Literature Collection

BACKGROUND: A wide range of opioid misuse motives have been documented in the literature, including to relieve physical pain, feel good/get high, relax, manage feelings/emotions, sleep, and moderate the effects of other substances. Despite a rise in opioid misuse among African Americans over the last 2 decades, their motivations for misuse remain unclear. Much of the research on opioid misuse motivations either rely on samples with little racial diversity or do not stratify their findings by race. As a result, less is known about the specific reasons why African Americans engage in opioid misuse. The objective of this study, therefore, was to identify and explain the most common motives for misusing opioids among African Americans. Qualitative interview data are also presented to explain/contextualize the most prevalent motivations. METHODS: This study used data from the Florida Minority Health Survey, a mixed-methods project that included online surveys (n = 303) and qualitative in-depth interviews (n = 30) of African Americans. Data collection was conducted from August 2021 to February 2022 throughout Southwest Florida. RESULTS: Analyses revealed that while some (33.9%) misused opioids for purposes of recreation/sensation seeking (eg, feel good/get high), the majority (66.1%) were attempting to self-treat perceived medical symptoms (eg, physical pain, anxiety/trauma, withdrawals, insomnia). CONCLUSIONS: This study contributes to a better understanding of why some African Americans engage in opioid misuse and findings highlight the need for interventions to be trauma informed and address unmanaged physical pain among African Americans. Given that most studies on motivations are quantitative in nature, the study contributes to the literature by capturing the voices of African Americans who use drugs.

BACKGROUND: Primary care is the initial contact point for most patients with opioid use disorder (OUD) but lacks tools for guiding treatment. Only a small fraction of patients access evidence-based care. Long-acting injectable buprenorphine has potential to improve medication adherence and program retention in low-barrier primary care treatment settings. We present the first clinical decision support algorithm incorporating long-acting buprenorphine (LAIB) in primary care. We include a protocol for a future evaluation of the algorithm's implementation process, "Medication for Opioid Use Disorder (MOUD) 2.0," at a housing and integrated care clinic at a Federally Qualified Health Center. METHODS: Literature review and expert consensus informed creation of the algorithm, which underwent iterative development with feedback from clinicians, staff, and patients. Patients are categorized by adherence to therapy and retention in the program, with recommendations for each category. Adherence is determined by urine screen supplemented by self-report. To ensure all patients in this high morbidity and mortality risk population are treated, we will treat patients as their own controls in the evaluation, with potential for multisite comparisons. We will present descriptive statistics for adherence proportion before and after MOUD 2.0 implementation, testing for differences using McNemar's test. We will then present pre- and post-implementation unadjusted six-month survival curves for retention. DISCUSSION: LAIB is incorporated as an alternative or adjunctive treatment for patients refractory to sublingual buprenorphine and as an initial treatment for selected patients. We developed an algorithm with 4-, 8-, and 12-week decision points to guide treatment for patients with varying levels of response to sublingual buprenorphine and LAIB. This clinical decision tool incorporates LAIB among treatment options for OUD in primary care settings. The protocol will evaluate the algorithm's implementation, presenting a replicable method for assessing adherence and retention among high-risk patients in similar settings.

BACKGROUND: Effective person-centred interventions are needed to support people living with mental-physical multimorbidity to achieve better health and wellbeing outcomes. Depression is identified as the most common mental health condition co-occurring with a physical health condition and is the focus of this intervention development study. The aim of this study is to identify the key components needed for an effective intervention based on a clear theoretical foundation, consideration of how motivational interviewing can inform the intervention, clinical guidelines to date, and the insights of primary care nurses. METHODS: A multimethod approach to intervention development involving review and integration of the theoretical principles of Theory of Planned Behavior and the patient-centred clinical skills of motivational interviewing, review of the expert consensus clinical guidelines for multimorbidity, and incorporation of a thematic analysis of group interviews with Australian nurses about their perspectives of what is needed in intervention to support people living with mental-physical multimorbidity. RESULTS: Three mechanisms emerged from the review of theory, guidelines and practitioner perspective; the intervention needs to actively 'engage' patients through the development of a collaborative and empathic relationship, 'focus' on the patient's priorities, and 'empower' people to make behaviour change. CONCLUSION: The outcome of the present study is a fully described primary care intervention for people living with mental-physical multimorbidity, with a particular focus on people living with depression and a physical health condition. It builds on theory, expert consensus guidelines and clinician perspective, and is to be tested in a clinical trial.

Autistic youth often experience co-occurring mental health needs, yet they have multi-level barriers to accessing needed care. To address these barriers, the ATTAIN NAV (Access to Tailored Autism Integrated Care through Family Navigation) intervention was co-designed with caregiver and healthcare partners and delivered by lay health navigators to facilitate access to and engagement with mental health services for school-age autistic youth. This manuscript describes the multi-method, partner-engaged, longitudinal adaptation process to (1) identify intervention content and implementation refinements prior to the hybrid trial and (2) track ongoing research, intervention, and implementation adaptations during the trial and their impacts on study outcomes. The adaptation processes used the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (Miller et al., 2021) to guide data collection and evaluation approaches. From the qualitative co-design activities with caregivers (n = 5), primary care providers (n = 6), developmental care clinicians (n = 4), and health informatics staff (n = 3), several intervention content and implementation adaptations were identified and integrated prior to the trial. From the longitudinal adaptation tracking process during the trial, a total of 19 adaptations were documented throughout the implementation trial. The adaptations were related to maintaining the feasibility and acceptability of the study procedures (32%), increasing family recruitment/engagement (26%), increasing the acceptability of the intervention components (16%), increasing physician recruitment/engagement (11%), expanding mental health resources (5%), complying with partnered healthcare organization policy (5%), and increasing navigator workflow efficiency (5%). Findings offer a structured and replicable approach adoptable by non-traditional mental health intervention and implementation research.

OBJECTIVES: Sleep disorders are wide-ranging in their causes and impacts on other physical and mental health conditions. Thus, sleep disorders could benefit from a multidisciplinary approach to assessment and treatment. An integrated care model is often recommended but is costly to implement. We sought to understand how, in the absence of an established organizational structure for integrated sleep care, providers from different clinics work together to provide care for sleep disorders. METHODS: A qualitative case study at one U.S. Department of Veterans Affairs (VA) medical center. We used a purposeful nested sampling strategy, combining maximum variation sampling and snowball sampling to recruit key staff involved in sleep care. RESULTS: We interviewed providers (N = 10) from sleep medicine, primary care, and mental health services. Providers identified the ubiquity of sleep disorders and a concomitant need for multidisciplinary care. However, they described limited opportunities for multidisciplinary interactions and consequently a negative impact on clinical care. Providers described fragmentation in two areas: among sleep specialists and between sleep specialists and other referring and managing providers. CONCLUSIONS: A range of interventions, based on setting and resources, could improve care coordination both among sleep specialists and between sleep and nonsleep providers. While integrated sleep specialist clinics could reduce care fragmentation, they may not directly impact coordination with referring providers, like primary care and general mental health, who are essential in managing chronic conditions. Future work should continue to explore improving care coordination for sleep problems to ensure patients receive high-quality, timely, patient-centered care.

Background: Treatment of opioid use disorder (OUD) is highly effective, but access is limited and care is often fragmented. Treatment in primary care can improve access to treatment and address psychiatric and physical co-morbidities in a holistic, efficient, and non-stigmatizing way. The Collaborative Care Model (CCM) of behavioral health integration into primary care has been widely disseminated and shown to improve outcomes and lower costs when studied for depression, but its use in treating substance use disorders has not been well documented. Methods: We used a mixed-methods approach to examine the impact of implementing multidisciplinary treatment of OUD in our health system's five primary care clinics using the framework of the CCM, with care shared between the primary care clinician (PCP), behavioral health clinician, and medical assistant. The implementation included staff education, creation of electronic health record tools, and implementation support, and was evaluated using data from the electronic health record, the medical staff office, and a clinician survey. Results: Over the last 2 years of implementation, the number of waivered providers increased from 11 to 35, providers prescribing for 5 or more patients increased from 2 to 18, and patients initiated on buprenorphine increased from 4/month to 18/month. 180-day treatment retention was 53%, and 81% of patients had consistently negative urine drug testing. Psychiatric and medical comorbidities were common, 70 and 44%, respectively. Although PCPs who prescribed buprenorphine found working in this model enjoyable and effective, the majority of non-waivered PCPs remained reluctant to participate. Conclusions: In our experience, treatment of OUD in primary care utilizing the CCM effectively addresses OUD and commonly comorbid anxiety and depression, and leads to an expansion of treatment. Successful implementation of OUD treatment requires addressing negative attitudes and perceptions.