Study design to evaluate a group-based therapy for support persons of adults on buprenorphine/naloxone

Buprenorphine discontinuation and utilization of psychosocial services: a national study in the Veterans Health Administration

BACKGROUND

Longer duration of treatment with medication for opioid use disorder (MOUD) is associated with improved outcomes, but long-term retention remains a challenge. Research is needed to identify psychosocial interventions that support MOUD retention. To address this gap, we examined associations between a wide range of psychosocial services and buprenorphine treatment discontinuation across 18 months among a large cohort of Veterans initiating buprenorphine nationwide.

METHODS

We identified a cohort of patients with new buprenorphine initiation in 2017-2018 in Veterans Health Administration electronic health record data (N = 11,704). We examined prescription fills for up to 18 months after initiation. The primary outcome was first discontinuation of buprenorphine. We examined a variety of services, including psychotherapy in specialty substance use disorder (SUD) and mental health clinics, other healthcare services, and residential programs. To examine time-varying associations between psychosocial services and risk of discontinuation, we fit extended Cox regression models for each service separately and simultaneously.

RESULTS

Overall, 80.5% of patients discontinued buprenorphine at least once within 18 months. Risk of discontinuation was 18% (HR: 0.82, 95% CI: 0.77, 0.87) relatively lower following SUD psychotherapy and 26% (HR: 1.26, 95% CI: 1.15,1.39) higher following residential treatment.

CONCLUSIONS

Several services, including residential treatment, were associated with greater risk of subsequent buprenorphine discontinuation, whereas only SUD psychotherapy was consistently associated with lower risk of later discontinuation. These findings emphasize the need for future studies to increase understandings of beneficial and disruptive components of psychosocial services to improve treatment retention among patients receiving MOUD.

Feasibility and acceptability of the delivery of a group telehealth intervention for support persons of patients receiving buprenorphine for opioid use disorder

BACKGROUND

Opioid-related overdoses increased substantially during the COVID-19 pandemic, eliciting an urgent demand for accessible treatment for individuals with opioid use disorder (OUD) and those who support them (support persons). Support persons can improve treatment initiation and retention in their individuals with OUD. Additionally, support persons may have their own mental health needs related to their loved one's OUD. Unfortunately, few treatment options exist for support persons of individuals with an OUD. A support person-focused group telehealth intervention (referred to as eINSPIRE) that is accessible and feasible could help fill the treatment gap for support persons and bolster outcomes for individuals with OUD.

METHODS

The study interviewed patients receiving buprenorphine (n = 9), their support persons (n = 12), and clinic staff members (n = 6) about their perceptions on a group telehealth intervention designed for support persons. Patient and support person dyads were recruited from two community health clinics to participate in a qualitative interview and/or focus group. Using classic content analysis, we then analyzed this data to evaluate the feasibility, acceptability, and usability of a group telehealth intervention for support persons.

RESULTS

The eINSPIRE intervention was deemed generally acceptable, feasible, and usable. All support persons (n = 12) agreed that group telehealth was acceptable and those who completed an eINSPIRE demo session found it usable (IUS = 72.5). Patients indicated that eINSPIRE would be beneficial for support persons, and could provide services that are unattainable to them in their immediate community, but that groups sometimes lacked intimacy. Participants also found group telehealth to be more accessible than in-person alternatives and suggested how to improve the delivery of the intervention.

CONCLUSIONS

Group telehealth may be a feasible and acceptable option for delivering an intervention to support persons and could reduce barriers to treatment that this population often experiences due to competing demands. However, due to sample size limitations, more participant perspectives and future research are needed.

Examining how support persons' buprenorphine attitudes and their communication about substance use impacts patient well-being

Background: While social support benefits those in treatment for opioid use disorder, it is unclear how social support impacts patient outcomes.Objectives: This study examines how support person attitudes toward buprenorphine and their communication about substance use are associated with the well-being of patients receiving buprenorphine treatment.Methods: We analyzed cross-sectional baseline data from 219 buprenorphine patients (40% female) and their support persons (72% female). Patients were recruited from five community health centers and asked to nominate a support person. Patient outcomes included symptoms of depression, anxiety, impairment due to substance use, and perceived social support. Support persons predictors included their attitudes toward buprenorphine from four statements (e.g. "Buprenorphine is just replacing one drug for another") and communication using two items (e.g. comfort and effectiveness discussing substance use).Results: More stigmatizing attitudes, such as believing patients should quit on their own without medication, were associated with increased patient substance use-related impairment (F = 4.53, p = .01). Effective communication was associated with lower patient depression (F = 10.15, p < .001), anxiety (F = 4.73, p = .001), lower impairment (F = 6.46, p < .001), and higher perceived social support (F = 3.68, p = .007).Conclusions: This study highlights how support person attitudes and communication dynamics significantly affect the mental health and impairment of individuals receiving buprenorphine treatment. Interventions that reduce stigma and promote effective communication between patients and their loved ones could enhance treatment outcomes and overall well-being among patients with OUD.

"I need as much support as I can get": A qualitative study of young adult perspectives on family involvement in treatment for opioid use disorder

BACKGROUND

Opioid use disorder (OUD) among young adults (YAs) continues to persist as a national health crisis. Best practice recommendations for YA OUD treatment highlight the importance of medication for OUD (MOUD) and family involvement across the treatment services continuum for better treatment retention and outcomes. Yet, concerned significant others (CSOs) such as family members, romantic partners, and family-of-choice members are not routinely involved in OUD and MOUD treatment for YAs.

METHOD

We used convenience sampling to recruit 25 YAs (ages 21 to 36) in treatment for OUD from two urban treatment centers. We discussed with YAs the identities of their CSOs and the dynamics of those relationships, their perspectives on CSO involvement in their OUD treatment, and the beliefs and attitudes they hold about family involvement in treatment and recovery. Thematic content analysis was deductive-dominant based on a semi-structured qualitative interview guide. Group consensus coding was followed by matrix analysis.

RESULTS

We identified five main themes: (1) YA and CSO relationships were supportive, evolving, and complex. (2) CSO support motivated treatment engagement and participation. (3) Only a small proportion of CSOs participated in treatment activities despite actively supporting treatment in other ways. (4) YAs experienced their CSOs as supportive of their treatment and recovery goals, including MOUD. (5) YAs believed family involvement is essential to treatment and many were unsatisfied with current family involvement in their care.

CONCLUSIONS

In this qualitative study of OUD treatment experiences among YAs, we learned that many YAs have CSOs who are invested in their treatment and recovery and yet are not routinely involved in treatment. Moreover, YAs often expressed family involvement is essential to OUD treatment, and many expressed a desire for greater family involvement in their own treatment. Clinical recommendations for relationship-oriented treatment are presented.

Mis-implementation of evidence-based behavioural health practices in primary care: lessons from randomised trials in Federally Qualified Health Centers

Background

Implementing evidence-based practices (EBPs) within service systems is critical to population-level health improvements - but also challenging, especially for complex behavioral health interventions in low-resource settings. "Mis-implementation" refers to poor outcomes from an EBP implementation effort; mis-implementation outcomes are an important, but largely untapped, source of information about how to improve knowledge exchange.

Aims and objectives

We present mis-implementation cases from three pragmatic trials of behavioral health EBPs in U.S. Federally Qualified Health Centers (FQHCs).

Methods

We adapted the Consolidated Framework for Implementation Research and its Outcomes Addendum into a framework for mis-implementation and used it to structure the case summaries with information about the EBP and trial, mis-implementation outcomes, and associated determinants (barriers and facilitators). We compared the three cases to identify shared and unique mis-implementation factors.

Findings

Across cases, there was limited adoption and fidelity to the interventions, which led to eventual discontinuation. Barriers contributing to mis-implementation included intervention complexity, low buy-in from overburdened providers, lack of alignment between providers and leadership, and COVID-19-related stressors. Mis-implementation occurred earlier in cases that experienced both patient- and provider-level barriers, and that were conducted during the COVID-19 pandemic.

Discussion and conclusion

Multi-level determinants contributed to EBP mis-implementation in FQHCs, limiting the ability of these health systems to benefit from knowledge exchange. To minimize mis-implementation, knowledge exchange strategies should be designed around common, core barriers but also flexible enough to address a variety of site-specific contextual factors and should be tailored to relevant audiences such as providers, patients, and/or leadership.

Methodological approaches to study context in intervention implementation studies: an evidence gap map

BACKGROUND

Within implementation science studies, contextual analysis is increasingly recognized as foundational to interventions' successful and sustainable implementation. However, inconsistencies between methodological approaches currently limit progress in studying context and guidance to standardize the use of those approaches is scant. Therefore, this study's objective was to systematically review and map current methodological approaches to contextual analysis in intervention implementation studies. The results would help us both to systematize the process of contextual analysis and identify gaps in the current evidence.

METHODS

We conducted an evidence gap map (EGM) based on literature data via a stepwise approach. First, using an empirically developed search string, we randomly sampled 20% of all intervention implementation studies available from PubMed per year (2015-2020). Second, we assessed included studies that conducted a contextual analysis. Data extraction and evaluation followed the Basel Approach for CoNtextual ANAlysis (BANANA), using a color-coded rating scheme. Also based on BANANA and on the Context and Implementation of Complex Interventions (CICI) framework-an implementation framework that pays ample attention to context- we created visual maps of various approaches to contextual analysis.

RESULTS

Of 15, 286 identified intervention implementation studies and study protocols, 3017 were screened for inclusion. Of those, 110 warranted close examination, revealing 22% that reported on contextual analysis. Only one study explicitly applied a framework for contextual analysis. Data were most commonly collected via surveys (n = 15) and individual interviews (n = 13). Ten studies reported mixed-methods analyses. Twenty-two assessed meso-level contextual and setting factors, with socio-cultural aspects most commonly studied. Eighteen described the use of contextual information for subsequent project phases (e.g., intervention development/adaption, selecting implementation strategies). Nine reported contextual factors' influences on implementation and/or effectiveness outcomes.

CONCLUSIONS

This study describes current approaches to contextual analysis in implementation science and provides a novel framework for evaluating and mapping it. By synthesizing our findings graphically in figures, we provide an initial evidence base framework that can incorporate new findings as necessary. We strongly recommend further development of methodological approaches both to conduct contextual analysis and to systematize the reporting of it. These actions will increase the quality and consistency of implementation science research.

A Call for Kindness, Connection, and Science

INTRODUCTION

This personal narrative describes our family's struggle with my adult son's substance use disorder (SUD). Years of traditional tough love treatment programs worsened his SUD and our relationship. When he experienced drug induced psychosis and was hospitalized, I realized I needed to change my approach and understand his behaviors.

METHODS

I reached out to the recovery community and spoke with many individuals who had walked in my son's shoes. They described feelings of loneliness, self-loathing, and hopelessness while being on the receiving end of tough love. They further described the contrast between those negative feelings, and the life affirming hope associated with communication, empathy, and inclusion. I became inspired to research programs that are based on communication, science, and connection, rather than isolation, judgment, and punishment.

RESULTS

Family and community are powerful tools and can motive change. An evidence-based program called CRAFT (Community Reinforcement and Family Training) encourages relationships and teaches families skills to connect with their loved ones by effectively communicating and reinforcing positive behaviors, even in the context of unhealthy behaviors. Receiving praise for healthy behavior, recognition for good work, or even a positive acknowledgement for taking baby steps toward self-care can activate the same dopamine-producing reward system as drugs. Individuals with SUD can learn how to feel good in ways that do not involve using substances. Traditional patient-focused treatment programs, which encourage separation, punishment, and distance should not be considered the only approach to treatment.

CONCLUSIONS

Loved ones are not powerless. While we can't make a person change, we can contribute to making them want to change. We have more influence than we once thought possible and need to proactively seek out empirically supported family-based programs that reinforce these approaches.

Review of medication-assisted treatment for opioid use disorder

CONTEXT

The American opioid epidemic has necessitated the search for safe and effective means of treatment for opioid use disorder (OUD). Medication-assisted treatment (MAT) encompasses select medications that are proven effective treatments for OUD. Understanding the mechanisms of action, indications, and implementation of MAT is paramount to increasing its availability to all individuals struggling with opioid addiction.

OBJECTIVES

This review is based on an educational series that aims to educate healthcare providers and ancillary healthcare members on the use of MAT for the treatment of OUD.

METHODS

The database PubMed was utilized to retrieve articles discussing the implementation of MAT. Boolean operators and Medical Subject Headings (MeSHs) were applied including: MAT and primary care, MAT and telehealth, methadone, buprenorphine, naltrexone, MAT and osteopathic, MAT and group therapy, and MAT and COVID-19.

RESULTS

Three medications have been approved for the treatment of OUD: methadone, naltrexone, and buprenorphine. Identifying ways to better treat and manage OUD and to combat stigmatization are paramount to dismantling barriers that have made treatment less accessible. Studies suggest that primary care providers are well positioned to provide MAT to their patients, particularly in rural settings. However, no study has compared outcomes of different MAT models of care, and more research is required to guide future efforts in expanding the role of MAT in primary care settings.

CONCLUSIONS

The coronavirus disease 2019 (COVID-19) pandemic has led to changes in the way MAT care is managed. Patients require a novel point-of-care approach to obtain care. This review will define the components of MAT, consider the impact of MAT in the primary care setting, and identify barriers to effective MAT. Increasing the availability of MAT treatment will allow for greater access to comprehensive treatment and will set the standard for accessibility of novel OUD treatment in the future.

Value of family involvement in substance use disorder treatment: Aligning clinical and financing priorities

BACKGROUND

Family members' support (e.g., informational, tangible, emotional) has important and lasting impacts on individuals' recovery from substance use disorders (SUDs). Unfortunately, SUD services in the United States do not consistently incorporate patients' family members effectively. One barrier to family involvement in SUD services is the mechanisms through which SUD services in the United States are commonly financed.

METHOD

Using our recent experiences with developing a group intervention for support persons of patients with opioid use disorder, we illustrate how gaps in feasible financing models limit SUD service systems from effectively implementing and sustaining family services for individuals receiving SUD treatment.

DISCUSSION

Long-term availability of family-inclusive interventions will require collaboration with payors and health systems. We offer two sets of recommendations for funding family involvement in SUD services; one set of immediately implementable recommendations and other longer-term goals requiring structural changes in SUD service delivery and financing.

Translating economic evaluations into financing strategies for implementing evidence-based practices

BACKGROUND

Implementation researchers are increasingly using economic evaluation to explore the benefits produced by implementing evidence-based practices (EBPs) in healthcare settings. However, the findings of typical economic evaluations (e.g., based on clinical trials) are rarely sufficient to inform decisions about how health service organizations and policymakers should finance investments in EBPs. This paper describes how economic evaluations can be translated into policy and practice through complementary research on financing strategies that support EBP implementation and sustainment.

MAIN BODY

We provide an overview of EBP implementation financing, which outlines key financing and health service delivery system stakeholders and their points of decision-making. We then illustrate how economic evaluations have informed decisions about EBP implementation and sustainment with three case examples: (1) use of Pay-for-Success financing to implement multisystemic therapy in underserved areas of Colorado, USA, based in part on the strength of evidence from economic evaluations; (2) an alternative payment model to sustain evidence-based oncology care, developed by the US Centers for Medicare and Medicaid Services through simulations of economic impact; and (3) use of a recently developed fiscal mapping process to collaboratively match financing strategies and needs during a pragmatic clinical trial for a newly adapted family support intervention for opioid use disorder.

CONCLUSIONS

EBP financing strategies can help overcome cost-related barriers to implementing and sustaining EBPs by translating economic evaluation results into policy and practice. We present a research agenda to advance understanding of financing strategies in five key areas raised by our case examples: (1) maximize the relevance of economic evaluations for real-world EBP implementation; (2) study ongoing changes in financing systems as part of economic evaluations; (3) identify the conditions under which a given financing strategy is most beneficial; (4) explore the use and impacts of financing strategies across pre-implementation, active implementation, and sustainment phases; and (5) advance research efforts through strong partnerships with stakeholder groups while attending to issues of power imbalance and transparency. Attention to these research areas will develop a robust body of scholarship around EBP financing strategies and, ultimately, enable greater public health impacts of EBPs.