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Springgate B, Matta I, True G, Doran H, Torres WV, Stevens E, Holland E, Mott K, Ardoin TR, Nixdorff N, Haywood C, Meyers D, Johnson A, Tatum T, Palinkas LA. Implementation of medication for opioid use disorder treatment during a natural disaster: The PROUD-LA study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 165:209469. [PMID: 39094901 DOI: 10.1016/j.josat.2024.209469] [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: 01/17/2024] [Revised: 05/17/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND The impacts of climate change-related extreme weather events (EWEs) on Medication for Opioid Use Disorders (MOUD) implementation for Medicaid beneficiaries are relatively unknown. Such information is critical to disaster planning and other implementation strategies. In this study we examined implementation determinants and strategies for MOUD during EWEs. METHODS The Louisiana-based Community Resilience Learning Collaborative and Research Network (C-LEARN) utilized Rapid Assessment Procedures-Informed Community Ethnography (RAPICE), involving community leaders in study design, execution, and data analysis. We conducted qualitative semi-structured interviews with 42 individuals, including MOUD Medicaid member patients and their caregivers, healthcare providers and administrators, and public health officials with experience with climate-related disasters. We mapped key themes onto updated Consolidated Framework for Implementation Research domains. RESULTS MOUD use is limited during EWEs by pharmacy closures, challenges to medication prescription and access across state lines, hospital and clinic service limits, overcrowded emergency departments, and disrupted communications with providers. MOUD demand simultaneously increases due to the stress associated with displacement, resource loss, the COVID-19 pandemic, and social determinants of health. Effective implementation strategies include healthcare system disaster plans with protocols for clear and regular patient-provider communication, community outreach, additional staffing, and virtual delivery of services. Providers can also increase MOUD access by having remote access to EHRs, laptops and contact information, resource lists, collaborative networks, and contact with patients via call centers and social media. Patients can retain access to MOUD via online patient portals, health apps, call centers, and provider calls and texts. The impact of EWEs on MOUD access and use is also influenced by individual characteristics of both patients and providers. CONCLUSIONS The increasing frequency and severity of climate-related EWEs poses a serious threat to MOUD for Medicaid beneficiaries. MOUD-specific disaster planning and use of telehealth for maintaining contact and providing care are effective strategies for MOUD implementation during EWEs. Potential considerations for policies and practices of Medicaid, providers, and others to benefit members during hurricanes or major community stressors, include changes in Medicaid policies to enable access to MOUD by interstate evacuees, improvement of medication refill flexibilities, and incentivization of telehealth services for more systematic use.
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Affiliation(s)
- Benjamin Springgate
- LSU Health Sciences Center - New Orleans, School of Medicine and School of Public Health, New Orleans, LA, USA.
| | - Isha Matta
- LSU Health Sciences Center - New Orleans, School of Medicine and School of Public Health, New Orleans, LA, USA.
| | - Gala True
- LSU Health Sciences Center - New Orleans, School of Medicine and School of Public Health, New Orleans, LA, USA.
| | - Hanna Doran
- LSU Health Sciences Center - New Orleans, School of Medicine and School of Public Health, New Orleans, LA, USA.
| | | | - Elyse Stevens
- LSU Health Sciences Center - New Orleans, School of Medicine and School of Public Health, New Orleans, LA, USA.
| | - Elizabeth Holland
- LSU Health Sciences Center - New Orleans, School of Medicine and School of Public Health, New Orleans, LA, USA.
| | - Karlee Mott
- LSU Health Sciences Center - New Orleans, School of Medicine and School of Public Health, New Orleans, LA, USA.
| | - Tiffany R Ardoin
- LSU Health Sciences Center - New Orleans, School of Medicine and School of Public Health, New Orleans, LA, USA.
| | - Neil Nixdorff
- Department of Internal Medicine, Division of Geriatric & Palliative Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Diana Meyers
- St. Anna's Episcopal Church, New Orleans, LA, USA.
| | - Arthur Johnson
- Lower Ninth Ward Center for Sustainable Engagement and Development, New Orleans, LA, USA.
| | - Thad Tatum
- Formerly Incarcerated Peers Support Group, New Orleans, LA, USA
| | - Lawrence A Palinkas
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, La Jolla, CA, USA.
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Austin EJ, Chen J, Soyer E, Idrisov B, Briggs ES, Moghimi Y, Saxon AJ, Fortney JC, Blanchard BE, Williams EC, Ratzliff AD, Ruiz MS, Koch U. Primary care team perspectives on approaches to engaging patients in treatment for opioid use disorder. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 165:209456. [PMID: 39067765 PMCID: PMC11347117 DOI: 10.1016/j.josat.2024.209456] [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: 12/20/2023] [Revised: 04/28/2024] [Accepted: 07/11/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Engagement is a critical component of successful treatment for opioid use disorder (OUD). However, rates of patient engagement in OUD treatment, especially in outpatient settings, are variable and often low. Little is known about the specific strategies members of primary care teams use to initiate and encourage ongoing participation in OUD treatment. In a national cohort of primary care clinics in the U.S., we explored the perspectives of primary care team members on the meaning of and approaches to OUD treatment engagement. METHODS We conducted semi-structured interviews with 35 providers from multidisciplinary primary care teams in an existing national cohort of 13 clinics across seven states. Teams were delivering OUD treatment via the Collaborative Care Model, a model that combines primary care providers (PCP), behavioral health care managers (BHCM) and consulting psychiatric providers (CPP) in a structured way to provide patient-centered, team-based, and measurement-based care. Interview participants included 14 PCPs, 13 BHCMs, and 8 CPPs. Interviews asked open-ended questions about provider experiences and practices that aided or hindered patient engagement in OUD treatment. Interview transcripts were double-coded by trained qualitative researchers and analyzed using a combination of deductive and inductive approaches to identify themes. RESULTS Two themes emerged that describe provider perspectives on the meaning of engagement: 1) qualifying engagement by the volume of contact with patients, and 2) the need for more multidimensional measures of engagement. Six themes emerged that characterized provider engagement practices: 1) creating an environment of disclosure, 2) normalizing OUD treatment, 3) offering gentle but persistent outreach, 4) providing human connection and encouragement, 5) tailoring treatment to patient needs, and 6) avoiding stigmatizing responses. Analysis identified multiple replicable strategies that providers used to support these engagement practices. CONCLUSIONS Providers consistently apply a range of strategies when trying to engage patients in OUD treatment. Specific engagement strategies used embodied compassion and pragmatism, hallmarks of patient-centered care. Further research is needed to understand the impact of scaling engagement approaches across all care settings.
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Affiliation(s)
- Elizabeth J Austin
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America; Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, D.C., United States of America.
| | - Jessica Chen
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America
| | - Elena Soyer
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America
| | - Bulat Idrisov
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America
| | - Elsa S Briggs
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America
| | - Yavar Moghimi
- Department of Psychiatry and Behavioral Sciences, School of Medicine and Health Sciences, The George Washington University, United States of America
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America; Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, WA, United States of America
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America; Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, United States of America; Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, United States of America
| | - Brittany E Blanchard
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America; Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, United States of America
| | - Emily C Williams
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America; Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, United States of America
| | - Anna D Ratzliff
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America; Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, United States of America
| | - Monica S Ruiz
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, D.C., United States of America
| | - Ulrich Koch
- Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, D.C., United States of America
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Harris LM, Guerrero EG, Khachikian T, Serrett V, Marsh JC. Expert providers implement integrated and coordinated care in opioid use disorder treatment. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 132:104567. [PMID: 39241532 DOI: 10.1016/j.drugpo.2024.104567] [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: 05/25/2024] [Revised: 07/29/2024] [Accepted: 08/13/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Enhancing care integration and coordination to improve patient outcomes in opioid use disorder treatment is a growing focus in the field. Understanding of how the treatment system implements coordination and integration, particularly in the aftermath of the COVID-19 pandemic, remains limited. In this study, we explored the implementation of medications for opioid use disorder (MOUD) and the evolution of service delivery toward a more comprehensive approach. We examined providers' perspectives from high-achieving programs in Los Angeles County, the largest and most diverse U.S. county, including barriers to integrating and coordinating care and strategies for integrating MOUD service delivery. METHODS We gathered qualitative interview data from 30 high-performing programs in Los Angeles County, each represented by a manager or supervisor. High performance was defined by empirical indicators of access, retention, and program completion. Our data collection and analysis followed the constructivist grounded theory approach, explicating the social processes used by participating managers during the pandemic and subsequent organizational shifts. This approach yielded 14 major and six minor codes. Interrater reliability tests yielded a pooled Cohen's kappa statistic of 93%. RESULTS Expert providers exhibited a strong commitment to destigmatizing MOUD and worked to overcome obstacles in delivering care to clients by advocating its efficacy to fellow health care providers. Along with their endorsement of MOUD, they identified challenges in integrating and coordinating MOUD care. Barriers included stigma at both patient and provider levels, inadequate education about MOUD, limited access to MOUD, and the complexities of operating in a fragmented health care framework. Despite these challenges, high-performing providers used strategies to harmonize and align MOUD service delivery with health and social services. These included establishing service colocation, adopting a multidisciplinary team-based approach, forming partnerships with the community, offering telehealth services, integrating and sharing data, and embracing a harm reduction philosophy. DISCUSSION Through the adoption of these strategies, providers enhanced care accessibility, boosted patient engagement, sustained retention in treatment, and enhanced treatment outcomes. Even among highly skilled treatment providers in Los Angeles County, barriers to integrating and coordinating care using MOUD remain intricate and multifaceted. Addressing these challenges necessitates a comprehensive strategy involving provider education and training, increased availability of MOUD, enhanced coordination and communication among health care providers, resolution of regulatory hurdles, and addressing patient hesitancy toward MOUD.
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Affiliation(s)
- Lesley M Harris
- University of Louisville, Kent School of Social Work & Family Science, 2217 S 3rd St, Louisville, KY, USA.
| | - Erick G Guerrero
- I-Lead Institute, Research to End Healthcare Disparities Corp, 150 Ocean Park Blvd, 418, Santa Monica, CA, USA
| | - Tenie Khachikian
- I-Lead Institute, Research to End Healthcare Disparities Corp, 150 Ocean Park Blvd, 418, Santa Monica, CA, USA
| | - Veronica Serrett
- I-Lead Institute, Research to End Healthcare Disparities Corp, 150 Ocean Park Blvd, 418, Santa Monica, CA, USA
| | - Jeanne C Marsh
- University of Chicago, Crown Family School of Social Work, Policy, and Practice, 969 East 60th Street, Chicago, IL, USA
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Williams EC, Matson TE, Hallgren KA, Oliver M, Wang X, Bradley KA. Assessing Substance Use Disorder Symptoms with a Checklist among Primary Care Patients with Opioid Use Disorder and/or Long-Term Opioid Treatment: An Observational Study. J Gen Intern Med 2024; 39:2169-2178. [PMID: 38954321 PMCID: PMC11347511 DOI: 10.1007/s11606-024-08845-0] [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: 12/05/2023] [Accepted: 05/24/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Primary care (PC) offers an opportunity to treat opioid use disorders (OUD). The Substance Use Symptom Checklist ("Checklist") can assess DSM-5 substance use disorder (SUD) symptoms in PC. OBJECTIVE To test the psychometric properties of the Checklist among PC patients with OUD or long-term opioid therapy (LTOT) in Kaiser Permanente Washington (KPWA). DESIGN Observational study using item response theory (IRT) and differential item functioning (DIF) analyses of measurement consistency across age, sex, race and ethnicity, and receipt of treatment. PATIENTS Electronic health records (EHR) data were extracted for all adult PC patients visiting KPWA 3/1/15-8/30/2020 who had ≥ 1 Checklist documented and indication of either (a) clinically-recognized OUD (i.e., documented OUD diagnosis and/or OUD medication treatment) or (b) LTOT in the year prior to the checklist. MAIN MEASURE The Checklist includes 11 items reflecting DSM-5 criteria for SUD. We described the prevalence of 2 SUD symptoms reported on the Checklist (consistent with mild-severe DSM-5 SUD). Analyses were conducted in the overall sample and in two subsamples (clinically-recognized OUD and LTOT only). KEY RESULTS Among 2007 eligible patients, 39.9% endorsed ≥ 2 SUD symptoms (74.3% in the clinically-recognized OUD subsample and 13.1% in LTOT subsample). IRT indicated that a unidimensional model for the 11 checklist items had excellent fit (comparative fit index = 0.998) with high item-level discrimination parameters for the overall sample and both subsamples. DIF across age, race and ethnicity, and treatment was observed for one item each, but had minimal impact on expected number of criteria (0-11) patients endorse. CONCLUSIONS The Substance Use Symptom Checklist measured SUD symptoms consistent with DSM-5 conceptualization (scaled, unidimensional) in patients with clinically-recognized OUD and LTOT and had similar measurement properties across demographic subgroups. The Checklist may support symptom assessment in patients with OUD and diagnosis in patients with LTOT.
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Affiliation(s)
- Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, The Hans Rosling Building, Floor 4, Seattle, WA, 98195, USA.
- Health Services Research & Development (HSR&D) Center for Innovation for Veteran-Centered and Value- Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, 98101, USA.
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, 98101, USA.
| | - Theresa E Matson
- Department of Health Systems and Population Health, University of Washington School of Public Health, The Hans Rosling Building, Floor 4, Seattle, WA, 98195, USA
- Health Services Research & Development (HSR&D) Center for Innovation for Veteran-Centered and Value- Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, 98101, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, 98101, USA
| | - Kevin A Hallgren
- Department of Health Systems and Population Health, University of Washington School of Public Health, The Hans Rosling Building, Floor 4, Seattle, WA, 98195, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, 98101, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, 98195, USA
| | - Malia Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, 98101, USA
| | - Xiaoming Wang
- National Institute On Drug Abuse, Clinical Trials Network, Bethesda, MD, USA
| | - Katharine A Bradley
- Department of Health Systems and Population Health, University of Washington School of Public Health, The Hans Rosling Building, Floor 4, Seattle, WA, 98195, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, 98101, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, 98195, USA
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McKendrick G, Stull SW, Sharma A, Dunn KE. Availability and Opportunities for Expansion of Buprenorphine for the Treatment of Opioid Use Disorder. Semin Neurol 2024; 44:419-429. [PMID: 38876459 DOI: 10.1055/s-0044-1787569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2024]
Abstract
There is an urgent need to expand access to treatment for persons with opioid use disorder (OUD). As neurologists may frequently encounter patients with chronic pain who have developed OUD, they are in a position to serve as advocates for treatment. Buprenorphine is the most scalable medication for OUD in the United States, yet expansion has plateaued in recent years despite growing treatment needs. Reluctance of providers to establish treatment with new patients, challenges with rural expansion, stigma related to buprenorphine-based care, and pharmacy pressures that incentivize low dispensing and inventories may have stalled expansion. This review introduces these challenges before outlining actionable and evidenced-based strategies that warrant investigation, including methods to improve patient access to care (remotely delivered care, mobile delivery programs, Bridge programs) and provider retention and confidence in prescribing (expert consults, Extension for Community Healthcare Outcomes, a telementoring model, hub-and-spoke services), as well as novel innovations (virtual reality, artificial intelligence, wearable technologies). Overall, fortifying existing delivery systems while developing new transformative models may be necessary to achieve more optimal levels of buprenorphine treatment expansion.
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Affiliation(s)
- Greer McKendrick
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Samuel W Stull
- Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA
| | | | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Austin EJ, Chen J, Soyer E, Idrisov B, Briggs ES, Ferro L, Saxon AJ, Fortney JC, Curran GM, Moghimi Y, Blanchard BE, Williams EC, Ratzliff AD, Ruiz MS, Koch U. Optimizing Patient Engagement in Treatment for Opioid Use Disorder: Primary Care Team Perspectives on Influencing Factors. J Gen Intern Med 2024:10.1007/s11606-024-08963-9. [PMID: 39073482 DOI: 10.1007/s11606-024-08963-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 07/18/2024] [Indexed: 07/30/2024]
Abstract
BACKGROUND Opioid use disorder (OUD) care engagement rates in primary care (PC) settings are often low. Little is known about PC team experiences when delivering OUD treatment and potential factors that influence their capacity to engage patients in treatment. Exploring PC team experiences may inform needed supports that can optimize OUD care delivery and improve outcomes for patients with OUD. OBJECTIVE We explored multidisciplinary PC team perspectives on barriers and facilitators to engaging patients in OUD treatment. DESIGN Qualitative study using in-depth interviews. PARTICIPANTS Primary care clinical teams. APPROACH We conducted semi-structured interviews (n = 35) with PC team members involved in OUD care delivery, recruited using a combination of criterion and maximal variation sampling. Data collection and analysis were informed by existing theoretical literature about patient engagement, specifically that patient engagement is influenced by factors across individual (patient, provider), interpersonal (patient-provider), and health system domains. Interviews were professionally transcribed and doubled-coded using a coding schema based on the interview guide while allowing for emergent codes. Coding was iteratively reviewed using a constant comparison approach to identify themes and verified with participants and the full study team. KEY RESULTS Analysis identified five themes that impact PC team ability to engage patients effectively, including limited patient contact (e.g., phone, text) in between visits, varying levels of provider confidence to navigate OUD treatment discussions, structural factors (e.g., schedules, productivity goals) that limited provider time, the role of team-based approaches in lessening discouragement and feelings of burnout, and lack of shared organizational vision for reducing harms from OUD. CONCLUSIONS While the capacity of PC teams to engage patients in OUD care is influenced across multiple levels, some of the most promising opportunities may involve addressing system-level factors that limit PC team time and collaboration and promoting organizational alignment on goals for OUD treatment.
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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, USA.
- Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, D.C., USA.
| | - Jessica Chen
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Box 351621, Seattle, WA, USA
| | - Elena Soyer
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Box 351621, Seattle, WA, USA
| | - Bulat Idrisov
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Box 351621, Seattle, WA, USA
| | - Elsa S Briggs
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Box 351621, Seattle, WA, USA
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, WA, USA
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, WA, USA
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
| | - Geoffrey M Curran
- Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Central Arkansas Veterans Health Care System, Little Rock, USA
| | - Yavar Moghimi
- Department of Psychiatry and Behavioral Sciences, School of Medicine and Health Sciences, The George Washington University, Washington, D.C., USA
| | - Brittany E Blanchard
- 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, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, 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
| | - Monica S Ruiz
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, D.C., 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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Metcalfe RK, Dobischok S, Bansback N, MacDonald S, Byres D, Lajeunesse J, Harrison S, Koch B, Topping B, Brock T, Foreman J, Schechter M, Oviedo-Joekes E. Client preferences for the design and delivery of injectable opioid agonist treatment services: Results from a best-worst scaling task. Addiction 2024. [PMID: 39054406 DOI: 10.1111/add.16620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 06/19/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND AND AIMS Clinical trials support injectable opioid agonist treatment (iOAT) for individuals with opioid use disorder (OUD) for whom other pharmacological management approaches are not well-suited. However, despite substantial research indicating that person-centered care improves engagement, retention and health outcomes for individuals with OUD, structural requirements (e.g. drug policies) often dictate how iOAT must be delivered, regardless of client preferences. This study aimed to quantify clients' iOAT delivery preferences to improve client engagement and retention. DESIGN Cross-sectional preference elicitation survey. SETTING Metro Vancouver, British Columbia, Canada. PARTICIPANTS 124 current and former iOAT clients. MEASUREMENTS Participants completed a demographic questionnaire package and an interviewer-led preference elicitation survey (case 2 best-worst scaling task). Latent class analysis was used to identify distinct preference groups and explore demographic differences between preference groups. FINDINGS Most participants (n = 100; 81%) were current iOAT clients. Latent class analysis identified two distinct groups of client preferences: (1) autonomous decision-makers (n = 73; 59%) and (2) shared decision-makers (n = 51; 41%). These groups had different preferences for how medication type and dosage were selected. Both groups prioritized access to take-home medication (i.e. carries), the ability to set their own schedule, receiving iOAT in a space they like and having other services available at iOAT clinics. Compared with shared decision-makers, fewer autonomous decision-makers identified as a cis-male/man and reported flexible preferences. CONCLUSIONS Injectable opioid agonist treatment (iOAT) clients surveyed in Vancouver, Canada, appear to prefer greater autonomy than they currently have in choosing OAT medication type, dosage and treatment schedule.
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Affiliation(s)
- Rebecca Kathleen Metcalfe
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, Vancouver, Canada
| | - Sophia Dobischok
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, Vancouver, Canada
- Department of Education and Counselling Psychology, McGill University, Montreal, Canada
| | - Nick Bansback
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, Vancouver, Canada
| | - David Byres
- Provincial Health Services Authority, Vancouver, Canada
| | | | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, Vancouver, Canada
| | - Bryce Koch
- Doctor Peter Center, Vancouver, BC, Canada
| | - Blue Topping
- Downtown Community Health Centre, Vancouver, Canada
| | - Terry Brock
- Lookout Housing and Health Society, Surrey, Canada
| | - Julie Foreman
- Hope to Health Research and Innovation Centre, Vancouver, Canada
| | - Martin Schechter
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Eugenia Oviedo-Joekes
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, Vancouver, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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Han BH, Orozco MA, Miyoshi M, Doland H, Moore AA, Jones KF. Experiences of Aging with Opioid Use Disorder and Comorbidity in Opioid Treatment Programs: A Qualitative Analysis. J Gen Intern Med 2024; 39:1673-1680. [PMID: 38436883 PMCID: PMC11255154 DOI: 10.1007/s11606-024-08676-z] [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: 11/13/2023] [Accepted: 02/02/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND The number of older adults entering opioid treatment programs (OTPs) to treat opioid use disorder (OUD) is increasing. However, the lived experiences of aging in OTPs have not been examined. OBJECTIVE To explore the aging experience with OUD and barriers to medical care for older adults who receive care in OTPs. DESIGN From November 2021 to July 2022, we conducted 1-to-1, semi-structured qualitative interviews in English and Spanish, audio-recorded, transcribed, systematically coded, and analyzed to identify key themes regarding the challenges of aging with OUD and managing chronic diseases. PARTICIPANTS Thirty-six adults aged ≥ 55 enrolled in OTPs in San Diego, California. APPROACH A descriptive qualitative approach was used. Major themes and subthemes were identified through thematic analysis until thematic saturation was reached. KEY RESULTS All participants were on methadone and had a mean age of 63.4 (SD 5.1) years; 11 (30.6%) identified as female, 14 (39%) as Hispanic/Latino, and 11 (36%) as Black, with a mean duration of methadone treatment of 5.6 years. Chronic diseases were common, with 21 (58.3%) reporting hypertension, 9 (25%) reporting untreated hepatitis C, and 32 (88.9%) having ≥ 2 chronic diseases. Three major themes emerged: (1) avoidance of medical care due to multiple intersectional stigmas, including those related to drug use, substance use disorder (SUD) treatment, ageism, and housing insecurity; (2) increasing isolation with aging and loss of family and peer groups; (3) the urgent need for integrating medical and aging-focused care with OUD treatment in the setting of increasing health and functional challenges. CONCLUSIONS Older adults with OUD reported increasing social isolation and declining health while experiencing multilevel stigma and discrimination. The US healthcare system must transform to deliver age-friendly care that integrates evidence-based geriatric models of care incorporated with substance use disorder treatment and addresses the intersectional stigma this population has experienced in healthcare settings.
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Affiliation(s)
- Benjamin H Han
- Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, University of California San Diego, La Jolla, CA, USA.
| | - Mirella A Orozco
- Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Mari Miyoshi
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Heidi Doland
- Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Alison A Moore
- Division of Geriatrics, Gerontology, and Palliative Care, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Katie Fitzgerald Jones
- New England Geriatric Research Education and Clinical Center (GRECC), VA Boston Healthcare System, Jamaica Plain, MA, USA
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Bergman AA, Oberman RS, Taylor SL, Kranke B, Chang ET. Prescribing and Acceptance of Medications for Opioid Use Disorder in VA Primary Care: Veteran and Provider Perspectives. J Gen Intern Med 2024; 39:1690-1697. [PMID: 38587730 PMCID: PMC11254870 DOI: 10.1007/s11606-024-08703-z] [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: 10/17/2023] [Accepted: 02/23/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Medications to treat opioid use disorder (MOUD) such as buprenorphine/naloxone can effectively treat OUD and reduce opioid-related mortality, but they remain underutilized, especially in non-substance use disorder settings such as primary care (PC). OBJECTIVE To uncover the factors that can facilitate successful prescribing of MOUD and uptake/acceptance of MOUD by patients in PC settings in the Veterans Health Administration. DESIGN Semi-structured qualitative telephone interviews with 77 providers (e.g., primary care providers, hospitalists, nurses, addiction psychiatrists) and 22 Veteran patients with experience taking MOUD. Interviews were recorded, transcribed, and analyzed thematically using a combination a priori/inductive approach. KEY RESULTS Providers and patients shared their general perceptions and experiences with MOUD, including high satisfaction with buprenorphine/naloxone with few side effects and caveats, although some patients reported drawbacks to methadone. Both providers and patients supported the idea of prescribing MOUD in PC settings to prioritize patient comfort and convenience. Providers described individual-level barriers (e.g., time, stigma, perceptions of difficulty level), structural-level barriers (e.g., pharmacy not having medications ready, space for inductions), and organizational-level barriers (e.g., inadequate staff support, lack of nursing protocols) to PC providers prescribing MOUD. Facilitators centered on education and knowledge enhancement, workflow and practice support, patient engagement and patient-provider communication, and leadership and organizational support. The most common barrier faced by patients to starting MOUD was apprehensions about pain, while facilitators focused on personal motivation, encouragement from others, education about MOUD, and optimally timed provider communication strategies. CONCLUSIONS These findings can help improve provider-, clinic-, and system-level supports for MOUD prescribing across multiple settings, as well as foster communication strategies that can increase patient acceptance of MOUD. They also point to how interprofessional collaboration across service lines and leadership support can facilitate MOUD prescribing among non-addiction providers.
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Affiliation(s)
- Alicia A Bergman
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA.
| | - Rebecca S Oberman
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
| | - Stephanie L Taylor
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Department of Health Policy and Management, University of California, Los Angeles Fielding School of Public Health, Los Angeles, CA, USA
| | - Bridget Kranke
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
| | - Evelyn T Chang
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation and Policy, VA Greater Los Angeles Healthcare System, 16111 Plummer Street, Los Angeles, CA, 91343, USA
- Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
- Division of General Internal Medicine, Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Tilhou AS, Burns M, Chachlani P, Chen Y, Dague L. How Does Telehealth Expansion Change Access to Healthcare for Patients With Different Types of Substance Use Disorders? SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:473-485. [PMID: 38494728 PMCID: PMC11179974 DOI: 10.1177/29767342241236028] [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: 03/19/2024]
Abstract
BACKGROUND Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown. METHODS Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake ("offset"), and the share of visits completed by telemedicine ("share"). RESULTS The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only. CONCLUSIONS Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.
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Affiliation(s)
- Alyssa Shell Tilhou
- Department of Family Medicine, Boston University Medical Center, Boston, MA, USA
| | - Marguerite Burns
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Preeti Chachlani
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, WI, USA
| | - Ying Chen
- Department of Risk and Insurance, Wisconsin School of Business, University of Wisconsin-Madison, Madison, WI, USA
| | - Laura Dague
- The Bush School of Government and Public Service, Texas A&M University, College Station, TX, USA
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Neeb C, McQuade BM, Lesondak L, Madrid S, Schlaeger JM, Watson DP, Karnik N, Huerta N, Bhatia S, Fleurimont J, Li N, Hammerdahl E, Pesantez R, Gastala N. Integration of a Community Opioid Treatment Program into a Federally Qualified Health Center. J Addict Med 2024:01271255-990000000-00334. [PMID: 38884619 DOI: 10.1097/adm.0000000000001336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
OBJECTIVES With the increasing rates of opioid overdose deaths in the United States, barriers to treatment access for patients seeking medications for opioid use disorder (OUD), and challenges of initiating buprenorphine in patients who use fentanyl, it is essential to explore novel approaches to expanding access to methadone treatment. An opioid treatment program (OTP) and a federally qualified health center (FQHC) partnered to develop and implement an innovative integrated methadone and primary care treatment model. The process for integrating an OTP and FQHC to provide methadone treatment in the primary care setting will be discussed. METHODS An OTP methadone dispensing site was co-located in the FQHC, utilizing a staffing matrix built on the expertise of each stakeholder. The OTP managed DEA and state regulatory processes, whereas the FQHC physicians provided medical treatment, including methadone treatment protocols, treatment plans, and primary care. Patient demographics, medical history, and retention data for those who entered the program between January 2021 and February 2023 were collected through chart review and analyzed with descriptive statistics. RESULTS A total of 288 OTP-FHQC patients were enrolled during the study. Retention rates in methadone treatment at 90 and 180 days were similar to partner clinics. CONCLUSIONS Collaboration between FQHCs and OTPs is operationally feasible and can be achieved utilizing the current staffing model of the FQHC and OTP. This model can increase access to treatment for OUD and primary care for an urban, underserved patient population.
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Affiliation(s)
- Christine Neeb
- From the Department of Medicine-Internal Medicine, University of Colorado School of Medicine, Aurora, CO (CN); Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, Chicago, IL (BMMQ); University of Illinois Chicago, UI Health, Mile Square Health Center, Chicago, IL (CN, LL, SM, NH, SB, JF, NL, EH, RP, NG); Department of Human Development Nursing Science, University of Illinois Chicago, Chicago, IL (JMS); Chestnut Health Systems, Lighthouse Institute, Chicago, IL (DPW); and Department of Psychiatry, University of Illinois Chicago, Chicago, IL (NK)
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12
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D'Aunno T, Neighbors CJ. Innovation in the Delivery of Behavioral Health Services. Annu Rev Public Health 2024; 45:507-525. [PMID: 37871139 DOI: 10.1146/annurev-publhealth-071521-024027] [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] [Indexed: 10/25/2023]
Abstract
Several factors motivate the need for innovation to improve the delivery of behavioral health services, including increased rates of mental health and substance use disorders, limited access to services, inconsistent use of evidence-based practices, and persistent racial and ethnic disparities. This narrative review identifies promising innovations that address these challenges, assesses empirical evidence for the effectiveness of these innovations and the extent to which they have been adopted and implemented, and suggests next steps for research. We review five categories of innovations: organizational models, including a range of novel locations for providing services and new ways of organizing services within and across sites; information and communication technologies; workforce; treatment technologies; and policy and regulatory changes. We conclude by discussing the need to strengthen and accelerate the contributions of implementation science to close the gap between the launch of innovative behavioral health services and their widespread use.
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Affiliation(s)
- Thomas D'Aunno
- Wagner Graduate School of Public Service, New York University, New York, NY, USA;
| | - Charles J Neighbors
- Department of Population Health, Grossman School of Medicine, New York University, New York, NY, USA
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13
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Williams EC, Frost MC, Danner AN, Lott AMK, Achtmeyer CE, Hood CL, Malte CA, Saxon AJ, Hawkins EJ. "The Only Reason I Am Willing to Do It at All": Evaluation of VA's SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center. J Addict Med 2024; 18:248-255. [PMID: 38385548 DOI: 10.1097/adm.0000000000001277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
OBJECTIVES Medication treatment for opioid use disorder (MOUD) is effective and recommended for outpatient settings. We implemented and evaluated the SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center-a quality improvement partnership to implement stepped care for MOUD in 2 Veterans Health Administration (VA) primary care (PC) clinics. METHODS SUPPORT provided a dedicated clinical team (nurse practitioner prescriber and social worker) and stepped care ([1] identification, assessment, referral; [2] MOUD induction; [3] stabilization; and [4] maintenance supporting PC providers [PCPs] to initiate and/or sustain treatment) coupled with ongoing internal facilitation (consultation, trainings, informatics support). Qualitative interviews with stakeholders (PCPs and patients) and meeting notes identified barriers and facilitators to implementation. Electronic health record and patient tracking data measured reach, adoption, and implementation outcomes descriptively. RESULTS SUPPORT's implementation barriers included the need for an X-waiver, VA's opioid tapering policies, patient and PCP knowledge gaps and PCP discomfort, and logistical compatibility and sustainability challenges for clinics. SUPPORT's dedicated clinical staff, ongoing internal facilitation, and high patient and PCP satisfaction were key facilitators. SUPPORT (January 2019 to September 2021) trained 218 providers; 63 received X-waivers, and 23 provided MOUD (10.5% of those trained). SUPPORT provided care to 167 patients, initiated MOUD for 33, and provided education and naloxone to 72 (all = 0 in year before launch). CONCLUSIONS SUPPORT reached many PCPs and patients and resulted in small increases in MOUD prescribing and high levels of stakeholder satisfaction. Dedicated clinical staff was key to observed successes. Although resource-intensive, SUPPORT offers a potential model for outpatient MOUD provision.
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Affiliation(s)
- Emily C Williams
- From the Health Services Research & Development (HSR&D), Seattle Center of Innovation for Veteran-centered and Value-driven Care, Veterans Affairs (VA), Puget Sound Healthcare System, Seattle, WA (ECW, MCF, AND, AMKL, CAM, EJH); Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA (ECW, MCF); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA (AND, AMKL, CEA, CLH, CAM, AJS, EJH); and Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA (AJS, EJH)
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14
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Ventres WB, Stone LA, Abou-Arab ER, Meza J, Buck DS, Crowder JW, Edgoose JYC, Brown A, Plumb EJ, Norris AK, Allen JJ, Giammar LE, Wood JE, Dickson SM, Brown GA. Storylines of family medicine IX: people and places-diverse populations and locations of care. Fam Med Community Health 2024; 12:e002826. [PMID: 38609086 PMCID: PMC11029404 DOI: 10.1136/fmch-2024-002826] [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] [Indexed: 04/14/2024] Open
Abstract
Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'IX: people and places-diverse populations and locations of care', authors address the following themes: 'LGBTQIA+health in family medicine', 'A family medicine approach to substance use disorders', 'Shameless medicine for people experiencing homelessness', '''Difficult" encounters-finding the person behind the patient', 'Attending to patients with medically unexplained symptoms', 'Making house calls and home visits', 'Family physicians in the procedure room', 'Robust rural family medicine' and 'Full-spectrum family medicine'. May readers appreciate the breadth of family medicine in these essays.
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Affiliation(s)
- William B Ventres
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Leslie A Stone
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Emad R Abou-Arab
- Family Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Julio Meza
- Family Medicine, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, USA
| | - David S Buck
- Community Medicine, University of Houston, Tilman J Fertitta Family College of Medicine, Houston, Texas, USA
| | - Jerome W Crowder
- Social and Behavioral Sciences, University of Houston, Tilman J Fertitta Family College of Medicine, Houston, Texas, USA
| | - Jennifer Y C Edgoose
- Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Alexander Brown
- NH Dartmouth Family Medicine Residency, Concord, New Hampshire, USA
| | - Ellen J Plumb
- San Francisco VA Medical Center, San Francisco, California, USA
| | - Amber K Norris
- Family and Preventive Medicine, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Jay J Allen
- Duluth Family Medicine Residency Program, University of Minnesota Medical School Duluth Campus, Duluth, Minnesota, USA
| | - Lauren E Giammar
- Duluth Family Medicine Residency Program, University of Minnesota Medical School Duluth Campus, Duluth, Minnesota, USA
| | - John E Wood
- Duluth Family Medicine Residency Program, University of Minnesota Medical School Duluth Campus, Duluth, Minnesota, USA
| | - Scott M Dickson
- UAMS Northeast Regional Campus Family Medicine Residency Program, Jonesboro, Arkansas, USA
| | - G Austin Brown
- Cascades East Family Medicine Residency Program, Oregon Health & Science University School of Medicine, Klamath Falls, Oregon, USA
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15
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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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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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Rush AJ, Gore-Langton RE, Bart G, Bradley KA, Campbell CI, McKay J, Oslin DW, Saxon AJ, Winhusen TJ, Wu LT, Moran LM, Tai B. Tools to implement measurement-based care (MBC) in the treatment of opioid use disorder (OUD): toward a consensus. Addict Sci Clin Pract 2024; 19:14. [PMID: 38419116 PMCID: PMC10902994 DOI: 10.1186/s13722-024-00446-w] [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: 08/29/2023] [Accepted: 02/13/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The prevalence and associated overdose death rates from opioid use disorder (OUD) have dramatically increased in the last decade. Despite more available treatments than 20 years ago, treatment access and high discontinuation rates are challenges, as are personalized medication dosing and making timely treatment changes when treatments fail. In other fields such as depression, brief measures to address these tasks combined with an action plan-so-called measurement-based care (MBC)-have been associated with better outcomes. This workgroup aimed to determine whether brief measures can be identified for using MBC for optimizing dosing or informing treatment decisions in OUD. METHODS The National Institute on Drug Abuse Center for the Clinical Trials Network (NIDA CCTN) in 2022 convened a small workgroup to develop consensus about clinically usable measures to improve the quality of treatment delivery with MBC methods for OUD. Two clinical tasks were addressed: (1) to identify the optimal dose of medications for OUD for each patient and (2) to estimate the effectiveness of a treatment for a particular patient once implemented, in a more granular fashion than the binary categories of early or sustained remission or no remission found in The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). DISCUSSION Five parameters were recommended to personalize medication dose adjustment: withdrawal symptoms, opioid use, magnitude (severity and duration) of the subjective effects when opioids are used, craving, and side effects. A brief rating of each OUD-specific parameter to adjust dosing and a global assessment or verbal question for side-effects was viewed as sufficient. Whether these ratings produce better outcomes (e.g., treatment engagement and retention) in practice deserves study. There was consensus that core signs and symptoms of OUD based on some of the 5 DSM-5 domains (e.g., craving, withdrawal) should be the basis for assessing treatment outcome. No existing brief measure was found to meet all the consensus recommendations. Next steps would be to select, adapt or develop de novo items/brief scales to inform clinical decision-making about dose and treatment effectiveness. Psychometric testing, assessment of acceptability and whether the use of such scales produces better symptom control, quality of life (QoL), daily function or better prognosis as compared to treatment as usual deserves investigation.
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Affiliation(s)
- A John Rush
- Duke-NUS Medical School, The National University of Singapore, Duke University School of Medicine, Singapore, Singapore
| | | | - Gavin Bart
- School of Medicine & Division of Medicine at Hennepin Healthcare, University of Minnesota, Minneapolis, MN, USA
| | | | - Cynthia I Campbell
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - James McKay
- Penn Center on the Continuum of Care in the Addictions, Philadelphia VA Center of Excellence in Substance Addiction Treatment and Education, University of Pennsylvania, Philadelphia, PA, USA
| | - David W Oslin
- University of Psychiatry, VISN 4 Mental Illness, Research, Education and Clinical Center Crescenz VA Medical Center, Stephen A. Cohen Military Family Clinic at the Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrew J Saxon
- University of Washington and Center of Excellence in Substance Addiction Treatment and Education at the VA Puget Sound Health Care System, Seattle, WA, USA
| | - T John Winhusen
- Addiction Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Li-Tzy Wu
- Duke University School of Medicine, Durham, NC, USA
| | - Landhing M Moran
- Center for Clinical Trials Network, National Institute on Drug Abuse, Bethesda, MD, USA
| | - Betty Tai
- Center for Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, 11601 Landsdown Street (3WF), Bethesda, MD, 20892, USA.
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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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Maxey HL, Vaughn SX, Dickinson A, Newhouse R. Exploring the Demographic and Professional Characteristics of Physicians and Nurse Practitioners Associated With Providing Medication-Assisted Treatment: A Retrospective Observational Study. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241237144. [PMID: 38528773 DOI: 10.1177/00469580241237144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Integration of medication-assisted treatment (MAT) for opioid use disorder in primary care settings is an emerging health care delivery model that supports increased access to specialized care but requires primary care provider engagement. Examining the characteristics of providers who provide this service is key to informing targeted recruitment. Using administrative and supplemental data collected during license renewal, this study aimed to identify the characteristics of primary care physicians and nurse practitioners (NPs) associated with greater odds of providing MAT in their practice. A retrospective observational study was conducted using a descriptive correlational design. The analysis included 5259 physicians and 3486 NPs who renewed their licenses electronically in 2021 and specialized in primary care or psychiatry. Chi-square and logistic regression analyses were conducted to identify the demographic and clinical characteristics of physicians and NPs associated with MAT participation in their practice. Physicians had a higher odds ratio (OR) of providing MAT if they were younger than 35 years (OR = 1.334; P = .0443), practiced in a federally qualified health center (OR = 3.101, P < .0001), and offered a sliding fee scale in their practice (OR = 2.046; P < .0001). Likewise, NPs had higher odds of providing MAT if they practiced in a public or community health center (OR = 3.866; P < .0001). The results of this study highlight the personal and professional characteristics of physicians and NPs associated with higher odds of providing MAT. These findings may have implications for the recruitment and sustainability of MAT integration in primary care.
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Affiliation(s)
- Hannah L Maxey
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sierra X Vaughn
- Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Robin Newhouse
- Indiana University School of Nursing, Indianapolis, IN, USA
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Luo SX, Feaster DJ, Liu Y, Balise RR, Hu MC, Bouzoubaa L, Odom GJ, Brandt L, Pan Y, Hser YI, VanVeldhuisen P, Castillo F, Calderon AR, Rotrosen J, Saxon AJ, Weiss RD, Wall M, Nunes EV. Individual-Level Risk Prediction of Return to Use During Opioid Use Disorder Treatment. JAMA Psychiatry 2024; 81:45-56. [PMID: 37792357 PMCID: PMC10551817 DOI: 10.1001/jamapsychiatry.2023.3596] [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: 04/17/2023] [Accepted: 07/11/2023] [Indexed: 10/05/2023]
Abstract
Importance No existing model allows clinicians to predict whether patients might return to opioid use in the early stages of treatment for opioid use disorder. Objective To develop an individual-level prediction tool for risk of return to use in opioid use disorder. Design, Setting, and Participants This decision analytical model used predictive modeling with individual-level data harmonized in June 1, 2019, to October 1, 2022, from 3 multicenter, pragmatic, randomized clinical trials of at least 12 weeks' duration within the National Institute on Drug Abuse Clinical Trials Network (CTN) performed between 2006 and 2016. The clinical trials covered a variety of treatment settings, including federally licensed treatment sites, physician practices, and inpatient treatment facilities. All 3 trials enrolled adult participants older than 18 years, with broad pragmatic inclusion and few exclusion criteria except for major medical and unstable psychiatric comorbidities. Intervention All participants received 1 of 3 medications for opioid use disorder: methadone, buprenorphine, or extended-release naltrexone. Main Outcomes and Measures Predictive models were developed for return to use, which was defined as 4 consecutive weeks of urine drug screen (UDS) results either missing or positive for nonprescribed opioids by week 12 of treatment. Results The overall sample included 2199 trial participants (mean [SD] age, 35.3 [10.7] years; 728 women [33.1%] and 1471 men [66.9%]). The final model based on 4 predictors at treatment entry (heroin use days, morphine- and cocaine-positive UDS results, and heroin injection in the past 30 days) yielded an area under the receiver operating characteristic curve (AUROC) of 0.67 (95% CI, 0.62-0.71). Adding UDS in the first 3 treatment weeks improved model performance (AUROC, 0.82; 95% CI, 0.78-0.85). A simplified score (CTN-0094 OUD Return-to-Use Risk Score) provided good clinical risk stratification wherein patients with weekly opioid-negative UDS results in the 3 weeks after treatment initiation had a 13% risk of return to use compared with 85% for those with 3 weeks of opioid-positive or missing UDS results (AUROC, 0.80; 95% CI, 0.76-0.84). Conclusions and Relevance The prediction model described in this study may be a universal risk measure for return to opioid use by treatment week 3. Interventions to prevent return to regular use should focus on this critical early treatment period.
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Affiliation(s)
- Sean X. Luo
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Daniel J. Feaster
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Ying Liu
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Raymond R. Balise
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Mei-Chen Hu
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Layla Bouzoubaa
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Gabriel J. Odom
- Department of Biostatistics, Stempel College of Public Health, Florida International University, Miami, Florida
| | - Laura Brandt
- Department of Psychology, City College of New York, New York
| | - Yue Pan
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Yih-Ing Hser
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | | | - Felipe Castillo
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Anna R. Calderon
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - John Rotrosen
- Department of Psychiatry, NYU Grossman School of Medicine, New York University, New York, New York
| | - Andrew J. Saxon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Roger D. Weiss
- Department of Psychiatry, Harvard Medical School, Belmont, Massachusetts
| | - Melanie Wall
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Edward V. Nunes
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
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Treitler P, Enich M, Bowden C, Mahone A, Lloyd J, Crystal S. Implementation of an office-based addiction treatment model for Medicaid enrollees: A mixed methods study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 156:209212. [PMID: 37935350 PMCID: PMC10842178 DOI: 10.1016/j.josat.2023.209212] [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: 02/10/2023] [Revised: 05/31/2023] [Accepted: 10/24/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Medications for opioid use disorder (MOUD) are the most effective treatment for opioid use disorder (OUD) but remain underutilized. To reduce barriers to MOUD prescribing and increase treatment access, New Jersey's Medicaid program implemented the Office-Based Addiction Treatment (OBAT) Program in 2019, which increased reimbursement for office-based buprenorphine prescribing and established newly reimbursable patient navigation services in OBAT clinics. Using a mixed-methods design, this study aimed to describe stakeholder experiences with the OBAT program and to assess implementation and uptake of the program. METHODS This study used a concurrent, triangulated mixed-methods design, which integrated complementary qualitative (semi-structured interviews) and quantitative (Medicaid claims) data to gain an in-depth understanding of the implementation of the OBAT program. We elicited stakeholder perspectives through interviews with 22 NJ Medicaid MOUD providers and 8 policy key informants, and examined trends in OBAT program utilization using 2019-2020 NJ Medicaid claims for 5380 Medicaid enrollees who used OBAT services. We used cross-case analysis (provider interviews) and a case study approach (key informant interviews) in analyzing qualitative data, and calculated descriptive statistics and trends for quantitative data. RESULTS Provider enrollment and utilization of OBAT services increased steadily during the first two years of program implementation. Interviewees reported that enhanced reimbursements for office-based MOUD incentivized greater MOUD prescribing, while coverage of patient navigation services improved patient care. Despite increasing enrollment in the OBAT program, the proportion of primary care physicians in the state who enrolled in the program remained limited. Key barriers to enrollment included: requirements for a patient navigator; concerns about administrative burdens and reimbursement delays from Medicaid; lack of awareness of the program; and beliefs that patients with OUD were better served in comprehensive care settings. Patient navigation was highlighted as a critical and valuable element of the program, but navigator enrollment and reimbursement challenges may have prevented greater uptake of this service. CONCLUSIONS Implementation of an OBAT model that enhanced reimbursement and provided coverage for patient navigation likely expanded access to MOUD in NJ. Results support initiatives like the OBAT program in improving access to MOUD, but program adaptations, where feasible, could improve uptake and utilization.
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Affiliation(s)
- Peter Treitler
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America; Boston University School of Social Work, 264 Bay State Rd., Boston, MA 02215, United States of America.
| | - Michael Enich
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America; School of Social Work, Rutgers, the State University of New Jersey, 120 Albany St., New Brunswick, NJ 08901, United States of America
| | - Cadence Bowden
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America
| | - Anais Mahone
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America; School of Social Work, Rutgers, the State University of New Jersey, 120 Albany St., New Brunswick, NJ 08901, United States of America
| | - James Lloyd
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America; School of Social Work, Rutgers, the State University of New Jersey, 120 Albany St., New Brunswick, NJ 08901, United States of America; School of Public Health, Rutgers, the State University of New Jersey, 683 Hoes Lane West, Piscataway, NJ 08854, United States of America
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Smith KR, Shah NK, Adamczyk AL, Weinstein LC, Kelly EL. Harm reduction in undergraduate and graduate medical education: a systematic scoping review. BMC MEDICAL EDUCATION 2023; 23:986. [PMID: 38129846 PMCID: PMC10734177 DOI: 10.1186/s12909-023-04931-9] [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: 08/15/2023] [Accepted: 12/04/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Substance use increasingly contributes to early morbidity and mortality, which necessitates greater preparation of the healthcare workforce to mitigate its harm. The purpose of this systematic scoping review is to: 1) review published curricula on harm reduction for substance use implemented by undergraduate (UME) and graduate medical education (GME) in the United States and Canada, 2) develop a framework to describe a comprehensive approach to harm reduction medical education, and 3) propose additional content topics for future consideration. METHODS PubMed, Scopus, ERIC: Education Resources Information Center (Ovid), and MedEdPORTAL were searched. Studies included any English language curricula about harm reduction within UME or GME in the United States or Canada from 1993 until Nov 22, 2021. Two authors independently reviewed and screened records for data extraction. Data were analyzed on trainee population, curricula objectives, format, content, and evaluation. RESULTS Twenty-three articles describing 19 distinct educational programs across the United States were included in the final sample, most of which created their own curricula (n = 17). Data on educational content were categorized by content and approach. Most programs (85%) focused on introductory substance use knowledge and skills without an understanding of harm reduction principles. Based on our synthesis of the educational content in these curricula, we iteratively developed a Harm Reduction Educational Spectrum (HRES) framework to describe curricula and identified 17 discrete content topics grouped into 6 themes based on their reliance on harm reduction principles. CONCLUSIONS Harm reduction is under-represented in published medical curricula. Because the drug supply market changes rapidly, the content of medical curricula may be quickly outmoded thus curricula that include foundational knowledge of harm reduction principles may be more enduring. Students should be grounded in harm reduction principles to develop the advanced skills necessary to reduce the physical harm associated with drugs while still simultaneously recognizing the possibility of patients' ongoing substance use. We present the Harm Reduction Educational Spectrum as a new framework to guide future healthcare workforce development and to ultimately provide the highest-quality care for patients who use drugs.
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Affiliation(s)
- Kelsey R Smith
- University of California San Diego School of Medicine, 9500 Gilman Dr, La Jolla, CA, 92093, USA.
- Department of Family and Community Medicine, Thomas Jefferson University, 1015 Walnut St, Curtis Building, Philadelphia, PA, 19107, USA.
| | - Nina K Shah
- Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut St, #100, Philadelphia, PA, 19107, USA
| | - Abby L Adamczyk
- Scott Memorial Library, Thomas Jefferson University, 1020 Walnut St, Philadelphia, PA, 19107, USA
| | - Lara C Weinstein
- Department of Family and Community Medicine, Thomas Jefferson University, 1015 Walnut St, Curtis Building, Philadelphia, PA, 19107, USA
| | - Erin L Kelly
- Department of Family and Community Medicine, Thomas Jefferson University, 1015 Walnut St, Curtis Building, Philadelphia, PA, 19107, USA
- Center for Social Medicine and Humanities, University of California Los Angeles, B7-435, Semel Institute, Los Angeles, CA, 90095-1759, USA
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23
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Dobischok S, Carvajal JR, Turner K, Jaffe K, Lehal E, Blawatt S, Redquest C, Baltzer Turje R, McDougall P, Koch B, McDermid C, Hassan D, Harrison S, Oviedo-Joekes E. "It feels like I'm coming to a friend's house": an interpretive descriptive study of an integrated care site offering iOAT (Dr. Peter Centre). Addict Sci Clin Pract 2023; 18:73. [PMID: 38042844 PMCID: PMC10693115 DOI: 10.1186/s13722-023-00428-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/20/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Injectable opioid agonist treatment (iOAT) has proven to be a safe and effective treatment option for severe opioid use disorder (OUD). Yet, iOAT is often isolated from other health and social services. To align with a person-centered care approach, iOAT can be embedded in sites that combine systems and services that have been historically fragmented and that address multiple comorbidities (integrated care sites). The present study investigates the addition of iOAT at an integrated care in Vancouver, British Columbia. We aimed to capture what it means for service users and service providers to incorporate iOAT in an integrated care site and describe the processes by which the site keeps people engaged. METHODS We conducted 22 interviews with 15 service users and 14 interviews with 13 service providers across two rounds of individual semi-structured interviews (Fall 2021, Summer 2022). The second interview round was precipitated by a service interruption in medication dispensation. Interview audio was recorded, transcribed, and then analysed in NVivo 1.6 following an interpretive description approach. RESULTS The emergent themes from the analysis are represented in two categories: (1) a holistic approach (client autonomy, de-medicalized care, supportive staff relationships, multiple opportunities for engagement, barriers to iOAT integration) and (2) a sense of place (physical location, social connection and community belonging, food). CONCLUSION Incorporating iOAT at an integrated care site revealed how iOAT delivery can be strengthened through its direct connection to a diverse, comprehensive network of health and social services that are provided in a community atmosphere with high quality therapeutic relationships.
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Affiliation(s)
- Sophia Dobischok
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
- Department of Education and Counselling Psychology, McGill University, 3700 McTavish St., Montreal, QC, H3A 1Y2, Canada
| | - José R Carvajal
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Kyle Turner
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Kaitlyn Jaffe
- Department of Health Promotion and Policy, University of Massachusetts Amherst, 715 North Pleasant Street, Amherst, MA, 01003, USA
| | - Eisha Lehal
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Sarinn Blawatt
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Casey Redquest
- Dr. Peter Centre, 1110 Comox Street, Vancouver, BC, V6E 1K5, Canada
| | | | | | - Bryce Koch
- Dr. Peter Centre, 1110 Comox Street, Vancouver, BC, V6E 1K5, Canada
| | - Cheryl McDermid
- Dr. Peter Centre, 1110 Comox Street, Vancouver, BC, V6E 1K5, Canada
- Providence Health Care, Providence Crosstown Clinic, 77 East Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Damon Hassan
- Dr. Peter Centre, 1110 Comox Street, Vancouver, BC, V6E 1K5, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 77 East Hastings Street, Vancouver, BC, V6B 1G6, Canada
| | - Eugenia Oviedo-Joekes
- Centre for Advancing Health Outcomes, Providence Health Care, St. Paul's Hospital, 575- 1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada.
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
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24
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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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Frost MC, Malte CA, Hawkins EJ, Glass JE, Hallgren KA, Williams EC. Impact of an intervention to implement provision of opioid use disorder medication among patients with and without co-occurring substance use disorders. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 155:209175. [PMID: 37751798 DOI: 10.1016/j.josat.2023.209175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/14/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023]
Abstract
INTRODUCTION Co-occurring substance use disorders (SUDs) are common among people with opioid use disorder (OUD) and known to hinder receipt of medications for OUD (MOUD). It is important to understand how MOUD care implemented outside of SUD specialty settings impacts access for patients with co-occurring SUDs. The Veterans Health Administration's (VA) Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative was implemented in primary care, mental health, and pain clinics in 18 VA facilities, and was found to increase MOUD receipt. This study assessed the SCOUTT initiative's impact among patients with and without co-occurring SUDs. METHODS This study used a controlled interrupted time series design. We extracted electronic health record data for patients with OUD with visits in SCOUTT intervention or matched comparison clinics during the post-implementation year (9/1/2018-8/31/2019). We examined the monthly proportion of patients who received MOUD in SCOUTT intervention or comparison clinics (primary care, mental health, and pain clinics), or in a VA SUD specialty clinic (where patients may have been referred), during the pre- and post-implementation years. Segmented logistic regression models estimated pre-post changes in outcomes (immediate level change from the final month of the pre-implementation period to the first month of the post-implementation period, change in trend/slope) in intervention vs. comparison facilities, adjusting for patient characteristics and pre-implementation trends. We stratified analyses by the presence of co-occurring SUDs. RESULTS Among patients without co-occurring SUDs, the pre-post trend/slope change in MOUD received in SCOUTT intervention or comparison clinics was greater in intervention vs. comparison facilities (adjusted odds ratio [aOR]: 1.06, 95% confidence interval [CI]: 1.02-1.10), and the immediate increase in MOUD received in SUD clinics was greater in intervention vs. comparison facilities (aOR: 1.12, 95% CI: 1.02-1.22). These changes did not significantly differ in intervention vs. comparison facilities among patients with co-occurring SUDs. CONCLUSIONS The SCOUTT initiative may have increased MOUD receipt primarily among patients without co-occurring SUDs. Focusing on increasing MOUD receipt for patients with co-occurring SUDs may improve the overall effectiveness of MOUD implementation efforts.
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Affiliation(s)
- Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America.
| | - Carol A Malte
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America; Center of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America.
| | - Eric J Hawkins
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America; Center of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States of America.
| | - Joseph E Glass
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, United States of America.
| | - Kevin A Hallgren
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, United States of America.
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America.
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Huber TP. Rethinking leadership approaches for community-wide opioid crisis intervention: harnessing positive inquiry to unearth front-line insight. BMJ LEADER 2023:leader-2023-000862. [PMID: 37979969 DOI: 10.1136/leader-2023-000862] [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: 06/26/2023] [Accepted: 10/26/2023] [Indexed: 11/20/2023]
Abstract
BACKGROUND/AIM The opioid crisis presents a complex and widespread health challenge for communities, necessitating a deeper exploration beyond simple solutions. To address this crisis, it is crucial to identify and disseminate best practices. In this study, we focused on positive deviance narratives from Columbus, Ohio, a community deeply affected by the opioid crisis. METHODS Employing an appreciative inquiry framework, we conducted purposive sampling to interview 47 frontline professionals and individuals grappling with opioid use disorder (OUD). RESULTS Our research revealed several key insights, highlighting successful themes through positive narratives. First, perceiving OUD as a chronic disease emerged as a critical perspective, acknowledging the long-term nature of the condition and the need for sustained care. Second, re-humanising and de-stigmatising opioid users played a vital role in facilitating their recovery and reintegration into society. Embracing inclusive care delivery was another important aspect, ensuring that individuals from diverse backgrounds receive equitable access to effective treatment. Moreover, re-energising professionals to combat burnout proved essential, emphasising the importance of supporting and motivating healthcare providers in their efforts. Finally, fostering cross-institutional relationship building and collaboration emerged as a significant factor, as it encouraged a coordinated approach to addressing the crisis. Designing adaptive organisational structures also played a crucial role, enabling healthcare institutions to respond effectively to evolving challenges. CONCLUSIONS Using a positive deviance approach to a challenging public health crisis like OUD can help us discover new and innovative care management approaches for community wide interventions.
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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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Zerden LDS, Sullivan C, Galloway E, Richman EL, Gaiser MG, Lombardi B. Are DEA-waivered buprenorphine prescribers colocated with behavioral health clinicians? Am J Addict 2023; 32:574-583. [PMID: 37559344 DOI: 10.1111/ajad.13462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Medication for opioid use disorder (MOUD) in primary care includes a combination of medication, behavioral therapy, and/or other psychosocial services. This study assessed rates of colocation between waivered prescribers and behavioral health clinicians across the United States to understand if rates varied by provider type and geographic indicators. METHODS Data from the DEA-Drug Addiction Treatment Act of 2000 provider list as of March 2022 and the National Plan and Provider Enumeration System's National Provider Identifier database were gathered, cleaned, and formatted in Stata. Data were geocoded with ESRI StreetMap® database and ArcGIS software. Covariates at individual, county, and state levels were examined and compared. Chi-square statistics and a mixed-effects logistic regression were analyzed. RESULTS The sample (N = 71, 292 prescribers) included physicians (64%), nurse practitioners (29%), and physician assistants (7%). About 48% of prescribers were colocated with a behavioral health clinician. Physicians were the least likely to be colocated (47%), but differences between provider types were modest. We observed significant geographic differences in provider colocation by provider type. Mixed effects logistic regression identified significant predictors of colocation at individual, county, and state levels. DISCUSSION AND CONCLUSIONS Optimally distributing the workforce providing MOUD is necessary to broadly ensure the provision of comprehensive MOUD care based on practice guidelines. SCIENTIFIC SIGNIFICANCE Less than half of all waivered prescribers, outside of hospitals, are colocated with behavioral health clinicians. Findings offer greater clarity on where integrated MOUD is occurring, among which types of providers, and where it needs to be expanded to increase MOUD uptake.
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Affiliation(s)
- Lisa de Saxe Zerden
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Connor Sullivan
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Evan Galloway
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Erica L Richman
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Maria G Gaiser
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brianna Lombardi
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Family Medicine, School of Social Work, Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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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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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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Austin EJ, Chen J, Briggs ES, Ferro L, Barry P, Heald A, Merrill JO, Curran GM, Saxon AJ, Fortney JC, Ratzliff AD, Williams EC. Integrating Opioid Use Disorder Treatment Into Primary Care Settings. JAMA Netw Open 2023; 6:e2328627. [PMID: 37566414 PMCID: PMC10422185 DOI: 10.1001/jamanetworkopen.2023.28627] [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: 03/15/2023] [Accepted: 06/29/2023] [Indexed: 08/12/2023] Open
Abstract
Importance Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist. Objective To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD. Design, Setting, and Participants This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022. Exposure Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services. Measures Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods. Results Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care. Conclusions and Relevance The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.
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Affiliation(s)
- Elizabeth J. Austin
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Jessica Chen
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Elsa S. Briggs
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Paul Barry
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Ashley Heald
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Joseph O. Merrill
- Department of Medicine, School of Medicine, University of Washington, Seattle
| | - Geoffrey M. Curran
- Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock
- Central Arkansas Veterans Health Care System
| | - Andrew J. Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, Washington
| | - John C. Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, Washington
| | - Anna D. Ratzliff
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Emily C. Williams
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound, Seattle, Washington
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Kokorelias KM, Grosse A, Zhabokritsky A, Sirisegaram L. Understanding geriatric models of care for older adults living with HIV: a scoping review and qualitative analysis. BMC Geriatr 2023; 23:417. [PMID: 37422631 PMCID: PMC10329351 DOI: 10.1186/s12877-023-04114-7] [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: 01/18/2023] [Accepted: 06/16/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND Advances in Human Immunodeficiency Virus (HIV) treatment have reduced mortality rates and consequently increased the number of individuals with HIV living into older age. Despite this, people aged 50 years and older have been left behind in recent HIV treatment and prevention campaigns, and a gold-standard model of care for this population has not yet been defined. Developing evidence-based geriatric HIV models of care can support an accessible, equitable, and sustainable HIV health care system that ensures older adults have access to care that meets their needs now and in the future. METHODS Guided by Arksey & O'Malley (2005)'s methodological framework, a scoping review was conducted to determine the key components of, identify gaps in the literature about, and provide recommendations for future research into geriatric models of care for individuals with HIV. Five databases and the grey literature were systematically searched. The titles, abstracts and full texts of the search results were screened independently in duplicate. Data were analyzed using a qualitative case study and key component analysis approach to identify necessary model components. RESULTS 5702 studies underwent title and abstract screening, with 154 entering full-text review. 13 peer-reviewed and 0 grey literature sources were included. Most articles were from North America. We identified three primary model of care components that may improve the successful delivery of geriatric care to people living with HIV: Collaboration and Integration; Organization of Geriatric Care; and Support for Holistic Care. Most articles included some aspects of all three components. CONCLUSION To provide effective geriatric care to older persons living with HIV, health services and systems are encouraged to use an evidence-based framework and should consider incorporating the distinct model of care characteristics that we have identified in the literature. However, there is limited data about models in developing countries and long-term care settings, and limited knowledge of the role of family, friends and peers in supporting the geriatric care of individuals living with HIV. Future evaluative research is encouraged to determine the impact of optimal components of geriatric models of care on patient outcomes.
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Affiliation(s)
- Kristina Marie Kokorelias
- Division of Geriatric Medicine, Department of Medicine, Sinai Health System and University Health Network, Suite 475 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
- Department of Occupational Science & Occupational Therapy, Temerty Faculty of Medicine, University of Toronto, 160 - 500 University Ave, Toronto, ON, M5G 1V7, Canada
- Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada
| | - Anna Grosse
- Division of Geriatric Medicine, Department of Medicine, Sinai Health System and University Health Network, Suite 475 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada
- Division of Geriatric Medicine, Department of Medicine, Medical Sciences Building, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada
| | - Alice Zhabokritsky
- Department of Medicine, Medical Sciences Building, The University of Toronto, King's College Cir, Toronto, ON, M5S 1A8, Canada
- Infectious Diseases, Department of Medicine, University Health Network, 610 University Ave, Toronto, Toronto, ON, M5G 2M9, Canada
- CIHR Canadian HIV Trails Network, 570-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada
| | - Luxey Sirisegaram
- Division of Geriatric Medicine, Department of Medicine, Sinai Health System and University Health Network, Suite 475 - 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
- Division of Geriatric Medicine, Department of Medicine, Medical Sciences Building, University of Toronto, 1 King's College Cir, Toronto, ON, M5S 1A8, Canada.
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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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Tabanelli R, Brogi S, Calderone V. Targeting Opioid Receptors in Addiction and Drug Withdrawal: Where Are We Going? Int J Mol Sci 2023; 24:10888. [PMID: 37446064 DOI: 10.3390/ijms241310888] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/14/2023] [Accepted: 06/28/2023] [Indexed: 07/15/2023] Open
Abstract
This review article offers an outlook on the use of opioids as therapeutics for treating several diseases, including cancer and non-cancer pain, and focuses the analysis on the opportunity to target opioid receptors for treating opioid use disorder (OUD), drug withdrawal, and addiction. Unfortunately, as has been well established, the use of opioids presents a plethora of side effects, such as tolerance and physical and physiological dependence. Accordingly, considering the great pharmacological potential in targeting opioid receptors, the identification of opioid receptor ligands devoid of most of the adverse effects exhibited by current therapeutic agents is highly necessary. To this end, herein, we analyze some interesting molecules that could potentially be useful for treating OUD, with an in-depth analysis regarding in vivo studies and clinical trials.
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Affiliation(s)
- Rita Tabanelli
- Department of Pharmacy, University of Pisa, Via Bonanno 6, 56126 Pisa, Italy
| | - Simone Brogi
- Department of Pharmacy, University of Pisa, Via Bonanno 6, 56126 Pisa, Italy
| | - Vincenzo Calderone
- Department of Pharmacy, University of Pisa, Via Bonanno 6, 56126 Pisa, Italy
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Amini-Rarani M, Moeeni M, Ponnet K. Male patients' preferences for opioid use treatment programs. BMC Psychiatry 2023; 23:440. [PMID: 37328768 PMCID: PMC10273501 DOI: 10.1186/s12888-023-04939-x] [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: 11/03/2022] [Accepted: 06/08/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND A patient-centered approach to the treatment of substance use is helpful in achieving positive treatment outcomes. This study aimed to explore male patients' preferences for opioid use treatments. METHODS A qualitative study was conducted in Isfahan, a city in the center of Iran. The study sample included 64 male participants who had started treatment for opioid use disorder (OUD). Using a purposive maximum variation sampling procedure, seven treatment centers were selected as interview venues. The semi-structured face-to-face interviews were conducted in a private room in the selected centers. A hybrid inductive/deductive approach was used to thematize the interview transcripts. RESULTS A total of three themes and 13 subthemes on opioid treatment preferences were identified: treatment concerns (anonymity, social stigma, fear of treatment distress, and family concerns), treatment attributes (treatment cost, location of the treatment center, treatment period, frequency of attendance, informed treatment, and treatment personnel), and treatment type (maintenance or abstinence and residential and community treatments). The study showed that all treatment programs were perceived to have their own strengths and weaknesses. CONCLUSIONS The results showed that patients with OUD carefully compare the positive and negative aspects of existing treatment programs, and they consider a treatment program to be a package of favorable and non-favorable qualities. The identified themes could inform policymakers about the treatment preferences of male patients and provide an opportunity to promote better treatment options for OUD.
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Affiliation(s)
- Mostafa Amini-Rarani
- Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Maryam Moeeni
- Social Determinants of Health Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Koen Ponnet
- Faculty of social sciences, imec-mict-ghent university, Ghent, Belgium
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Leibowitz GS, Turner W, Bruckenthal P, Mezzatesta M, Ramsey KS, Dyer ME. Lessening the Impact of Opioid Misuse at a Federally Qualified Health Center in New York: Outcomes of an Integrated Workforce Training Program. Public Health Rep 2023; 138:42S-47S. [PMID: 37226953 PMCID: PMC10226063 DOI: 10.1177/00333549231170216] [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: 05/26/2023] Open
Abstract
The COVID-19 pandemic has placed an unprecedented burden on patients, health care providers, and communities and has been particularly challenging for medically underserved populations impacted by the social determinants of health, as well as people with co-occurring mental health and substance use risks. This case study examines outcomes and lessons learned from a multisite low-threshold medication-assisted treatment (MAT) program at a federally qualified health center in partnership with a large suburban public university in New York to integrate and train Health Resources & Services Administration Behavioral Health Workforce Education and Training-funded graduate student trainees in social work and nursing in screening, brief intervention, and referral to treatment and patient care coordination, including social determinants of health and medical and behavioral comorbidities. The MAT program for the treatment of opioid use disorder has a low threshold for entry that is accessible and affordable, reduces barriers to care, and uses a harm reduction approach. Outcome data showed an average 70% retention rate in the MAT program and reductions in substance use. And, while more than 73% of patients reported being somewhat or definitely impacted by the pandemic, most patients endorsed the effectiveness of telemedicine and telebehavioral health, such that 86% indicated the pandemic did not affect the quality of their health care. The main implementation lessons learned were the importance of increasing the capacity of primary care and health care centers to deliver integrated care, using cross-disciplinary practicum experiences to enhance trainee competencies, and addressing the social determinants of health among populations with social vulnerabilities and chronic medical conditions.
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Affiliation(s)
- George S Leibowitz
- Schools of Social Welfare and Nursing, Stony Brook University, Stony Brook, NY, USA
| | - Win Turner
- Schools of Social Welfare and Nursing, Stony Brook University, Stony Brook, NY, USA
| | - Patricia Bruckenthal
- Schools of Social Welfare and Nursing, Stony Brook University, Stony Brook, NY, USA
| | | | - Kelly S Ramsey
- Office of Addiction Services and Supports, Albany, NY, USA
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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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Matson TE, Hallgren KA, Lapham GT, Oliver M, Wang X, Williams EC, Bradley KA. Psychometric Performance of a Substance Use Symptom Checklist to Help Clinicians Assess Substance Use Disorder in Primary Care. JAMA Netw Open 2023; 6:e2316283. [PMID: 37234003 PMCID: PMC10220521 DOI: 10.1001/jamanetworkopen.2023.16283] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/18/2023] [Indexed: 05/27/2023] Open
Abstract
Importance Substance use disorders (SUDs) are underrecognized in primary care, where structured clinical interviews are often infeasible. A brief, standardized substance use symptom checklist could help clinicians assess SUD. Objective To evaluate the psychometric properties of the Substance Use Symptom Checklist (hereafter symptom checklist) used in primary care among patients reporting daily cannabis use and/or other drug use as part of population-based screening and assessment. Design, Setting, and Participants This cross-sectional study was conducted among adult primary care patients who completed the symptom checklist during routine care between March 1, 2015, and March 1, 2020, at an integrated health care system. Data analysis was conducted from June 1, 2021, to May 1, 2022. Main Outcomes and Measures The symptom checklist included 11 items corresponding to SUD criteria in the Diagnostic and Statistical Manual for Mental Disorders (Fifth Edition) (DSM-5). Item response theory (IRT) analyses tested whether the symptom checklist was unidimensional and reflected a continuum of SUD severity and evaluated item characteristics (discrimination and severity). Differential item functioning analyses examined whether the symptom checklist performed similarly across age, sex, race, and ethnicity. Analyses were stratified by cannabis and/or other drug use. Results A total of 23 304 screens were included (mean [SD] age, 38.2 [5.6] years; 12 554 [53.9%] male patients; 17 439 [78.8%] White patients; 20 393 [87.5%] non-Hispanic patients). Overall, 16 140 patients reported daily cannabis use only, 4791 patients reported other drug use only, and 2373 patients reported both daily cannabis and other drug use. Among patients with daily cannabis use only, other drug use only, or both daily cannabis and other drug use, 4242 (26.3%), 1446 (30.2%), and 1229 (51.8%), respectively, endorsed 2 or more items on the symptom checklist, consistent with DSM-5 SUD. For all cannabis and drug subsamples, IRT models supported the unidimensionality of the symptom checklist, and all items discriminated between higher and lower levels of SUD severity. Differential item functioning was observed for some items across sociodemographic subgroups but did not result in meaningful change (<1 point difference) in the overall score (0-11). Conclusions and Relevance In this cross-sectional study, a symptom checklist, administered to primary care patients who reported daily cannabis and/or other drug use during routine screening, discriminated SUD severity as expected and performed well across subgroups. Findings support the clinical utility of the symptom checklist for standardized and more complete SUD symptom assessment to help clinicians make diagnostic and treatment decisions in primary care.
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Affiliation(s)
- Theresa E. Matson
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle
- Health Services Research & Development Center for Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Kevin A. Hallgren
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle
| | - Gwen T. Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle
| | - Malia Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Xiaoming Wang
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Emily C. Williams
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle
- Health Services Research & Development Center for Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Katharine A. Bradley
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle
- Department of Medicine, University of Washington School of Medicine, Seattle
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Krupp J, Hung F, LaChapelle T, Yarrington ME, Link K, Choi Y, Chen H, Marais AD, Sachdeva N, Chakraborty H, McKellar MS. Impact of Policy Change on Access to Medication for Opioid Use Disorder in Primary Care. South Med J 2023; 116:333-340. [PMID: 37011580 PMCID: PMC10045971 DOI: 10.14423/smj.0000000000001544] [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] [Accepted: 11/17/2022] [Indexed: 04/05/2023]
Abstract
OBJECTIVES The opioid overdose epidemic is escalating. Increasing access to medications for opioid use disorder in primary care is crucial. The impact of the US Department of Health and Human Services' policy change removing the buprenorphine waiver training requirement on primary care buprenorphine prescribing remains unclear. We aimed to investigate the impact of the policy change on primary care providers' likelihood of applying for a waiver and the current attitudes, practices, and barriers to buprenorphine prescribing in primary care. METHODS We used a cross-sectional survey with embedded educational resources disseminated to primary care providers in a southern US academic health system. We used descriptive statistics to aggregate survey data, logistic regression models to evaluate whether buprenorphine interest and familiarity correlate with clinical characteristics, and a χ2 test to evaluate the effect of the educational intervention on screening. RESULTS Of the 54 respondents, 70.4% reported seeing patients with opioid use disorder, but only 11.1% had a waiver to prescribe buprenorphine. Few nonwaivered providers were interested in prescribing, but perceiving buprenorphine to be beneficial to the patient population was associated with interest (adjusted odds ratio 34.7, P < 0.001). Two-thirds of nonwaivered respondents reported the policy change having no impact on their decision to obtain a waiver; however, among interested providers, it increased their likelihood of obtaining a waiver. Barriers to buprenorphine prescribing included lack of clinical experience, clinical capacity, and referral resources. Screening for opioid use disorder did not increase significantly after the survey. CONCLUSIONS Although most primary care providers reported seeing patients with opioid use disorder, interest in prescribing buprenorphine was low and structural barriers remained the dominant obstacles. Providers with a preexisting interest in buprenorphine prescribing reported that removing the training requirement was helpful.
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Affiliation(s)
| | - Frances Hung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine
| | | | - Michael E. Yarrington
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine
| | - Katherine Link
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine
| | - Yujung Choi
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Hillary Chen
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Andrea Des Marais
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Nidhi Sachdeva
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Mehri S. McKellar
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine
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Turi ER, McMenamin A, Wolk CB, Poghosyan L. Primary care provider confidence in addressing opioid use disorder: A concept analysis. Res Nurs Health 2023; 46:263-273. [PMID: 36611290 PMCID: PMC10033432 DOI: 10.1002/nur.22294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 01/09/2023]
Abstract
Primary care providers (PCPs) are well-positioned to provide care for opioid use disorder (OUD), yet very few address OUD regularly. One contributing factor may be PCPs' lack of confidence in their ability to effectively treat OUD. Evidence demonstrates that clinician confidence in home care and hospital settings is associated with improved care delivery and patient outcomes. However, a conceptual definition of PCP confidence in addressing OUD has yet to be established. The aim of this concept analysis is to enhance conceptual understanding of PCP confidence in addressing OUD and inform future measurement strategies. Following Walker and Avant's method of concept analysis, PubMed, PsycINFO, and Google Scholar were searched in October 2021. Manuscripts were included if they referenced confidence in relation to PCPs who provide care to adult patients with OUD. Studies conducted outside the US and not published in English were excluded. The search resulted in 18 studies which were synthesized to conceptualize PCP confidence in addressing OUD. Defining attributes include self-efficacy, experience, and readiness to address OUD. These attributes may be influenced by organizational culture, training, support, and resources. Consequences of PCP confidence addressing OUD may include improved patient outcomes, improved delivery of and access to OUD care, and PCP attitude changes. This concept analysis-which grounds the concept of PCP confidence in addressing OUD in the theoretical and empirical literature-lays the framework for future measurement of the concept. This represents a critical first step towards developing strategies to enhance PCP confidence in addressing OUD.
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Affiliation(s)
- Eleanor R Turi
- Columbia University School of Nursing, New York, New York, USA
| | - Amy McMenamin
- Columbia University School of Nursing, New York, New York, USA
| | | | - Lusine Poghosyan
- Columbia University School of Nursing, New York, New York, USA
- Columbia University Mailman School of Public Health, New York, New York, USA
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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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Parker DG, Zentner D, Burack JA, Wendt DC. The impact of the COVID-19 pandemic on medications for opioid use disorder services in the U.S. and Canada: a scoping review. DRUGS: EDUCATION, PREVENTION AND POLICY 2023. [DOI: 10.1080/09687637.2023.2181147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Affiliation(s)
- Daniel G. Parker
- Department of Educational & Counselling Psychology, McGill University, Montreal, Quebec, Canada
| | - Daysi Zentner
- Department of Educational & Counselling Psychology, McGill University, Montreal, Quebec, Canada
| | - Jacob A. Burack
- Department of Educational & Counselling Psychology, McGill University, Montreal, Quebec, Canada
| | - Dennis C. Wendt
- Department of Educational & Counselling Psychology, McGill University, Montreal, Quebec, Canada
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Austin EJ, Briggs ES, Ferro L, Barry P, Heald A, Curran GM, Saxon AJ, Fortney J, Ratzliff AD, Williams EC. Integrating Routine Screening for Opioid Use Disorder into Primary Care Settings: Experiences from a National Cohort of Clinics. J Gen Intern Med 2023; 38:332-340. [PMID: 35614169 PMCID: PMC9132563 DOI: 10.1007/s11606-022-07675-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/11/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The U.S. Preventive Services Task Force recommends routine population-based screening for drug use, yet screening for opioid use disorder (OUD) in primary care occurs rarely, and little is known about barriers primary care teams face. OBJECTIVE As part of a multisite randomized trial to provide OUD and behavioral health treatment using the Collaborative Care Model, we supported 10 primary care clinics in implementing routine OUD screening and conducted formative evaluation to characterize early implementation experiences. DESIGN Qualitative formative evaluation. APPROACH Formative evaluation included taking detailed observation notes at implementation meetings with individual clinics and debriefings with external facilitators. Observation notes were analyzed weekly using a Rapid Assessment Process guided by the Consolidated Framework for Implementation Research, with iterative feedback from the study team. After clinics launched OUD screening, we conducted structured fidelity assessments via group interviews with each site to evaluate clinic experiences with routine OUD screening. Data from observation and structured fidelity assessments were combined into a matrix to compare across clinics and identify cross-cutting barriers and promising implementation strategies. KEY RESULTS While all clinics had the goal of implementing population-based OUD screening, barriers were experienced across intervention, individual, and clinic setting domains, with compounding effects for telehealth visits. Seven themes emerged characterizing barriers, including (1) challenges identifying who to screen, (2) complexity of the screening tool, (3) staff discomfort and/or hesitancies, (4) workflow barriers that decreased screening follow-up, (5) staffing shortages and turnover, (6) discouragement from low screening yield, and (7) stigma. Promising implementation strategies included utilizing a more universal screening approach, health information technology (HIT), audit and feedback, and repeated staff trainings. CONCLUSIONS Integrating population-based OUD screening in primary care is challenging but may be made feasible via implementation strategies and tailored practice facilitation that standardize workflows via HIT, decrease stigma, and increase staff confidence regarding OUD.
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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.
| | - Elsa S Briggs
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Box 351621, Seattle, WA, 98105, USA
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Paul Barry
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
| | - Ashley Heald
- Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, USA
| | - Geoffrey M Curran
- Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Central Arkansas Veterans Health Care System, Little Rock, AR, USA
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, WA, USA
| | - John Fortney
- 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
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, 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
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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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Abstract
INTRODUCTION The opioid epidemic has evolved into a combined stimulant epidemic, with escalating stimulant and fentanyl-related overdose deaths. Primary care providers are on the frontlines grappling with patients' methamphetamine use. Although effective models exist for treating opioid use disorder in primary care, little is known about current clinical practices for methamphetamine use. METHODS Six semistructured group interviews were conducted with 38 primary care providers. Interviews focused on provider perceptions of patients with methamphetamine use problems and their care. Data were analyzed using inductive and thematic analysis and summarized along the following dimensions: (1) problem identification, (2) clinical management, (3) barriers and facilitators to care, and (4) perceived needs to improve services. RESULTS Primary care providers varied in their approach to identifying and treating patient methamphetamine use. Unlike opioid use disorders, providers reported lacking standardized screening measures and evidence-based treatments, particularly medications, to address methamphetamine use. They seek more standardized screening tools, Food and Drug Administration-approved medications, reliable connections to addiction medicine specialists, and more training. Interest in novel behavioral health interventions suitable for primary care settings was also noteworthy. CONCLUSIONS The findings from this qualitative analysis revealed that primary care providers are using a wide range of tools to screen and treat methamphetamine use, but with little perceived effectiveness. Primary care faces multiple challenges in effectively addressing methamphetamine use among patients singularly or comorbid with opioid use disorders, including the lack of Food and Drug Administration-approved medications, limited patient retention, referral opportunities, funding, and training for methamphetamine use. Focusing on patients' medical issues using a harm reduction, motivational interviewing approach, and linkage with addiction medicine specialists may be the most reasonable options to support primary care in compassionately and effectively managing patients who use methamphetamines.
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Kiluk BD, Kleykamp BA, Comer SD, Griffiths RR, Huhn AS, Johnson MW, Kampman KM, Pravetoni M, Preston KL, Vandrey R, Bergeria CL, Bogenschutz MP, Brown RT, Dunn KE, Dworkin RH, Finan PH, Hendricks PS, Houtsmuller EJ, Kosten TR, Lee DC, Levin FR, McRae-Clark A, Raison CL, Rasmussen K, Turk DC, Weiss RD, Strain EC. Clinical Trial Design Challenges and Opportunities for Emerging Treatments for Opioid Use Disorder: A Review. JAMA Psychiatry 2023; 80:84-92. [PMID: 36449315 PMCID: PMC10297827 DOI: 10.1001/jamapsychiatry.2022.4020] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Importance Novel treatments for opioid use disorder (OUD) are needed to address both the ongoing opioid epidemic and long-standing barriers to existing OUD treatments that target the endogenous μ-opioid receptor (MOR) system. The goal of this review is to highlight unique clinical trial design considerations for the study of emerging treatments for OUD that address targets beyond the MOR system. In November 2019, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration sponsored a meeting to discuss the current evidence regarding potential treatments for OUD, including cannabinoids, psychedelics, sedative-hypnotics, and immunotherapeutics, such as vaccines. Observations Consensus recommendations are presented regarding the most critical elements of trial design for the evaluation of novel OUD treatments, such as: (1) stage of treatment that will be targeted (eg, seeking treatment, early abstinence/detoxification, long-term recovery); (2) role of treatment (adjunctive with or independent of existing OUD treatments); (3) primary outcomes informed by patient preferences that assess opioid use (including changes in patterns of use), treatment retention, and/or global functioning and quality of life; and (4) adverse events, including the potential for opioid-related relapse or overdose, especially if the patient is not simultaneously taking maintenance MOR agonist or antagonist medications. Conclusions and Relevance Applying the recommendations provided here as well as considering input from people with lived experience in the design phase will accelerate the development, translation, and uptake of effective and safe therapeutics for individuals struggling with OUD.
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Affiliation(s)
- Brian D Kiluk
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut
| | - Bethea A Kleykamp
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Sandra D Comer
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York
- Department of Psychiatry, Columbia University Irving Medical Center, New York, New York
| | - Roland R Griffiths
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew S Huhn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Matthew W Johnson
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kyle M Kampman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Marco Pravetoni
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Harborview Medical Center, Seattle
| | - Kenzie L Preston
- Clinical Pharmacology and Therapeutics Research Branch, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Ryan Vandrey
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cecilia L Bergeria
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michael P Bogenschutz
- Department of Psychiatry, NYU Grossman School of Medicine, New York University, New York
| | - Randall T Brown
- Department of Family Medicine and Community Health, University of Wisconsin-Madison School of Medicine and Public Health, Madison
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Robert H Dworkin
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | - Patrick H Finan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Peter S Hendricks
- Department of Health Behavior, School of Public Health, University of Alabama at Birmingham
| | | | - Thomas R Kosten
- Baylor College of Medicine, Houston, Texas
- Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Dustin C Lee
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Frances R Levin
- Division on Substance Use Disorders, New York State Psychiatric Institute, New York
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York
| | - Aimee McRae-Clark
- Department of Psychiatry, Medical University of South Carolina, Charleston
| | - Charles L Raison
- Department of Human Development and Family Studies, School of Human Ecology, University of Wisconsin-Madison
- Department of Psychiatry, School of Medicine and Public Health, University of Wisconsin-Madison
| | | | - Dennis C Turk
- University of Washington School of Medicine, Seattle
| | - Roger D Weiss
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Bart G, Jaber M, Giang LM, Brundage RC, Korthuis PT. Findings from a pilot study of buprenorphine population pharmacokinetics: A potential effect of HIV on buprenorphine bioavailability. Drug Alcohol Depend 2022; 241:109696. [PMID: 36402052 PMCID: PMC9771970 DOI: 10.1016/j.drugalcdep.2022.109696] [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: 10/10/2022] [Revised: 11/07/2022] [Accepted: 11/08/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Buprenorphine is widely used in the treatment of opioid use disorder (OUD). There are few pharmacokinetic models of buprenorphine across diverse populations. Population pharmacokinetics (POPPK) allows for covariates to be included in pharmacokinetic studies, thereby opening the potential to evaluate the effect of comorbidities, medications, and other factors on buprenorphine pharmacokinetics. This pilot study used POPPK to explore buprenorphine pharmacokinetics in patients with and without HIV receiving buprenorphine for OUD. METHODS Plasma buprenorphine levels were measured in 54 patients receiving buprenorphine for OUD just prior to and 2-5 h following regular buprenorphine dosing. A linear one-compartment POPPK model with first-order estimation was used to evaluate buprenorphine clearance (CL/F) and volume of distribution (V/F). Covariates included weight and HIV status. RESULTS All HIV+ patients reported complete past-month adherence to taking antiretroviral therapy that included either efavirenz or nevirapine. Buprenorphine CL/F was 76% higher in HIV+ patients (n = 17) than HIV- patients (n = 37). Buprenorphine V/F was 41% higher in the HIV+ patients. CONCLUSIONS POPPK can be used to model buprenorphine pharmacokinetics in a real-world clinical population. While interactions between ART and buprenorphine alter buprenorphine CL/F, we also found alteration in V/F. Proportionate changes in CL/F and V/F might indicate a primary effect on bioavailability (F) rather than two separate effects. These findings indicate reduced buprenorphine bioavailability in patients with HIV.
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Affiliation(s)
- Gavin Bart
- Department of Medicine, Hennepin Healthcare, 701 Park Avenue, Minneapolis, MN 55415, USA.
| | - Mutaz Jaber
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, 417 Delaware Street SE, Minneapolis, MN 55455, USA.
| | - Le Minh Giang
- Center for Training and Research on Substance Abuse and HIV, Hanoi Medical University, 1 Ton That Tung, Hanoi, Viet Nam.
| | - Richard C Brundage
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, 417 Delaware Street SE, Minneapolis, MN 55455, USA.
| | - P Todd Korthuis
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University School of Medicine, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
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Allen B, Jent VA, Cerdá M. Cycles of Chronic Opioid Therapy Following Mandatory Prescription Drug Monitoring Program Legislation: A Retrospective Cohort Study. J Gen Intern Med 2022; 37:4088-4094. [PMID: 35411535 PMCID: PMC9708972 DOI: 10.1007/s11606-022-07551-z] [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: 10/03/2021] [Accepted: 03/31/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Mandates for prescriber use of prescription drug monitoring programs (PDMPs), databases tracking controlled substance prescriptions, are associated with reduced opioid analgesic (OA) prescribing but may contribute to care discontinuity and chronic opioid therapy (COT) cycling, or multiple initiations and terminations. OBJECTIVE To estimate risks of COT cycling in New York City (NYC) due to the New York State (NYS) PDMP mandate, compared to risks in neighboring New Jersey (NJ) counties. DESIGN We estimated cycling risk using Prentice, Williams, and Peterson gap-time models adjusted for age, sex, OA dose, payment type, and county population density, using a life-table difference-in-differences design. Failure time was duration between cycles. In a subgroup analysis, we estimated risk among patients receiving high-dose prescriptions. Sensitivity analyses tested robustness to cycle volume considering only first cycles using Cox proportional hazard models. PARTICIPANTS The cohort included 7604 patients dispensed 12,695 prescriptions. INTERVENTIONS The exposure was the August 2013 enactment of the NYS PDMP prescriber use mandate. MAIN MEASURES We used monthly, patient-level data on OA prescriptions dispensed in NYC and NJ between August 2011 and July 2015. We defined COT as three sequential months of prescriptions, permitting 1-month gaps. We defined recurrence as re-initiation of COT after at least 2 months without prescriptions. The exposure was enactment of the PDMP mandate in NYC; NJ was unexposed. KEY RESULTS Enactment of the NYS PDMP mandate was associated with an adjusted hazard ratio (HR) for cycling of 1.01 (95% CI, 0.94-1.08) in NYC. For high-dose prescriptions, the risk was 1.16 (95% CI, 1.01-1.34). Sensitivity analyses estimated an overall risk of 1.01 (95% CI, 0.94-1.11) and high-dose risk of 1.09 (95% CI, 0.91-1.31). CONCLUSIONS The PDMP mandate had no overall effect on COT cycling in NYC but increased cycling risk among patients receiving high-dose opioid prescriptions by 16%, highlighting care discontinuity.
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Affiliation(s)
- Bennett Allen
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
| | - Victoria A Jent
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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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
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