Literature Collection

BACKGROUND AND AIMS: Opioid agonist therapies (OATs) are highly effective treatments for opioid use disorders (OUDs), especially for pregnant women; thus, improving access to OAT is an urgent public policy goal. Our objective was to determine if insurance and pregnancy status were barriers to obtaining access to OAT in 4 Appalachian states disproportionately impacted by the opioid epidemic. METHODS: Between April and May 2017, we conducted phone surveys of OAT providers, opioid treatment programs (OTPs), and outpatient buprenorphine providers, in Kentucky, North Carolina, Tennessee, and West Virginia. Survey response rates were 59%. Logistic models for dichotomous outcomes (e.g., patient acceptance) and negative binomial models were created for count variables (e.g., wait time), overall and for pregnant women. RESULTS: The majority of OAT providers were accepting new patients; however, providers were less likely to treat pregnant women (91% vs. 75%; p < .01). OTPs were more likely to accept new patients than waivered buprenorphine providers (97% vs. 83%; p = .01); rates of accepting pregnant patients were lower in both (91% and 53%; p < .01). OTPs and buprenorphine providers accepted cash payments for services at high rates (OTP: 100%; buprenorphine: 89.4%; p < .01); Medicaid and private insurance were accepted at lower rates. In adjusted models, providers were less likely to accept pregnant women if they took any insurance (adjusted odds ratio [aOR] = 0.15, 95% confidence interval [CI]: 0.03-0.68) or were a buprenorphine provider (aOR = 0.09, 95% CI: 0.02-0.37). CONCLUSIONS: We found that OAT providers frequently did not accept any insurance and frequently did not treat pregnant women in an area of the country disproportionately affected by the opioid epidemic. Policymakers could prioritize improvements in provider training (e.g., training of obstetricians to become buprenorphine prescribers) as a means to enhance access to pregnant women or enhancing reimbursement rates as a means of improving insurance acceptance for OAT.

The cornerstone in managing alcohol-associated liver disease is the treatment of alcohol use disorder (AUD). Several barriers prevent the implementation of adequate treatment and integrated care models. There are patient-level barriers, including the lack of self-awareness of AUD and being ashamed of AUD. There are clinician-level barriers, including lack of training and discomfort in managing patients with AUD. There are system-level barriers, including challenges related to insurance-based health care systems, and the general reluctance to invest in AUD by organizations focused on for-profit milestones. Therefore, it is imperative to develop multidisciplinary hepatology/addiction integrated care approaches.

BACKGROUND: Many autistic young people and/or those with attention deficit hyperactivity disorder (ADHD) have co-occurring mental health conditions. These individuals can experience significant challenges when transitioning from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). However, barriers and enablers to the transition from CAMHS to AMHS are poorly understood for this population. This scoping review sought to synthesise the available evidence on barriers and enablers to the transition from CAMHS to AMHS for autistic young people and/or those with ADHD. METHODS: Arksey and O'Malley's six-step framework for scoping reviews was used to map out the evidence available and report the findings with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines (PRISMA-ScR). Electronic databases of Medline, PsycINFO, CINAHL, Scopus and ProQuest Central were searched for relevant studies published in English with no date limitations. The review included studies that focused on young people with a primary diagnosis of autism spectrum disorder (ASD) and/or ADHD (population) and their care transition barriers and/or enablers (concept) from CAMHS to AMHS (context). A socioecological framework informed data extraction and narrative synthesis of data on barriers and enablers to transition. RESULTS: This review identified 1677 studies, of which 66 proceeded to full-text screening, and 10 were included. Most studies focused on institutional-level transition barriers, including poor communication between CAMHS and AMHS and lack of clarity about their role in the transition process. Involvement of the neurodivergent young person in decision-making processes about their mental health care and clinicians who tailored their approaches to the needs of the neurodivergent young person emerged as key enablers of a positive transition experience. Studies largely failed to examine community and policy-related barriers to mental health care transitions. Most studies examined the perspectives of providers or carers, with only five representing the perspectives of neurodivergent people. CONCLUSION: Young people who are autistic and/or have ADHD experience many barriers to their transition from CAMHS to AMHS; however, few studies have examined barriers and enablers to the service transition process.

BACKGROUND: Since the Declaration of Alma-Ata in 1978, global health policy has prioritised primary and integrated care reform to better manage chronic illness, improve health access, and prevent disease. Yet internationally, primary care, like the health systems it struggles to support, is currently far from strengthened and is increasingly challenged by chronic underfunding, lack of recognition, and a diminishing and demoralised workforce. AIM: To better understand the policy barriers responsible for the current status from the perspective of general practice in England. DESIGN & SETTING: Key informant interviews between August and October 2024 with 12 general practice policy or practice leaders identified from publicly available position statements, publications, or innovative programmes in UK primary care reform over the past decade. METHOD: A qualitative deductive approach using thematic analysis to analyse informant data to understand historical barriers and explore facilitators for future reform. RESULTS: The analysis resulted in eight main themes: 1) dynamics of power and autonomy; 2) underinvestment in primary care; 3) aligning policy and implementation; 4) navigating complexity and change; 5) building trust through relationships and leadership; 6) the revolving door of policy and leadership; 7) valuing the workforce: a key to morale and retention; and 8) strategic communication and media engagement. CONCLUSION: Better-targeted funding reform, more effective systems integration building on general practice and community service strengths, and better valuing the complex role of the primary care sector as central to a high-functioning health system were seen as key to the future. Participants also called for more effective policy input from those skilled in the delivery of care and the capacity for earned autonomy and flexibility to deliver care relevant to individual community need. Action to address these opportunities is pressing, as finalisation of the 10 Year Health Plan and more immediate NHS restructure rapidly gathers momentum.

BACKGROUND: Naloxone is a safe and effective medication to help reverse opioid overdose. Providing take-home naloxone to patients in opioid treatment settings is a critical step to reducing opioid overdose deaths. In New Mexico, a US state with one of the highest rates of opioid overdose deaths, legislation was passed in 2017 (House Bill 370) to support take-home naloxone, and followed by naloxone training of Opioid Treatment Program staff to increase distribution. METHODS: Naloxone training was offered to all New Mexico Opioid Treatment Programs along with a baseline survey to assess current practices and barriers to take-home naloxone distribution. Focus groups were conducted approximately 1 year post-training with staff at a subset of the trained Opioid Treatment Programs to assess the impact of the legislation and training provided. RESULTS: Baseline survey results show most Opioid Treatment Program staff were unfamiliar with House Bill 370, reported conflicting understandings of their agency's current take-home naloxone practices, and reported a number of barriers at the patient, agency, and policy level. Follow-up focus groups revealed support for House Bill 370 but persistent barriers to its implementation at the patient, agency, and policy level including patient receptivity, cost of naloxone, staff time, and prohibitive pharmacy board regulations. CONCLUSIONS: In spite of targeted legislation and training, provision of take-home naloxone at remained low. This is alarming given the need for this lifesaving medication among the Opioid Treatment Program patient population, and high opioid death rate in New Mexico. Locally, important next steps include clarifying regulatory guidelines and supporting policy/billing changes to offset costs to Opioid Treatment Programs. Globally, additional research is needed to identify the prevalence of take-home naloxone distribution in similar settings, common barriers, and best practices that can be shared to increase access to this vital lifesaving medication in this critical context.

Background: Medication for Opioid Use Disorder (MOUD) is a best practice for treating individuals with opioid use disorder (OUD), and primary care-based MOUD management can reduce treatment barriers among OUD patients. Individuals with OUD experience disproportionately high rates of trauma and violence, highlighting the importance of addressing trauma, mental health, and substance use concurrently. However, clear guidelines for trauma-informed treatment in a primary care setting remain poorly established. Methods: A qualitative approach was engaged to explore primary care providers' perceptions of barriers and facilitators to assessing and treating trauma among MOUD patients. Twenty in-depth interviews were conducted in 2021 with Baltimore-based MOUD prescribers, including primary care physicians and nurse practitioners. Interview questions assessed experiences with identifying and treating trauma among MOUD patients, including challenges and opportunities. Results: Providers reported extensive histories of trauma experienced by MOUD patients. Barriers to addressing trauma include a lack of standardized protocols/procedures for identifying trauma, insufficient training/time to assess and treat trauma, and the limited availability of external mental health providers and specialty services. Opportunities included building strong, mutually respectful patient-provider relationships, providing individualized, person-centered care, and establishing connections to coordinated multidisciplinary treatment networks. Conclusions: MOUD treatment within primary care is an important way to increase OUD treatment access, but clearer standards are needed for the treatment of trauma within this patient population. These findings demonstrate opportunities to improve standards and systems such that primary care providers are better equipped to assess and treat the complex histories of trauma experienced by individuals with OUD.