Predicting biopsychosocial outcomes for heroin users in primary care treatment: a prospective longitudinal cohort study

Barriers and facilitators to primary care engagement for people who inject drugs: A systematic review

INTRODUCTION

People who inject drugs (PWID) have a greater burden of multimorbid chronic diseases than the general population. However, little attention has been paid to the engagement in primary care for services related specifically to injection drug use and management of underlying chronic comorbid diseases for this population. This systematic review identified facilitators and barriers to healthcare engagement in the primary care setting among PWID.

DESIGN AND METHODS

Studies were identified by a literature search of PubMed, CINAHL, and EMBASE, and by searching the references of retrieved articles. Studies were included if they measured active injection drug use, and outcomes related to primary care engagement characterized by: diagnosis of a health condition, linkage or retention in care, health condition-related outcomes, and reported patient-provider relationship.

RESULTS

Twenty-three articles were included. Using the behavioral model, factors within predisposing, enabling, need, and health behavior domains were identified. Having co-located services and a positive patient-provider relationship were among the strongest factors associated with healthcare utilization and engagement while active injection drug use was associated with decreased engagement.

CONCLUSIONS

To our knowledge, this is the only review of evidence that has examined factors related to primary care engagement for people who inject drugs. Most articles were observational studies utilizing descriptive designs. Although the assessment of the evidence was primarily rated 'Good', this review identifies a significant need to improve our understanding of primary care engagement for PWID. Future research and intervention strategies should consider these findings to better integrate the holistic care needs of PWID into primary care to reduce morbidity and mortality associated with injection drug use and chronic disease.

CLINICAL RELEVANCE

Primary care engagement is important for preventative care, early diagnosis of disease, and management of chronic diseases, including addressing problems of substance use. This review highlights factors nurses can utilize to facilitate primary care engagement of PWID.

Social Cognition in Opioid Use Disorder

Background: Opioid use disorder (OUD) is associated with significant functional impairment and neurocognitive dysfunction, but only a handful of studies have investigated social cognitive abilities in this condition. This study aimed to investigate facial emotion recognition accuracy/biases and two different aspects of theory of mind (ToM) (ToM-decoding vs ToM-reasoning) in people with recovered OUD. Methods: The participants included 32 people with recovered OUD who were on Buprenorphine + Naloxone (B/N) maintenance treatment and 32 healthy controls. In addition to neurocognitive tasks, both groups were assessed by a facial emotion recognition task, the faux pas recognition task, and the reading the mind from the eyes task. Results: In comparison to healthy controls, people on B/N maintenance treatment showed deficits in facial emotion recognition (d = 1.32) and both aspects of ToM (d = 0.87-1.21). In analyses of individual emotions, people on B/N maintenance treatment had decreased accuracy in recognition of anger and fear and had a bias to identify other emotions as sad. The duration of opioid use was robustly associated with difficulties in the recognition of anger. Conclusion: People in B/N maintenance treatment have significant difficulties in recognizing the emotions and mental states of others. Deficits in social cognition might be important for understanding the difficulties in interpersonal and social functioning in people with OUD.

COPD and asthma in patients with opioid dependency: a cross-sectional study in primary care

Patients treated for drug addiction have high asthma and COPD prevalence rates. The relative contributions of cigarette smoking, smoking intensity and possible smoking of other substances has not been described. We aimed to describe the prevalence and determinants of asthma and COPD in patients prescribed methadone as opioid substitution therapy (OST). In a cross-sectional study of an anonymised patient-level primary care dataset of UK inner-city general practices (n = 46), 321,395 patients aged ≥18 years were identified. A total of 676 (0.21%) had a record of a methadone ever issued in primary care. The association between respiratory disease and methadone prescribing was examined using logistic regression. Models were adjusted for potential effects of clustering by practice. A total of 97.3% of patients prescribed methadone were cigarette smokers, either current (81.2%) or ex-smokers (16.1%). The prevalences of asthma and COPD were higher in methadone patients (14.2% and 12.4%, respectively) compared to non-methadone patients (4.4% and 1.1%, respectively). Methadone was an independent determinant of asthma, adjusting for smoking status (OR 3.21; 95% CI: 2.52, 4.10) or for smoking intensity (3.08; 2.27, 4.19), and of COPD, adjusting for smoking status (6.00; 4.61, 7.80) or for smoking intensity (5.80; 4.12, 8.17). COPD and asthma prevalence were substantially higher in those prescribed methadone compared to those never prescribed methadone. Prescription of methadone was an independent predictor for both COPD and asthma, even after adjustment for smoking status and smoking intensity. Possible explanations include confounding by association with smoking of heroin or crack cocaine, both of which may have a causal association with COPD and asthma.

Barriers and facilitators to office-based opioid agonist therapy prescribing and effective interventions to increase provider prescribing: protocol for a systematic review

BACKGROUND

Opiate agonist therapy (OAT) prescribing rates by family physicians are low in the context of community-based, comprehensive primary care. Understanding the factors that support and/or inhibit OAT prescribing within primary care is needed. Our study objectives are to identify and synthesize documented barriers to, and facilitators of, primary care opioid agonist prescribing, and effective strategies to inform intervention planning and support increased primary care OAT prescribing.

METHODS/DESIGN

We will systematically search EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, MEDLINE, and gray literature in three domains: primary care providers, opioid agonist therapy, and opioid abuse. We will retain and assess primary studies reporting documented participation, or self-reported willingness to participate, in OAT prescribing; and/or at least one determinant of OAT prescribing; and/or strategies to address determinants of OAT prescribing from the perspective of primary care providers in comprehensive, community-based practice settings. There will be no restrictions on study design or publication date. Studies limited to specialty clinics with specialist prescribers, lacking extractable data, or in languages other than English or French will be excluded. Two reviewers will perform abstract review and data extraction independently. We will assess the quality of included studies using the Joanna Briggs Institute Critical Appraisal Tool. We will use a framework method of analysis to deductively code barriers and facilitators and to characterize effective strategies to support prescribing using a combined, modified a priori framework comprising the Theoretical Domains Framework and the Consolidated Framework for Implementation Research.

DISCUSSION

To date, no synthesis has been undertaken of the barriers and facilitators or effective interventions promoting OAT prescribing by primary care clinicians in community-based comprehensive care settings. Enacting change in physician behaviors, community-based programming, and health services is complex and best informed by using theoretical frameworks that allow the analysis of the available data to assist in designing and implementing interventions. In light of the current opioid crisis, increasing the capacity of primary care clinicians to provide OAT is an important strategy to curb morbidity and mortality from opioid use disorder.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD86835.

The impact of employment on perceived recovery from opiate dependence

Purpose

Less than 15 per cent of people starting opiate substitution treatment (OST) in England are employed, but few gain employment during treatment. Increasingly punitive approaches have been tried to encourage individuals with substance dependence into employment in the hope of facilitating recovery. It is not clear which factors are associated with the successful maintenance of employment whilst receiving OST, and whether this group can be said to be “in recovery”. The paper aims to discuss these issues.

Design/methodology/approach

A cross-sectional study of the OST population in one English region was conducted between January and April 2017. Measures of physical health, employment patterns, drug use, mental health, recovery capital, and dependence severity were administered to 55 employed and 55 unemployed clients.

Findings

Those in employment had higher levels of “recovery capital”, better physical and mental health, fewer drug problems, and less severe dependence, despite reporting heroin use at a similar level. Three variables were significantly associated with employment: longest period of employment (OR=1.01, p=0.003); number of chronic medical conditions (OR=0.44, p=0.011); and number of days of psychological problems in the last month (OR=0.95, p=0.031).

Practical implications

These results suggest that abstinence may not be required in order to maintain stable employment when OST is in place. Different treatment strategies are required for clients receiving OST already in employment compared with those who are unemployed.

Originality/value

This is the first UK study to the author’s knowledge to focus on people receiving OST who are also in employment.

Primary healthcare-based integrated care with opioid agonist treatment: First experience from Ukraine

BACKGROUND

Ukraine's HIV epidemic is concentrated among people who inject drugs (PWID), however, coverage with opioid agonist therapies (OATs) available mostly at specialty addiction clinics is extremely low. OAT integrated into primary healthcare clinics (PHCs) provides an opportunity for integrating comprehensive healthcare services and scaling up OAT.

METHODS

A pilot study of PHC-based integrated care for drug users conducted in two Ukrainian cities between 2014 and 2016 included three sub-studies: 1) cross-sectional treatment site preference assessment among current OAT patients (N=755); 2) observational cohort of 107 PWID who continued the standard of care versus transition of stabilized and newly enrolled PWID into PHC-based integrated care; and 3) pre/post analysis of attitudes toward PWID and HIV patients by PHC staff (N=26).

RESULTS

Among 755 OAT patients, 53.5% preferred receiving OAT at PHCs, which was independently correlated with convenience, trust in physician, and treatment with methadone (vs. buprenorphine). In 107 PWID observed over 6 months, retention in treatment was high: 89% in PWID continuing OAT in specialty addiction treatment settings (standard of care) vs 94% in PWID transitioning to PHCs; and 80% among PWID newly initiating OAT in PHCs. Overall, satisfaction with treatment, subjective self-perception of well-being, and trust in physician significantly increased in patients prescribed OAT in PHCs. Among PHC staff, attitudes towards PWID and HIV patients significantly improved over time.

CONCLUSIONS

OAT can be successfully integrated into primary care in low and middle-income countries and improves outcomes in both patients and clinicians while potentially scaling-up OAT for PWID.

Effect of Case Management Interventions for Patients with Substance Use Disorders: A Systematic Review

BACKGROUND

Substance use disorder (SUD) is an important health problem that requires a complex range of care because of the chronic nature of the disorder and the multiple psychosocial problems involved. Current outpatient programs often have difficulties in delivering and coordinating ongoing care and access to different health-care providers. Various case management (CM) models have been developed, first for patients in other psychiatric domains and then for patients with SUD, in order to improve treatment outcomes.

AIM

This paper aims to assess the effectiveness of CM for patients with SUD.

METHODS

We performed a systematic review of CM interventions for patients with SUD by analyzing randomized controlled studies published on the subject between 1996 and 2016 found on the electronic database PubMed.

RESULTS AND CONCLUSION

Fourteen studies were included in the analysis. Differences between studies in outcome measures, populations included, and intervention characteristics made it difficult to compare results. Most of these studies reported improvement in some of the chosen outcomes. Treatment adherence mostly improved, but substance use was reported to decrease in only a third of the studies. Overall functioning improved in about half of the studies. The heterogeneity of the results might be linked to these differences between studies. Further research is needed in the field.

Responding to illicit drug use in family practice

PURPOSE OF REVIEW

To examine and analyse recent published research on the impact and management of drug use and related disorders in primary care settings. Emerging trends in drug use and the development of new treatment approaches are making new demands on the primary care sector.

RECENT FINDINGS

Most recent publications relate to descriptions of the drugs used and their impact on mental health. The use of cannabis and newer stimulants and 'legal highs' tends to coexist with opiate use, and their physical and mental health sequelae often overlap. Several studies address methadone and buprenorphine prescribing, its efficacy and limitations, and organizational issues in delivery of treatment. Other areas identified in this review are pain control, adverse consequences of drug use including morbidity from infections associated with drug taking and death due to overdose, and longer-term outcomes. Several publications cover management of chronic conditions in an ageing population of drug users with multiple health problems, and others examine the trend toward community instead of specialist care.

SUMMARY

A picture is presented of extensive use of psychoactive substances in many communities. This ranges from club drug taking and low level cannabis use to more invasive and self-harming drug taking resulting from the use of opiates and stimulants. Treatment services are challenged with the need to change.