Medical improvisation-based motivational interviewing for internal medicine residents: Mixed-methods evaluation of a novel course

PURPOSE

Develop and assess a novel medical improvisation-based motivational interviewing (MI) curriculum for residents.

MATERIALS AND METHODS

A 6-h medical improv-based MI curriculum occurred in 2022 for internal medicine residents. A mixed-methods evaluation included: pre- and post-role plays using the Motivational Interviewing Treatment Integrity Score (MITI) to assess MI competency, a post-course survey assessing confidence, and focus groups to understand learning through improvisation.

RESULTS

Participants increased their confidence in applying MI skills after the curriculum in responding to a patient's argument against change (29% pre vs. 72% post, p < 0.001), eliciting change talk (21% vs. 86%, p < 0.001), and providing information in an MI-centric way (39% vs. 86%, p < 0.001). All role-play participants achieved at least beginning proficiency on MITI technical and relational global summary scores post-course. MI-adherent behaviors increased, and MI-non-adherent behaviors decreased in post-course role plays. Themes on learning through improvisation included: (1) improvisation can enhance the learning of MI skills, (2) using non-medical scenarios in improvisation exercises has benefits, and (3) trying improvisation had positive effects on the learning environment.

DISCUSSION

A medical improvisation-based course is a promising, engaging way to teach residents MI skills and can improve competence and confidence with MI.

Recognition and Treatment of Wounds in Persons Using Xylazine: A Case Report From New Haven, Connecticut

BACKGROUND

Xylazine is an α 2 -adrenergic agonist that is commonly used as a veterinary tranquilizer and is increasingly present in the unregulated US drug supply since at least 2019. There are many suspected clinical complications of xylazine use, including unusual skin wounds, atypical overdose presentations, and possible dependence and withdrawal syndromes. However, there are few reports of cutaneous manifestations of xylazine in patients who inject drugs that can guide diagnosis and management in patients with confirmed xylazine toxicology.

CASE SUMMARY

We present the cases of 3 stably housed patients in Connecticut with opioid use disorder and intravenous use of fentanyl who presented with atypical, chronic wounds at the site of injection drug use. Xylazine toxicology sent on all 3 patients was positive. All patients were seen by wound care and dermatology, and 1 patient was followed by infectious diseases. Wound care management strategies are discussed as well as harm reduction strategies. For all patients, the dose of their medication for opioid use disorder was increased to decrease frequency of drug use given concern that patients were exposed to a drug supply containing xylazine.

CLINICAL SIGNIFICANCE

This case report presents wound characteristics that raise the index of suspicion for xylazine-involved injection wounds and might assist in their diagnosis and management. There is urgent need for more reporting of such cases as well as rigorous research to understand the potential impact of xylazine on people who use drugs. Multidisciplinary best practices should be established.

Facilitation and Preferred Models for Delivering Substance Use Disorder Treatment in HIV Clinics: Results From a Multisite Randomized Trial

BACKGROUND

Integrated addiction treatment in HIV clinics is associated with improved outcomes, yet it is offered inconsistently and with variable models of care. We sought to evaluate the impact of Implementation Facilitation ("Facilitation") on clinician and staff preference for provision of addiction treatment in HIV clinics with on-site resources (all trained or designated on-site specialist) versus outside resources (outside specialist or refer out).

METHODS

From July 2017 to July 2020, surveys assessed clinician and staff preferences for addiction treatment models during control (ie, baseline), intervention, evaluation, and maintenance phases in 4 HIV clinics in the Northeast United States.

RESULTS

During the control phase, among 76 respondents (response rate, 58%), the proportions who preferred treatment with on-site resources for opioid use disorder (OUD), alcohol use disorder (AUD), and tobacco use disorder (TUD) were 63%, 55%, and 63%, respectively. Compared with control, there were no significant differences in preferred model during the intervention and evaluation phases except for AUD where there was an increased preference for treatment with on-site resources in the intervention versus control phase. Compared with control, during the maintenance phase, a higher proportion of clinicians and staff preferred providing addiction treatment with on-site resources versus outside resources: OUD, 75% (odds ratio [OR; 95% confidence interval {CI}], 1.79 [1.06-3.03]); AUD, 73% (OR [95% CI], 2.23 [1.36-3.65]), and TUD, 76% (OR [95% CI], 1.88 [1.11-3.18]).

CONCLUSIONS

The findings from this study lend support for "Facilitation" as a strategy to enhance clinician and staff preference for integrated addiction treatment in HIV clinics with on-site resources.

The impact of benzodiazepine exposure on treatment retention in an open-access methadone program: A retrospective cohort study

BACKGROUND

Open-access opioid treatment programs (OTP) offer same-day access to methadone without an appointment and aim to minimize treatment barriers that often reduce admission and/or retention. We explored whether patients with benzodiazepine exposure at treatment entry would have similar 12-month retention compared to those without benzodiazepine exposure.

METHODS

We conducted a retrospective cohort study of 2968 patients consecutively initiated on methadone between January 2015 and February 2017 at an open-access OTP. The sample was stratified into benzodiazepine-exposed and nonexposed groups based on intake urine toxicology. Group comparison of 12-month retention was conducted. Kaplan Meier analysis compared time to methadone treatment discontinuation between groups with a log-rank test. Multivariable Cox regression was performed to compare retention by baseline benzodiazepine exposure with adjustment for confounders.

RESULTS

Overall, 31% of patients with benzodiazepine exposure (n = 171) and 31% without exposure (n = 2423) were retained at 12 months (p = 0.95). Median treatment duration was 182 days (95% CI, 152-239) and 175 days (95% CI, 156-196) for patients with and without benzodiazepine exposure, respectively. Kaplan-Meier analysis showed no significant difference in treatment duration between groups (log-rank test p = 0.73). Cox regression found no difference in treatment retention between groups (adjusted Hazard Ratio= 1.03, 95% CI, 0.91-1.16).

CONCLUSIONS

In this cohort of patients receiving methadone at an open-access OTP, benzodiazepine exposure at intake was not observed to impact 12-month treatment retention or duration. These findings support U.S. Food and Drug Administration (FDA) recommendations to not withhold medications for opioid use disorder from patients taking benzodiazepines.

Effect of Implementation Facilitation to Promote Adoption of Medications for Addiction Treatment in US HIV Clinics: A Randomized Clinical Trial

Importance

Medications for addiction treatment (MAT) are inconsistently offered in HIV clinics.

Objective

To evaluate the impact of implementation facilitation (hereafter referred to as "facilitation"), a multicomponent implementation strategy, on increasing provision of MAT for opioid use disorder (MOUD), alcohol use disorder (MAUD), and tobacco use disorder (MTUD).

Design, Setting, and Participants

Conducted from July 26, 2016, through July 25, 2020, the Working with HIV Clinics to adopt Addiction Treatment using Implementation Facilitation (WHAT-IF?) study used an unblinded, stepped wedge design to sequentially assign each of 4 HIV clinics in the northeastern US to cross over from control (ie, baseline practices) to facilitation (ie, intervention) and then evaluation and maintenance periods every 6 months. Participants were adult patients with opioid, alcohol, or tobacco use disorder. Data analysis was performed from August 2020 to September 2022.

Interventions

Multicomponent facilitation.

Main Outcomes and Measures

Outcomes, assessed using electronic health record data, were provision of MAT among patients with opioid, alcohol, or tobacco use disorder during the evaluation (primary outcome) and maintenance periods compared with the control period.

Results

Among 3647 patients, the mean (SD) age was 49 (12) years, 1814 (50%) were Black, 781 (22%) were Hispanic, and 1407 (39%) were female; 121 (3%) had opioid use disorder, 126 (3%) had alcohol use disorder, and 420 (12%) had tobacco use disorder. Compared with the control period, there was no increase in provision of MOUD with facilitation during the evaluation period (243 patients [27%; 95% CI, 22%-32%] vs 135 patients [28%; 95% CI, 22%-35%]; P = .59) or maintenance period (198 patients [29%; 95% CI, 22%-36%]; P = .48). The change in provision of MAUD from the control period to the evaluation period was not statistically significant (251 patients [8%; 95% CI, 5%-12%] vs 112 patients [13%; 95% CI, 8%-21%]; P = .11); however, the difference increased and became significant during the maintenance period (180 patients [17%; 95% CI, 12%-24%]; P = .009). There were significant increases in provision of MTUD with facilitation during both the evaluation (810 patients [33%; 95% CI, 30%-36%] vs 471 patients [40%; 95% CI, 36%-45%]; P = .005) and maintenance (643 patients [38%; 95% CI, 34%-41%]; P = .047) periods.

Conclusions and Relevance

In this randomized clinical trial, facilitation led to increased provision of MTUD, delayed improvements in MAUD, and no improvements in MOUD in HIV clinics. Enhanced strategies, potentially including clinic and patient incentives, especially for MOUD, may be needed to further increase provision of MAT in HIV clinics.

Trial Registration

ClinicalTrials.gov Identifier: NCT02907944.

Xylazine and Overdoses: Trends, Concerns, and Recommendations

Xylazine is a nonopioid veterinary anesthetic and sedative that is increasingly detected in the illicit drug supply in the United States. Data indicate a striking prevalence of xylazine among opioid-involved overdose deaths. The emergence of xylazine in the illicit drug supply poses many unknowns and potential risks for people who use drugs. The public health system needs to respond by increasing testing to determine the prevalence of xylazine, identifying its potential toxicity at various exposure levels, and taking mitigating action to prevent harms. Currently, there is little testing capable of identifying xylazine in drug supplies, which limits the possibility of public health intervention, implementation of harm reduction strategies, or development of novel treatment strategies. (Am J Public Health. 2022;112(8):1212-1216. https://doi.org/10.2105/AJPH.2022.306881).

Patients' perspectives of medications for addiction treatment in HIV clinics: A qualitative study

BACKGROUND

While substance use disorders (SUD) disproportionately impact people with HIV (PWH), HIV clinics inconsistently provide evidence-based medications for addiction treatment (MAT). Patient receptivity to MAT is critical to enhance addiction treatment in these settings. However, we know little from patients about how to best integrate MAT into HIV clinics.

METHODS

This qualitative study used four focus groups informed by the Promoting Action on Research Implementation in Health Services framework to identify barriers and facilitators to receiving opioid, alcohol, and tobacco use disorder care in HIV clinics. The study population included 28 patients with HIV and SUD receiving care at one of four HIV clinics in the northeastern United States. Focus groups were recorded and transcribed for content analysis. The study also performed a brief survey assessing demographics and behaviors.

RESULTS

Focus groups revealed several major themes related to MAT in HIV clinics. Barriers included stigma around MAT, knowledge deficits about available MAT options and the impact of substance use on PWH, concerns about medication side effects, substance use screening without adequate clinician follow-up, and peers who discouraged MAT. Facilitators included recognition of substance use as a threat to overall health, integrated care from HIV clinicians, and support for addiction treatment from peers with lived experience.

CONCLUSIONS

Efforts to enhance MAT in HIV clinics should include patient education to help them recognize addiction as a chronic disease with available medication treatment options; clinician and staff training to promote integrated, multidisciplinary screening and treatment; and thoughtful inclusion of peers with lived experience.

Benzodiazepines and Related Sedatives

Benzodiazepine and related sedative use has been increasing. There has been a growing number of unregulated novel psychoactive substances, including designer benzodiazepines. Benzodiazepines have neurobiological and pharmacologic properties that result in a high potential for misuse and physical dependence. Options for discontinuing long-term benzodiazepine use include an outpatient benzodiazepine taper or inpatient withdrawal management at a hospital or detoxification facility. The quality of evidence on medications for benzodiazepine discontinuation is overall low, whereas cognitive behavioral therapy has shown the most benefit in terms of behavioral treatments. Benzodiazepines may also have significant adverse effects, increasing the risk of overdose and death.

Readiness to Provide Medications for Addiction Treatment in HIV Clinics: A Multisite Mixed-Methods Formative Evaluation

BACKGROUND

We sought to characterize readiness, barriers to, and facilitators of providing medications for addiction treatment (MAT) in HIV clinics.

SETTING

Four HIV clinics in the northeastern United States.

METHODS

Mixed-methods formative evaluation conducted June 2017-February 2019. Surveys assessed readiness [visual analog scale, less ready (0-<7) vs. more ready (≥7-10)]; evidence and context ratings for MAT provision; and preferred addiction treatment model. A subset (n = 37) participated in focus groups.

RESULTS

Among 71 survey respondents (48% prescribers), the proportion more ready to provide addiction treatment medications varied across substances [tobacco (76%), opioid (61%), and alcohol (49%) treatment medications (P values < 0.05)]. Evidence subscale scores were higher for those more ready to provide tobacco [median (interquartile range) = 4.0 (4.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.008] treatment medications, but not significantly different for opioid [5.0 (4.0, 5.0) vs. 4.0 (4.0, 5.0), P = 0.11] and alcohol [4.0 (3.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.42] treatment medications. Median context subscale scores ranged from 3.3 to 4.0 and generally did not vary by readiness status (P values > 0.05). Most favored integrating MAT into HIV care but preferred models differed across substances. Barriers to MAT included identification of treatment-eligible patients, variable experiences with MAT and perceived medication complexity, perceived need for robust behavioral services, and inconsistent availability of on-site specialists. Facilitators included knowledge of adverse health consequences of opioid and tobacco use, local champions, focus on quality improvement, and multidisciplinary teamwork.

CONCLUSIONS

Efforts to implement MAT in HIV clinics should address both gaps in perspectives regarding the evidence for MAT and contextual factors and may require substance-specific models.

Law enforcement assisted diversion: Qualitative evaluation of barriers and facilitators of program implementation

BACKGROUND

Despite widespread interest in adoption, there has been limited systematic examination of Law Enforcement Assisted Diversion (LEAD) implementation, a model for police-led arrest diversion for those with substance use disorders (SUD). In the fall of 2017, the City of New Haven started a LEAD program. During the first 9 months of the pilot, only 2 clients were successfully diverted from arrest. Therefore, we examined the and barriers and facilitators of LEAD implementation.

METHODS

We conducted semi-structured interviews and field observations of LEAD police officers and health care providers between August 2018 and June 2019. Interviews and field observations were analyzed using directed content analysis and guided by the Integrated Promoting Action on Research Implementation in Health Services framework.

RESULTS

Lead professionals participated in 19 semi-structured interviews and three field observations. Barriers to arrest diversion implementation included procedural complexity of arrest diversion, concerns about reduced penalties for substance use among officers, stigma of SUDs, and a belief in a punitive role for policing. Facilitators included a positive longitudinal relationship with potential clients and an understanding of SUD as a chronic disease.

CONCLUSION

We identified several barriers to LEAD implementation. Our results suggest promotion of SUD as a chronic disease, ongoing training of officers, and positive incentives for entering substance use treatment should be utilized to facilitate implementation.

Safety of Gabapentin Prescribed for Any Indication in a Large Clinical Cohort of 571,718 US Veterans with and without Alcohol Use Disorder

BACKGROUND

Gabapentin is prescribed for seizures and pain and has efficacy for treating alcohol use disorder (AUD) starting at doses of 900 milligrams per day (mg/d). Recent evidence suggests safety concerns associated with gabapentin including adverse neurologic effects. Individuals with hepatitis C (HCV), HIV, or AUD may be at increased risk due to comorbidities and potential medication interactions.

METHODS

We identified patients prescribed gabapentin for ≥ 60 days for any indication between 2002 and 2015. We propensity-score matched each gabapentin-exposed patient with up to 5 gabapentin-unexposed patients. We followed patients for 2 years or until diagnosed with (i) falls or fractures, or (ii) altered mental status using validated ICD-9 diagnostic codes. We used Poisson regression to estimate incidence rates and relative risk (RR) of these adverse events in association with gabapentin exposure overall and stratified by age, race/ethnicity, sex, HCV, HIV, AUD, and dose.

RESULTS

Incidence of falls or fractures was 1.81 per 100 person-years (PY) among 140,310 gabapentin-exposed and 1.34/100 PY among 431,408 gabapentin-unexposed patients (RR 1.35, 95% confidence interval [CI] 1.28 to 1.44). Incidence of altered mental status was 1.08/100 PY among exposed and 0.97/100 PY among unexposed patients, RR of 1.12 (95% CI 1.04 to 1.20). Excess risk of falls or fractures associated with gabapentin exposure was observed in all subgroups except patients with HCV, HIV, or AUD; however, these groups had elevated incidence regardless of exposure. There was a clear dose-response relationship for falls or fractures with highest risk observed among those prescribed ≥ 2,400 mg/d (RR 1.90, 95% CI 1.50 to 2.40). Patients were at increased risk for altered mental status at doses 600 to 2,399 mg/d; however, low number of events in the highest dose category limited power to detect a statistically significant association ≥ 2,400 mg/d.

CONCLUSIONS

Gabapentin is associated with falls or fractures and altered mental status. Clinicians should be monitoring gabapentin safety, especially at doses ≥ 600 mg/d, in patients with and without AUD.

Pharmacy-based methadone dispensing and drive time to methadone treatment in five states within the United States: A cross-sectional study

BACKGROUND

Within the United States, there is a shortage of opioid treatment programs (OTPs), facilities which dispense methadone for opioid use disorder. It is unknown how pharmacy-based methadone dispensing, as available internationally, could affect methadone access. We aimed to compare drive times to the nearest OTP with drive times to the nearest chain pharmacy in urban and rural census tracts.

METHODS

Cross-sectional geospatial analysis of 2018 OTP location data and 2017 pharmacy location data. We included census tracts with non-zero population in Indiana, Kentucky, Ohio, Virginia, and West Virginia, states with highest rates of opioid overdose deaths. Our outcome was minimum drive time in minutes from census tract mean center of population to the nearest dispensing facility.

RESULTS

Among 7918 census tracts, median (IQR) drive time to OTPs increased from urban to increasingly rural census tract classification [16.1 min (10.2-25.9) to 48.4 min (34.0-63.3);p < .001]. Median (IQR) drive time to OTPs was greater than drive time to chain pharmacies among all census tracts: 19.6 min (11.6-35.1) versus 4.4 min (2.9-7.7) respectively; p < .001. The median (IQR) difference in drive time was greater for increasingly rural census tracts [11.5 min (6.1-19.2) to 35.2 min (19.6-49.7); p <.001] with pharmacy-based methadone dispensing.

CONCLUSION

Rural census tracts have disproportionately long drive times to OTPs. Drawing from policies to increase methadone access in countries like Canada and Australia, this geographic methadone disparity could be mitigated through implementation of pharmacy-based methadone dispensing.

Pain symptomology, functional impact, and treatment of people with Neurofibromatosis type 1

Introduction

Neurofibromatosis type 1 (NF1) is a neurogenetic disorder affecting 1 in 3000 people worldwide, where individuals are prone to develop benign and malignant tumors. In addition, many people with NF1 complain of pain that limits their daily functioning. Due to the complexity of the disorder, there are few options for treating pain symptoms besides surgery and medications. Moreover, the spectrum of pain symptomatology and treatment, as well as the mechanisms underlying NF1-associated pain, has been understudied.

Methodology

To address this knowledge gap, we conducted a survey of 255 adults with NF1, leveraging the Washington University NF1 Patient Registry Initiative (NPRI) database. Demographic and pain data were collected using a Qualtrics survey.

Results

All participants had at least one surgical procedure, with 55% reporting having at least one surgery within the last year and 17% being currently prescribed opioid medication. A positive relationship was shown (p<0.001) between those prescribed prescription pain medication, and their pain severity and interference. Moreover, there was a significant relationship (p=0.049) between the usage of complementary treatments and pain severity and interference.

Conclusion

The current study demonstrates that individuals with NF1 report a higher incidence of pain severity and interference than observed in NF1 previous studies, with pain symptoms not localized to any specific region of the body. The consideration for alternative treatments and careful monitoring of current treatments that are more conservative or have less potential adverse side effects may improve pain management and reduce the risk of developing medication dependence.