07/07/2021] [Accepted: 08/14/2021] [Indexed: 12/13/2022]
Abstract
Despite the efficacy of medications for treating opioid use disorder (OUD), they are underutilized, especially in rural areas. Our objectives were to determine the association between primary care practitioners (PCPs) rurality and concerns for patient substance use, and to identify factors associated with PCP comfort treating OUD, focusing on barriers to treatment. We developed a web-based survey completed by 116 adult-serving PCPs located in Vermont's rural and non-rural counties between April-August 2020. The instrument included PCP-identified concerns for substance use among patients, barriers to treating patients with OUD, and current level of comfort treating patients with OUD. On a scale from 0 to 10, rural PCPs reported higher concern for heroin (mean difference; Mdiff = 1.38, 95% CI: 0.13 to 2.63), fentanyl (Mdiff = 1.52, 95% CI: 0.29 to 2.74), and methamphetamine (Mdiff = 1.61, 95% CI: 0.33 to 2.90) use among patients compared to non-rural PCPs, and practitioners in both settings expressed high concern regarding their patients' use of tobacco (7.6 out of 10) and alcohol (7.0 out of 10). There was no difference in reported comfort in treating patients with OUD among rural vs. non-rural PCPs (Mdiff = 0.65, 95%CI: 0.17 to 1.46; P = 0.119), controlling for higher comfort among male PCPs and those waivered to prescribe buprenorphine (Ps < 0.05). Lack of training/experience and medication diversion were PCP-identified barriers associated with less comfort treating OUD patients, while time constraints was associated with more comfort (Ps < 0.05). Taken together, these data highlight important areas for dissemination of evidence-based training, support, and resources to expand OUD treatment capacity in rural communities.
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Affiliation(s)
- Valerie S Harder
- Center on Rural Addiction, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Department of Psychiatry, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Department of Pediatrics, Robert Larner, M.D. College of Medicine, University of Vermont, S-253 Given Courtyard, 89 Beaumont Avenue, Burlington, VT 05401, USA.
| | - Andrea C Villanti
- Center on Rural Addiction, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Department of Psychiatry, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Vermont Center on Behavior and Health, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA
| | - Sarah H Heil
- Center on Rural Addiction, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Department of Psychiatry, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Vermont Center on Behavior and Health, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Department of Psychological Science, University of Vermont, 2 Colchester Ave., Burlington, VT 05401, USA
| | - M Lindsey Smith
- Center on Rural Addiction, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Cutler Institute for Health and Social Policy, Muskie School of Public Service, University of Southern Maine, 34 Bedford St., Portland, ME 04104, USA
| | - Diann E Gaalema
- Center on Rural Addiction, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Department of Psychiatry, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Vermont Center on Behavior and Health, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Department of Psychological Science, University of Vermont, 2 Colchester Ave., Burlington, VT 05401, USA
| | - Marjorie C Meyer
- Center on Rural Addiction, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Department of Obstetrics, Gynecology and Reproductive Sciences, Robert Larner, M.D. College of Medicine, University of Vermont, 111 Colchester Ave, Main Campus, East Pavilion, Level 4, Burlington, VT 05401, USA
| | - Nathaniel H Schafrick
- Center on Rural Addiction, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA
| | - Stacey C Sigmon
- Center on Rural Addiction, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Department of Psychiatry, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Vermont Center on Behavior and Health, Robert Larner, M.D. College of Medicine, University of Vermont, 1 S. Prospect St., Burlington, VT, 05401, USA; Department of Psychological Science, University of Vermont, 2 Colchester Ave., Burlington, VT 05401, USA
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Abstract
BACKGROUND Research has shown that medications, especially opioid agonist treatments, are an effective way to treat opioid use disorder (OUD); however, negative attitudes held by health professionals contribute to their underutilization. Methods: A 23-year review of studies that examined health professionals' attitudes toward medications for OUD (MOUD) was conducted to describe the current state of knowledge and to inform future research and interventions. Results: Studies examined attitudes toward the use of methadone, buprenorphine, and naltrexone among various types of health professionals: prescribers, non-prescribing clinicians, pharmacists, and administrators. The characteristics and findings of the included studies were reviewed and synthesized. Findings indicate that attitudes toward MOUD affect access and utilization by influencing prescribing practices, referrals, and adoption within programs. Exposure, knowledge, and treatment orientation were found to be important factors related to attitudes toward MOUD across multiple studies of various types of health professionals. Conclusions: To increase access and utilization, continued efforts are needed to increase positive attitudes toward MOUD among various types of health professionals. Findings indicate that interventions should seek to increase knowledge about MOUD and foster interprofessional communication related to MOUD, especially between prescribers and behavioral health providers.
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Affiliation(s)
- Aaron R Brown
- Department of Social Work, College of Health & Human Sciences, Western Carolina University, Cullowhee, North Carolina, USA
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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.
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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
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