Literature Collection

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.

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.

BACKGROUND: Citizens affected by substance use disorders are high-risk populations for both SARS-CoV-2 infection and COVID-19-related mortality. Relevant vulnerabilities to COVID-19 in people who suffer substance use disorders are described in previous communications. The COVID-19 pandemic offers a unique opportunity to reshape and update addiction treatment networks. MAIN BODY: Renewed treatment systems should be based on these seven pillars: (1) telemedicine and digital solutions, (2) hospitalization at home, (3) consultation-liaison psychiatric and addiction services, (4) harm-reduction facilities, (5) person-centered care, (6) promote paid work to improve quality of life in people with substance use disorders, and (7) integrated addiction care. The three "best buys" of the World Health Organization (reduce availability, increase prices, and a ban on advertising) are still valid. Additionally, new strategies must be implemented to systematically deal with (a) fake news concerning legal and illegal drugs and (b) controversial scientific information. CONCLUSION: The heroin pandemic four decades ago was the last time that addiction treatment systems were updated in many western countries. A revised and modernized addiction treatment network must include improved access to care, facilitated where appropriate by technology; more integrated care with addiction specialists supporting non-specialists; and reducing the stigma experienced by people with SUDs.

Syringe services programs (SSPs) complement substance use disorder treatment in providing services that improve the health of people who use drugs (PWUD). Buprenorphine treatment is an effective underutilized opioid use disorder treatment. Regulations allow buprenorphine prescribing from office-based settings, potentially including SSPs although few studies have examined this approach. Our objective was to assess the attitudes among PWUD toward the potential introduction of buprenorphine treatment in an SSP. Methods: In this qualitative study, we recruited 34 participants who were enrolled at a New York City-based SSP to participate in one of seven focus group sessions. The focus group facilitators prompted participants to share their thoughts in five domains: attitudes toward (1) medical clinics; (2) harm reduction in general; (3) SSP-based buprenorphine treatment; (4) potential challenges of SSP-based treatment; and (5) logistical considerations of an SSP-based buprenorphine treatment program. Four researchers analyzed focus group transcripts using thematic analysis. Results: Of the 34 participants, most were white (68%), over the age of 40 years old (56%), and had previously tried buprenorphine (89%). Common themes were: 1) The SSP is a supportive community for people who use drugs; 2) Participants felt less stigmatized at the SSP than in general medical settings; 3) Offering buprenorphine treatment could change the SSP's culture; and 4) SSP participants receiving buprenorphine may be tempted to divert their medication. Participants offered suggestions for a slow intentional introduction of buprenorphine treatment at the SSP including structured appointments, training medical providers in harm reduction, and program eligibility criteria. Conclusion: Overall, participants expressed enthusiasm for onsite buprenorphine treatment at SSPs. Research on SSP-based buprenorphine treatment should investigate standard buprenorphine treatment outcomes but also any effects on the program itself and medication diversion. Implementation should consider cultural and environmental aspects of the SSP and consult program staff and participants.