Literature Collection

OBJECTIVES: The objectives of this article are to present findings from recent qualitative research with patients in a combined perinatal substance use treatment program in Central Appalachia, and to describe and analyze participants' ambivalence about medication-assisted treatment for opioid use disorder (OUD), in the context of widespread societal stigma and judgement. METHODS: We conducted research in a comprehensive outpatient perinatal substance use treatment program housed in a larger obstetric practice serving a large rural, Central Appalachian region. The program serves patients across the spectrum of substance use disorders but specifically offers medication-assisted treatment to perinatal patients with OUD. We purposively and opportunistically sampled patients receiving prescriptions for buprenorphine or buprenorphine-naloxone dual product, along with prenatal care and other services. Through participant-observation and semi-structured interviews, we gathered qualitative data from 27 participants, in a total of 31 interviews. We analyzed transcripts of interviews and fieldnotes using modified Grounded Theory. RESULTS: Participants in a combined perinatal substance use treatment program value supportive, non-judgmental care but report ambivalence about medication, within structural and institutional contexts of criminalized, stigmatized substance use and close scrutiny of their pregnancies. Women are keenly aware of the social and public consequences for themselves and their parenting, if they begin or continue medication treatment for OUD. CONCLUSIONS: Substance use treatment providers should consider the social consequences of medication treatment, as well as the clinical benefits, when presenting treatment options and recommendations to patients. Patient-centered care must include an understanding of larger social and structural contexts.

Background Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs are highly effective to prevent overdose mortality, but little is known about people who use drugs' (PWUD) experience with these interventions in rural areas. Here, we analyze qualitative data with rural PWUD to learn about their experiences with an OEND intervention, and about how their perceptions of their rural risk environments influenced the interventions' effects. Methods Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework. Results The OEND intervention transformed participants' roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing PWUD's confidence in naloxone administration. Through the intervention, over half of participants gained knowledge on naloxone (access points, administration technique) and on the criminal-legal environment as it pertained to naloxone. Most participants opted to accept and carry naloxone, citing factors related to the social environment (sense of responsibility to their community) and physical/healthcare environments (high overdose prevalence, suboptimal emergency response systems). Over half of participants described recent experiences administering intervention-provided naloxone. These experiences were shaped by features of the local rural social environment (anticipated negative reaction from recipients, prior naloxone conversations). Conclusions By providing naloxone paired with non-stigmatizing health and policy information, the OEND intervention offered the material and informational support that allowed participants to become a part of the healthcare environment. Findings highlight need for more outreach to rural PWUD on local policy that impacts them; tailored strategies to help rural PWUD engage in productive dialogue with peers about naloxone and navigate interpersonal conflict associated with overdose reversal; and opportunities for rural PWUD to formally participate in emergency response systems as peer overdose responders. Trial Registration The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registration date was October 19 (th) , 2019.

Medication for opioid use disorder (MOUD) with buprenorphine is effective in treating opioid use disorder yet remains underutilized. Scant research has examined the experience of patients, clinic staff, and providers in a "low-threshold" group-based MOUD program. This study evaluates a "low-threshold" MOUD program at a federally qualified health center (FQHC) in Philadelphia, Pennsylvania through the perspectives of its key stakeholders. Methods: This qualitative study involved focus groups of patients, providers, and clinic staff. Focus groups were conducted between October 2017 and June 2018. Grounded theory was used for analysis. Results: There were a total of 10 focus groups, including 20 patient participants and 26 staff members. Program participants noted that a strength of the program is its person-centered harm reduction approach, which is reflected in the program's policies and design. Program participants discussed the programmatic design choices that facilitated their participation and engagement in the program: ease of access, integration into primary care, and group-based visit model. Challenges in program implementation included varying acceptance and understanding of harm reduction among staff, the unpredictability of clinic volume and workflow, and the need to balance access to primary care and MOUD. Conclusion: This group-based MOUD program's philosophy of person-centered harm reduction, low-barrier approach, the structure of group-based visits, and integrated care contributes to increased patient access and retention. Understanding the strengths and challenges of the program may be useful for other safety-net clinics considering a MOUD program.

The expansion of access to medication-assisted treatment by states and the federal government serves as one important tool for tackling the opioid crisis. Achieving this goal requires increasing the number of medical professionals who hold DATA Waiver 2000 waived status, which allows providers to prescribe the medication utilized by treatment programs. Waived providers are scarce throughout rural America, placing a potentially large burden on those who do hold a waiver. This paper uses data gathered through qualitative interviews with healthcare workers and patients at MAT clinics in Montana to understand how the relationship between rural healthcare workers and MAT patients contributes to burnout and potential staff turnover in a rural setting. Patients defined quality care via the patient-staff relationship, including expectations of personal support and viewing staff availability as a requirement for their recovery. Healthcare workers, in contrast, refer to their availability to patients as overwhelming and necessary both during and after business hours. These findings illuminate the need to continue expanding MAT access in rural communities, especially in non-specialty care settings including primary care offices and Federally Qualified Health Centers.

BACKGROUND: Substance use disorder (SUD) is a chronic illness impacting more than 59 million Americans last year. Opioid use disorder (OUD) is a subset of SUD. The literature supports that healthcare providers frequently stigmatize patients with OUD. Individuals with OUD often feel shame associated with their disorder. Shame has been associated with maladaptive and avoidant behaviors. AIM: The aim of this qualitative descriptive study was to examine and describe the experiences of shame and health-seeking behaviors in individuals with OUD. METHODS: A qualitative exploratory design using focus groups with individuals in treatment for OUD was used to identify the issue of shame and its relationship to health-seeking behaviors. RESULTS: A systematic content analysis of discussions with 11 participants in four focus groups revealed four major themes and associated subthemes: Avoidance of Preventive Care (belief providers are judgmental); the Hidden Disorder (keeping secrets); Constraints of Shame (justification for the continuation of drug usage); and Trust in MOUD (Medication for Opioid Use Disorder) Providers. The feeling of shame leads to a reluctance to engage in health-promoting actions, such as scheduling appointments with primary care providers and dentists. CONCLUSION: Healthcare practitioners must prioritize providing a safe, nonstigmatizing environment for patients with SUD/OUD. This includes establishing trust and rapport, providing education, collaboration with psychiatric mental health specialists and other healthcare providers, and the offering support and resources to help patients manage their condition to achieve optimal health outcomes.

The opioid use disorder (OUD) epidemic is a national public health crisis. Access to effective treatment with buprenorphine is limited, in part because few physicians are trained to prescribe it. Little is known about how post-graduate trainees learn to prescribe buprenorphine or how to optimally train them to prescribe. We therefore aimed to explore the experiences and attitudes of residents learning to prescribe buprenorphine within two primary care-based opioid treatment models. Methods: We performed semi-structured interviews with second- and third-year internal medicine residents at an urban academic residency program. Participating residents practiced in clinics providing buprenorphine care using either a nurse care manager model or a provider-centric model. Subjects were sampled purposively to ensure that a diversity of perspectives were included. Interviews were conducted until theoretical saturation was reached and were analyzed using principles of thematic analysis. The research team developed a consensus code list. Each transcript was then independently coded by two researchers. The team then summarized each code and generated a set of themes that captured the main ideas emerging from the data. Results: We completed 14 interviews. Participants reported learning to prescribe buprenorphine through didactics, longitudinal outpatient prescribing, mentorship, and inpatient experiences. We characterized their attitudes toward patients with OUD, medication treatment of OUD, their own role in buprenorphine care, and future prescribing. Participants practicing in both clinical models viewed learning to prescribe buprenorphine as a normal part of their training and demonstrated positive attitudes toward buprenorphine prescribing. Conclusions: Longitudinal outpatient experiences with buprenorphine prescribing can prepare residents to prescribe buprenorphine and stimulate interest in prescribing after residency. Both nurse care manager and provider-centric clinical models can provide meaningful experiences for medical residents. Educators should attend to the volume of patients and inductions managed by each trainee, patient-provider continuity, and supporting trainees in the clinical encounter.

Background: Ohio's opioid epidemic continues to progress, severely affecting its rural Appalachian counties-areas marked by high mortality rates, widespread economic challenges, and a history of extreme opioid overprescribing. Substance use may be particularly prevalent in the region due to interactions between community and interpersonal trauma. Purpose/Objectives: We conducted qualitative interviews to explore the local context of the epidemic and the contributing role of trauma. Methods: Two interviewers conducted in-depth interviews (n = 34) with stakeholders in three rural Appalachian counties, including healthcare and substance use treatment professionals, law enforcement officials, and judicial officials. Semi-structured interview guides focused on the social, economic, and historical context of the opioid epidemic, perceived causes and effects of the epidemic, and ideas for addressing the challenge. Results: Stakeholders revealed three pervasive forms of trauma related to the epidemic in their communities: environmental/community trauma (including economic and historical distress), physical/sexual trauma, and emotional trauma. Traumas interact with one another and with substance use in a self-perpetuating cycle. Although stakeholders in all groups discussed trauma from all three categories, their interpretation and proposed solutions differed, leading to a fragmented epidemic response. Participants also discussed the potential of finding hope and community through efforts to address trauma and substance use. Conclusions: Findings lend support to the cyclical relationship between trauma and substance use, as well as the importance of environmental and community trauma as drivers of the opioid epidemic. Community-level and trauma-informed interventions are needed to increase stakeholder consensus around treatment and prevention strategies, as well as to strengthen community organization networks and support community resilience. Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2021.1887248.

Purpose: This article summarizes lessons learned from five AHRQ grants to implement Medication for Opioid Use Disorder (MOUD) in rural primary care practices. Methods: Lessons learned were extracted from quarterly and annual grantee progress reports, minutes from quarterly virtual meetings, and minutes and notes from annual grantee in-person meetings. The lessons learned were drafted by the authors and reviewed by the grantees for accuracy. Results: The experience of these projects suggest that recruiting providers in rural areas and engaging them to initiate and sustain provision of MOUD is very difficult. Innovative approaches and providing supports are required for supporting providers to overcome barriers. Implications: Implementation of MOUD in rural primary care is challenging but success is more likely if implementers are attentive to the needs of individual providers, are flexible and tailor implementation to the local situation, and provide on-going support.