Literature Collection

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.

BACKGROUND: Homeless-tailored office-based opioid treatment (OBOT) programs have been developed to address the ongoing opioid overdose crisis, which disproportionately affects people experiencing homelessness. The objective of this study was to evaluate the facilitators of and barriers to retention in a homeless-tailored OBOT program. METHODS: We performed in-depth qualitative interviews with 24 homeless-experienced adults who newly enrolled in Boston Health Care for the Homeless Program's OBOT program from January 6, 2022 through January 5, 2023. We purposively sampled participants based on whether they were retained at 1 month (n = 12) or not (n = 12). We used an abductive analytic process, applying codes to the interview transcripts from an a priori analytic framework based on the Behavioral Model for Vulnerable Populations and supplementing with emergent codes as needed. We compared themes by participants' 1-month retention status to explore facilitators of and barriers to retention in OBOT care. RESULTS: The average age was 41.9 years, 29.2% were female, 20.8% were Black, 58.3% were White, and 33.0% were Hispanic. Facilitators of retention common to many participants included the clinic experience, low-threshold model, clinic staff, and provision of comprehensive care. Among participants who were retained at 1-month, personal motivation, use of extended-release buprenorphine, and adequate buprenorphine efficacy were additional facilitators. Barriers to retention common to many participants included the clinic's surrounding environment, competing subsistence difficulties, and transportation difficulty. Among participants who were not retained at 1-month, opioid use severity, drug use in social networks, and inadequate buprenorphine efficacy represented additional barriers. CONCLUSIONS: We identified several common determinants of OBOT retention among our homeless-experienced participants as well as some facilitators and barriers that differed by 1-month retention status. These divergent factors represent potential points of intervention to promote retention in homeless-tailored OBOT programs.

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.

The unintentional consumption of fentanyl is a serious health risk for people who use illicit drugs. In an ongoing community-based study regarding polysubstance use among people who use opioids, we found that 17 of 58 (29%) of participants who did not endorse fentanyl use in the past thirty days tested positive for fentanyl during point-of-care urinalysis (UA). This paper describes the reactions and experiences of participants who were informed they had consumed fentanyl unintentionally, as well as how the research team handled the unanticipated occurrence of discordant results. Consistent with other recent studies, we found that people learning of unintentional fentanyl use expressed strong concerns about accidental overdose. It was common for participants to reflect on recent substance use experiences that were atypical and might have involved fentanyl, as well as to examine sources of recent drug purchases. While not all participants were surprised that they had unintentionally consumed fentanyl, all felt that learning their positive results was important due to risk of overdose. Research and medical staff who routinely conduct urinalysis have an opportunity to promote awareness of possible contamination by sharing and discussing UA test results with people who use drugs in non-judgmental manner. In addition to the widely promoted harm reduction strategy of testing drugs with fentanyl test strips, self-administered UA, particularly after an unexpected reaction to using a drug, could provide useful information for people buying and using illicit drugs.