Literature Collection

BACKGROUND: Rising rates of serious injection-related infections (SIRI) and hospitalizations have been documented nationally in the context of the ongoing opioid and polysubstance use epidemic in the United States. This qualitative interview study assessed multi-level facilitators and barriers to the implementation of an integrated inpatient opioid use disorder (OUD) and SIRI care intervention among organizational stakeholders in the healthcare setting as a secondary aim of a randomized clinical trial. METHODS: The PRISM (Practical, Robust, Implementation, and Sustainability Model) implementation science framework guided stakeholder interviews. Eligible stakeholders were at least 18 years old and employed in an inpatient or outpatient care setting that served the study patient population. Qualitative interviews assessed contextual factors that supported or hindered the implementation of the novel study intervention and priorities for sustainability and future investment. Interviews lasted approximately 60 min. Qualitative coding and analysis were conducted in NVivo. RESULTS: Overall, thirteen stakeholders were interviewed, including clinicians from cardiothoracic surgery, hospital medicine, infectious disease, and addiction medicine, hospital administrators, social work and case management staff, pharmacists, Bridge Clinic staff, and staff from home infusion. Within the four overarching PRISM domains thirteen critical elements were activated by the study intervention that represented key barriers and facilitators to implementation, including: Intervention (Coordination across departments, Strength of the evidence base, Burden, Barriers of frontline staff, SUD stigma); Recipients (Clinical leadership, Organizational health and culture; Patient disease burden, Patient demographics); External Environment (Community Resources, Reimbursement); and Implementation and Sustainability Infrastructure (Dedicated team, Plan for sustainability). CONCLUSIONS: Examination of implementation determinants highlighted organizational and external barriers and facilitators. Barriers centered on the complexities of care coordination across departments, the inpatient-outpatient transition, and specialized training needs; these appeared modifiable through adoption of specific implementation strategies. The presence of critical clinical infrastructure to support this transitional OUD-SIRI integrated care model was an essential facilitator, which could represent a challenge for other health systems. External factors, including low resource availability, and SUD-related stigma that excludes patients from opportunities to receive care in the community, collectively pose challenges to wider implementation and sustainability.

The field of Hospice and Palliative Medicine (HPM) has its roots in the principles, promulgated by Dame Cicely Saunders, that patient and family are the unit of care and that comprehensive integration of physical, psychological, social, and spiritual care is necessary to address suffering in all its dimensions. Although we aspire to provide comprehensive care for our patients, most hospice and palliative care (HPM) physicians lack basic competencies for identifying and managing patients with psychological distress and mental health distress and disorders, a growing segment of our clinical population. In this article, I argue that we are not living up to the founding values of our field in how we practice, how we educate our trainees, our research, and in how we pursue our own professional development as faculty. The history of our field, the nature of our clinical workforce, the culture of PC, and our educational programs all contribute to our current practice model, which is not adequate to meet the mental health needs of our patients. I propose strategies to address these challenges focused on enhancing integration between psychiatry/psychology and HPM, changes in fellowship education and faculty development, addressing the stigma against people with mental health diagnoses, and addressing system and cultural challenges that limit our ability to provide the kind of comprehensive, integrative care that our field aspires to.

This report builds on a previous study that describes the collaboration between an urban academic medical center and a rural drug treatment center, the goal of which is to provide medication-based treatment to individuals with OUD via videoconferencing. We describe results of a retrospective chart review of 472 patients treated in the program between August 2015 and April 2019. We examined several demographic and substance use variables for individuals who consented to telemedicine treatment, retention in treatment over time, and opioid use over time to understand further the impact of prescribing buprenorphine and naltrexone via telemedicine to patients in a rural OUD treatment setting. Our findings support the effectiveness of prescribing medications via telemedicine. The inclusion of more than three times as many patients as in our prior report revealed retention rates and toxicology results that are comparable to face-to-face treatment. These findings have implications for policymakers and clinicians considering implementation of similar programs.

BACKGROUND: The integration of opioid use disorder (OUD) care and competencies in graduate medical education training is needed. Previous research shows improvements in knowledge, attitudes, and practices after exposure to OUD care. Few studies report outcomes for patients with OUD in resident physician continuity practices. METHODS: A novel internal office-based opioid treatment (OBOT) program was initiated in a resident continuity clinic. Surveys of resident and staff knowledge and attitudes of OBOT were administered at baseline and 4 months. A retrospective chart review of the 15-month OBOT clinic obtained patient characteristics and outcomes. RESULTS: Twelve patients with OUD were seen in the OBOT clinic. Seven patients (58%) were retained in care at the end of the study period for a range of 9-15 months. Eight patients demonstrated a good clinical response. Surveys of residents and staff at 4 months were unchanged from baseline showing persistent lack of comfort in caring for patients with OUD. CONCLUSIONS: OBOT can be successfully integrated into resident continuity practices with positive patient outcomes. Improvement in resident and staff attitudes toward OBOT were not observed and likely require direct and frequent exposure to OUD care to increase acceptance.