Literature Collection

INTRODUCTION: Opioid and other substance use disorders (OUD/SUDs) have been and continue to be significant public health issues. The standard of care for OUD is the use of medication for opioid use disorder (MOUD) in conjunction with counseling or behavioral therapies, yet research has indicated that barriers exist for patients accessing MOUD as well as for physicians prescribing MOUD due to requirements associated with the DATA 2000 waiver. METHODS: A pilot cross-sectional survey was conducted among Kentucky physicians in order to reassess common barriers as well as to explore barriers that non-waivered providers face to becoming waivered. Barriers were compared by waiver status (waiver vs. non-waivered) as well as geographic location (rural vs. non-rural). RESULTS: Compared to waivered physicians, non-waivered physicians were significantly less likely to report positive personal beliefs related to the use of MOUD for OUD and reported significantly more barriers to treating OUD patients in the areas of physicians' practice and culture, auditing, and institutional support and resources (p < .05). The majority (69%) of all physicians indicated they would benefit from a tool kit with evidence-based clinical guidelines. CONCLUSIONS: The barriers and beliefs identified in this pilot study indicate the need for policy action at the federal level to reduce barriers and incentivize more physicians to obtain waivers to treat OUD. Further, the development of brief educational resources tailored to physicians to treat OUD patients including pregnant patients with OUD is recommended.

IMPORTANCE: Given that COVID-19 and recent natural disasters exacerbated the shortage of medication for opioid use disorder (MOUD) services and were associated with increased opioid overdose mortality, it is important to examine how a community's ability to respond to natural disasters and infectious disease outbreaks is associated with MOUD access. OBJECTIVE: To examine the association of community vulnerability to disasters and pandemics with geographic access to each of the 3 MOUDs and whether this association differs by urban, suburban, or rural classification. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study of zip code tabulation areas (ZCTAs) in the continental United States excluding Washington, DC, conducted a geospatial analysis of 2020 treatment location data. EXPOSURES: Social vulnerability index (US Centers for Disease Control and Prevention measure of vulnerability to disasters or pandemics). MAIN OUTCOMES AND MEASURES: Drive time in minutes from the population-weighted center of the ZCTA to the ZCTA of the nearest treatment location for each treatment type (buprenorphine, methadone, and extended-release naltrexone). RESULTS: Among 32 604 ZCTAs within the continental US, 170 within Washington, DC, and 20 without an urban-rural classification were excluded, resulting in a final sample of 32 434 ZCTAs. Greater social vulnerability was correlated with longer drive times for methadone (correlation, 0.10; 95% CI, 0.09 to 0.11), but it was not correlated with access to other MOUDs. Among rural ZCTAs, increasing social vulnerability was correlated with shorter drive times to buprenorphine (correlation, -0.10; 95% CI, -0.12 to -0.08) but vulnerability was not correlated with other measures of access. Among suburban ZCTAs, greater vulnerability was correlated with both longer drive times to methadone (correlation, 0.22; 95% CI, 0.20 to 0.24) and extended-release naltrexone (correlation, 0.15; 95% CI, 0.13 to 0.17). CONCLUSIONS AND RELEVANCE: In this study, communities with greater vulnerability did not have greater geographic access to MOUD, and the mismatch between vulnerability and medication access was greatest in suburban communities. Rural communities had poor geographic access regardless of vulnerability status. Future disaster preparedness planning should match the location of services to communities with greater vulnerability to prevent inequities in overdose deaths.

BACKGROUND: Irritability, a common behavioral problem for school-aged children, is often first assessed by primary care providers, who manage about a third of mental health conditions in children. Until recent changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM), irritability was often associated with mood disorders, which may have led to increases in bipolar disorder diagnosis and prescription of mood stabilizing medication. OBJECTIVE: Our aim was to explore differences between the approaches psychiatric and primary care providers use to assess irritability. METHODS: A single trained interviewer conducted detailed interviews and collected demographic data from a homogeneous group of physicians that saturated with a sample size of 17 pediatric, family medicine, and psychiatric providers who evaluate and treat school-aged children. Qualitative and quantitative data were collected and analyzed. RESULTS: In general, primary care providers chose to refer children with irritability to mental health specialists when medication management became complex, while the psychiatric providers chose behavior modification and parent education strategies rather than medications. The psychiatric group had a significantly higher caseload mix, prior experience with irritability, and more confidence in their assessment capabilities. There was lack of continuing medical education about irritability in all groups. CONCLUSION: This preliminary study highlights the importance of collaboration between primary care and subspecialties to promote accurate assessment and subsequent treatment of school-aged children with irritability, who can represent a safety concern for self and others. More research is needed to establish an efficient method of assessing and managing irritability in primary care and better utilization of specialists.

BACKGROUND: Integrated care addresses the fragmentation of patient health services and potentially improves the experience of care, reduces healthcare costs, and improves health outcomes. This study assessed the improvements in mental health and physical health outcomes among patients living with mental health challenges and treated in an integrated care setting. METHODS: The longitudinal retrospective cohort study evaluated anxiety (GAD-7), depression (PHQ-9), systolic blood pressure, and glycated hemoglobin levels from baseline to the next three assessments recorded from October 1, 2018, to December 31, 2023. RESULTS: At baseline, 239 participants responded to mental health outcome measures, 344 to systolic blood pressure, and 164 to glycated hemoglobin level. The Generalized Estimating Equations analysis showed an improvement in GAD-7 (-1.28 [95% CI, -1.71 to -0.85]) and PHQ-9 (-1.37 [95% CI, -1.73 to -0.92]) scores in successive assessments. The physical health outcomes (Systolic blood pressure (-0.004 [95% CI, -1.34 to 1.35]) and glycated hemoglobin (0.04 [95% CI, -0.07 to 0.15])) remained stable. CONCLUSION: This study demonstrates that patients with mental health challenges treated in integrated care experience improvements in depression and anxiety symptoms, with stable physical health outcomes.

IMPORTANCE: A central tenet of harm reduction and prevention of opioid overdose deaths is the distribution and use of naloxone. Patient-centered methods that investigate naloxone acquisition and carrying can guide opioid overdose education and naloxone distribution efforts. OBJECTIVE: To assess patients' self-reported naloxone acquisition and carrying after an emergency department (ED) encounter using automated text messaging. DESIGN, SETTING, AND PARTICIPANTS: This cohort study investigated self-reported patient behaviors involving naloxone after ED discharge in a large, urban academic health system in Philadelphia, Pennsylvania. Adult patients who were prescribed or dispensed naloxone and who had a mobile phone number listed in the electronic health record provided informed consent after ED discharge, and data were collected prospectively using text messaging from October 10, 2020, to March 19, 2021. Patients who did not respond to the survey or who opted out were excluded. EXPOSURE: Automated text message-based survey after ED discharge for patients who were prescribed or dispensed naloxone. MAIN OUTCOMES AND MEASURES: The primary outcome was patient-reported naloxone acquisition, carrying, and use. Descriptive statistics were used to summarize patient demographic characteristics. RESULTS: Of 205 eligible patients, 41 (20.0%) completed the survey; of those patients, the mean (SD) age was 39.5 (13.7) years, and 21 (51.2%) were women. Fifteen (36.6%) had a personal history of being given naloxone after an overdose. As indicated by the ED record, 27 participants (65.9%) had naloxone dispensed in the ED, and 36 (87.8%) self-reported acquiring naloxone during or after their ED visit. Twenty-four participants (58.5%) were not carrying naloxone in the week before their ED visit. Twenty participants (48.8%) were carrying naloxone after the ED visit, and 27 (65.9%) reported planning to continue carrying naloxone in the future. Of the 24 individuals (58.5%) not carrying naloxone before their ED encounter, 13 (54.2%) reported planning to continue carrying naloxone in the future. CONCLUSIONS AND RELEVANCE: In this cohort study of adult patients dispensed or prescribed naloxone from the ED, most reported acquiring naloxone on or after discharge. The ED remains a key point of access to naloxone for individuals at high risk of opioid use and overdose, and text messaging could be a method to engage and motivate patient-reported behaviors in enhancing naloxone acquisition and carrying.