Literature Collection

INTRODUCTION: Screening and referral for substance use are essential components of prenatal care. However, little is known about barriers to participation in substance use interventions that are integrated within prenatal care. METHODS: Our study examines demographic and clinical correlates of participation in an initial assessment and counseling intervention integrated into prenatal care in a large healthcare system. The sample comprised Kaiser Permanente Northern California pregnant women with a live birth in 2014 or 2015 who screened positive for prenatal substance use via a self-reported questionnaire and/or urine toxicology test given as part of standard prenatal care (at ~ 8 weeks gestation). RESULTS: Of the 11,843 women who screened positive for prenatal substance use (median age = 30 years; 42% white; 38% screened positive for alcohol only, 20% for cannabis only, 5% nicotine only, 17% other drugs only, and 19% ≥ 2 substance categories), 9836 (83%) completed the initial substance use assessment and counseling intervention. Results from multivariable logistic regression analyses indicated that younger age, lower income, single marital status, and a positive urine toxicology test predicted higher odds of participation, while other/unknown race/ethnicity, greater parity, receiving the screening later in pregnancy, and screening positive for alcohol only or other drugs only predicted lower odds of participation (all Ps < .05). DISCUSSION: Findings suggest that integrated substance use interventions can successfully reach vulnerable populations of pregnant women (e.g., younger, lower income, racial/ethnic minorities). Future research should address whether differences in participation are due to patient (e.g., type of substance used, perceived stigma) or provider factors (e.g., working harder to engage traditionally underserved patients).

BACKGROUND: Opioid use disorder (OUD) disproportionately impacts rural and American Indian communities and has quadrupled among pregnant individuals nationwide in the past two decades. Yet, limited data are available about access and quality of care available to pregnant individuals in rural areas, particularly among American Indians (AIs). Unannounced standardized patients (USPs), or "secret shoppers" with standardized characteristics, have been used to assess healthcare access and quality when outcomes cannot be measured by conventional methods or when differences may exist between actual versus reported care. While the USP approach has shown benefit in evaluating primary care and select specialties, its use to date for OUD and pregnancy is very limited. METHODS: We used literature review, current practice guidelines for perinatal OUD management, and stakeholder engagement to design a novel USP protocol to assess healthcare access and quality for OUD in pregnancy. We developed two USP profiles-one white and one AI-to reflect our target study area consisting of three rural, predominantly white and AI US counties. We partnered with a local community health center network providing care to a large AI population to define six priority outcomes for evaluation: (1) OUD treatment knowledge among clinical staff answering telephones; (2) primary care clinic facilitation and provision of prenatal care and buprenorphine treatment; (3) appropriate completion of evidence-based screening, symptom assessment, and initial steps in management; (4) appropriate completion of risk factor screening/probing about individual circumstances that may affect care; (5) patient-directed tone, stigma, and professionalism by clinic staff; and (6) disparities in care between whites and American Indians. DISCUSSION: The development of this USP protocol tailored to a specific environment and high-risk patient population establishes an innovative approach to evaluate healthcare access and quality for pregnant individuals with OUD. It is intended to serve as a roadmap for our own study and for future related work within the context of substance use disorders and pregnancy.

BACKGROUND: Community stigma against people with opioid use disorder (OUD) and intervention stigma (e.g., toward naloxone) exacerbate the opioid overdose crisis. We examined the effects of the Communities that HEAL (CTH) intervention on perceived opioid-related community stigma by stakeholders in the HEALing Communities Study (HCS). METHODS: We collected three surveys from community coalition members in 66 communities across four states participating in HCS. Communities were randomized into Intervention (Wave 1) or Wait-list Control (Wave 2) arms. We conducted multilevel linear mixed models to compare changes in primary outcomes of community stigma toward people treated for OUD, naloxone, and medication for opioid use disorder (MOUD) by arm from time 1 (before the start of the intervention) to time 3 (end of the intervention period in the Intervention arm). FINDINGS: Intervention stakeholders reported a larger decrease in perceived community stigma toward people treated for OUD (adjusted mean change (AMC) -3.20 [95% C.I. -4.43, -1.98]) and toward MOUD (AMC -0.33 [95% C.I. -0.56, -0.09]) than stakeholders in Wait-list Control communities (AMC -0.18 [95% C.I. -1.38, 1.02], p = 0.0007 and AMC 0.11 [95% C.I. -0.09, 0.31], p = 0.0066). The relationship between intervention status and change in stigma toward MOUD was moderated by rural-urban status (urban AMC -0.59 [95% CI, -0.87, -0.32], rural AMC not sig.) and state. The difference in stigma toward naloxone between Intervention and Wait-list Control stakeholders was not statistically significant (p = 0.18). INTERPRETATION: The CTH intervention decreased stakeholder perceptions of community stigma toward people treated for OUD and stigma toward MOUD. Implementing the CTH intervention in other communities could decrease OUD stigma across diverse settings nationally. FUNDING: US National Institute on Drug Abuse.

More than 20 million people in the United States have a substance use disorder (SUD), increasing their risk for overdose (OD). Patients arriving to emergency departments (EDs) with OD typically require lifesaving interventions, but inconsistencies exist regarding further intervention and discharge instructions. The purpose of the current integrative review was to determine best care practices for patients presenting to EDs with an illicit drug OD. A literature search included the databases PubMed, EBSCO Host, ProQuest Health and Medicine, and Google Scholar. Thirty-five articles outlined interventions for SUD/OD initiated in EDs; most for opioid OD. Best practice intervention components included psychiatric evaluations, SUD screening tools, buprenorphine initiation, naloxone distribution and training, OD prevention education, referrals to medication-assisted treatment, and harm reduction strategies. Barriers to implementation included legislation, insurance/costs, community resource availability, staffing, training, and potential stigma. With myriad approaches, nurses with SUD care experience can advocate for instituting best practices for patients in the ED and upon discharge. [Journal of Psychosocial Nursing and Mental Health Services, 61(6), 18-24.].

BACKGROUND: The Confederated Tribes of the Grand Ronde Community of Oregon began a Mobile Medication Unit (MMU) as part of their Great Circle Recovery Opioid Treatment Program (OTP) to address elevated rates of opioid use disorder (OUD) among American Indians and Alaska Natives in Oregon. The MMU provides methadone or buprenorphine for individuals with OUD, enrolled in the OTP, who are living either on the reservation or in surrounding rural communities. An implementation study describes the service through document review and qualitatively assesses patient and staff experiences and the perceived barriers and facilitators to mobile services. METHODS: Semi-structured qualitative interviews with patients (n = 11), MMU staff (n = 5), and the state opioid treatment authority (n = 1) gathered details on the initiative's development and operations. Provider interviews probed implementation experiences. Patient interviews focused on their experiences with the MMU and staff, changes in quality of life and recommendations for enhancing treatment. Interviews were transcribed and analysed using a Thematic Analysis approach. RESULTS: Staff themes identified two driving forces (i.e. staff desire for an inclusive approach to wellness that is accessible to all community members; the catalysts for the MMU), two steps toward MMU development (i.e. Tribal approvals and support; the construction and maintenance of community relationships) and two perspectives on MMU implementation and impact (i.e. initial implementation barriers; facilitators and observations of how the MMU reduced stigma associated with agonist therapy). Patients' themes noted the MMU's professional and 'caring' environment, accessible rural locations and general suggestions including culturally responsive ancillary services. CONCLUSION: The Great Circle MMU enhanced access to opioid agonist therapy for people with OUD (i.e. American Indians/Alaska Natives, and non-natives) living in rural communities. The Confederated Tribes of Grand Ronde operates the first Tribally owned OTP MMU, grounded in cultural humility and committed to Tribal members and the great circle of the larger community.

INTRODUCTION: Reducing substance-related morbidity requires an educated and well-supported workforce. The New England Office Based Addiction Treatment Extension for Community Healthcare Outcomes (NE OBAT ECHO) began in 2019 to support community-based addiction care teams through virtual mentoring and case-based learning. We sought to characterize the program's impact on the knowledge and attitudes of NE OBAT ECHO participants. METHODS: We conducted an 18-month prospective evaluation of the NE OBAT ECHO. Participants registered for 1 of 2 successive ECHO clinics. Each 5-month clinic included ten 1.5-hour sessions involving brief didactic lectures and de-identified patient case presentations. Participants completed surveys at Month-0, -6, -12, and -18 to assess attitudes about working with patients who use drugs and evidence based practices (EBPs), stigma toward people who use drugs, and addiction treatment knowledge. We compared outcomes using 2 approaches: (i) between-groups, which involved comparing the first intervention group to the delayed intervention (comparison) group, and (ii) within-groups, which involved comparing outcomes at different time points for all participants. In the within-group approach, each participant acted as their own control. RESULTS: Seventy-six health professionals participated in the NE OBAT ECHO, representing various roles in addiction care teams. Approximately half (47% [36/76]) practiced primary care, internal, or family medicine. The first intervention group reported improved job satisfaction and openness toward EBPs compared to the delayed intervention group. Within-group analyses revealed that ECHO participation was associated with increased positive perceptions of role adequacy, support, legitimacy, and satisfaction 6 months following program completion. No changes were identified in willingness to adopt EBPs or treatment knowledge. Stigma toward people who use drugs was persistent in both groups across time points. CONCLUSIONS: NE OBAT ECHO may have improved participants' confidence and satisfaction providing addiction care. ECHO is likely an effective educational tool for expanding the capacity of the addiction workforce.

BACKGROUND: Opioid use has escalated dramatically resulting in an increase in deaths. Access to treatment for opioid use disorder (OUD) is poor. The addition of nurse practitioners (NPs) as prescribers of methadone for OUD offers potential for improving access. Little is known about what support NPs will require as they prescribe methadone. PURPOSE: This paper identifies facilitators and barriers to NPs prescribing methadone. METHODS: In this qualitative study, in-person and phone semi-structured interviews were conducted with 18 participants. Participants included NPs (n=5), physicians (n=5), and stakeholders including members of professional regulatory bodies and government, academics and other clinicians (n=8). Interviews were recorded, transcribed, and analyzed using thematic analysis and software (NVivo 12.4.0) for data management. RESULTS: Four themes emerged: 1) Pervasive Barrier of Stigma; 2) Perceived Complexity of Patients Living with OUD; 3) NP Education and Practice Supports and; 4) Health Care Context and NP Role Implementation. CONCLUSIONS: Barriers and facilitators to NP prescribing are similar to those encountered by physicians. Factors unique to NPs include the identification of role clarity as a facilitator and navigation of physician networks as a barrier. Research conducted with current NP methadone prescribers is required to evaluate implementation of this service.

BACKGROUND: Opioid use has escalated dramatically resulting in an increase in deaths. Access to treatment for opioid use disorder (OUD) is poor. The addition of nurse practitioners (NPs) as prescribers of methadone for OUD offers potential for improving access. Little is known about what support NPs will require as they prescribe methadone. PURPOSE: This paper identifies facilitators and barriers to NPs prescribing methadone. METHODS: In this qualitative study, in-person and phone semi-structured interviews were conducted with 18 participants. Participants included NPs (n=5), physicians (n=5), and stakeholders including members of professional regulatory bodies and government, academics and other clinicians (n=8). Interviews were recorded, transcribed, and analyzed using thematic analysis and software (NVivo 12.4.0) for data management. RESULTS: Four themes emerged: 1) Pervasive Barrier of Stigma; 2) Perceived Complexity of Patients Living with OUD; 3) NP Education and Practice Supports and; 4) Health Care Context and NP Role Implementation. CONCLUSIONS: Barriers and facilitators to NP prescribing are similar to those encountered by physicians. Factors unique to NPs include the identification of role clarity as a facilitator and navigation of physician networks as a barrier. Research conducted with current NP methadone prescribers is required to evaluate implementation of this service.

OBJECTIVE: Utilization of medications for opioid use disorder (MOUD) has not been widely adopted by primary care providers. This study sought to identify interprofessional barriers and facilitators for use of MOUD (specifically naltrexone and buprenorphine) among current and future primary care providers in a southeastern academic center in South Carolina. METHOD: Faculty, residents, and students within family medicine, internal medicine, and a physician assistant program participated in focus group interviews, and completed a brief survey. Survey data were analyzed quantitatively, and focus group transcripts were analyzed using a deductive qualitative content analysis, based upon the theory of planned behavior. RESULTS: Seven groups (N = 46) completed focus group interviews and surveys. Survey results indicated that general attitudes towards MOUD were positive and did not differ significantly among groups. Subjective norms around prescribing and controllability (i.e., beliefs about whether prescribing was up to them) differed between specialties and between level of training groups. Focus group themes highlighted attitudes about MOUD (e.g., "opens the flood gates" to patients with addiction) and perceived facilitators and barriers of using MOUD in primary care settings. Participants felt that although MOUD in primary care would improve access and reduce stigma for patients, prescribing requires improved provider education and an integrated system of care. CONCLUSIONS: The results of this study provide an argument for tailoring education to specifically address the barriers primary care prescribers perceive. Results promote the utilization of active, hands-on learning approaches, to ultimately promote uptake of MOUD prescribing in the primary care setting in South Carolina.