Literature Collection

OBJECTIVE: To educate health care professionals and nurses on buprenorphine initiations in pregnancy, establish a mutual care agreement to promote therapeutic partnership, and standardize buprenorphine initiation using the Epic electronic health record (EHR) order set. PROJECT SUMMARY: This project provides resources that can be adapted and implemented at other institutions to perform inpatient buprenorphine initiations for pregnant patients with opioid use disorder (OUD). The toolkit includes educational PowerPoint presentations, a mutual care agreement template, and a comprehensive order set. This project begins by addressing the gap in health care professional knowledge about medications for opioid use disorder (MOUD) in pregnancy. We supply educational resources in PowerPoint format. The presentations cover the role of buprenorphine in pregnancy, micro-dose initiation pharmacology, and the use of ancillary supportive medications to manage withdrawal symptoms. Clear expectations and goals help facilitate smooth integration of buprenorphine initiation into inpatient care. The toolkit includes a templated "Mutual Care Agreement" for patients and health care professionals to sign on admission. Lastly, this toolkit addresses the technical barrier of prescribing by providing an order set. The Epic EHR order set, which can be replicated or adapted for other systems, includes dosing and timing for buprenorphine micro-dosing initiation, supportive medications, and comprehensive care considerations. These considerations include treatments for co-occurring substance use, consultations with social workers and psychiatrists, infectious disease screening, and vaccinations. OUTCOME: Disseminating this program will improve pregnant patients' access to MOUD and empower clinicians to provide for patients with OUD. RELEVANCE TO WOMENS HEALTH AND PHYSICIANS IN PRACTICE: Due to the opioid epidemic, pregnancy-related overdose deaths have risen significantly and are becoming a leading cause of maternal mortality. Medications for opioid use disorder decrease mortality. Despite the American College of Obstetricians and Gynecologists' recommendation to treat OUD with MOUD during pregnancy, many health care professionals lack the education and tools to initiate MOUD for pregnant patients with active substance use.

The year 2021 was the most deadly year for overdose deaths in the USA and Canada. The stress and social isolation stemming from the COVID-19 pandemic coupled with a flood of fentanyl into local drug markets created conditions in which people who use drugs were more susceptible to accidental overdose. Within territorial, state, and local policy communities, there have been longstanding efforts to reduce morbidity and mortality within this population; however, the current overdose crisis clearly indicates an urgent need for additional, easily accessible, and innovative services. Street-based drug testing programs allow individuals to learn the composition of their substances prior to use, averting unintended overdoses while also creating low threshold opportunities for individuals to connect to other harm reduction services, including substance use treatment programs. We sought to capture perspectives from service providers to document best practices around fielding community-based drug testing programs, including optimizing their position within a constellation of other harm reduction services to best serve local communities. We conducted 11 in-depth interviews from June to November 2022 via Zoom with harm reduction service providers to explore barriers and facilitators around the implementation of drug checking programs, the potential for integration with other health promotion services, and best practices for sustaining these programs, taking the local community and policy landscape into account. Interviews lasted 45-60 min and were recorded and transcribed. Thematic analysis was used to reduce the data, and transcripts were discussed by a team of trained analysts. Several key themes emerged from our interviews: (1) the instability of drug markets amid an inconsistent and dangerous drug supply; (2) implementing drug checking services in dynamic environments in response to the rapidly changing needs of local communities; (3) training and ongoing capacity building needed to create sustainable programs; and (4) the potential for integrating drug checking programs into other services. There are opportunities for this service to make a difference in overdose deaths as the contours of the drug market itself have changed over time, but a number of challenges remain to implement them effectively and sustain the service over time. Drug checking itself represents a paradox within the larger policy context, putting the sustainability of these programs at risk and challenging the potential to scale these programs as the overdose epidemic worsens.

INTRODUCTION: Doctor of pharmacy programs are encouraged to proactively promote well-being for students, faculty, and staff. In addition, a need has been highlighted to place greater focus on reducing mental health stigma within the promotion of patient-centered care. Mental Health First Aid (MHFA) is an evidence-based, early-intervention course that teaches participants how to support individuals experiencing a mental health challenge. Incorporation of MHFA into healthcare education has become an interest for many programs to address these needs, however, limited research is available regarding implementation of MHFA into pharmacy curricula. This study aimed to assess the current state of MHFA within existing PharmD programs and present opportunities to facilitate MHFA integration. METHODS: An online survey was administered to all Accreditation Council for Pharmacy Education (ACPE)-accredited pharmacy programs within the United States (US). Survey questions collected information on institution demographics, whether MHFA training is currently offered, and specifics of the MHFA training program. Questions assessing barriers and successes with MHFA implementation were also included. RESULTS: Twenty-six of the 52 programs that responded to the survey indicated that they offer MHFA to pharmacy students, with thirteen programs incorporating it as a core requirement within their curriculum. The top identified barriers to implementation included time requirements for training, cost, and curricular structure. CONCLUSION: Implementation of MHFA is feasible as a required element of pharmacy curricula and aligns with ACPE standards 2025. MHFA training can assist student pharmacists with developing competency in providing care for persons with mental health and substance use challenges.

BACKGROUND: In the last decade there has been an increase in the development and marketing of digital therapeutic (DTx) products aiming to prevent, manage, or treat a medical disorder or disease. Health insurance coverage for these products is not well established, and payers are facing increasing pressure to include these products as a covered benefit. OBJECTIVE: To examine factors and characteristics that could drive health insurance coverage of DTx products from US payers' and coverage decision-makers' perspectives. METHODS: This was a qualitative noninterventional, cross-sectional study conducted from August 2022 to October 2022. Virtual focus group meetings with pharmacy benefit managers/directors or medical directors representing a range of health insurance organizations were held following a semistructured interview guide. Convenience and snowball sampling techniques were used to identify participants. Transcripts were coded and analyzed with Atlas.ti software to identify common themes and subthemes. RESULTS: Five focus group meetings and 1 individual interview were held from August to October 2022. Participants (n = 22) were mostly pharmacists (n = 18, 85%) with more than 15 years of experience (n = 18, 85%). Some participants indicated that DTx products for diabetes (n = 6, 29%), mental/behavioral health (n = 3, 14%), and substance abuse disorders (n = 3, 14%) were already covered by their organizations. The topics generating the most comments grouped by code were issues around the evidence for DTx (67 unique comments) and barriers for coverage (60 unique comments). Participants indicated they want to have evidence of effectiveness that is similar to traditional pharmaceutical products. Barriers for coverage included a need to revise benefit policies, exclusion of nonprescription products, and mechanisms for billing. DTx products with an indication for mental/behavioral health were viewed as most likely to be reimbursed. Coverage of DTx products may occur under either the pharmacy or medical benefit. CONCLUSIONS: Health care payers stated that evidence of effectiveness was a necessary condition for health insurance coverage of DTx products. Given these are relatively new in health care, payers had more questions than answers regarding how these products will be integrated into health benefits.

Egypt is experiencing an increasing drug problem (cannabis, heroin, amphetamines, pharmaceutical opioids, synthetic cannabinoids). Whilst harm reduction and addiction treatment are provided by government and non-governmental organizations in Egypt, very little is known about physicians experience of handling patient substance use and substance use disorder (SUD) in primary care. A cross-sectional national study of 392 Egyptian Family Physicians (FPs) & General Practitioners (GPs) explored their knowledge, attitude and professional practice regarding management of SUD in primary care, as a first step toward identifying professional development support needs and informing general practice. Findings underscore the need for greater depth of addiction training during undergraduate medical education and in continuing professional development, so that Egyptian FPs/GPs can better prevent harmful substance use, detect patients with SUD, intervene and support those in treatment. This study provides unique information which will inform further development and scale of evidence based SUD brief intervention and treatment within Egyptian primary care.

OBJECTIVE: The American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine endorse checklist use to improve obstetric care. However, there is limited research into development, implementation, and sustained use of perinatal emergency checklists to inform individual institutions. This study aimed to investigate the development and implementation of perinatal emergency checklists in diverse hospital settings in the United States. STUDY DESIGN: A qualitative study was conducted individually with clinicians from three health care systems. The participants developed and implemented institution-tailored perinatal emergency checklists. Interview transcriptions were coded using the Consolidated Framework for Implementation Research. RESULTS: The study sites included two health care systems and one individual hospital. Delivery volumes ranged from 3,500 to 48,000 deliveries a year. Interviews were conducted with all 10 participants approached. Checklists for 19 perinatal emergencies were developed at the three health care systems. Ten of the checklist topics were the same at all three institutions. Participants described the checklists as improving patient care during crises. The tools were viewed as opportunities to promote a shared mental model across clinical roles, to reduce redundancy and coordinate obstetric crisis management. Checklist were developed in small groups. Implementation was facilitated by those who developed the checklists. Participants agreed that simulation was essential for checklist refinement and effective use by response teams. Barriers to implementation included limited clinician availability. There was also an opportunity to strengthen integration of checklists workflow early in perinatal emergencies. Participants articulated that culture change took time, active practice, persistence, reinforcement, and process measurement. CONCLUSION: This study outlines processes to develop, implement, and sustain perinatal emergency checklists at three institutions. Participants agreed that multiple, parallel implementation tactics created the culture shift for integration. The overview and specific Consolidated Framework for Implementation Research components may be used to inform adaptation and sustainability for others considering implementing perinatal emergency checklists. KEY POINTS: · Perinatal emergency checklists reduce redundancy and coordinate obstetric crisis management.. · Perinatal emergency simulation is essential for checklist refinement and effective team use.. · Integrations of perinatal emergency checklists requires culture change and process measurement..

BACKGROUND: Major depressive disorder (MDD) and insulin resistance-related conditions are major contributors to global disability. Their co-occurrence complicates clinical outcomes, increasing mortality and symptom severity. AIMS: In this study, we investigated the association of insulin resistance-related conditions and related polygenic scores (PGSs) with MDD clinical profile and treatment outcomes, using primary care records from UK Biobank. METHOD: We identified MDD cases and insulin resistance-related conditions, as well as measures of depression treatment outcomes (e.g. resistance) from the records. Clinical-demographic variables were derived from self-reports, and insulin resistance-related PGSs were calculated using PRS-CS. Univariable analyses were conducted to compare sociodemographic and clinical variables of MDD cases with (IR+) and without (IR-) lifetime insulin resistance-related conditions. Multiple regressions were performed to identify factors, including insulin resistance-related PGSs, potentially associated with treatment outcomes, adjusting for confounders. RESULTS: Among 30 919 MDD cases, 51.95% were IR+. These had more antidepressant prescriptions and classes utilisation and longer treatment duration than patients without insulin resistance-related conditions (P < 0.001). IR+ participants showed distinctive depressive profiles, characterised by concentration issues, loneliness and inadequacy feelings, which varied according to the timing of MDD diagnosis relative to insulin resistance-related conditions. After adjusting for confounders, insulin resistance-related conditions (i.e. cardiovascular diseases, hypertension, non-alcoholic fatty liver disease, obesity/overweight, prediabetes and type 2 diabetes mellitus) were associated with antidepressant non-response/resistance and longer treatment duration, particularly when MDD preceded insulin resistance-related conditions. No significant PGS associations were found with antidepressant treatment outcomes. CONCLUSIONS: Our findings support an integrated treatment approach, prioritising both psychiatric and metabolic health, and public health strategies aimed at early intervention and prevention of insulin resistance in MDD.

The public health impact of alcohol-associated liver disease (ALD), a serious consequence of problematic alcohol use, and alcohol use disorder (AUD) is growing, with ALD becoming a major cause of alcohol-associated death overall and the leading indication for liver transplantation in the United States. Comprehensive care for ALD often requires treatment of AUD. Although there is a growing body of evidence showing that AUD treatment is associated with reductions in liver-related morbidity and mortality, only a minority of patients with ALD and AUD receive this care. Integrated and collaborative models that streamline both ALD and AUD care for patients with ALD and AUD are promising approaches to bridge this treatment gap and rely on multidisciplinary and interprofessional teams and partnerships. Here, we review the role of AUD care in ALD treatment, the effects of AUD treatment on liver-related outcomes, the impact of comorbid conditions such as other substance use disorders, obesity, and metabolic syndrome, and the current landscape of integrated and collaborative care for ALD and AUD in various treatment settings. We further review knowledge gaps and unmet needs that remain, including the role of precision medicine, the application of harm reduction approaches, the impact of health disparities, and the need for additional AUD treatment options, as well as further efforts to support implementation and dissemination.