Literature Collection

Physicians who want to prescribe buprenorphine to treat opioid use disorder require a waiver established by the Drug Addiction Treatment Act (DATA) of 2000, often through completion of an eight-hour training course. This is an issue for a number of reasons, including that opioid overdose deaths continue to rise nationally. However, on October 24, 2018, the SUPPORT (Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment) for Patients and Communities Act was signed into law. This bill allows any physician who graduates in good standing from an allopathic or osteopathic medical school in the United States that incorporates necessary material around opioid misuse in their standard curriculum, without need for any additional training, to prescribe buprenorphine. This perspective piece describes why this is an important first step and what more needs to be done within medical education to combat the opioid epidemic.

BACKGROUND: Methadone is a synthetic mu-opioid receptor agonist that is used in the management of pain, neonatal abstinence withdrawal syndrome, and opioid dependence. Overdose can cause miosis, respiratory depression, and central nervous system depression. Rarely, hypoglycemia has been reported. We present the case of an 11-month-old male who developed hypoketotic, hyperinsulinemic, hypoglycemia after an acute, unintentional methadone exposure. CASE DETAILS: The patient was a previously healthy 11-month-old male who presented in respiratory failure. He was intubated and transferred to a large tertiary care center where his physical exam was notable for miosis. His labs were notable for a blood glucose of 17 mg/dL, an elevated insulin level, and suppressed serum beta-hydroxybutyrate. The patient was given a dextrose bolus with improvement in blood glucose. Administration of IV naloxone improved his miosis and mental status. A quantitative methadone level was sent upon arrival and was 123 ng/mL. Testing for ethanol, salicylates, sulfonylureas, and metabolic causes of hypoglycemia was negative. A fasting study showed euglycemia with suppression of insulin and appropriate ketosis. Case discussion: We present the case of an 11-month-old male who developed hypoketotic, hyperinsulinemic, hypoglycemia after an acute, unintentional methadone exposure. Alternative explanations for hypoketotic hypoglycemia were rule out. Methadone-induced hypoglycemia has been reported in cancer patients receiving methadone for pain, but a mechanism has not been identified. Based on this case, we believe that the patient's hypoglycemia was the result of methadone-induced insulin secretion. CONCLUSIONS: This case proposes that hyperinsulinism is the mechanism responsible for methadone-associated hypoglycemia. Methadone exposure should be included in the differential diagnosis of new onset hypoglycemia.

The US government funds integrated care demonstration projects to decrease health disparities for individuals with serious mental illness. Drawing on the Exploration Preparation Implementation Sustainability (EPIS) implementation framework, this case study of a community mental health clinic describes implementation barriers and sustainability challenges with grant-funded integrated care. Findings demonstrate that integrated care practices evolve during implementation and the following factors influenced sustainability: workforce rigidity, intervention clarity, policy and funding congruence between the agency and state/federal regulations, on-going support and training in practice application, and professional institutions. Implementation strategies for primary care integration within CMHCs include creating a flexible workforce, shared definition of integrated care, policy and funding congruence, and on-going support and training.

INTRODUCTION: Veteran patient partnerships in research improve patient-centred healthcare outcomes within US Department of Veterans Affairs (VA) medical centres. To achieve this, researchers must contextualize perspectives, motivations, and contributions of Veteran patients engaged in research (VPERs) as valued consultants within a complex healthcare environment. Our objective was to investigate best practices for research teams partnering with VPERs by utilizing the expertise of our research team's own VPER. The parent project of this case study, Hybrid Controlled Trial to Implement Collaborative Care in General Mental Health, was approved by the VA Boston Healthcare System Institutional Review Board and deemed research. OBJECTIVE: Provide three key recommendations when engaging military Veterans and/or VA Veteran Patients in research to facilitate sustained teamwork and integration. STUDY DESIGN AND METHODOLOGIES: This paper is structured as a qualitative descriptive data-based case study. Two team members used a semi-structured conversation guide to interview Dr. Colleen Turner, MSW, PhD, Lt. Col. (Ret., US Air Force Reserves) for one hour about her experience as a VPER on the 5-year research project. This manuscript was then written collaboratively by members of the team, with heavy influence and editing from Colleen for details and accuracy. RESULTS: Improving mental healthcare for Veterans motivated Colleen to serve as a VPER from 2015 to 2020. She used organizational and provider-level mental health expertise gained during her Air Force service, applied her graduate social work training, and offered her experience as a VA patient. A diverse background and an ability to codeswitch helped her navigate the study and enriched the team's partnership dynamics. Through a qualitative interview with Colleen about her experience as a VPER, three recommendations emerged for research teams to better situate VPERs on studies: (1) ensure initial project literacy and provide ongoing support, (2) incorporate VPER goals into project work and (3) communicate both (a) offers of reasonable compensation and professional acknowledgement and (b) visible patient-centred outcomes. CONCLUSION: This case study deepens the understanding of how to meaningfully incorporate VPERs into a partnered research study. Engagement starts early, continues throughout the study, and culminates with well-communicated outcomes as they pertain to the researchers' and VPERs' goals. These recommendations closely align with widely accepted community-engaged research practices and may guide ongoing and future studies to further improve patient engagement in research and the collaboration experiences of VPERs. PATIENT OR PUBLIC CONTRIBUTION: This manuscript focuses on Colleen's contributions to the design and conduct of a hybrid implementation/effectiveness study. Colleen also contributed to the manuscript itself. Uniquely, Dr. Turner brought her experience as a practitioner with master's and doctoral degrees in social work, as an institutional communications analyst, and as an independent author. Because of this, she was able to bring even more expertise to the project beyond just that of a patient, which is valuable in its own right. Colleen was involved in the research project from inception to conclusion, including study design, general analysis, and manuscript publication, with overall consultation throughout.

Help-seeking for depression and anxiety disorders from primary care physicians in Western countries is at three times the rate of China. Western help-seeking models for common mental disorders have limitations in the Chinese settings. This article argues that an adapted model based on Andersen's Behavioral Model of Health Services Use could be an appropriate tool to better understand patients' help-seeking behaviors and improve outcomes. We applied a narrative review approach to integrate research findings from China into Andersen's model to generate a model that fits the Chinese context. We found 39 relevant articles in PubMed, MEDLINE, and Chinese journal databases from 1999 to 2022. Findings were mapped onto predisposing, enabling, and need factors of the model. This model emphasizes that predisposing factors including demographics, social norms, and health beliefs influence help-seeking preferences. Mental health service users in China tend to be older and female. Chinese generally have high concern about psychotropic medications, and social norms that consider psychological distress a personal weakness may discourage help-seeking. However, help-seeking can be enhanced by enabling factors in the health system, including training of primary care physicians, longer consultation time, and continuity of care. Need factors for treatment increase with the severity of distress symptoms, and doctor's skills and attitudes in recognizing psychosomatic symptoms. While predisposing factors are relatively hard to change, enabling factors in the health system and need factors for treatment can be targeted by enhancing the role of family doctors and training in mental health.