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Saunders EC, Budney AJ, Cavazos-Rehg P, Scherer E, Bell K, John D, Marsch LA. Evaluating preferences for medication formulation and treatment model among people who use opioids non-medically: A web-based cross-sectional study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 163:209383. [PMID: 38670531 PMCID: PMC11180569 DOI: 10.1016/j.josat.2024.209383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 02/19/2024] [Accepted: 04/22/2024] [Indexed: 04/28/2024]
Abstract
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.
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Affiliation(s)
- Elizabeth C Saunders
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA.
| | - Alan J Budney
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA.
| | - Patricia Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.
| | - Emily Scherer
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
| | - Kathleen Bell
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA.
| | | | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA.
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Tillman AR, Bacon E, Bender B, McEwen D, Blum J, Hoag M, Scott KA, Everhart R, Hanratty R, Podewils LJ, Close C, Mills J, Davidson AJ. Using 42 CFR part 2 revisions to integrate substance use disorder treatment information into electronic health records at a safety net health system. Addict Sci Clin Pract 2024; 19:48. [PMID: 38849888 PMCID: PMC11157711 DOI: 10.1186/s13722-024-00477-3] [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: 09/12/2023] [Accepted: 05/24/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Regulations put in place to protect the privacy of individuals receiving substance use disorder (SUD) treatment have resulted in an unintended consequence of siloed SUD treatment and referral information outside of the integrated electronic health record (EHR). Recent revisions to these regulations have opened the door to data integration, which creates opportunities for enhanced patient care and more efficient workflows. We report on the experience of one safety-net hospital system integrating SUD treatment data into the EHR. METHODS SUD treatment and referral information was integrated from siloed systems into the EHR through the implementation of a referral order, treatment episode definition, and referral and episode-related tools for addiction therapists and other clinicians. Integration was evaluated by monitoring SUD treatment episode characteristics, patient characteristics, referral linkage, and treatment episode retention before and after integration. Satisfaction of end-users with the new tools was evaluated through a survey of addiction therapists. RESULTS After integration, three more SUD treatment programs were represented in the EHR. This increased the number of patients that could be tracked as initiating SUD treatment by 250%, from 562 before to 1,411 after integration. After integration, overall referral linkage declined (74% vs. 48%) and treatment episode retention at 90-days was higher (45% vs. 74%). Addiction therapists appreciated the efficiency of having all SUD treatment information in the EHR but did not find that the tools provided a large time savings shortly after integration. CONCLUSIONS Integration of SUD treatment program data into the EHR facilitated both care coordination in patient treatment and quality improvement initiatives for treatment programs. Referral linkage and retention rates were likely modified by a broader capture of patients and changed outcome definition criteria. Greater preparatory workflow analysis may decrease initial end-user burden. Integration of siloed data, made possible given revised regulations, is essential to an efficient hub-and-spoke model of care, which must standardize and coordinate patient care across multiple clinics and departments.
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Affiliation(s)
- Alexandra R Tillman
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA.
| | - Emily Bacon
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - Brooke Bender
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - Dean McEwen
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - Joshua Blum
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - Matthew Hoag
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - Kenneth A Scott
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - Rachel Everhart
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - Rebecca Hanratty
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - Laura J Podewils
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - Carolina Close
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - John Mills
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
| | - Arthur J Davidson
- Denver Health and Hospital Authority, 777 Bannock Street, Denver, CO, 80204, USA
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Osilla KC, Manuel JK, Becker K, Nameth K, Burgette L, Ober AJ, DeYoreo M, Lodge BS, Hurley B, Watkins KE. It takes a village: A pilot study of a group telehealth intervention for support persons affected by opioid use disorder. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 161:209290. [PMID: 38272117 DOI: 10.1016/j.josat.2024.209290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 11/28/2023] [Accepted: 01/11/2024] [Indexed: 01/27/2024]
Abstract
INTRODUCTION Opioid use disorder (OUD) has devastating effects on individuals, families, and communities. The Community Reinforcement and Family Training (CRAFT) is a Support Person (SP)-focused intervention that aims to increase SPs' communication strategies, positive reinforcement/rewards, and social support. This pilot study, called eINSPIRE (INtegrating Support Persons Into REcovery), adapted CRAFT for delivery via group telehealth. The aims were to evaluate the feasibility, acceptability, and preliminary effectiveness of this intervention on patient buprenorphine retention and SP mental health. METHODS The study recruited patients receiving buprenorphine treatment in a primary care setting across five community health centers with their SP (N = 100 dyads). SP participants were randomly assigned to receive usual care (UC) or the eINSPIRE intervention. We interviewed Patients and SPs at baseline and three months later. The study collected patient buprenorphine retention data from the electronic medical record three months post-baseline. RESULTS About 88 % (656/742) of potentially eligible patients were able to nominate a SP and 69 % (100/145) of nominated SPs were eligible and consented to the study. eINSPIRE groups had low reach (25 % of SPs attended), but high exposure (M = 7 of 10 sessions attended) and acceptability (classes helped them with their patient's OUD). The proportion of eINSPIRE patients (68 %) and UC patients (53 %) retained on buprenorphine at follow-up were similar (p = 0.203). SPs in both conditions reported similar reductions in their depression, anxiety, and impairment symptoms. CONCLUSIONS Preliminary data suggest that eINSPIRE groups may not be feasible in primary care without further adaptations for this population. A future study with a larger sample size is needed to elucidate the observed distribution differences in buprenorphine retention. Future research should also explore methods to reduce barriers to SP session attendance to improve the reach of this evidence-based intervention.
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Affiliation(s)
- Karen Chan Osilla
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1070 Arastradero Road, Palo Alto, CA 94304, United States.
| | - Jennifer K Manuel
- University of California San Francisco, Department of Psychiatry and Behavioral Sciences, 675 18th St, San Francisco, CA 94143, United States; San Francisco VA Health Care System, 4150 Clement St, San Francisco, CA 94121, United States
| | - Kirsten Becker
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, United States
| | - Katherine Nameth
- Stanford University School of Medicine, Department of Psychiatry and Behavioral Sciences, 1070 Arastradero Road, Palo Alto, CA 94304, United States
| | - Lane Burgette
- RAND Corporation, 1200 S Hayes St, Arlington, VA 22202, United States
| | - Allison J Ober
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, United States
| | - Maria DeYoreo
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, United States
| | | | - Brian Hurley
- University of California Los Angeles, Department of Family Medicine, 10833 Le Conte Avenue, Los Angeles, CA 90095, United States; County of Los Angeles, Department of Public Health, Bureau of Substance Abuse Prevention and Control 1000 S. Fremont Avenue, Alhambra, CA 91803, United States
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Rizk JG, Saini J, Kim K, Pathan U, Qato DM. County-level factors associated with a mismatch between opioid overdose mortality and availability of opioid treatment facilities. PLoS One 2024; 19:e0301863. [PMID: 38578818 PMCID: PMC10997118 DOI: 10.1371/journal.pone.0301863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/23/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Opioid overdose deaths in the United States remain a major public health crisis. Little is known about counties with high rates of opioid overdose mortality but low availability of opioid use disorder (OUD) treatment facilities. We sought to identify characteristics of United States (US) counties with high rates of opioid overdose mortality and low rates of opioid treatment facilities. METHODS Rates of overdose mortality from 3,130 US counties were compared with availability of opioid treatment facilities that prescribed or allowed medications for OUD (MOUD), from 2018-2019. The outcome variable, "risk-availability mismatch" county, was a binary indicator of a high rate (above national average) of opioid overdose mortality with a low (below national average) rate of opioid treatment facilities. Covariates of interest included county-level sociodemographics and rates of insurance, unemployment, educational attainment, poverty, urbanicity, opioid prescribing, depression, heart disease, Gini index, and Theil index. Multilevel logistic regression, accounting for the clustering of counties within states, was used to determine associations with being a "risk-availability mismatch" county. RESULTS Of 3,130 counties, 1,203 (38.4%) had high rates of opioid overdose mortality. A total of 1,098 counties (35.1%) lacked a publicly-available opioid treatment facility in 2019. In the adjusted model, counties with an additional 1% of: white residents (odds ratio, OR, 1.02; 95% CI, 1.01-1.03), unemployment (OR, 1.11; 95% CI, 1.05-1.19), and residents without insurance (OR, 1.04; 95% CI, 1.01-1.08) had increased odds of being a mismatch county. Counties that were metropolitan (versus non-metropolitan) had an increased odds of being a mismatch county (OR, 1.85; 95% CI, 1.45-2.38). CONCLUSION Assessing mismatch between treatment availability and need provides useful information to characterize counties that require greater public health investment. Interventions to reduce overdose mortality are unlikely to be effective if they do not take into account diverse upstream factors, including sociodemographics, disease burden, and geographic context of communities.
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Affiliation(s)
- John G. Rizk
- Department of Practice, Sciences and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Jannat Saini
- Department of Practice, Sciences and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Kyungha Kim
- Department of Practice, Sciences and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Uzma Pathan
- Department of Practice, Sciences and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Danya M. Qato
- Department of Practice, Sciences and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
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Haddad M, Coman E, Bifulco L. Nine-year substance use treatment outcomes with buprenorphine for opioid use disorder in a federally qualified health center. Drug Alcohol Depend 2024; 257:111252. [PMID: 38484404 DOI: 10.1016/j.drugalcdep.2024.111252] [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: 12/01/2023] [Revised: 02/23/2024] [Accepted: 02/24/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND Prescribing medication for opioid use disorder (MOUD) in primary care helps meet treatment demand, but few studies examine long-term treatment retention among medically-underserved primary care patients. METHODS This 9-year retrospective study assessed overall retention at 6 months, and yearly up to 9 years, among 1451 patients with at least 6 months of buprenorphine prescription data from a federally-qualified health center (FQHC). We also examined whether patients who had gaps in treatment (>14 days without medication) later returned to care. Associations with treatment retention over total time in care were assessed. RESULTS On average, patients received buprenorphine treatment for 2.26 years. Among patients who experienced gaps in treatment but returned to care within 90 days, 64% were still receiving buprenorphine at six months (n=930 of 1451), and 70% (n =118 of 169) at 9 years, with an average yearly interval retention of 69% (range: 58-74%). Patients were on MOUD treatment and not in a gap about 81% of the time, and averaged 1.0 gap per patient per year (SD: 1.09; range 0-7.87). The mean gap length over the treatment period was 33.16 days. Older age, higher percentages of negative opioid tests, negative cocaine tests, and positive buprenorphine tests, and having diabetes were associated with longer treatment retention. CONCLUSIONS Opioid use disorder (OUD) can be treated successfully in primary care FQHCs. Treatment gaps are common and reflect the chronic relapsing nature of OUD.
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Affiliation(s)
- Marwan Haddad
- Center for Key Populations, Community Health Center, Inc., 631 Main Street, Middletown, CT 06457, USA; Weitzman Institute, Moses-Weitzman Health System, 19 Grand Street, Middletown, CT 06457, USA.
| | - Emil Coman
- Health Disparities Institute, University of Connecticut School of Medicine, Hartford, CT 06106, USA
| | - Lauren Bifulco
- Weitzman Institute, Moses-Weitzman Health System, 19 Grand Street, Middletown, CT 06457, USA
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McLeman B, Gauthier P, Lester LS, Homsted F, Gardner V, Moore SK, Joudrey PJ, Saldana L, Cochran G, Harris JP, Hefner K, Chongsi E, Kramer K, Vena A, Ottesen RA, Gallant T, Boggis JS, Rao D, Page M, Cox N, Iandiorio M, Ambaah E, Ghitza U, Fiellin DA, Marsch LA. Implementing a pharmacist-integrated collaborative model of medication treatment for opioid use disorder in primary care: study design and methodological considerations. Addict Sci Clin Pract 2024; 19:18. [PMID: 38500166 PMCID: PMC10949656 DOI: 10.1186/s13722-024-00452-y] [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: 11/03/2023] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Pharmacists remain an underutilized resource in the treatment of opioid use disorder (OUD). Although studies have engaged pharmacists in dispensing medications for OUD (MOUD), few studies have evaluated collaborative care models in which pharmacists are an active, integrated part of a primary care team offering OUD care. METHODS This study seeks to implement a pharmacist integrated MOUD clinical model (called PrIMO) and evaluate its feasibility, acceptability, and impact across four diverse primary care sites. The Consolidated Framework for Implementation Research is used as an organizing framework for study development and interpretation of findings. Implementation Facilitation is used to support PrIMO adoption. We assess the primary outcome, the feasibility of implementing PrIMO, using the Stages of Implementation Completion (SIC). We evaluate the acceptability and impact of the PrIMO model at the sites using mixed-methods and combine survey and interview data from providers, pharmacists, pharmacy technicians, administrators, and patients receiving MOUD at the primary care sites with patient electronic health record data. We hypothesize that it is feasible to launch delivery of the PrIMO model (reach SIC Stage 6), and that it is acceptable, will positively impact patient outcomes 1 year post model launch (e.g., increased MOUD treatment retention, medication regimen adherence, service utilization for co-morbid conditions, and decreased substance use), and will increase each site's capacity to care for patients with MOUD (e.g., increased number of patients, number of prescribers, and rate of patients per prescriber). DISCUSSION This study will provide data on a pharmacist-integrated collaborative model of care for the treatment of OUD that may be feasible, acceptable to both site staff and patients and may favorably impact patients' access to MOUD and treatment outcomes. TRIAL REGISTRATION The study was registered on Clinicaltrials.gov (NCT05310786) on April 5, 2022, https://www. CLINICALTRIALS gov/study/NCT05310786?id=NCT05310786&rank=1.
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Affiliation(s)
- Bethany McLeman
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA.
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.
| | - Phoebe Gauthier
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Laurie S Lester
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | | | - Vernon Gardner
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
| | - Sarah K Moore
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Paul J Joudrey
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lisa Saldana
- Lighthouse Institute, Chestnut Health Systems, Eugene, OR, USA
| | - Gerald Cochran
- University of Utah, Salt Lake City, UT, USA
- Greater Intermountain Node, NIDA Drug Abuse Treatment Clinical Trials Network, Salt Lake City, UT, USA
| | | | | | | | | | | | | | - Tess Gallant
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Jesse S Boggis
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Deepika Rao
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | | | - Nicholas Cox
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | | | - Ekow Ambaah
- Harbor Care Health & Wellness, Nashua, NH, USA
| | - Udi Ghitza
- National Institute on Drug Abuse, North Bethesda, MD, USA
| | - David A Fiellin
- New England Consortium Node, NIDA Drug Abuse Treatment Clinical Trials Network, New Haven, CT, USA
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lisa A Marsch
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
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Chiu K, Pandya S, Sharma M, Hooimeyer A, de Souza A, Sud A. An international comparative policy analysis of opioid use disorder treatment in primary care across nine high-income jurisdictions. Health Policy 2024; 141:104993. [PMID: 38237202 DOI: 10.1016/j.healthpol.2024.104993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/09/2023] [Accepted: 01/09/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Opioid use disorder (OUD) and opioid-related harms are current health priorities in many high-income countries such as Canada. Opioid agonist therapy (OAT) is an effective evidence-based treatment for OUD, but access is often limited. AIMS To describe and compare OUD treatment policies across nine international jurisdictions, and to understand how they are situated within their primary care and health systems. METHODS Using policy documents, we collected data on health systems, drug use epidemiology, drug policies, and OUD treatment from Australia, Canada, France, Germany, Ireland, Portugal, Sweden, Switzerland, and Taiwan. We used the health system dynamics framework and adapted definitions of low- and high-threshold treatment to describe and compare OUD treatment policies, and to understand how they may be shaped by their health systems context. RESULTS Broad similarities across jurisdictions included the OAT pharmacological agents used and the need for supervised dosing; however, preferred OAT, treatment settings, primary care and specialist physicians' roles, and funding varied. Most jurisdictions had elements of lower-threshold treatment access, such as the availability of treatment through primary care and multiple OAT options, but the higher-threshold criteria of supervised dosing. CONCLUSIONS From the Canadian perspective, there are opportunities to improve accessibility of OUD care by drawing on how different jurisdictions incorporate multidisciplinary care, regulate OAT medications, remunerate healthcare professionals, and provide funding for services.
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Affiliation(s)
- Kellia Chiu
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
| | - Saloni Pandya
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Manu Sharma
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Alexandra de Souza
- Menzies Centre for Health Policy and Economics, The University of Sydney, Sydney, NSW, Australia
| | - Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Humber River Hospital, Toronto, ON, Canada.
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Austin EJ, O'Brien QE, Ruiz MS, Ratzliff AD, Williams EC, Koch U. Patient and Provider Perspectives on Processes of Engagement in Outpatient Treatment for Opioid Use Disorder: A Scoping Review. Community Ment Health J 2024; 60:330-339. [PMID: 37668745 DOI: 10.1007/s10597-023-01175-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 07/22/2023] [Indexed: 09/06/2023]
Abstract
Effective treatment for opioid use disorder (OUD) is available, but patient engagement is central to achieving care outcomes. We conducted a scoping review to describe patient and provider-reported strategies that may contribute to patient engagement in outpatient OUD care delivery. We searched PubMed and Scopus for articles reporting patient and/or provider experiences with outpatient OUD care delivery. Analysis included: (1) describing specific engagement strategies, (2) mapping strategies to patient-centered care domains, and (3) identifying themes that characterize the relationship between engagement and patient-centered care. Of 3,222 articles screened, 30 articles met inclusion criteria. Analysis identified 14 actionable strategies that facilitate patient engagement and map to all patient-centered care domains. Seven themes emerged that characterize interpersonal approaches to OUD care engagement. Interpersonal interactions between patients and providers play a pivotal role in encouraging engagement throughout OUD treatment. Future research is needed to further evaluate promising engagement strategies.
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Affiliation(s)
- Elizabeth J Austin
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Box 351621, Seattle, WA, 98105, USA.
- Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, D.C, USA.
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, D.C, USA.
| | - Quentin E O'Brien
- Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, D.C, USA
| | - Monica S Ruiz
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, D.C, USA
| | - Anna D Ratzliff
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
| | - Emily C Williams
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Box 351621, Seattle, WA, 98105, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, USA
| | - Ulrich Koch
- Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, D.C, USA
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Wartko PD, Bobb JF, Boudreau DM, Matthews AG, McCormack J, Lee AK, Qiu H, Yu O, Hyun N, Idu AE, Campbell CI, Saxon AJ, Liu DS, Altschuler A, Samet JH, Labelle CT, Zare-Mehrjerdi M, Stotts AL, Braciszewski JM, Murphy MT, Dryden D, Arnsten JH, Cunningham CO, Horigian VE, Szapocznik J, Glass JE, Caldeiro RM, Phillips RC, Shea M, Bart G, Schwartz RP, McNeely J, Liebschutz JM, Tsui JI, Merrill JO, Lapham GT, Addis M, Bradley KA, Ghiroli MM, Hamilton LK, Hu Y, LaHue JS, Loree AM, Murphy SM, Northrup TF, Shmueli-Blumberg D, Silva AJ, Weinstein ZM, Wong MT, Burganowski RP. Nurse Care Management for Opioid Use Disorder Treatment: The PROUD Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:1343-1354. [PMID: 37902748 PMCID: PMC10616772 DOI: 10.1001/jamainternmed.2023.5701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/01/2023] [Indexed: 10/31/2023]
Abstract
Importance Few primary care (PC) practices treat patients with medications for opioid use disorder (OUD) despite availability of effective treatments. Objective To assess whether implementation of the Massachusetts model of nurse care management for OUD in PC increases OUD treatment with buprenorphine or extended-release injectable naltrexone and secondarily decreases acute care utilization. Design, Setting, and Participants The Primary Care Opioid Use Disorders Treatment (PROUD) trial was a mixed-methods, implementation-effectiveness cluster randomized clinical trial conducted in 6 diverse health systems across 5 US states (New York, Florida, Michigan, Texas, and Washington). Two PC clinics in each system were randomized to intervention or usual care (UC) stratified by system (5 systems were notified on February 28, 2018, and 1 system with delayed data use agreement on August 31, 2018). Data were obtained from electronic health records and insurance claims. An implementation monitoring team collected qualitative data. Primary care patients were included if they were 16 to 90 years old and visited a participating clinic from up to 3 years before a system's randomization date through 2 years after. Intervention The PROUD intervention included 3 components: (1) salary for a full-time OUD nurse care manager; (2) training and technical assistance for nurse care managers; and (3) 3 or more PC clinicians agreeing to prescribe buprenorphine. Main Outcomes and Measures The primary outcome was a clinic-level measure of patient-years of OUD treatment (buprenorphine or extended-release injectable naltrexone) per 10 000 PC patients during the 2 years postrandomization (follow-up). The secondary outcome, among patients with OUD prerandomization, was a patient-level measure of the number of days of acute care utilization during follow-up. Results During the baseline period, a total of 130 623 patients were seen in intervention clinics (mean [SD] age, 48.6 [17.7] years; 59.7% female), and 159 459 patients were seen in UC clinics (mean [SD] age, 47.2 [17.5] years; 63.0% female). Intervention clinics provided 8.2 (95% CI, 5.4-∞) more patient-years of OUD treatment per 10 000 PC patients compared with UC clinics (P = .002). Most of the benefit accrued in 2 health systems and in patients new to clinics (5.8 [95% CI, 1.3-∞] more patient-years) or newly treated for OUD postrandomization (8.3 [95% CI, 4.3-∞] more patient-years). Qualitative data indicated that keys to successful implementation included broad commitment to treat OUD in PC from system leaders and PC teams, full financial coverage for OUD treatment, and straightforward pathways for patients to access nurse care managers. Acute care utilization did not differ between intervention and UC clinics (relative rate, 1.16; 95% CI, 0.47-2.92; P = .70). Conclusions and Relevance The PROUD cluster randomized clinical trial intervention meaningfully increased PC OUD treatment, albeit unevenly across health systems; however, it did not decrease acute care utilization among patients with OUD. Trial Registration ClinicalTrials.gov Identifier: NCT03407638.
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Affiliation(s)
- Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Biostatistics, School of Public Health, University of Washington, Seattle
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle
- Now with Genentech Inc, South San Francisco, California
| | | | | | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, Seattle
- Now with Kaiser Permanente Washington, Renton
| | - Hongxiang Qiu
- Kaiser Permanente Washington Health Research Institute, Seattle
- Now with Department of Epidemiology and Biostatistics, Michigan State University, East Lansing
| | - Onchee Yu
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Noorie Hyun
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Abisola E Idu
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, Washington
| | - David S Liu
- National Institute on Drug Abuse Center for Clinical Trials Network, North Bethesda, Maryland
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jeffrey H Samet
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Boston, Massachusetts
| | - Colleen T Labelle
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Boston, Massachusetts
| | - Mohammad Zare-Mehrjerdi
- Department of Family and Community Medicine, UTHealth Houston McGovern Medical School, Houston, Texas
| | - Angela L Stotts
- Department of Family and Community Medicine, UTHealth Houston McGovern Medical School, Houston, Texas
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | | | - Douglas Dryden
- MultiCare Health System, Tacoma, Washington
- Now with Mosaic Medical, Bend, Oregon
| | - Julia H Arnsten
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, Bronx, New York
- Now with New York State Office of Addiction Services and Supports, New York
| | - Viviana E Horigian
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida
| | - José Szapocznik
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Ryan M Caldeiro
- Mental Health and Wellness Department, Kaiser Permanente Washington, Renton
| | | | - Mary Shea
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Gavin Bart
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota
- University of Minnesota Medical School, Minneapolis
| | | | - Jennifer McNeely
- Department of Population Health, Grossman School of Medicine, New York University, New York
| | - Jane M Liebschutz
- Center for Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Judith I Tsui
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Joseph O Merrill
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle
| | - Megan Addis
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
- Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California
| | - Megan M Ghiroli
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Leah K Hamilton
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Yong Hu
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | | | - Amy M Loree
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Thomas F Northrup
- Department of Family and Community Medicine, UTHealth Houston McGovern Medical School, Houston, Texas
| | | | | | - Zoe M Weinstein
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Boston, Massachusetts
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Hodgkin D, Horgan CM, Jordan Brown S, Bart G, Stewart MT. Financial Sustainability of Novel Delivery Models in Behavioral Health Treatment. THE JOURNAL OF MENTAL HEALTH POLICY AND ECONOMICS 2023; 26:149-158. [PMID: 38113385 PMCID: PMC10752219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/26/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND In the US, much of the research into new intervention and delivery models for behavioral health care is funded by research institutes and foundations, typically through grants to develop and test the new interventions. The original grant funding is typically time-limited. This implies that eventually communities, clinicians, and others must find resources to replace the grant funding -otherwise the innovation will not be adopted. Diffusion is challenged by the continued dominance in the US of fee-for-service reimbursement, especially for behavioral health care. AIMS To understand the financial challenges to disseminating innovative behavioral health delivery models posed by fee-for-service reimbursement, and to explore alternative payment models that promise to accelerate adoption by better addressing need for flexibility and sustainability. METHODS We review US experience with three specific novel delivery models that emerged in recent years. The models are: collaborative care model for depression (CoCM), outpatient based opioid treatment (OBOT), and the certified community behavioral health clinic (CCBHC) model. These examples were selected as illustrating some common themes and some different issues affecting diffusion. For each model, we discuss its core components; evidence on its effectiveness and cost-effectiveness; how its dissemination was funded; how providers are paid; and what has been the uptake so far. RESULTS The collaborative care model has existed for longest, but has been slow to disseminate, due in part to a lack of billing codes for key components until recently. The OBOT model faced that problem, and also (until recently) a regulatory requirement requiring physicians to obtain federal waivers in order to prescribe buprenorphine. Similarly, the CCBHC model includes previously nonbillable services, but it appears to be diffusing more successfully than some other innovations, due in part to the approach taken by funders. DISCUSSION A common challenge for all three models has been their inclusion of services that were not (initially) reimbursable in a fee-for-service system. However, even establishing new procedure codes may not be enough to give providers the flexibility needed to implement these models, unless payers also implement alternative payment models. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE For providers who receive time-limited grant funding to implement these novel delivery models, one key lesson is the need to start early on planning how services will be sustained after the grant ends. IMPLICATIONS FOR HEALTH POLICY For research funders (e.g., federal agencies), it is clearly important to speed up the process of obtaining coverage for each novel delivery model, including the development of new billable service codes, and to plan for this as early as possible. Funders also need to collaborate with providers early in the grant period on sustainability planning for the post-grant environment. For payers, a key lesson is the need to fold novel models into stable existing funding streams such as Medicaid and commercial insurance coverage, rather than leaving them at the mercy of revolving time-limited grants, and to provide pathways for contracting for innovations under new payment models. IMPLICATIONS FOR FURTHER RESEARCH For researchers, a key recommendation would be to pay greater attention to the payment environment when designing new delivery models and interventions.
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Affiliation(s)
- Dominic Hodgkin
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts 02453, United States
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11
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Renda S, Eshkevari L, Glymph D, Knestrick J, Lundy KS, Ortiz M, Sharp D, Solari-Twadell PA, Valentine NM. Mobilizing nurses to address the opioid misuse epidemic. Nurs Outlook 2023; 71:102033. [PMID: 37769501 DOI: 10.1016/j.outlook.2023.102033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND The opioid epidemic is a major health challenge in the United States. PURPOSE Members from the American Academy of Nursing joined to write a consensus paper about nurses' role in the opioid epidemic. METHODS The panel reviewed the history of the opioid epidemic and policies to care for patients with opioid use disorder (OUD) and how registered nurses (RNs) and advanced practice nurses (APRNs) could increase care for people with OUD. DISCUSSION Recommendations are presented to advance policies that empower RNs and APRNs to abate the opioid epidemic. CONCLUSION Recommendations include (a) advance legislation that supports RNs and APRNs full scope of practice and expands professional role in pain management and addiction prevention; (b) evaluate effective policies that promote RN and APRN care; support federal elimination of X-waiver with state law alignment; (c) sustain the use of nurses in telemedicine; (d) support nursing research on nurse involvement in all aspects of OUD.
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Affiliation(s)
- Susan Renda
- Primary Care Expert Panel, American Academy of Nursing, Washington, DC.
| | - Ladan Eshkevari
- Psychiatric, Mental Health, and Substance Use Expert Panel, American Academy of Nursing, Washington, DC
| | - Derrick Glymph
- Psychiatric, Mental Health, and Substance Use Expert Panel, American Academy of Nursing, Washington, DC
| | - Joyce Knestrick
- Primary Care Expert Panel, American Academy of Nursing, Washington, DC
| | | | - Mario Ortiz
- Primary Care Expert Panel, American Academy of Nursing, Washington, DC
| | - Daryl Sharp
- Psychiatric, Mental Health, and Substance Use Expert Panel, American Academy of Nursing, Washington, DC
| | | | - Nancy M Valentine
- Psychiatric, Mental Health, and Substance Use Expert Panel, American Academy of Nursing, Washington, DC
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Tay Wee Teck J, Butner JL, Baldacchino A. Understanding the use of telemedicine across different opioid use disorder treatment models: A scoping review. J Telemed Telecare 2023:1357633X231195607. [PMID: 37661829 DOI: 10.1177/1357633x231195607] [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: 09/05/2023]
Abstract
INTRODUCTION The COVID-19 pandemic has instigated the development of telemedicine-mediated provision of medications for opioid use disorder such as buprenorphine and methadone, referred to as TMOUD in this study. As services start to return to pre-pandemic norms, there is a debate around the role of TMOUD as addition to or replacement of the conventional cascade of care for people with opioid use disorder (PWOUD). This scoping review is designed to characterize existing TMOUD services and provide insights to enable a more nuanced discussion on the role of telemedicine in the care of PWOUD. METHODS The literature search was conducted in OVID Medline, CINAHL, and PsycINFO, from inception up to and including April 2023, using the Joanna Briggs Institute methodology for scoping reviews. The review considered any study design that detailed sufficient descriptive information on a given TMOUD service. A data extraction form was developed to collect and categorize a range of descriptive characteristics of each discrete TMOUD model identified from the obtained articles. RESULTS A total of 45 articles met the inclusion criteria, and from this, 40 discrete TMOUD services were identified. In total, 33 services were US-based, three from Canada, and one each from India, Ireland, the UK, and Norway. Through a detailed analysis of TMOUD service characteristics, four models of care were identified. These were TMOUD to facilitate inclusion health, to facilitate transitions in care, to meet complex healthcare needs, and to maintain opioid use disorder (OUD) service resilience. CONCLUSIONS Characterizing TMOUD according to its functional benefits to PWOUD and OUD services will help support evidence-based policy and practice. Additionally, particular attention is given to how digital exclusion of PWOUD can be mitigated against.
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Affiliation(s)
- Joseph Tay Wee Teck
- DigitAS Project, Population and Behavioural Science, School of Medicine, University of St Andrews, St Andrews, UK
- Forward Leeds and Humankind Charity, Durham, UK
| | - Jenna L Butner
- Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Alex Baldacchino
- DigitAS Project, Population and Behavioural Science, School of Medicine, University of St Andrews, St Andrews, UK
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French R, Worley J, Lowenstein M, Bogner HR, Calderbank T, DePhilippis D, Forrest A, Gibbons MBC, Harris RA, Heywood S, Kampman K, Mandell DS, McKay JR, Newman ST, Oslin DW, Wadden S, Wolk CB. Adapting psychotherapy in collaborative care for treating opioid use disorder and co-occurring psychiatric conditions in primary care. FAMILIES, SYSTEMS & HEALTH : THE JOURNAL OF COLLABORATIVE FAMILY HEALTHCARE 2023; 41:377-388. [PMID: 37227828 PMCID: PMC10517081 DOI: 10.1037/fsh0000791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Opioid use disorder (OUD) and psychiatric conditions commonly co-occur yet are infrequently treated with evidence-based therapeutic approaches, resulting in poor outcomes. These conditions, separately, present challenges to treatment initiation, retention, and success. These challenges are compounded when individuals have OUD and psychiatric conditions. METHOD Recognizing the complex needs of these individuals, gaps in care, and the potential for primary care to bridge these gaps, we developed a psychotherapy program that integrates brief, evidence-based psychotherapies for substance use, depression, and anxiety, building on traditional elements of the Collaborative Care Model (CoCM). In this article, we describe this psychotherapy program in a primary care setting as part of a compendium of collaborative services. RESULTS Patients receive up to 12 sessions of evidence-based psychotherapy and case management based on a structured treatment manual that guides treatment via Motivational Enhancement; Cognitive Behavioral Therapies for depression, anxiety, and/or substance use disorder; and/or Behavioral Activation components. DISCUSSION Novel, integrated treatments are needed to advance service delivery for individuals with OUD and psychiatric conditions and these programs must be rigorously evaluated. We describe our team's efforts to test our psychotherapy program in a large primary care network as part of an ongoing three-arm randomized controlled trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Rachel French
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Julie Worley
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Margaret Lowenstein
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hillary R. Bogner
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Tara Calderbank
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Dominick DePhilippis
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- VA Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington DC, 20420, USA
| | - Andrew Forrest
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Mary Beth Connolly Gibbons
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rebecca Arden Harris
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Saida Heywood
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kyle Kampman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David S. Mandell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - James R. McKay
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
| | - Schyler Tristen Newman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David W. Oslin
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
| | - Steven Wadden
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Courtney Benjamin Wolk
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
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FISCELLA KEVIN, EPSTEIN RONALDM. The Profound Implications of the Meaning of Health for Health Care and Health Equity. Milbank Q 2023; 101:675-699. [PMID: 37343061 PMCID: PMC10509522 DOI: 10.1111/1468-0009.12660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 06/23/2023] Open
Abstract
Policy Points The meaning of health in health care remains poorly defined, defaulting to a narrow, biomedical disease model. A national dialogue could create a consensus regarding a holistic and humanized definition of health that promotes health care transformation and health equity. Key steps for operationalizing a holistic meaning of health in health care include national leadership by federal agencies, intersectoral collaborations that include diverse communities, organizational and cultural change in medical education, and implementation of high-quality primary care. The 2023 report by the National Academies of Sciences, Engineering, and Medicine on achieving whole health offers recommendations for action.
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Truong A, Kablinger A, Hartman C, Hartman D, West J, Hanlon A, Lozano A, McNamara R, Seidel R, Trestman R. Noninferiority Clinical Trial of Adapted START NOW Psychotherapy for Outpatient Opioid Treatment. RESEARCH SQUARE 2023:rs.3.rs-3229052. [PMID: 37609219 PMCID: PMC10441517 DOI: 10.21203/rs.3.rs-3229052/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
Background Medications for opioid use disorder (MOUD) such as buprenorphine is effective for treating opioid use disorder (OUD). START NOW (SN) is a manualized, skills-based group psychotherapy originally developed and validated for the correctional population and has been shown to result in reduced risk of disciplinary infractions and future psychiatric inpatient days with a dose response effect. We investigate whether adapted START NOW is effective for treating OUD in a MOUD office-based opioid treatment (OBOT) setting in this non-inferiority clinical trial. Methods Patients enrolled in once weekly buprenorphine/suboxone MOUD OBOT were eligible for enrollment in this study. Participants were cluster-randomized, individually-randomized, or not randomized into either START NOW psychotherapy or treatment-as-usual (TAU) for 32 weeks of therapy. Treatment effectiveness was measured as the number of groups attended, treatment duration, intensity of attendance, and overall drug use as determined by drug screens. Results 137 participants were quasi-randomized to participate in SN (n = 79) or TAU (n = 58). Participants receiving START NOW psychotherapy, when compared to TAU, had comparable number of groups attended (16.5 vs. 16.7, p = 0.80), treatment duration in weeks (24.1 vs. 23.8, p = 0.62), and intensity defined by number of groups attended divided by the number of weeks to last group (0.71 vs. 0.71, p = 0.90). SN compared to TAU also had similar rates of any positive drug screen result (81.0% vs. 91.4%, p = 0.16). This suggests that adapted START NOW is noninferior to TAU, or the standard of care at our institution, for treating opioid use disorder. Conclusion Adapted START NOW is an effective psychotherapy for treating OUD when paired with buprenorphine/naloxone in the outpatient group therapy setting. Always free and publicly available, START NOW psychotherapy, along with its clinician manual and training materials, are easily accessible and distributable and may be especially useful for low-resource settings in need of evidence-based psychotherapy.
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Nakaishi L, Sugden SG, Merlo G. Primary Care at the Intersection of Lifestyle Interventions and Unhealthy Substance Use. Am J Lifestyle Med 2023; 17:494-501. [PMID: 37426739 PMCID: PMC10328212 DOI: 10.1177/15598276221111047] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023] Open
Abstract
Primary care physicians are well-positioned to integrate lifestyle interventions into the management of patients with unhealthy substance use, who may also have mental and physical chronic health comorbidities. However, the COVID-19 pandemic exacerbated the U.S.'s poor state of health, revealing that its current approach to chronic disease management is neither effective nor sustainable. Today's full spectrum comprehensive care model requires an expanded toolkit. Lifestyle interventions broaden current treatment approaches and may enhance Addiction Medicine care. Primary care providers have the potential to have the greatest impact on unhealthy substance use care because they are experts in chronic disease management and their frontline accessibility minimizes healthcare barriers. Individuals with unhealthy substance use are at an increased risk of chronic physical conditions. Incorporating lifestyle interventions with unhealthy substance use care at every level of medicine, from medical school through practice, normalizes both as part of the standard care of medicine and will drive evidence-based best practices to support patients through prevention, treatment, and reversal of chronic diseases.
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Affiliation(s)
- Lindsay Nakaishi
- Family Medicine, University of Pittsburgh Medical Center St. Margaret, Pittsburgh, PA, USA (LN); Huntsman Mental Health Institute, Spencer Fox Eccles University of Utah School of Medicine, Salt Lake City, UT, USA (SS); and Psychiatry, NYU Grossman School of Medicine, Rory Meyers College of Nursing, New York University, New York, NY, USA (GM)
| | - Steven G Sugden
- Family Medicine, University of Pittsburgh Medical Center St. Margaret, Pittsburgh, PA, USA (LN); Huntsman Mental Health Institute, Spencer Fox Eccles University of Utah School of Medicine, Salt Lake City, UT, USA (SS); and Psychiatry, NYU Grossman School of Medicine, Rory Meyers College of Nursing, New York University, New York, NY, USA (GM)
| | - Gia Merlo
- Family Medicine, University of Pittsburgh Medical Center St. Margaret, Pittsburgh, PA, USA (LN); Huntsman Mental Health Institute, Spencer Fox Eccles University of Utah School of Medicine, Salt Lake City, UT, USA (SS); and Psychiatry, NYU Grossman School of Medicine, Rory Meyers College of Nursing, New York University, New York, NY, USA (GM)
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Guerra-Alejos BC, Kurz M, Min JE, Dale LM, Piske M, Bach P, Bruneau J, Gustafson P, Hu XJ, Kampman K, Korthuis PT, Loughin T, Maclure M, Platt RW, Siebert U, Socías ME, Wood E, Nosyk B. Comparative effectiveness of urine drug screening strategies alongside opioid agonist treatment in British Columbia, Canada: a population-based observational study protocol. BMJ Open 2023; 13:e068729. [PMID: 37258082 PMCID: PMC10255039 DOI: 10.1136/bmjopen-2022-068729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Urine drug tests (UDTs) are commonly used for monitoring opioid agonist treatment (OAT) responses, supporting the clinical decision for take-home doses and monitoring potential diversion. However, there is limited evidence supporting the utility of mandatory UDTs-particularly the impact of UDT frequency on OAT retention. Real-world evidence can inform patient-centred approaches to OAT and improve current strategies to address the ongoing opioid public health emergency. Our objective is to determine the safety and comparative effectiveness of alternative UDT monitoring strategies as observed in clinical practice among OAT clients in British Columbia, Canada from 2010 to 2020. METHODS AND ANALYSIS We propose a population-level retrospective cohort study of all individuals 18 years of age or older who initiated OAT from 1 January 2010 to 17 March 2020. The study will draw on eight linked health administrative databases from British Columbia. Our primary outcomes include OAT discontinuation and all-cause mortality. To determine the effectiveness of the intervention, we will emulate a 'per-protocol' target trial using a clone censoring approach to compare fixed and dynamic UDT monitoring strategies. A range of sensitivity analyses will be executed to determine the robustness of our results. ETHICS AND DISSEMINATION The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.
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Affiliation(s)
- B Carolina Guerra-Alejos
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Laura M Dale
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Micah Piske
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Paxton Bach
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Julie Bruneau
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, Québec, Canada
- Research Center, Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Paul Gustafson
- Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - X Joan Hu
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Kyle Kampman
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - P Todd Korthuis
- School of Public Health, OHSU-PSU, Portland, Oregon, USA
- Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Tom Loughin
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert W Platt
- Departments of Epidemiology, Biostatistics, and Occupational Health and of Pediatrics, McGill University, Montreal, Québec, Canada
| | - U Siebert
- Center for Health Decision Science, Department of Health Policy and Management, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Public Health, Health Services Research and Health Technology Assessment, Private University of Health Sciences Medical Informatics and Technology Hall/Tyrol Institute for Health Information Systems, Hall in Tirol, Austria
| | - M Eugenia Socías
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Evan Wood
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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18
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Hempel S, Ganz D, Saluja S, Bolshakova M, Kim T, Turvey C, Cordasco K, Basu A, Page T, Mahmood R, Motala A, Barnard J, Wong M, Fu N, Miake-Lye IM. Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel. BMJ Open 2023; 13:e060232. [PMID: 37197809 DOI: 10.1136/bmjopen-2021-060232] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/19/2023] Open
Abstract
OBJECTIVE For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy. DESIGN The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys. SETTING The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care. PARTICIPANTS The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems. OUTCOME MEASURES The study planned to formulate a research agenda, implications for practice and recommendations for policy. RESULTS For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients. CONCLUSIONS Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.
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Affiliation(s)
- Susanne Hempel
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - David Ganz
- Geriatrics Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California, USA
| | - Sonali Saluja
- Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, California, USA
| | - Maria Bolshakova
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - Timothy Kim
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Carolyn Turvey
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine at the University of Iowa, Iowa City, Iowa, USA
- Rural Health Resource Center, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
| | - Kristina Cordasco
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Aashna Basu
- Department of Medicine, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California, USA
- Care in the Community Service, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Tonya Page
- Office of Community, Clinical Integration & Field Support, Veteran Affairs Central Office, Kentucky City, Kentucky, USA
| | - Reshma Mahmood
- Santa Maria and San Luis Obispo Community Outpatient Clinics, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Aneesa Motala
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - Jenny Barnard
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Michelle Wong
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ning Fu
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
- School of Public Administration and Emergency Management, Jinan University, Guangzhou, Guangdong, China
| | - Isomi M Miake-Lye
- VA West Los Angeles Evidence-based Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
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19
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Nguyen T, Cheetham TC, Fawaz S, Beuttler R, Xavioer S. Factors Affecting Initiation and Retention of Medication-Assisted Recovery (MAR) within a Pilot Pharmacist-Involved Practice Model at a Federally Qualified Healthcare Center (FQHC) during the COVID-19 Pandemic. Healthcare (Basel) 2023; 11:healthcare11101393. [PMID: 37239679 DOI: 10.3390/healthcare11101393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 04/28/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND During the COVID-19 pandemic, opioid-related overdose deaths increased. Although Medication-Assisted Treatment or Recovery (MAT or MAR) is available, initiation and retention rates vary. The goal of this study was to evaluate clinical, demographic, and Social Determinant of Health factors affecting MAR initiation, on-time initiation of medications, and successful retention in the program. The secondary goal was to evaluate the impact of a novel interprofessional practice model incorporating pharmacists. METHODS A retrospective analysis was conducted using electronic health record data from a pilot MAR Program initiated within a California Federally Qualified Healthcare Center. RESULTS From September 2019 to August 2020, 48 patients enrolled into the program. On-time initiation of medications occurred in 68% of patients and average program retention was 96.4 ± 95.8 days. Patients currently using opioids (p = 0.005) and those receiving supportive medications (p = 0.049) had lower odds of on-time MAR initiation. There were no statistically significant factors associated with successful retention in the program. The number of visits with members of the interprofessional team did not significantly affect on-time initiation or successful retention. CONCLUSIONS Current opioid use and receipt of supportive medications were associated with lower on-time medication initiation. Further studies are warranted to explore additional factors which may affect initiation and retention.
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Affiliation(s)
- Tiffany Nguyen
- Department of Pharmacy Administration, Institute for Health Equity, AltaMed Health Services, Los Angeles, CA 90040, USA
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, CA 92618, USA
| | | | - Souhiela Fawaz
- Department of Biomedical and Pharmaceutical Sciences, Chapman University School of Pharmacy, Irvine, CA 92618, USA
| | | | - Sharon Xavioer
- Department of Pharmacy Practice, Chapman University School of Pharmacy, Irvine, CA 92618, USA
- HIV Services, AltaMed Health Services, Anaheim, CA 92801, USA
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20
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Nguyen DB, Nguyen TT, Lin C, Dinh TTT, Le GM, Li L. Challenges of methadone maintenance treatment decentralisation from Vietnamese primary care providers' perspectives. Drug Alcohol Rev 2023; 42:803-814. [PMID: 36851865 PMCID: PMC10191884 DOI: 10.1111/dar.13613] [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: 11/18/2021] [Revised: 12/07/2022] [Accepted: 12/29/2022] [Indexed: 03/01/2023]
Abstract
INTRODUCTION Decentralising methadone maintenance treatment to primary care improves patients' access to care and their drug and HIV treatment outcomes. However, primary care providers (PCP), especially those working in limited-resource settings, are facing great challenges to provide quality methadone treatment. This study explores the challenges perceived by PCP providing methadone treatment at commune health centres in a mountainous region in Vietnam. METHOD We conducted in-depth interviews with 26 PCP who worked as program managers, physicians, counsellors, pharmacists and medication dispensing staff at the methadone programs of eight commune health centres in Dien Bien, Vietnam, in November and December 2019. We used the health-care system framework in developing the interview guides and in summarising data themes. RESULTS Participants identified major challenges in providing methadone treatment in commune health centres at the individual, clinic and environmental levels. Individual-level challenges included a lack of confidence and motivation in providing methadone treatment. Clinic-level factors included inadequate human resources, lack of institutional support, insufficient technical support, lack of referral resources and additional support for patients. Environment-level factors comprised a lack of reasonable policies on financial support for providers at commune health centres for providing methadone treatment, lack of regulations and mechanisms to ensure providers' safety in case of potential violence by patients and to share responsibility for overdose during treatment. DISCUSSION AND CONCLUSION PCP in Vietnam faced multi-level challenges in providing quality methadone treatment. Supportive policies and additional resources are needed to ensure the effectiveness of the decentralisation program.
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Affiliation(s)
- Diep Bich Nguyen
- Center for Training and Research on Substance Abuse and HIV/AIDS, Hanoi Medical University, Hanoi, Vietnam
- Department of Epidemiology, Institute of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Trang Thu Nguyen
- Center for Training and Research on Substance Abuse and HIV/AIDS, Hanoi Medical University, Hanoi, Vietnam
| | - Chunqing Lin
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience & Human Behavior, University of California Los Angeles, Los Angeles, USA
| | - Thuy Thi Thanh Dinh
- Center for Training and Research on Substance Abuse and HIV/AIDS, Hanoi Medical University, Hanoi, Vietnam
| | - Giang Minh Le
- Center for Training and Research on Substance Abuse and HIV/AIDS, Hanoi Medical University, Hanoi, Vietnam
- Department of Epidemiology, Institute of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam
| | - Li Li
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience & Human Behavior, University of California Los Angeles, Los Angeles, USA
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21
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Jawa R, Tin Y, Nall S, Calcaterra SL, Savinkina A, Marks LR, Kimmel SD, Linas BP, Barocas JA. Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics. JAMA Netw Open 2023; 6:e237888. [PMID: 37043198 PMCID: PMC10098970 DOI: 10.1001/jamanetworkopen.2023.7888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/28/2023] [Indexed: 04/13/2023] Open
Abstract
Importance US primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown. Objective To estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids. Design, Setting, and Participants In this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort. Main Outcomes and Measures Life-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs). Results The simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000. Conclusions and Relevance This modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.
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Affiliation(s)
- Raagini Jawa
- Section of General Internal Medicine, Center for Research on Healthcare, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Yjuliana Tin
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Samantha Nall
- Division of General Internal Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Susan L. Calcaterra
- Division of Hospital Medicine, University of Colorado Anschutz Medical Campus, Aurora
| | - Alexandra Savinkina
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Laura R. Marks
- Division of Infectious Diseases, School of Medicine, Washington University in St Louis, Missouri
| | - Simeon D. Kimmel
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Benjamin P. Linas
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Joshua A. Barocas
- Divisions of General Internal Medicine and Infectious Diseases, University of Colorado Anschutz Medical Campus, Aurora
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22
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Li L, Nguyen TA, Liang LJ, Lin C, Pham TH, Nguyen HTT, Kha S. Strengthening Addiction Care Continuum Through Community Consortium in Vietnam: Protocol for a Cluster-Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e44219. [PMID: 36947125 PMCID: PMC10131887 DOI: 10.2196/44219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/01/2023] [Accepted: 01/24/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND A chronic condition, drug addiction, requires long-term multipronged health care and treatment services. Community-based approaches can offer the advantages of managing integrated care along the care continuum and improving clinical outcomes. However, scant rigorous research focuses on sustainable, community-based care and service delivery. OBJECTIVE This protocol describes a study aiming to develop and test an intervention that features the alliance of community health workers and family members to provide integrated support and individualized services and treatment for people who use drugs (PWUD) in community settings. METHODS Based on the National Institute on Drug Abuse's Seek-Test-Treat-Retain (STTR) framework, an intervention that provides training to community health workers will be developed and piloted before an intervention trial. Trained community health workers will conduct home visits and provide support for PWUD and their families. The intervention trial will be conducted in 3 regions in Vietnam, with 60 communities (named communes). These communes will be randomized to either an intervention or control condition. Intervention outcomes will be evaluated at baseline and at 3, 6, 9, and 12 months. The primary outcome measure is PWUD's STTR fulfillment, consisting of multiple individual fulfillment indicators across 5 domains: Seek, Test, Treat, Retain, and Health. The secondary outcomes of interest are the community health workers' service provision and family members' support. The primary analysis will follow an intention-to-treat approach. Generalized mixed-effects regression models will be used to compare changes in the outcome measures from baseline between intervention and control conditions. RESULTS During the first year of the project, we conducted formative studies, including in-depth interviews and focus groups, to identify service barriers and intervention strategies. The intervention and assessment pilots are scheduled in 2023 before commencing the trial. Reports based on the baseline data will be distributed in early 2024. The intervention outcome results will be available within 6 months of the final data collection date, that is, the main study findings are expected to be available in early 2026. CONCLUSIONS This study will inform the establishment of community health workers and family members alliance, a locally available infrastructure, to support addiction services and care for PWUD. The methodology, findings, and lessons learned are expected to shed light on the addiction service continuum's implementation and demonstrate a community-based addiction service delivery model that can be transferable to other countries. TRIAL REGISTRATION ClinicalTrials.gov NCT05315492; https://clinicaltrials.gov/ct2/show/NCT05315492. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/44219.
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Affiliation(s)
- Li Li
- University of California, Los Angeles, Los Angeles, CA, United States
| | - Tuan Anh Nguyen
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | - Li-Jung Liang
- University of California, Los Angeles, Los Angeles, CA, United States
| | - Chunqing Lin
- University of California, Los Angeles, Los Angeles, CA, United States
| | - Thang Hong Pham
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | | | - Steven Kha
- University of California, Los Angeles, Los Angeles, CA, United States
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23
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Klusaritz H, Bilger A, Paterson E, Summers C, Barg FK, Cronholm PF, Saine ME, Sochalski J, Doubeni CA. Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative. Ann Fam Med 2023; 21:S31-S38. [PMID: 36849482 PMCID: PMC9970664 DOI: 10.1370/afm.2920] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/03/2022] [Accepted: 10/12/2022] [Indexed: 03/01/2023] Open
Abstract
PURPOSE We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs. METHODS We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data. RESULTS Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients. CONCLUSIONS OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.
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Affiliation(s)
- Heather Klusaritz
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrea Bilger
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Emily Paterson
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Courtney Summers
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frances K Barg
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter F Cronholm
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, Pennsylvania
| | - M Elle Saine
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julie Sochalski
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chyke A Doubeni
- The National Center for Integrated Behavioral Health in Primary Care, Rochester, Minnesota and Philadelphia, Pennsylvania .,Department of Family and Community Medicine, The Ohio State University, Columbus, Ohio
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24
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Reed MK, Smith KR, Ciocco F, Hass RW, Cox AL, Kelly EL, Weinstein LC. Sorting through life: evaluating patient-important measures of success in a medication for opioid use disorder (MOUD) treatment program. Subst Abuse Treat Prev Policy 2023; 18:4. [PMID: 36641478 PMCID: PMC9839958 DOI: 10.1186/s13011-022-00510-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/22/2022] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Medication for opioid use disorder (MOUD) is the gold standard treatment for opioid use disorder. Traditionally, "success" in MOUD treatment is measured in terms of program retention, adherence to MOUD, and abstinence from opioid and other drug use. While clinically meaningful, these metrics may overlook other aspects of the lives of people with opioid use disorder (OUD) and surprisingly do not reflect the diagnostic criteria for OUD. METHODS Authors identified items for a pilesorting task to identify participant-driven measures of MOUD treatment success through semi-structured interviews. Interviews were transcribed verbatim and coded in Nvivo using directed and conventional content analysis to identify measures related to treatment success and quality of life goals. Participants of a low-threshold MOUD program were recruited and asked to rank identified measures in order of importance to their own lives. Multidimensional scaling (MDS) compared the similarity of items while non-metric MDS in R specified a two-dimensional solution. Descriptive statistics of participant demographics were generated in SPSS. RESULTS Sixteen semi-structured interviews were conducted between June and August 2020 in Philadelphia, PA, USA, and 23 measures were identified for a pilesorting activity. These were combined with 6 traditional measures for a total list of 29 items. Data from 28 people were included in pilesorting analysis. Participants identified a combination of traditional and stakeholder-defined recovery goals as highly important, however, we identified discrepancies between the most frequent and highest ranked items within the importance categories. Measures of success for participants in MOUD programs were complex, multi-dimensional, and varied by the individual. However, some key domains such as emotional well-being, decreased drug use, and attendance to basic functioning may have universal importance. The following clusters of importance were identified: emotional well-being, decreased drug use, and human functioning. CONCLUSIONS Outcomes from this research have practical applications for those working to provide services in MOUD programs. Programs can use aspects of these domains to both provide patient-centered care and to evaluate success. Specifics from the pilesorting results may also inform approaches to collaborative goal setting during treatment.
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Affiliation(s)
- Megan K. Reed
- grid.265008.90000 0001 2166 5843Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 704, PA 19107 Philadelphia, USA ,grid.265008.90000 0001 2166 5843Center for Connected Care, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA ,grid.265008.90000 0001 2166 5843Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA USA
| | - Kelsey R. Smith
- grid.265008.90000 0001 2166 5843Department of Family and Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Francesca Ciocco
- grid.265008.90000 0001 2166 5843Department of Family and Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Richard W. Hass
- grid.265008.90000 0001 2166 5843Jefferson College of Population Health, Thomas Jefferson University, Philadelphia, PA USA ,grid.265008.90000 0001 2166 5843Jefferson Center for Interprofessional Practice and Education, Thomas Jefferson University, Philadelphia, PA USA
| | - Avery Lin Cox
- grid.265008.90000 0001 2166 5843Department of Family and Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Erin L. Kelly
- grid.265008.90000 0001 2166 5843Department of Family and Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
| | - Lara C. Weinstein
- grid.265008.90000 0001 2166 5843Department of Family and Community Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA USA
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25
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Torres-Leguizamon M, Favaro J, Coello D, Reynaud EG, Néfau T, Duplessy C. Remote harm reduction services are key solutions to reduce the impact of COVID-19-like crises on people who use drugs: evidence from two independent structures in France and in the USA. Harm Reduct J 2023; 20:1. [PMID: 36611167 PMCID: PMC9823260 DOI: 10.1186/s12954-023-00732-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 01/03/2023] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Harm Reduction (HR) policies for People Who Use Drugs (PWUD) have a significant positive impact on their health. Such approaches limit the spread of infections and reduce opioid overdose mortality. These policies have led to the opening of specialized structures located mainly in big cities and urbanized zones. The COVID-19 pandemic reduced access to HR structures in locations undergoing lockdown. Before the pandemic, HR services in France and in the USA were complemented by the development of remote HR programs: HaRePo (Harm Reduction by Post) for France, implemented in 2011, and NEXT Distro for the USA founded in 2017. These programs are free and specifically designed for people who have difficulties accessing HR tools and counseling in-person. PWUD can access HaRePo program by phone and/or email. NEXT Distro users can access the program through its dedicated website. The aim of the study is to test if and possibly how COVID-19 pandemic and the associated lockdowns have impacted the HR services in both countries. METHODS By using t-test comparing the year 2019 with the year 2020, we analyzed how lockdowns impacted the number of new users entering the programs, as well as the numbers of parcels sent and naloxone distributed, by using records of both structures. RESULTS We showed that the activity of both programs was significantly impacted by the pandemic. Both show an increase in the number of new users joining the programs (+ 77.6% for HaRePo and + 247.7% for NEXT Distro) as well as for the number of parcels sent per month (+ 42.7% for HaRePo and + 211.3% for NEXT Distro). It shows that remote HR was able to partially compensate for the reduced HR activities due to COVID-19. We also observed that the distribution of naloxone per parcel tends to increase for both structures. CONCLUSION With the ability to reach PWUD remotely, HaRePo and NEXT Distro were particularly effective at maintaining service continuity and scaling up services to meet the needs of PWUD during the COVID-19 pandemic. By studying two independent structures in France and in the USA sharing similar objectives (remote HR), we showed that this approach can be a key solution to crises that impact classical HR structures despite various differences in operating procedures between countries.
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Affiliation(s)
| | | | | | - Emmanuel G. Reynaud
- grid.7886.10000 0001 0768 2743School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Thomas Néfau
- SAFE, 11 Avenue de la Porte de la Plaine, 75015 Paris, France
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Hooker SA, Crain AL, LaFrance AB, Kane S, Fokuo JK, Bart G, Rossom RC. A randomized controlled trial of an intervention to reduce stigma toward people with opioid use disorder among primary care clinicians. Addict Sci Clin Pract 2023; 18:10. [PMID: 36774521 PMCID: PMC9922036 DOI: 10.1186/s13722-023-00366-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 02/02/2023] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND Many primary care clinicians (PCCs) hold stigma toward people with opioid use disorder (OUD), which may be a barrier to care. Few interventions exist to address PCC stigma toward people with OUD. This study examined whether an online training incorporating patient narratives reduced PCCs' stigma toward people with OUD (primary) and increased intentions to treat people with OUD compared to an attention-control training (secondary). METHODS PCCs from 15 primary care clinics were invited to complete a 30 min online training for an electronic health record-embedded clinical decision support (CDS) tool that alerts PCCs to screen, diagnose, and treat people with OUD. PCCs were randomized to receive a stigma-reduction version of the training with patient narrative videos or a control training without patient narratives and were blinded to group assignment. Immediately after the training, PCCs completed surveys of stigma towards people with OUD and intentions and willingness to treat OUD. CDS tool use was monitored for 6 months. Analyses included independent samples t-tests, Pearson correlations, and logistic regression. RESULTS A total of 162 PCCs were randomized; 88 PCCs (58% female; 68% white) completed the training (Stigma = 48; Control = 40) and were included in analyses. There was no significant difference between intervention and control groups for stigma (t = - 0.48, p = .64, Cohen's d = - 0.11), intention to get waivered (t = 1.11, p = .27, d = 0.26), or intention to prescribe buprenorphine if a waiver were no longer required (t = 0.90, p = 0.37, d = 0.21). PCCs who reported greater stigma reported lower intentions both to get waivered (r = - 0.25, p = 0.03) and to prescribe buprenorphine with no waiver (r = - 0.25, p = 0.03). Intervention group and self-reported stigma were not significantly related to CDS tool use. CONCLUSIONS Stigma toward people with OUD may require more robust intervention than this brief training was able to accomplish. However, stigma was related to lower intentions to treat people with OUD, suggesting stigma acts as a barrier to care. Future work should identify effective interventions to reduce stigma among PCCs. TRIAL REGISTRATION ClinicalTrials.gov NCT04867382. Registered 30 April 2021-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04867382.
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Affiliation(s)
- Stephanie A. Hooker
- grid.280625.b0000 0004 0461 4886Research and Evaluation Division, HealthPartners Institute, 8170 33rdAve S, Mail stop 21112R, Minneapolis, MN 55440 USA
| | - A. Lauren Crain
- grid.280625.b0000 0004 0461 4886Research and Evaluation Division, HealthPartners Institute, 8170 33rdAve S, Mail stop 21112R, Minneapolis, MN 55440 USA
| | - Amy B. LaFrance
- grid.280625.b0000 0004 0461 4886Research and Evaluation Division, HealthPartners Institute, 8170 33rdAve S, Mail stop 21112R, Minneapolis, MN 55440 USA
| | - Sheryl Kane
- grid.280625.b0000 0004 0461 4886Research and Evaluation Division, HealthPartners Institute, 8170 33rdAve S, Mail stop 21112R, Minneapolis, MN 55440 USA
| | - J. Konadu Fokuo
- grid.185648.60000 0001 2175 0319Department of Psychiatry, University of Illinois at Chicago, Chicago, IL USA
| | - Gavin Bart
- Division of Addiction Medicine, Hennepin Healthcare, Minneapolis, MN USA
| | - Rebecca C. Rossom
- grid.280625.b0000 0004 0461 4886Research and Evaluation Division, HealthPartners Institute, 8170 33rdAve S, Mail stop 21112R, Minneapolis, MN 55440 USA
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Hyland CJ, McDowell MJ, Bain PA, Huskamp HA, Busch AB. Integration of pharmacotherapy for alcohol use disorder treatment in primary care settings: A scoping review. J Subst Abuse Treat 2023; 144:108919. [PMID: 36332528 PMCID: PMC10321472 DOI: 10.1016/j.jsat.2022.108919] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 09/01/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Alcohol use disorder (AUD) represents the most prevalent addiction in the United States. Integration of AUD treatment in primary care settings would expand care access. The objective of this scoping review is to examine models of AUD treatment in primary care that include pharmacotherapy (acamprosate, disulfiram, naltrexone). METHODS The team undertook a search across MEDLINE, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials, and Web of Science on May 21, 2021. Eligibility criteria included: patient population ≥ 18 years old, primary care-based setting, US-based study, presence of an intervention to promote AUD treatment, and prescription of FDA-approved AUD pharmacotherapy. Study design was limited to controlled trials and observational studies. We assessed study bias using a modified Oxford Centre for Evidence-based Medicine Rating Framework quality rating scheme. RESULTS The qualitative synthesis included forty-seven papers, representing 25 primary studies. Primary study sample sizes ranged from 24 to 830,825 participants and many (44 %) were randomized controlled trials. Most studies (80 %) included a nonpharmacologic intervention for AUD: 56 % with brief intervention, 40 % with motivational interviewing, and 12 % with motivational enhancement therapy. A plurality of studies (48 %) included mixed pharmacologic interventions, with administration of any combination of naltrexone, acamprosate, and/or disulfiram. Of the 47 total studies included, 68 % assessed care initiation and engagement. Fewer studies (15 %) explored practices surrounding screening for or diagnosing AUD. Outcome measures included receipt of pharmacotherapy and alcohol consumption, which about half of studies included (53 % and 51 %, respectively). Many of these outcomes showed significant findings in favor of integrated care models for AUD. CONCLUSIONS The integration of AUD pharmacotherapy in primary care settings may be associated with improved process and outcome measures of care. Future research should seek to understand the varied experiences across care integration models.
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Affiliation(s)
- Colby J Hyland
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, United States of America.
| | - Michal J McDowell
- Department of Psychiatry, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114, United States of America
| | - Paul A Bain
- Countway Library of Medicine, Harvard Medical School, 10 Shattuck Street, Boston, MA 02115, United States of America.
| | - Haiden A Huskamp
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, United States of America.
| | - Alisa B Busch
- Department of Health Care Policy, Harvard Medical School, 180 Longwood Avenue, Boston, MA 02115, United States of America; McLean Hospital, Harvard Medical School, 115 Mill Street, Belmont, MA 02478, United States of America.
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Bartholomew JB, Bute JJ. Exploring Internal Medicine Interns' Educational Experiences on Opioid Addiction: A Narrative Analysis. HEALTH COMMUNICATION 2023; 38:169-176. [PMID: 34114896 DOI: 10.1080/10410236.2021.1939232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Increased efforts to educate physicians on addiction are crucial based on widespread addiction rates and the ongoing opioid crisis. Physicians in the United States hesitate to adopt medication-assisted treatment (MAT) due to a lack of addiction education. For this study, we used a narrative framework to understand how internal medicine interns (first-year residents) recount their educational experiences on addiction during their medical school education and early residency. In using a sensemaking function, our results revealed four types of narratives: dearth, futility, priority, and impact. We found that the narratives were interrelated and indicated that interns understood addiction as a disease yet felt unprepared to treat it. We also discovered that interns did not fully appreciate the nuances of addiction. Their attempts to engage patients in substance recovery or reduction were often unsuccessful, leaving them feeling disappointed. Interns had mixed feelings when working with addiction-related issues as patients' addiction was rarely ever addressed. Interns also encountered "eye-opening" events leaving them astonished. Thus, shaping their views on the opioid crisis, and by extension, addiction. Increasing medical students' and residents' competency through practical education and training may improve physician comfort and confidence leading to the adoption of opioid addiction treatment such as MAT, potentially reducing the opioid epidemic.
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Affiliation(s)
| | - Jennifer J Bute
- Department of Communication Studies, Indiana University-Purdue University
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Jones AL, Kelley AT, Suo Y, Baylis JD, Codell NK, West NA, Gordon AJ. Trends in Health Service Utilization After Enrollment in an Interdisciplinary Primary Care Clinic for Veterans with Addiction, Social Determinants of Health, or Other Vulnerabilities. J Gen Intern Med 2023; 38:12-20. [PMID: 35194740 PMCID: PMC8862702 DOI: 10.1007/s11606-022-07456-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/03/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Models of interdisciplinary primary care (IPC) may improve upon traditional primary care approaches in addressing addiction and social determinants of health. OBJECTIVE To compare the trends in health care utilization in the year before and after enrollment in an IPC clinic model, and explore the variations in temporal patterns for patients with histories of high emergency department (ED) use, homelessness, and/or substance use disorders (SUDs). DESIGN AND PARTICIPANTS Interrupted time series study of utilization among IPC patients. MAIN MEASURES Quarterly ED, inpatient, primary care, and behavioral health visits were abstracted from administrative data before and after IPC enrollment. Negative binomial segmented regressions estimated changes in health care utilization over time. We used interactions to test for statistical differences in temporal patterns for IPC subgroups. RESULTS Among IPC patients (n=994), enrollment was associated with overall reductions in ED, inpatient, and behavioral health visits (p's<0.001) and increases in primary care (p's<0.001). Temporal patterns of ED visits, hospitalizations, and behavioral health differed across IPC subgroups (interaction p's<0.001). For those with histories of high ED use (n=265), ED, inpatient, and behavioral health visits decreased after enrollment (level change incidence rate ratios [IRRs]=0.57-0.69) and continued to decline over time (post-enrollment IRRs=0.80-0.88). Among other patients with homeless experiences (n=123), there were initial declines in hospitalizations (IRR=0.33) and overall declines in behavioral health visits (level change and post-enrollment IRRs=0.46-0.94). Other patients with SUDs had initial declines in hospitalizations (IRR=0.46), and post-enrollment declines in rates of specialty SUD visits (IRR=0.92). For all patients, primary care visits initially increased (level change IIRs=2.47-1.34) then gradually declined (post-enrollment IRRs=0.92-0.92). CONCLUSIONS An IPC model of care reduces acute care and behavioral health service use, particularly for patients with historically high ED use. IPC models may improve patient and system outcomes of vulnerable patient populations with social, clinical, and addiction morbidities.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - A Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ying Suo
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jacob D Baylis
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nodira K Codell
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nancy A West
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Greater Intermountain Node (GIN) of the NIDA Clinical Trials Network, University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
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Pashchenko O, Bromberg DJ, Dumchev K, LaMonaca K, Pykalo I, Filippovych M, Esserman D, Polonsky M, Galvez de Leon SJ, Morozova O, Dvoriak S, Altice FL. Preliminary analysis of self-reported quality health indicators of patients on opioid agonist therapy at specialty and primary care clinics in Ukraine: A randomized control trial. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000344. [PMID: 36962514 PMCID: PMC10021202 DOI: 10.1371/journal.pgph.0000344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 08/29/2022] [Indexed: 11/07/2022]
Abstract
International agencies recommend integrating addiction treatment into primary care for people who inject drugs (PWID) with opioid use disorder (OUD). Empirical data supporting integration that incorporates comprehensive health outcomes, however, are not known. For this randomized controlled trial in Ukraine, adult PWID with OUD were randomized to receive opioid agonist therapy (OAT) in specialty addiction treatment clinics (SATC) or to primary care clinics (PCCs). For those randomized to PCC, they were subsequently allocated to PCCs where clinicians received pay-for-performance (P4P) incentives (PCC with P4P) or not (PCC without P4P). Participating cities had one of each of the three intervention sites to control for geographic variation. Ongoing tele-education specialty training (OAT, HIV, tuberculosis) was provided to all PCCs. While the primary outcome for the parent trial focuses on patient medical record data, this preliminary analysis focuses on assessment of self-reported achievement of nationally recommended quality health indicators (QHIs) which is summed as a composite QHI score. Secondary outcomes included specialty and primary care QHI subscores. This study occurred from 01/20/2018-11/1/2020 with 818 of 990 randomized participants having complete self-reported data for analysis. Relative to SATC (treatment as usual), the mean composite QHI score was 12.7 (95% CI: 10.1-15.3; p<0.001) percentage points higher at PCCs; similar and significantly higher scores were observed in PCCs compared to SATCs for both primary care (PCC vs SATC: 18.4 [95% CI: 14.8-22.0; p<0.001] and specialty (PCC vs SATC: 5.9 [95% CI: 2.6-9.2; p<0.001] QHI scores. Additionally, the mean composite QHI score was 4.6 (95% CI: 2.0-7.2; p<0.001) points higher in participants with long term (>3 months) experience with OAT compared to participants newly initiating OAT. In summary, PWID with OUD receive greater primary care and specialty healthcare services when receiving OAT at PCCs supported by tele-education relative to treatment as usual provided in SATCs. Clinical trial registration: This trial was registered at clinicaltrials.gov and can be found using the following registration number: NCT04927091.
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Affiliation(s)
| | - Daniel J. Bromberg
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, United States of America
- Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America
| | | | - Katherine LaMonaca
- Yale School of Medicine, Yale University, New Haven, CT, United States of America
| | - Iryna Pykalo
- Yale School of Medicine, Yale University, New Haven, CT, United States of America
- European Institute on Public Health Policy, Kyiv, Ukraine
| | | | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Maxim Polonsky
- Keck Graduate Institute, Claremont, CA, United States of America
| | | | - Olga Morozova
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, IL, United States of America
| | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Frederick L. Altice
- Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America
- Yale School of Medicine, Yale University, New Haven, CT, United States of America
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Peterson L, Murugesan M, Nocon R, Hoang H, Bolton J, Laiteerapong N, Pollack H, Marsh J. Health care use and spending for Medicaid patients diagnosed with opioid use disorder receiving primary care in Federally Qualified Health Centers and other primary care settings. PLoS One 2022; 17:e0276066. [PMID: 36256662 PMCID: PMC9578596 DOI: 10.1371/journal.pone.0276066] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 09/28/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION This nationwide study builds on prior research, which suggests that Federally Qualified Health Centers (FQHCs) and other primary care providers are associated with increased access to opioid use disorder (OUD) treatment. We compare health care utilization, spending, and quality for Medicaid patients diagnosed with OUD who receive primary care at FQHCs and Medicaid patients who receive most primary care in other settings, such as physician offices (non-FQHCs). We hypothesized that the integrated care model of FQHCs would be associated with greater access to medication for opioid use disorder (MOUD) and/or behavioral health therapy and lower rates of potentially inappropriate co-prescribing. METHODS This cross-sectional study examined 2012 Medicaid Analytic eXtract files for patients diagnosed with OUD receiving most (>50%) primary care at FQHCs (N = 37,142) versus non-FQHCs (N = 196,712) in all 50 states and Washington DC. We used propensity score overlap weighting to adjust for measurable confounding between patients who received care at FQHCs versus non-FQHCs and increase generalizability of findings given variation in Medicaid programs and substance use policies across states. RESULTS FQHC patients displayed higher primary care utilization and fee-for-service spending, and similar or lower utilization and fee-for-service spending for other health service categories. Contrary to our hypotheses, non-FQHC patients were more likely to receive timely (≤90 days) MOUD (buprenorphine, methadone, naltrexone, or suboxone) (Relative Risk [RR] = 1.10, 95% CI: 1.07, 1.12) and more likely be retained in medication treatment (>180 days) (RR = 1.12, 95% CI: 1.09, 1.14). However, non-FQHC patients were less likely to receive behavioral health therapy (mental health or substance use therapy) (RR = 0.90, 95% CI: 0.88, 0.92) and less likely to remain in behavioral health treatment (RR = 0.92, 95% CI: 0.89, 0.94). Non-FQHC patients were more likely to fill potentially inappropriate prescriptions of benzodiazepines and opioids after OUD diagnosis (RR = 1.35, 95% CI: 1.30, 1.40). CONCLUSIONS Observed patterns suggest that Medicaid patients diagnosed with OUD who obtained primary care at FQHCs received more integrated care compared to non-FQHC patients. Greater care integration may be associated with increased access to behavioral health therapy and quality of care (lower potentially inappropriate co-prescribing) but not necessarily greater access to MOUD.
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Affiliation(s)
- Lauren Peterson
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, Illinois, United States of America
| | - Manoradhan Murugesan
- Department of Public Health Sciences, University of Chicago, Chicago, IL, United States of America
| | - Robert Nocon
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, United States of America
| | - Hank Hoang
- Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland, United States of America
| | - Joshua Bolton
- Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland, United States of America
| | - Neda Laiteerapong
- Department of Medicine, University of Chicago, Chicago, Illinois, United States of America
| | - Harold Pollack
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, Illinois, United States of America
- Department of Public Health Sciences, University of Chicago, Chicago, IL, United States of America
| | - Jeanne Marsh
- Crown Family School of Social Work, Policy, and Practice, University of Chicago, Chicago, Illinois, United States of America
- * E-mail:
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Ellerbroek H, van den Heuvel SAS, Dahan A, Timmerman H, Kramers C, Schellekens AFA. Buprenorphine/naloxone versus methadone opioid rotation in patients with prescription opioid use disorder and chronic pain: study protocol for a randomized controlled trial. Addict Sci Clin Pract 2022; 17:47. [PMID: 36057608 PMCID: PMC9441071 DOI: 10.1186/s13722-022-00326-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 08/01/2022] [Indexed: 11/26/2022] Open
Abstract
Background Opioids are effective in pain-management, but long-term opioid users can develop prescription opioid use disorder (OUD). One treatment strategy in patients with OUD is rotating from a short-acting opioid to a long-acting opioid (buprenorphine/naloxone (BuNa) or methadone). Both BuNa and methadone have been shown to be effective strategies in patients with OUD reducing opioid misuse, however data on head-to-head comparison in patients with chronic non-malignant pain and prescription OUD are limited. Methods This two-armed open-label, randomized controlled trial aims to compare effectiveness between BuNa and methadone in patients with chronic non-malignant with prescription OUD (n = 100). Participants receive inpatient rotation to either BuNa or methadone with a flexible dosing regimen. The primary outcome is opioid misuse 2 months after rotation. Secondary outcomes include treatment compliance, side effects, analgesia, opioid craving, quality of life, mood symptoms, cognitive and physical functioning over 2- and 6 months follow-up. Linear mixed model analysis will be used to evaluate change in outcome parameters over time between the treatment arms. Discussion This is one of the first studies comparing buprenorphine/naloxone and methadone for treating prescription OUD in a broad patient group with chronic non-malignant pain. Results may guide future treatment for patients with chronic pain and prescription OUD. Trial registrationhttps://www.trialregister.nl/, NL9781
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Affiliation(s)
- Hannah Ellerbroek
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Sandra A S van den Heuvel
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Hans Timmerman
- Department of Anesthesiology, Pain Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Cornelis Kramers
- Department of Clinical Pharmacy, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands.,Department of Pharmacology-Toxicology and Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arnt F A Schellekens
- Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands.,Donders Center for Medical Neuroscience, Donders Institute for Brain, Cognition and Behavior, Nijmegen, The Netherlands.,Nijmegen Institute for Scientist-Practitioners in Addiction (NISPA), Nijmegen, The Netherlands
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Harris RA, Campbell K, Calderbank T, Dooley P, Aspero H, Maginnis J, O’Donnell N, Coviello D, French R, Bao Y, Mandell DS, Bogner HR, Lowenstein M. Integrating peer support services into primary care-based OUD treatment: Lessons from the Penn integrated model. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2022; 10:100641. [PMID: 35785613 PMCID: PMC9933784 DOI: 10.1016/j.hjdsi.2022.100641] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/04/2022]
Abstract
Opioid use disorder (OUD) is a major public health emergency in the United States. In 2020, 2.7 million individuals had an OUD. Medication for opioid use disorder is the evidence-based, standard of care for treating OUD in outpatient settings, especially buprenorphine because it is effective and has low toxicity. Buprenorphine is increasingly prescribed in primary care, a setting that provides greater anonymity and convenience than substance use disorder treatment centers. Yet two-thirds of people who begin buprenorphine treatment discontinue within the first six months. Treatment dropout elevates the risks of return to use, infections, higher levels of medical care and related costs, justice system involvement, and death. One promising form of retention support is peer service programs. Peers combine their lived experience of substance use and recovery with formal training to help patients engage and persist in OUD treatment. They provide a range of services, including health education, encouragement and empathy, coping skills, recovery modeling, and concrete assistance in overcoming the situational barriers to retention. However, guidance is needed to define the peer role in primary care, the specific tasks peers should perform, the competencies those tasks require, training and professional development needs, and peer performance standards. Guidance also is needed to integrate peers into the care team, allocate and coordinate responsibilities among care team members, manage peer operations and workflow, and facilitate effective team communication. Here we describe a peer support program in the University of Pennsylvania Health System (UPHS or Penn Medicine) network of primary care practices. This paper details the program's core components, values, and activities. We also report the organizational challenges, unresolved questions, and lessons for the field in administering a peer support program to meet the needs of patients served by a large, urban medical system with an extensive suburban and rural catchment area. CLINICAL TRIALS REGISTRATION: www.clinicaltrials.gov registration: NCT04245423.
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Affiliation(s)
- Rebecca Arden Harris
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Kristen Campbell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Tara Calderbank
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Patrick Dooley
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Heather Aspero
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Jessica Maginnis
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Nicole O’Donnell
- Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Donna Coviello
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rachel French
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA,School of Nursing, University of Pennsylvania, Philadelphia, PA, 19104, USA,National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, 10065, USA
| | - David S. Mandell
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hillary R. Bogner
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Margaret Lowenstein
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Spinella S, McCune N, McCarthy R, El-Tahch M, George J, Dorritie M, Ford A, Posteraro K, DiNardo D. WVSUD-PACT: a Primary-Care-Based Substance Use Disorder Team for Women Veterans. J Gen Intern Med 2022; 37:837-841. [PMID: 36042085 PMCID: PMC9481786 DOI: 10.1007/s11606-022-07577-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Sara Spinella
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA. .,VA Pittsburgh Healthcare System, Pittsburgh, USA.
| | - Nicole McCune
- VA Pittsburgh Healthcare System, Pittsburgh, USA.,Waynesburg University, Waynesburg, USA
| | | | - Maria El-Tahch
- Primary Care Mental Health Integration, VA Pittsburgh Healthcare System, Pittsburgh, USA
| | | | | | - Alyssa Ford
- Primary Care Mental Health Integration, VA Pittsburgh Healthcare System, Pittsburgh, USA
| | | | - Deborah DiNardo
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA.,VA Pittsburgh Healthcare System, Pittsburgh, USA
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Weitzman ER, Kossowsky J, Blakemore LM, Cox R, Dowling DJ, Levy O, Needles EW, Levy S. Acceptability of a Fentanyl Vaccine to Prevent Opioid Overdose and Need for Personalized Decision-Making. Clin Infect Dis 2022; 75:S98-S109. [PMID: 35579508 PMCID: PMC9376272 DOI: 10.1093/cid/ciac344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The opioid epidemic worsened during the coronavirus disease 2019 (COVID-19) pandemic. Synthetic opioids (primarily fentanyl) comprise the most common drugs involved in overdose (OD) death. A vaccine that blocks fentanyl from reaching the brain to prevent OD is under development, and insight is needed into its acceptability. METHODS Using a semi-structured interview guide, persons with opioid use disorder (OUD), family, professionals, and the public were interviewed about attitudes and concerns regarding a fentanyl vaccine. Reactions to fictional clinical vignettes of persons at risk of OUD because of pain and/or substance use histories were collected, analyzed, and quantified for favorability. Interviews were transcribed, coded, and analyzed thematically. RESULTS Among N = 64 participants, (70.3% female, average age 32.4 years), attitudes were favorable toward a fentanyl vaccine, with preference for lifelong durability (76% of n = 55 asked). Perceived benefits centered on the potential for a life-saving intervention, suffering averted, healthcare dollars saved, and the utility of a passive harm reduction strategy. Concerns centered on uncertainty regarding vaccine safety, questions about efficacy, worry about implications for future pain management, stigma, and need for supportive counseling and guidance to personalize decision making. Reactions to vignettes revealed complex attitudes toward fentanyl vaccination when considering recipient age, health history, and future risks for addiction and pain. CONCLUSIONS Positive responses to a fentanyl vaccine were found along with appreciation for the complexity of a vaccine strategy to prevent OD in the setting of pain and uncertain durability. Further research is needed to elucidate operational, ethical, and communications strategies to advance the model.
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Affiliation(s)
- Elissa R Weitzman
- Correspondence: E. R. Weitzman, 1 Autumn Street, Boston, MA 02215 ()
| | - Joe Kossowsky
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Laura M Blakemore
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Rachele Cox
- Division of Adolescent/Young Adult Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - David J Dowling
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Precision Vaccines Program, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Ofer Levy
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Precision Vaccines Program, Boston Children’s Hospital, Boston, Massachusetts, USA
- Division of Infectious Diseases, Boston Children’s Hospital, Boston, Massachusetts, USA
- Broad Institute of MIT & Harvard, Cambridge, Massachusetts, USA
| | - Emma W Needles
- Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
| | - Sharon Levy
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Adolescent Substance Use and Addiction Program, Division of Developmental Medicine, Boston Children’s Hospital, Boston, Massachusetts, USA
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Roles and Perceptions of Nurses During Implementation of a Medication Treatment for Opioid Use Disorder National Initiative. J Addict Nurs 2022; 33:70-79. [PMID: 35640210 DOI: 10.1097/jan.0000000000000455] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND In the United States, a national priority exists to improve access to medication treatment for opioid use disorder (MOUD). Nurses can be an essential component of that care. We examined the perceptions and evolving roles of nurses in a national Veterans Health Administration (VHA) initiative designed to improve MOUD access within general medical settings. METHODS From April 15, 2021, to June 16, 2021, we recruited nurses participating in VHA's Stepped Care for Opioid Use Disorder Train the Trainer Initiative-a national program intending to implement MOUD in general medical settings-to participate in an interview about their roles, perceptions, and experiences. The respondents answered our inquiries through an interview or responded to an email solicitation with written responses, which were then recorded, transcribed, and independently coded to identify themes. RESULTS Nurses from 10 VHA facilities participated in an interview (n = 7) or completed the questionnaire (n = 4). Inadequate staffing, high patient-to-provider ratios, and time constraints were identified as barriers to MOUD care. Mentorship activities, existing VHA informational resources, and patients' willingness to accept treatment were identified as facilitators of MOUD care. The Stepped Care for Opioid Use Disorder Train the Trainer Initiative processes were acknowledged to promote role confidence, which in turn increased job satisfaction and empowered nurses to become content experts. Respondents often identified nurses as local lead facilitators in MOUD care. CONCLUSIONS In a national initiative to implement MOUD within general medical settings, nurses identified several barriers and facilitators to MOUD implementation. Nurses play vital collaborative care roles in enhancing access to MOUD.
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Liu G, Chen L, Yang Y, Zhang Y, Luo S. Registered clinical trials on addiction: a cross-sectional study on ClinicalTrials.gov. J Addict Dis 2022; 40:394-404. [PMID: 35348044 DOI: 10.1080/10550887.2021.2010972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Guina Liu
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Lingmin Chen
- Department of Anesthesiology and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University & The Research Units of West China (2018RU012, Chinese Academy of Medical Sciences), Chengdu, China
| | - Yi Yang
- Department of Clinical Medicine, Gansu University of Traditional Chinese Medicine, Lanzhou, China
| | - Yonggang Zhang
- Department of Periodical Press and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, China
| | - Shanxia Luo
- Department of Mental Health Center, West China Hospital, Sichuan University, Chengdu, China
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Abbott P, Watt K, Magin P, Davison J, Hu WCY. Welcomeness for people with substance use disorders to general practice: a qualitative study. Fam Pract 2022; 39:257-263. [PMID: 34791184 DOI: 10.1093/fampra/cmab151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Good primary care for people with substance use disorders (SUDs) is crucial given the high prevalence of SUDs and overdose deaths. OBJECTIVE To explore general practice care for people with a history of SUDs from the perspectives of women involved with the criminal justice system. METHODS Qualitative interview study with pre- and postrelease interviews, undertaken in Australian prisons and community settings. We utilized thematic analysis informed by constructivist grounded theory. RESULTS We undertook 65 interviews with 39 women. Access to and experience of general practitioner (GP) care was affected by perceived welcomeness, decisions around disclosure, and consultation experiences related to medication prescription. Participants reported that they were not as welcome as other patients, welcome could be conditional on not disclosing SUDs or only requesting unrelated healthcare, and GPs did not always differentiate between past and current drug use. Participants perceived difficulty finding general practices where the potential benefit of disclosing SUDs outweighed the risks of stigmatized reactions and lack of GP skills and interest. Participants did not always recognize that care beyond physical health could occur in general practice. The pejorative implications of labelling patients as "doctor shoppers" were challenged by participants, as they considered it could be necessary to attend multiple GPs to find a welcoming practice. CONCLUSIONS People with histories of SUDs do not uniformly experience welcomeness in general practice, perpetuating poor engagement in healthcare and poor outcomes related to SUDs. Programmes targeting prescription drug misuse through general practice should also promote welcomeness for people with SUDs.
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Affiliation(s)
- Penelope Abbott
- Department of General Practice, School of Medicine, Western Sydney University, Sydney, Australia
| | - Kelly Watt
- Aboriginal and Torres Strait Islander Community Health Service, Brisbane, Australia
| | - Parker Magin
- Discipline of General Practice, University of Newcastle, Newcastle, Australia
| | | | - Wendy C Y Hu
- Medical Education Unit, School of Medicine, Western Sydney University, Sydney, Australia
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Du CX, Shi J, Tetrault JM, Madden LM, Barry DT. Primary care and medication management characteristics among patients receiving office-based opioid treatment with buprenorphine. Fam Pract 2022; 39:234-240. [PMID: 34893825 PMCID: PMC8947790 DOI: 10.1093/fampra/cmab166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Office-based opioid treatment (OBOT) is an evidence-based treatment model for opioid use disorder (OUD) offered by both addiction and general primary care providers (PCPs). Calls exist for more PCPs to offer OBOT. Few studies have been conducted on the primary care characteristics of OBOT patients. OBJECTIVE To characterize medical conditions, medications, and treatment outcomes among patients receiving OBOT with buprenorphine for OUD, and to describe differences among patients by age and by time in care. METHODS This study is a retrospective review of medical records on or before 4/29/2019 at an outpatient primary care clinic within a nonprofit addiction treatment setting. Inclusion criterion was all clinic patients actively enrolled in the OBOT program. Patients not prescribed buprenorphine or with no OBOT visits were excluded. RESULTS Of 355 patients, 42.0% had another PCP. Common comorbid conditions included chronic pain and psychiatric diagnosis. Few patients had chronic viral hepatitis or HIV. Patients reported a median of 4 medications. Common medications were cardiovascular, antidepressant, and nonopioid pain agents. Older patients had a higher median number of medications. There was no significant difference in positive opioid urine toxicology (UT) based on age, chronic pain status, or psychoactive medications. Patients retained >1 year were less likely to have positive opioid UT. CONCLUSION Clinical needs of many patients receiving OBOT are similar to those of the general population, supporting calls for PCPs to provide OBOT.
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Affiliation(s)
- Cindy Xinxin Du
- Yale University School of Medicine, New Haven, CT, United States
| | - Julia Shi
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
- The APT Foundation Inc., New Haven, CT, United States
| | - Jeanette M Tetrault
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
- The APT Foundation Inc., New Haven, CT, United States
| | - Lynn M Madden
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
- The APT Foundation Inc., New Haven, CT, United States
| | - Declan T Barry
- The APT Foundation Inc., New Haven, CT, United States
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, United States
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40
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Ghanem N, Dromgoole D, Hussein A, Jermyn RT. Review of medication-assisted treatment for opioid use disorder. J Osteopath Med 2022; 122:367-374. [PMID: 35285220 DOI: 10.1515/jom-2021-0163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 02/14/2022] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Nessreen Ghanem
- Neuromusculoskeletal Institute at Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Devin Dromgoole
- Neuromusculoskeletal Institute at Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Ahmad Hussein
- Neuromusculoskeletal Institute at Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
| | - Richard T Jermyn
- Neuromusculoskeletal Institute at Rowan University School of Osteopathic Medicine, Stratford, NJ, USA
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Auty SG, Griffith KN. Medicaid expansion and drug overdose mortality during the COVID-19 pandemic in the United States. Drug Alcohol Depend 2022; 232:109340. [PMID: 35131533 PMCID: PMC8809643 DOI: 10.1016/j.drugalcdep.2022.109340] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/28/2022] [Accepted: 01/28/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The COVID-19 pandemic caused disruptions in the delivery of health services, which may have adversely affected access to substance use disorder (SUD) treatment services. Medicaid expansion has been previously associated with increased access to SUD services for low-income adults. Thus, the pandemic may have differentially impacted overdose mortality depending on expansion status. This study examined trends in overdose mortality nationally and by state Medicaid expansion status from 2013 to 2020. METHODS State-level data on overdose mortality were obtained from the Centers for Disease Control and Prevention's WONDER database for 2013-2020 (N = 408 state-years). The primary outcomes were drug and opioid overdose deaths per 100,000 residents. The primary exposure was Medicaid expansion status as of January 1st, 2020. Difference-in-difference (DID) models were used to compare changes in outcomes between expansion and non-expansion states after the onset of the COVID-19 pandemic. RESULTS The U.S. experienced 91,799 drug overdose deaths in 2020, a 29.9% relative increase from 2019. Expansion states experienced an adjusted increase of 7.0 drug overdose deaths per 100,000 residents (95% CI 3.3, 10.7) and non-expansion states experienced an increase of 4.3 deaths (95% CI 1.5, 8.2) from 2019 to 2020. Similar trends were observed in opioid overdose deaths. In DID models, Medicaid expansion was not associated with changes in drug (0.9 deaths, 95% CI -2.0, 3.7) or opioid overdose deaths (0.8 deaths, 95% CI -1.8, 3.5). CONCLUSIONS The increase in drug or opioid overdose deaths experienced during the first year of the COVID-19 pandemic was similar in states with and without Medicaid expansion.
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Affiliation(s)
- Samantha G. Auty
- Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, Massachusetts 02118, USA,Correspondence to: 715 Albany Street, Talbot Building, Boston, Massachusetts 02118, USA
| | - Kevin N. Griffith
- Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Avenue, Nashville, Tennessee 37203, USA,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, 150 S. Huntington Avenue, Boston, MA 02130, USA
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Li L, Lin C, Liang LJ, Song W, Pham LQ, Le TA, Nguyen TA. A community approach to promote healthcare services for people living with HIV who use drugs in Vietnam. Int J STD AIDS 2022; 33:164-172. [PMID: 34727808 PMCID: PMC10443225 DOI: 10.1177/09564624211053430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND People living with HIV who use drugs (PLHWUD) face enormous challenges to access antiretroviral therapy (ART), addiction treatment, and other healthcare services. This study evaluated the effect of a community capacity-building approach on PLHWUD's access to healthcare services. METHODS A cluster randomized controlled trial was conducted in four provinces of Vietnam. Trained commune health workers in the intervention condition were encouraged to provide services to PLHWUD in the community and engage them in HIV/addiction treatment and care using learned knowledge and skills. A total of 241 PLHWUD participated in surveys at the baseline and every three months for one year. The primary outcome was PLHWUD's reported barriers to seeking healthcare. A linear mixed-effects regression model with a difference in difference approach was used to estimate the intervention effect on the primary outcome. RESULTS Adjusted analyses indicated that significant intervention effects were observed at the Sixth and ninth month follow-ups for those on ART at the baseline and increased motivation to engage in treatment at the 3-month follow-up (60.2% vs 34.4% for the intervention and control groups, respectively). CONCLUSIONS The community capacity-building intervention had shown promising yet limited outcomes among a subset of PLHWUD in the community, that is, PLHWUD who had already initiated ART.
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Affiliation(s)
- Li Li
- Semel Institute for Neuroscience and Human Behavior – Center for Community Health, University of California, Los Angeles, CA, USA
| | - Chunqing Lin
- Semel Institute for Neuroscience and Human Behavior – Center for Community Health, University of California, Los Angeles, CA, USA
| | - Li-Jung Liang
- Semel Institute for Neuroscience and Human Behavior – Center for Community Health, University of California, Los Angeles, CA, USA
| | - Weilu Song
- Semel Institute for Neuroscience and Human Behavior – Center for Community Health, University of California, Los Angeles, CA, USA
| | - Loc Quang Pham
- Semel Institute for Neuroscience and Human Behavior – Center for Community Health, University of California, Los Angeles, CA, USA
| | - Tuan Anh Le
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
| | - Tuan Anh Nguyen
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
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Caron O, Fay AE, Pressley H, Seamon G, Taylor SR, Wilson CG. Four models of pharmacist‐integrated office‐based opioid treatment. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2022. [DOI: 10.1002/jac5.1607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Olivia Caron
- Mountain Area Health Education Center (MAHEC) Family Health Center, 123 Hendersonville Rd Asheville North Carolina USA
| | | | - Haley Pressley
- University of North Carolina (UNC) Eshelman School of Pharmacy Chapel Hill North Carolina
| | - Gwen Seamon
- MAHEC Family Health Center Asheville North Carolina
| | | | - Courtenay Gilmore Wilson
- Department of Family Medicine, Mountain Area Health Education Center (MAHEC) Asheville North Carolina
- Department of Research, UNC Health Sciences at MAHEC Asheville North Carolina
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy Chapel Hill North Carolina
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Farhoudian A, Razaghi E, Hooshyari Z, Noroozi A, Pilevari A, Mokri A, Mohammadi MR, Malekinejad M. Barriers and Facilitators to Substance Use Disorder Treatment: An Overview of Systematic Reviews. Subst Abuse 2022; 16:11782218221118462. [PMID: 36062252 PMCID: PMC9434658 DOI: 10.1177/11782218221118462] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Accepted: 07/20/2022] [Indexed: 11/22/2022]
Abstract
objective: This investigation explored the barriers and facilitators to substance use
disorder (SUD) treatment in the integrated paradigm. methods: A search technique for barriers and facilitators of SUD treatment was applied
to the PubMed and Web of Science databases to identify relevant systematic
reviews. The eligibility criteria included systematic review (SR) or SR plus
meta-analysis (MA) articles published before the end of 2021, human
research, and the English language. Each of the 12 relevant review articles
met the inclusion criteria. AMSTAR was utilised to evaluate the
methodological quality of the systematic reviews. results: Two authors analysed 12 SR/SR-MA articles to identify barriers or
facilitators of SUD treatment. The cumulative summary results of these 12
evaluations revealed that barriers and facilitators may be classified into 3
levels: individual, social and structural. By analysing these review papers,
37 structural barriers, 21 individual barriers and 19 social barriers were
uncovered, along with 15 structural facilitators, 9 social facilitators and
3 individual facilitators. conclusions: The majority of barriers indicated in the review articles included in this
analysis are structural, as are the majority of facilitators. Consequently,
the design of macro models for the treatment of substance use disorders may
yield various outcomes and potentially affect society and individual
levels.
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Affiliation(s)
- Ali Farhoudian
- Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Emran Razaghi
- Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Hooshyari
- Department of Geriatric Medicine, Ziaeian Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Alireza Noroozi
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Science, Tehran, Iran
| | - Azam Pilevari
- Department of Sociology, Kharazmi University, Karaj, Iran
| | - Azarakhsh Mokri
- Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Mohammadi
- Department of Psychiatry, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Psychiatry and Psychology Research Center, Roozbeh Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Malekinejad
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, CA, USA
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de Vargas D, Pereira CF, Volpato RJ, Lima AVC, da Silva Ferreira R, de Oliveira SR, Aguilar TF. Strategies Adopted by Addiction Facilities during the Coronavirus Pandemic to Support Treatment for Individuals in Recovery or Struggling with a Substance Use Disorder: A Scoping Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182212094. [PMID: 34831850 PMCID: PMC8624445 DOI: 10.3390/ijerph182212094] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 11/16/2022]
Abstract
This review aimed to identify and synthesize strategies and actions adopted by addiction facilities to support and maintain treatment during the coronavirus disease 2019 (COVID-19) pandemic. A scoping review was conducted using the following information sources: Virtual Health Library, SCOPUS, Web of Science, PubMed, CINAHL, and Latin American and Caribbean Health Science Literature. From a total of 971 articles, 28 studies were included. The strategies to maintain the care offer were telehealth/telemedicine, counselling/screening, 24-h telephone, webinars, conducting group therapy and support among users, adaptation for electronic health records, increased methadone/naloxone dispensing, restriction in the number of medication dispensing/day, and electronic prescription and home delivery medications. These strategies can be used to support health professionals in addressing the impact of the pandemic on the treatment of those in recovery or struggling with a substance use disorder when in-person treatment is not possible.
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Affiliation(s)
- Divane de Vargas
- School of Nursing, São Paulo University, São Paulo 05403-000, Brazil; (C.F.P.); (R.J.V.); (A.V.C.L.); (S.R.d.O.); (T.F.A.)
- Nucleon of Addiction Nursing Research, School of Nursing (NEPEEA), University of São Paulo, São Paulo 05403-000, Brazil;
- Correspondence:
| | - Caroline Figueira Pereira
- School of Nursing, São Paulo University, São Paulo 05403-000, Brazil; (C.F.P.); (R.J.V.); (A.V.C.L.); (S.R.d.O.); (T.F.A.)
- Nucleon of Addiction Nursing Research, School of Nursing (NEPEEA), University of São Paulo, São Paulo 05403-000, Brazil;
| | - Rosa Jacinto Volpato
- School of Nursing, São Paulo University, São Paulo 05403-000, Brazil; (C.F.P.); (R.J.V.); (A.V.C.L.); (S.R.d.O.); (T.F.A.)
- Nucleon of Addiction Nursing Research, School of Nursing (NEPEEA), University of São Paulo, São Paulo 05403-000, Brazil;
| | - Ana Vitória Corrêa Lima
- School of Nursing, São Paulo University, São Paulo 05403-000, Brazil; (C.F.P.); (R.J.V.); (A.V.C.L.); (S.R.d.O.); (T.F.A.)
- Nucleon of Addiction Nursing Research, School of Nursing (NEPEEA), University of São Paulo, São Paulo 05403-000, Brazil;
| | - Rogério da Silva Ferreira
- Nucleon of Addiction Nursing Research, School of Nursing (NEPEEA), University of São Paulo, São Paulo 05403-000, Brazil;
| | - Sheila Ramos de Oliveira
- School of Nursing, São Paulo University, São Paulo 05403-000, Brazil; (C.F.P.); (R.J.V.); (A.V.C.L.); (S.R.d.O.); (T.F.A.)
- Nucleon of Addiction Nursing Research, School of Nursing (NEPEEA), University of São Paulo, São Paulo 05403-000, Brazil;
| | - Thiago Faustino Aguilar
- School of Nursing, São Paulo University, São Paulo 05403-000, Brazil; (C.F.P.); (R.J.V.); (A.V.C.L.); (S.R.d.O.); (T.F.A.)
- Nucleon of Addiction Nursing Research, School of Nursing (NEPEEA), University of São Paulo, São Paulo 05403-000, Brazil;
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Meteliuk A, Galvez S, Fomenko T, Kalandiia H, Iaryi V, Farnum SO, Islam Z, Altice FL, Madden LM. Successful transfer of stable patients on opioid agonist therapies from specialty addiction treatment to primary care settings in Ukraine: A pilot study. J Subst Abuse Treat 2021; 134:108619. [PMID: 34579978 DOI: 10.1016/j.jsat.2021.108619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/20/2021] [Accepted: 09/02/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION In Ukraine, HIV is concentrated among people who inject drugs (PWID), and opioid agonist therapies (OAT) are the most effective approach to preventing HIV transmission. OAT coverage is well below internationally recommended levels, with OAT provided primarily in specialty addiction treatment clinics. Integrating OAT into primary care settings represents a promising practice for increasing OAT coverage. METHODS The study collected data prospectively from the first 50 stable patients transferred from the largest OAT site to 10 primary care clinics in Kiev; patients had negative urine drug tests for the previous six months. Participants completed the BASIS-24-the 24-item Behaviour and Symptom Identification Scale-to assess symptoms of psychiatric and social function across 6 domains: (1) depression and functioning, (2) relationships, (3) self-harm, (4) emotional lability, (5) psychosis, and (6) substance use before transfer and 6 months after transfer from May through November 2019. RESULTS Participants were on average 36 years old, mostly male (84.0%) and had some employment (64.0%). After six months, some employment increased to 88.0% and BASIS-24 scores significantly improved on four domains: depression (1.09 vs 0.73, p = 0.0005), relationships (2.15 vs 1.7, p < 0.0001), emotional liability (1.30 vs 1.00, p = 0.0209) and substance use (1.23 vs 1.07, p = 0073). CONCLUSIONS Stable OAT patients can be successfully transferred from specialty to primary care clinics without deterioration in mental health symptoms or functioning. Patients transferred to primary care showed significant improvement in their emotional well-being, their substance use, and their employment status.
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Affiliation(s)
- Anna Meteliuk
- Alliance for Public Health of Ukraine, Kyiv, Ukraine
| | - Samy Galvez
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States
| | | | - Hela Kalandiia
- Kyiv City Drug Addiction Clinical Hospital 'Sociotherapy', Kyiv, Ukraine
| | - Volodymyr Iaryi
- Kyiv City Drug Addiction Clinical Hospital 'Sociotherapy', Kyiv, Ukraine
| | | | - Zahedul Islam
- Alliance for Public Health of Ukraine, Kyiv, Ukraine
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States; APT Foundation, New Haven, CT, United States; Yale School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, United States.
| | - Lynn M Madden
- Yale School of Medicine, Section of Infectious Diseases, New Haven, CT, United States; APT Foundation, New Haven, CT, United States
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Snell-Rood C, Pollini RA, Willging C. Barriers to Integrated Medication-Assisted Treatment for Rural Patients With Co-occurring Disorders: The Gap in Managing Addiction. Psychiatr Serv 2021; 72:935-942. [PMID: 33530734 DOI: 10.1176/appi.ps.202000312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Guidelines for treatment of opioid use disorder stipulate for mental health assessment and the option for treatment alongside medication for opioid use disorder (MOUD). Yet efforts to expand MOUD treatment capacity have focused on expanding the workforce of buprenorphine providers. This article aims to describe the processes facilitating and impeding integrated care for rural patients with co-occurring opioid use disorder and mental health conditions. METHODS Qualitative interviews were conducted with primary care and specialty providers (N=26) involved in integrated care through the state's hub-and-spoke system and with system-level stakeholders (N=16) responsible for expanding access to MOUD in rural California. RESULTS Rural primary care providers struggled to offer adequate mental health resources to patients with co-occurring conditions because of personnel shortages and inadequate availability of telehealth. Efforts to intensify care through referral to county mental health systems and private community providers were thwarted by access barriers. The bifurcated nature of treatment systems resulted in inadequate training in integrated care and the deprioritization of mental health in patient evaluations. CONCLUSIONS Significant system-level barriers undermine the implementation of integrated MOUD in rural areas, potentially increasing the suffering of residents with co-occurring conditions and intensifying burnout among providers.
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Affiliation(s)
- Claire Snell-Rood
- School of Public Health, University of California, Berkeley (Snell-Rood); School of Public Health, West Virginia University, Morgantown (Pollini); Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico (Willging)
| | - Robin A Pollini
- School of Public Health, University of California, Berkeley (Snell-Rood); School of Public Health, West Virginia University, Morgantown (Pollini); Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico (Willging)
| | - Cathleen Willging
- School of Public Health, University of California, Berkeley (Snell-Rood); School of Public Health, West Virginia University, Morgantown (Pollini); Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico (Willging)
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Schottenfeld RS, Chawarski MC, Mazlan M. Behavioral counseling and abstinence-contingent take-home buprenorphine in general practitioners' offices in Malaysia: a randomized, open-label clinical trial. Addiction 2021; 116:2135-2149. [PMID: 33404150 DOI: 10.1111/add.15399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/27/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM To address the widespread severe problems with opioid use disorder, buprenorphine-naloxone treatment provided by primary care physicians has greatly expanded treatment access; however, treatment is often provided with minimal or no behavioral interventions. Whether or which behavioral interventions are feasible to implement in various settings and improve treatment outcomes has not been established. This study aimed to evaluate two behavioral interventions to improve buprenorphine-naloxone treatment. DESIGN A 2 × 2 factorial, repeated-measures, open-label, randomized clinical trial. SETTINGS General medical practice offices in Muar, Malaysia. PARTICIPANTS Opioid-dependent individuals (n = 234). INTERVENTIONS Participants were randomly assigned to one of four treatment conditions and received study interventions for 24 weeks: (1) physician management with or without behavioral counseling and (2) physician management with or without abstinence-contingent buprenorphine-naloxone (ACB) take-home doses. MEASUREMENTS The primary outcomes were proportions of opioid-negative urine tests and HIV risk behaviors [assessed by audio computer-assisted AIDS risk inventory (ACASI-ARI)]. FINDINGS The rates of opioid-negative urine tests over 24 weeks of treatment were significantly higher with [68.2%, 95% confidence interval (CI) = 65-71] than without behavioral counseling (59.2%, 95% CI = 56-62, P < 0.001) and with (71.0%, 95% CI = 68-74) than without ACB (56.4%, 95% CI = 53-59, P < 0.001); interaction effects between and among behavioral interventions and time were not statistically significant. Scores on ACASI-ARI decreased significantly from baseline across all treatment groups (P < 0.001) and did not differ significantly with or without behavioral counseling (P = 0.099) or with or without ACB (P = 0.339). CONCLUSIONS Providing opioid-dependent patients in Muar, Malaysia with buprenorphine-naloxone and physician management plus behavioral counseling or abstinence-contingent buprenorphine-naloxone (ACB) resulted in greater reductions of opioid use compared with providing buprenorphine-naloxone and physician management without behavioral counseling or ACB.
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Affiliation(s)
- Richard S Schottenfeld
- Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC, USA
| | - Marek C Chawarski
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Boudreau DM, Lapham G, Johnson EA, Bobb JF, Matthews AG, McCormack J, Liu D, Campbell CI, Rossom RC, Binswanger IA, Yarborough BJ, Arnsten JH, Cunningham CO, Glass JE, Murphy MT, Zare M, Hechter RC, Ahmedani B, Braciszewski JM, Horigian VE, Szapocznik J, Samet JH, Saxon AJ, Schwartz RP, Bradley KA. Documented opioid use disorder and its treatment in primary care patients across six U.S. health systems. J Subst Abuse Treat 2021; 112S:41-48. [PMID: 32220410 DOI: 10.1016/j.jsat.2020.02.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/05/2020] [Accepted: 02/08/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The United States is in the middle of an opioid overdose epidemic, and experts are calling for improved detection of opioid use disorders (OUDs) and treatment with buprenorphine or extended release (XR) injectable naltrexone, which can be prescribed in general medical settings. To better understand the magnitude of opportunities for treatment among primary care (PC) patients, we estimated the prevalence of documented OUD and medication treatment of OUD among PC patients. METHODS This cross-sectional study included patients with ≥2 visits to PC clinics across 6 healthcare delivery systems who were ≥16 years of age during the study period (fiscal years 2014-2016). Diagnoses, prescriptions, and healthcare utilization were ascertained from electronic health records and insurance claims (5 systems that also offer health insurance). Documented OUDs were defined as ≥1 International Classification of Diseases code for OUDs (active or remission), and OUD treatment was defined as ≥1 prescription(s) for buprenorphine formulations indicated for OUD or naltrexone XR, during the 3-year study period. The prevalence of documented OUD and treatment (95% confidence intervals) across health systems were estimated, and characteristics of patients by treatment status were compared. Prevalence of OUD and OUD treatment were adjusted for age, gender, and race/ethnicity. Combined results were also adjusted for site. RESULT Among 1,403,327 eligible PC patients, 54-62% were female and mean age ranged from 46 to 51 years across health systems. The 3-year prevalence of documented OUD ranged from 0.7-1.4% across the health systems. Among patients with documented OUD, the prevalence of medication treatment (primarily buprenorphine) varied across health systems: 3%, 12%, 16%, 20%, 22%, and 36%. CONCLUSION The prevalence of documented OUD and OUD treatment among PC patients varied widely across health systems. The majority of PC patients with OUD did not have evidence of treatment with buprenorphine or naltrexone XR, highlighting opportunities for improved identification and treatment in medical settings. These results can inform initiatives aimed at improving treatment of OUD in PC. Future research should focus on why there is such variation and how much of the variation can be addressed by improving access to medication treatment.
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Affiliation(s)
- Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, United States of America.
| | - Gwen Lapham
- Kaiser Permanente Washington Health Research Institute, United States of America
| | - Eric A Johnson
- Kaiser Permanente Washington Health Research Institute, United States of America
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, United States of America
| | | | | | - David Liu
- National Institute on Drug Abuse Center for Clinical Trials Network, United States of America
| | - Cynthia I Campbell
- Kaiser Permanente Northern California Division of Research, United States of America
| | | | - Ingrid A Binswanger
- Kaiser Permanente Colorado Institute for Health Research and Colorado Permanente Medical Group, United States of America
| | - Bobbi Jo Yarborough
- Kaiser Permanente Northwest Center for Health Research, United States of America
| | | | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, United States of America
| | | | - Mohammad Zare
- University of Texas at Houston, United States of America
| | - Rulin C Hechter
- Kaiser Permanente Southern California Department of Research and Evaluation, United States of America
| | | | | | | | | | - Jeffrey H Samet
- Boston Medical Center, Boston University School of Medicine, United States of America
| | - Andrew J Saxon
- Veteran Affairs Puget Sound Health Care System, United States of America
| | | | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, United States of America
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Anderson JB, Martin SA, Gadomski A, Krupa N, Mullin D, Cahill A, Jenkins P. Project ECHO and primary care buprenorphine treatment for opioid use disorder: Implementation and clinical outcomes. Subst Abus 2021; 43:222-230. [PMID: 34086529 DOI: 10.1080/08897077.2021.1931633] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Our rural health system sought to (1) increase the number of primary care clinicians waivered to prescribe buprenorphine for treatment of opioid use disorder (OUD) and (2) consequently increase the number of our patients receiving this treatment. Methods: We used the Project for Extension for Community Health Outcomes (ECHO) tele-education model as an implementation strategy. We examined the number of clinicians newly waivered, the number of patients treated with buprenorphine, the relationship between clinician engagement with ECHO training and rates of buprenorphine prescribing, and treatment retention at 180 days. Results: The number of clinicians with a waiver and number of patients treated increased during and after ECHO training. There was a moderate correlation between the number of ECHO sessions attended by a clinician and number of their buprenorphine prescriptions (r = 0.50, p = 0.01). The 180-day retention rate was 80.7%. Conclusions: Project ECHO was highly effective for increasing access to this evidence-based treatment. The high retention rate in this rural context indicates that most patients are increasing their likelihood of favorable outcomes.
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Affiliation(s)
- James B Anderson
- Department of Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - Stephen A Martin
- Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA.,UMassMemorial Healthcare, Worcester, MA, USA
| | - Anne Gadomski
- Bassett Medical Center, Bassett Research Institute, Cooperstown, NY, USA
| | - Nicole Krupa
- Bassett Medical Center, Bassett Research Institute, Cooperstown, NY, USA
| | - Daniel Mullin
- Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA.,UMassMemorial Healthcare, Worcester, MA, USA
| | - Amber Cahill
- Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA
| | - Paul Jenkins
- Bassett Medical Center, Bassett Research Institute, Cooperstown, NY, USA
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