Addiction Science & Clinical Practice最新文献

Background: How communities impact patients taking medication for opioid use disorder (MOUD) has not been well-studied. Understanding the experience of MOUD providers allows us to better understand and measure community attitudes toward MOUD and identify strategies to increase support.

Methods: We deployed an explanatory sequential mixed methods design to analyze baseline data from the SITT-MAT clinical trial. Our quantitative instrument was seven Likert-scale questions asking about community attitudes toward MOUD analyzed through means, standard deviations, and principal components. The qualitative data were semi-structured interviews coded inductively using a thematic analysis. The quantitative and qualitative results were integrated to produce the findings.

Results: We surveyed staff from 20 specialty care addiction and primary care clinics in Washington state as part of a larger clinical trial. Eleven sites were also selected to complete an interview. Participating clinics were primarily specialty addiction treatment programs (N = 14, 70%), outpatient (N = 17, 85%), and/or located in urban areas (N = 12, 81%). In the survey, participants most agreed that relationships with other clinics help provide better care and least agreed that system-level policies mandate MOUD. In interviews, some staff described how reliable relationships with other clinics improved employee morale and patient care while others added that loose collaborations had fallen apart, leaving patients without the care they need. Interviewees described how insurer and government policies have made it difficult to expand their MOUD offerings. The interview data also indicated community attitudes on MOUD have improved over time with some clinics using direct outreach to garner support for MOUD.

Conclusions: Our results suggest that building local peer networks of clinics can improve staff morale and patient care in areas where community support for MOUD is low. Though system-level barriers to MOUD have been reduced, there is still room for improvement in simplifying reimbursements and funding for clinics looking to improve care. Our findings encourage further measurement of community attitudes toward MOUD and development of implementation strategies to build networks that support patients and clinics alike.

Trial registration: The data for this study is from the Stagewise Implementation-to-Target - Medications for Addiction Treatment clinical trial registered as NCT05343793 on April 25, 2022.

Background: Human immunodeficiency virus (HIV) cases among people who inject drugs increased during the US overdose crisis. Although HIV pre-exposure prophylaxis (PrEP) decreases HIV acquisition, and medications for opioid use disorder (MOUD) reduce overdose deaths, uptake remains suboptimal. The CHORUS + study will test the efficacy of a comprehensive peer recovery coaching intervention to increase PrEP and MOUD initiation and adherence.

Methods: This two-arm RCT will enroll 284 people who inject opioids (PWIO) and are negative for HIV from two sites. Participants randomized to the CHORUS + intervention will receive a study smartphone, motivational interviewing sessions, assistance connecting to PrEP and/or MOUD, and support to access resources addressing social needs such as employment and housing. We will also incorporate adapted 'Life-Steps for PrEP' modules to increase adherence. The control arm will receive information on local organizations with access to PrEP and MOUD. Participants will complete assessments at baseline, 1-, 3-, 6-, and 12-month visits. The primary outcome is adherence to HIV PrEP, assessed by tenofovir-diphosphate drug levels at 6-months post enrollment. Secondary outcomes include PrEP adherence assessed at 3- and 12-months, measured by drug levels (3-months), prescription refills, and self-report; and MOUD receipt at 3-, 6-, and 12-months, measured by prescription refills, self-report, and urine toxicology. The primary analysis will employ intent-to-treat logistic regression to assess differences in adherence between treatment arms, adjusting for stratification factors including site, race and sex assigned at birth. We will analyze secondary outcomes using similar methods. We will use multilevel growth curve modeling to evaluate changes in adherence over time by treatment group, incorporating random intercepts and slopes to account for individual trajectories. We will use exploratory multilevel structural equation modeling to assess mediators including HIV risk perception and PrEP/MOUD knowledge to understand pathways that may influence adherence.

Discussion: The CHORUS + intervention integrates a novel, theory-based, peer-delivered, smartphone-supported approach to address HIV prevention and opioid use disorder, while tackling social and structural barriers to care. Findings will inform strategies for linking PWIO to rapid HIV prevention and substance use treatment.

Trial registration: ClinicalTrials.gov number: NCT05769218.

Background: Incentive programs are an effective yet underutilized behavioral intervention that can improve outcomes in medication for opioid use disorder (MOUD) treatment. Contingency Management (CM) is a rigorous incentive program run per seven evidence-based principles (e.g. objectively verifiable target behaviors, frequent opportunities for incentives). Prior implementation attempts have focused on implementing CM in specialized addiction clinics with methadone as the primary medication treatment. However, many people get MOUD from less specialized, more accessible family medicine clinics. These clinics might also benefit from the use of incentive programs, yet present unique challenges for implementation. For example, family medicine clinics typically use buprenorphine as their primary medication, which requires less intensive dosing schedules than methadone and thus provides fewer incentive opportunities. As an initial step in user-centered design of a CM-informed incentive program for the family medicine context, we conducted qualitative interviews with patients and staff in the buprenorphine treatment program of a family medicine department. We gathered and analyzed qualitative data on CM knowledge, preferred program parameters, and implementation considerations.

Method: Participants (N = 24) were buprenorphine treatment staff (n = 12) and patients (n = 12). Participants completed 30-50-minute semi-structured interviews, analyzed using rapid matrix analysis.

Results: Participants had little experience with formal incentive programs, but generally viewed incentives as acceptable, appropriate, and feasible. Interviewees coalesced around having staff who were not MOUD prescribers run the program, consistent rather than escalating payments, and physical rewards delivered in-person. Potential challenges included medical record integration, demands on staff time, and confirmation of patients' goal completion.

Conclusions: Patient and staff feedback was well-aligned, especially regarding rewards as an opportunity for staff-patient connection and the need for simplicity. Comparing end-user suggestions with the literature, some consensus suggestions (e.g. non-escalating rewards) highlighted feasible places to compromise on ideal effectiveness to gain implementability. However, others (e.g. use of self-report to verify goals) conflicted directly with CM principles and indicate where more intensive education, support, and monitoring will be needed for implementation fidelity. These findings inform user-centered design and iteration of an incentive program for this accessible, non-specialized family medicine setting.