"It's way more than just writing a prescription": A qualitative study of preferences for integrated versus non-integrated treatment models among individuals with opioid use disorder

Evaluating preferences for medication formulation and treatment model among people who use opioids non-medically: A web-based cross-sectional study

INTRODUCTION

Over the past decade, treatment for opioid use disorder has expanded to include long-acting injectable and implantable formulations of medication for opioid use disorder (MOUD), and integrated treatment models systematically addressing both behavioral and physical health. Patient preference for these treatment options has been underexplored. Gathering data on OUD treatment preferences is critical to guide the development of patient-centered treatment for OUD. This cross-sectional study assessed preferences for long-acting MOUD and integrated treatment using an online survey.

METHODS

An online Qualtrics survey assessed preferences for MOUD formulation and integrated treatment models. The study recruited participants (n = 851) in October and November 2019 through advertisements or posts on Facebook, Google AdWords, Reddit, and Amazon Mechanical Turk (mTurk). Eligible participants scored a two or higher on the opioid pain reliever or heroin scales of the Tobacco, Alcohol Prescription Medication and other Substance Use (TAPS) Tool. Structured survey items obtained patient preference for MOUD formulation and treatment model. Using stated preference methods, the study assessed preference via comparison of preferred options for MOUD and treatment model.

RESULTS

In the past year, 824 (96.8 %) participants reported non-prescribed use of opioid pain relievers (mean TAPS score = 2.72, SD = 0.46) and 552 (64.9 %) reported heroin or fentanyl use (mean TAPS score = 2.73, SD = 0.51). Seventy-four percent of participants (n = 631) reported currently or previously receiving OUD treatment, with 407 (48.4 %) receiving MOUD. When asked about preferences for type of MOUD formulation, 452 (53.1 %) preferred a daily oral formulation, 115 (13.5 %) preferred an implant, 114 (13.4 %) preferred a monthly injection and 95 (11.2 %) preferred a weekly injection. Approximately 8.8 % (n = 75) would not consider MOUD regardless of formulation. The majority of participants (65.2 %, n = 555) preferred receiving treatment in a specialized substance use treatment program distinct from their medical care, compared with receiving care in an integrated model (n = 296, 34.8 %).

CONCLUSIONS

Though most participants expressed willingness to try long-acting MOUD formulations, the majority preferred short-acting formulations. Likewise, the majority preferred non-integrated treatment in specialty substance use settings. Reasons for these preferences provide insight on developing effective educational tools for patients and suggesting targets for intervention to develop a more acceptable treatment system.

Examining a Triple Threat: The Intersection of Mental Health, Substance Use, and Re-entry of a Sample of Justice-Involved Persons

Having a mental health (MH) or substance use (SU) issue can make the transition from prison to the community a challenging process. Despite this, few studies have quantified how justice-involved individuals with mental health issues only, substance use only, those with both struggles, and those with neither are uniquely affected. Using a sample of re-entering men who were released from twelve state prisons in the United States, we assessed the effects of having MH and SU issues on their drug use during re-entry. Furthermore, we examined their differing coping reactions to housing insecurity, joblessness, and family tension after release. The results demonstrated that respondents' risk of SU during re-entry was associated with MH and SU issues measured at release. Those with co-occurring MH and SU challenges were at the highest risk of SU during re-entry. Furthermore, challenging life situations during re-entry exerted an amplified effect on SU for respondents with both anxiety and SU issues. The findings suggest that post-incarcerated individuals with co-occurring MH and SU issues have the highest risk of SU, and their reaction to re-entry barriers is distinct from their peers. Quality services to address co-occurring MH and SU may be needed to facilitate a smooth transition from prison to the community.

The Lived Experiences of Pregnant and Parenting Women in Recovery Toward Medication Treatment for Opioid Use Disorder

BACKGROUND

Maternal misuse of prescription opioids and illicit drugs such as, heroin and non-pharmaceutical fentanyl analogs has increased in the last 2 decades and one in 5 women reported misuse of opioids. Medications for opioid use disorder (MOUD) are recommended for treating pregnant women with opioid use disorder (OUD). MOUD is effective in reducing cravings and negative outcomes, yet treatment is underutilized and varies in integration and intensity of resources across health systems. Exploring perceptions of MOUD delivery among pregnant/parenting women promises to uncover and address the underlying challenges to treatment, a perspective that may be different for providers and stakeholders. Therefore, our main purpose is to elicit patients' experiences and perceptions of MOUD, associated access to treatment, and availability of supportive resources during pregnancy/postpartum to inform OUD treatment.

METHODS

Through a qualitative research approach we gathered data from individual interviews/focus group discussions for this pilot study. Pregnant and postpartum parenting women (n = 17) responded to questions related to perceptions of MOUD, access to treatment, and availability of social and psychosocial resources. Data were collected, transcribed, and coded (by consensus) and emerging themes were analyzed using grounded theory methodology.

RESULTS

Emerging themes revealed positive uptake and perceptions of MOUD, continuing gaps in knowledge, negative impact of stigmatization, and limited access to programs and resources. Supportive relationships from family, peers, healthcare providers and child welfare staff, and co-located services were perceived as positive motivators to recovery.

CONCLUSIONS

Through the unique lenses of women with lived experience, this study revealed several themes that can be transformative for women. Overall perceptions of MOUD were positive and likely to facilitate uptake and promote positive recovery outcomes. Bridging knowledge gaps will reduce anxieties, fears about neonatal opioid withdrawal syndrome and adverse maternal outcomes. Additionally, a deeper understanding of stigmatization and relationships can inform an integrated patient-centered approach to OUD treatment.

"It feels like I'm coming to a friend's house": an interpretive descriptive study of an integrated care site offering iOAT (Dr. Peter Centre)

BACKGROUND

Injectable opioid agonist treatment (iOAT) has proven to be a safe and effective treatment option for severe opioid use disorder (OUD). Yet, iOAT is often isolated from other health and social services. To align with a person-centered care approach, iOAT can be embedded in sites that combine systems and services that have been historically fragmented and that address multiple comorbidities (integrated care sites). The present study investigates the addition of iOAT at an integrated care in Vancouver, British Columbia. We aimed to capture what it means for service users and service providers to incorporate iOAT in an integrated care site and describe the processes by which the site keeps people engaged.

METHODS

We conducted 22 interviews with 15 service users and 14 interviews with 13 service providers across two rounds of individual semi-structured interviews (Fall 2021, Summer 2022). The second interview round was precipitated by a service interruption in medication dispensation. Interview audio was recorded, transcribed, and then analysed in NVivo 1.6 following an interpretive description approach.

RESULTS

The emergent themes from the analysis are represented in two categories: (1) a holistic approach (client autonomy, de-medicalized care, supportive staff relationships, multiple opportunities for engagement, barriers to iOAT integration) and (2) a sense of place (physical location, social connection and community belonging, food).

CONCLUSION

Incorporating iOAT at an integrated care site revealed how iOAT delivery can be strengthened through its direct connection to a diverse, comprehensive network of health and social services that are provided in a community atmosphere with high quality therapeutic relationships.

The four-factor personality model and its qualitative correlates among opioid agonist therapy clients

Background

The Four Factor Personality Vulnerability model identifies four specific personality traits (e.g., sensation seeking [SS], impulsivity [IMP], anxiety sensitivity [AS], and hopelessness [HOP]) as implicated in substance use behaviors, motives for substance use, and co-occurring psychiatric conditions. Although the relationship between these traits and polysubstance use in opioid agonist therapy (OAT) clients has been investigated quantitatively, no study has examined the qualitative expression of each trait using clients' voice.

Method

Nineteen Methadone Maintenance Therapy (MMT) clients (68.4% male, 84.2% white, mean age[SD] = 42.71 [10.18]) scoring high on one of the four personality traits measured by the Substance Use Risk Profile Scale [SURPS] completed a semi-structured qualitative interview designed to explore their lived experience of their respective trait. Thematic analysis was used to derive themes, which were further quantified using content analysis.

Results

Themes emerging from interviews reflected (1) internalizing and externalizing symptoms, (2) adversity experiences, and (3) polysubstance use. Internalizing symptoms subthemes included symptoms of anxiety, fear, stress, depression, and avoidance coping. Externalizing subthemes included anger, disinhibited cognitions, and anti-social and risk-taking behaviors. Adverse experiences subthemes included poor health, poverty, homelessness, unemployment, trauma, and conflict. Finally, polysubstance use subthemes include substance types, methods of use, and motives. Differences emerged between personality profiles in the relative endorsement of various subthemes, including those pertaining to polysubstance use, that were largely as theoretically expected.

Conclusion

Personality is associated with unique cognitive, affective, and behavioral lived experiences, suggesting that personality may be a novel intervention target in adjunctive psychosocial treatment for those undergoing OAT.

Commentary on Nowakowski et al.: Bringing the participants' own words into addictions research-a win-win for patients and investigators

Bringing the participant’s own words into the design of clinical investigations, such as with qualitative and mixed methodologies, should be prioritized in addictions research across the translational science spectrum.

Patient-provider relationships: Opioid use disorder and HIV treatment in Vietnam

Background

The provider-patient relationship has been implicated as a positive force in health outcomes. This study examined the provider-patient relationship in the setting of integrated, partially-integrated, and non-integrated opioid use disorder (OUD) and HIV care models in Vietnam.

Objective

To examine the provider-patient relationship in the setting of integrated, partially integrated, and non-integrated OUD and HIV treatment in North Vietnam.

Methods

Between 2013 and 2018, we conducted face-to-face qualitative interviews with 44 patients living with HIV and OUD and 43 providers in northern Vietnam. These were analyzed using a semantic, inductive approach to qualitative thematic analysis.

Results

Several themes were identified. 1) Trust was important to the patient-provider relationship and sensitive to provider attitudes and competence. 2) Patients perceived greater provider competence and understanding of patient health problems in integrated treatment. 3) Patient-provider relationships were initially superficial but deepened over time, facilitated by continuity of care.

Conclusions

Patient perceptions of competence and respect were important to feeling cared for. Providers felt empathy and competence came with more experience caring for patients with OUD and HIV.

Brief Report: Heterogeneous Preferences for Care Engagement Among People With HIV Experiencing Homelessness or Unstable Housing During the COVID-19 Pandemic

BACKGROUND/SETTING

In San Francisco, HIV viral suppression is 71% among housed individuals but only 20% among unhoused individuals. We conducted a discrete choice experiment at a San Francisco public HIV clinic to evaluate care preferences among people living with HIV (PLH) experiencing homelessness/unstable housing during the COVID-19 pandemic.

METHODS

From July to November 2020, we conducted a discrete choice experiment among PLH experiencing homelessness/unstable housing who accessed care through (1) an incentivized, drop-in program (POP-UP) or (2) traditional primary care. We investigated 5 program features: single provider vs team of providers; visit incentives ($0, $10, and $20); location (current site vs current + additional site); drop-in vs scheduled visits; in-person only vs optional telehealth visits; and navigator assistance. We estimated relative preferences using mixed-effects logistic regression and conducted latent class analysis to evaluate preference heterogeneity.

RESULTS

We enrolled 115 PLH experiencing homelessness/unstable housing, 40% of whom lived outdoors. The strongest preferences were for the same provider (β = 0.94, 95% CI: 0.48 to 1.41), visit incentives (β = 0.56 per $5; 95% CI: 0.47 to 0.66), and drop-in visits (β = 0.47, 95% CI: 0.12 to 0.82). Telehealth was not preferred. Latent class analysis revealed 2 distinct groups: 78 (68%) preferred a flexible care model, whereas 37 (32%) preferred a single provider.

CONCLUSIONS

We identified heterogeneous care preferences among PLH experiencing homelessness/unstable housing during the COVID-19 pandemic, with two-thirds preferring greater flexibility and one-third preferring provider continuity. Telehealth was not preferred, even with navigator facilitation. Including patient choice in service delivery design can improve care engagement, particularly for marginalized populations, and is an essential tool for ending the HIV epidemic.

Clinicians' perceptions of barriers to cervical cancer screening for women living with behavioral health conditions: a focus group study

Background

Women with behavioral health (BH) conditions (e.g., mental illness and substance abuse) receive fewer cervical cancer (CC) screenings, are diagnosed at more advanced cancer stages, and are less likely to receive specialized treatments. The aim of this study was to identify barriers that healthcare providers face in providing CC screening to women with BH conditions.

Methods

Guided by the Consolidated Framework for Implementation Research, we conducted four focus groups in North Florida with 26 primary care and BH clinicians and staff to examine perceived barriers to CC screening among their patients with BH conditions to guide the future development of a tailored cervical cancer screening and follow-up intervention. Thematic analysis was used to analyze verbatim transcripts from audiotaped focus groups.

Results

Three main themes of barriers emerged from the data: 1) BH conditions related barriers included a history of trauma, stigma and discrimination, and uncontrolled comorbid conditions, 2) System level barriers related to lack of integration between BH and primary care, and 3) Similar barriers to the general population including lack of health insurance, insufficient processes to send out reminders, and challenges with communicating with patients.

Conclusions

Tailored CC screening interventions that address the unique needs of women with BH conditions are needed. Strategies that address improving trust between patients and healthcare providers, identifying avenues to improve receipt of screening during time-limited clinical visits, connecting BH and primary care providers, and addressing the social determinants of health have potential to improve CC screening rates for women with BH conditions.

Together in care: Lessons learned at the intersection of integrated care, quality improvement, and implementation practice in opioid treatment programs

Background

Integrated care programs that systematically and comprehensively address both behavioral and physical health may improve patient outcomes. However, there are few examples of such programs in addiction treatment settings. This article is a practical implementation report describing the implementation of an integrated care program into two opioid treatment programs (OTPs).

Method

Strategies used to implement integrated care into two OTPs included external facilitation, quality improvement (QI) processes, staff training, and an integrated organizational structure. Service, implementation, and client outcomes were examined using qualitative interviews with program staff (n  =  16), program enrollment data, and client outcome data (n  =  593) on mental health (MH), physical health, and functional indicators.

Results

Staff found the program to generally be acceptable and appropriate, but also noted that the new services added to already busy workflows and more staffing were needed to fully reach the program's potential. The program had a high level of penetration (∼60%–70%), enrolling over 1,200 clients. Staff noted difficulties in connecting clients with some services. Client general functioning and MH symptoms improved, and heavy smoking decreased. The organizational structure and QI activities provided a strong foundation for interactive problem-solving and adaptations that were needed during implementation.

Conclusions

This article highlights an example of the intersection of QI and implementation practice. Simplified QI processes, consistent post-implementation meetings, and change teams and champions facilitated implementation; however, ongoing training and support, especially related to data are needed. The OTP setting provided a strong foundation to build integrated care, but careful consideration of new workflows and changes in philosophy for staff is necessary. Plain Language Summary: Providing medical and behavioral health treatment services in the same clinic using coordinated treatment teams, also known as integrated care, improves outcomes among those with chronic physical and behavioral health conditions. However, there are few practical examples of implementation of such programs in addiction treatment settings, which are promising, yet underutilized settings for integrated care programs. A multi-sectoral team used quality improvement (QI) and implementation strategies to implement integrated care into two opioid treatment programs (OTPs). The program enrolled over 1,200 clients and client general functioning and mental health (MH) symptoms improved, and heavy smoking decreased. Qualitative interviews provided important information about the barriers, facilitators, and context around implementation of this program. The OTP setting provided a strong foundation to build integrated care, but careful consideration of new workflows and changes in philosophy for staff, as well as ongoing training and supports for staff, are necessary. This project may help to advance the implementation of integrated care in OTPs by identifying barriers and facilitators to implementation, lessons learned, as well as providing a practical example of potentially useful QI and implementation strategies.

Integrated vs nonintegrated treatment for perinatal opioid use disorder: retrospective cohort study

BACKGROUND

Pregnant women with opioid use disorder and their infants often experience worse perinatal outcomes than women without opioid use disorder, including longer hospitalizations after delivery and a higher risk for preterm delivery. Integrated treatment models, which combine addiction treatment and maternity care, represent an innovative approach that is widely endorsed, however, limited studies have compared the outcomes between integrated and standard, nonintegrated programs from real-world programs.

OBJECTIVE

This study aimed to evaluate the perinatal and substance use outcomes for pregnant women with opioid use disorder receiving coordinated, colocated obstetrical care and opioid use disorder treatment (integrated treatment) and to compare it with those of women receiving obstetrical care and opioid use disorder treatment in distinct programs of care (nonintegrated treatment).

STUDY DESIGN

In this observational, retrospective cohort study, we abstracted the perinatal and opioid use disorder treatment data from the records of pregnant women with opioid use disorder (n=225) who delivered at a rural, academic medical center from 2015 to 2017. The women either received integrated (n=92) or nonintegrated (n=133) opioid use disorder treatment and obstetrical care. Using inverse probability weighted regression models to adjust for a potential covariate imbalance, we evaluated the impact of the treatment model on the risk for preterm delivery and positive meconium or umbilical cord toxicology screens. We explored whether the number of obstetrical visits mediated this relationship by using a quasi-Bayesian Monte Carlo algorithm.

RESULTS

Women receiving integrated treatment were less likely to deliver prematurely (11.8% vs 26.6%; P<.001) and their infants had shorter hospitalizations (6.5±4.8 vs 10.7±16.2 days). Using a robust inverse probability weighted model showed that receiving integrated treatment was associated with a 74.7% decrease in the predicted probability of preterm delivery (average treatment effect, -0.19; standard error, 0.14; P<.001). There were no differences in the risk for a positive meconium or umbilical cord toxicology screen, a marker for second and third trimester substance use, between women receiving integrated treatment and those receiving coordinated treatment (29.4% vs 34.6%; P=.41), however, integrated treatment was associated with significantly lower rates of positive maternal urine toxicology screens at the time of delivery (35.9% vs 74.4%; P<.001).

CONCLUSION

Among a cohort of rural pregnant women with opioid use disorder, receiving integrated obstetrical care and opioid use disorder treatment was associated with a reduced risk for preterm birth, a lower risk for positive maternal urine toxicology screen at the time of delivery, and shorter infant hospitalization. This relationship was mediated by the number of obstetrical visits attended during pregnancy, suggesting that increased engagement with obstetrical care through integration of services may contribute to improved perinatal outcomes.

Prevalence and Correlates of Prescription Drug Misuse in a Nationwide Population Survey in Taiwan

BACKGROUND

Prescription drug misuse (PDM) is a critical mental health issue relating to psychiatric morbidity. This study investigated the prevalence of PDM and its associated psychopathology and psychosocial factors in the general population in Taiwan.

METHODS

The survey randomly selected a representative sample >15 year-olds using the stratified proportional randomization method. The measurements included demographic variables, previous experience with PDM, self-rated physical and mental health, health self-efficacy, risk factors for suicidality, and psychological distress.

RESULTS

The weighted one-year prevalence of PDM was 8.5% (n = 180) among 2126 participants. Those with psychological distress and lifetime suicide ideation (23.3%) or suicide attempts (5.0%) were significantly associated with PDM. PDM was also prevalent among those with poorer self-rated health and lower self-efficacy. Insomnia (OR = 1.52), depression (OR = 1.77), and low self-efficacy (OR = 2.29) had higher odds of PDM after adjustment in the logistic regression model.

CONCLUSIONS

Individuals who misused prescription drugs had a higher prevalence of psychological distress and suicidality and lower levels of self-rated health. Prescription drug misuse problems should be screened for early prevention when prescribing medications for people with insomnia, depression, or lower perceived health beliefs or conditions.

Comparing the feasibility of four web-based recruitment strategies to evaluate the treatment preferences of rural and urban adults who misuse non-prescribed opioids

This cross-sectional study examined the feasibility of using four different web-based strategies to recruit rural and urban adults who use opioids non-medically for a survey on opioid use disorder (OUD) treatment preferences, and compared the treatment preferences of rural versus urban participants. Preferences for medication for opioid use disorder (MOUD) formulation and OUD treatment models were assessed through an online survey. Recruitment advertisements were shown on Facebook, Google AdWords, Reddit, and Amazon Mechanical Turk (MTurk). Participants were categorized by zip code into urban versus rural residence using the Centers for Medicaid and Medicaid Health Resources and Services Administration definitions. OUD treatment preferences were compared using chi-square and t-tests. Among the 851 participants recruited, 815 provided zip codes and were classified as residing in rural (n = 200, 24.5%) or urban (n = 615, 75.4%) regions. A crowdsourcing service (MTurk) recruited the most rural participants, while posts on a social news website (Reddit) recruited the most urban participants (χ²₃ = 17.0, p < 0.01). While preferred MOUD formulation and OUD treatment model did not differ by rurality, rural participants were more likely to report a willingness to receive OUD treatment integrated with general medical care (χ²₁ = 18.9, p < 0.0001). This study demonstrated that web-based strategies are feasible for recruiting rural adults who misuse opioids. Results suggest OUD treatment preferences largely did not differ by rural residence, and highlight the importance of enhancing the availability and increasing education about MOUD formulations in rural regions.