Addiction Science & Clinical Practice最新文献

Background: Hepatitis C infection (HCV) and opioid use disorder (OUD) are syndemic in the U.S., thus primary care providers (PCPs) who treat OUD by prescribing buprenorphine can play key roles to advance HCV elimination targets. We compared HCV screening and treatment among PCPs who do and do not prescribe buprenorphine in Washington (WA) State.

Methods: This study utilized a cross-sectional survey of PCPs in WA State, designed to characterize HCV care delivery practices and experiences/attitudes toward HCV. In this study, the independent variable was self-reported buprenorphine prescribing, and the main outcomes were (1) guideline-concordant HCV screening and (2) directly providing treatment for HCV. We used descriptive statistics to describe respondent characteristics. We used logistic regression to assess the association between buprenorphine prescribing status and HCV screening and treatment outcomes.

Results: Our sample included 73 PCPs, of whom 55% prescribe buprenorphine. We found that 25% of buprenorphine prescribers directly treated HCV. There was over a 2x greater relative odds that buprenorphine prescribers would correctly screen for HCV relative to non-prescribers (OR = 2.24; 95% CI: 0.67-8.18, p = .20) and a nearly 2.5x greater relative odds that they would treat HCV relative to non-prescribers (OR = 2.42; 0.72-9.61; p = .17), although both findings were not statistically significant.

Conclusion: In a sample of PCPs in WA state, buprenorphine prescribers compared to non-prescribers appear more likely to screen for and directly treat HCV, yet only a minority treat HCV. Interventions are needed to enhance HCV guideline-concordant care among these and all PCPs on the frontlines of caring for persons with OUD.

Background: Accessing opioid use disorder (OUD) treatment is difficult for individuals with unstable housing. This population often uses public libraries for computer and internet access, which could provide telehealth access to OUD treatment. Therefore, we developed a novel 12-week library-facilitated telehealth intervention study called "Bupe by the Book" (BBB) that uses library resources to facilitate initiation and retention in OUD treatment with buprenorphine.

Methods: The study is a partnership between the San Diego Public Library and a federally qualified healthcare center attached to a homeless shelter (Father Joe's Villages (FJV) Village Health Center). We co-designed a pilot randomized controlled trial to assess the feasibility and acceptability of a library-facilitated telehealth intervention in San Diego, California. The intervention is being evaluated for its feasibility and acceptability (library tele-buprenorphine uptake) by obtaining an estimate of the effect of the library telehealth arm of the intervention on buprenorphine treatment outcomes (primary outcome: buprenorphine uptake, i.e., a pharmacy pickup and taking the prescription 1 + times) and adherence (i.e., > 1 buprenorphine positive screens, ideally for 8 + weeks), compared to the control (standard care at the clinic) intervention. Individuals reporting homelessness and OUD (with or without other substance use) are eligible. Forty library patrons will be recruited via flyers, screened for eligibility, and referred to FJV Health Center for in-person initial buprenorphine treatment intake visits. Participants who complete intake are enrolled and randomized to the library-facilitated telehealth condition, which involves using library internet and computer resources for follow-up buprenorphine treatment appointments with the medical provider via library telehealth. In the control condition, participants do not use library telehealth for their buprenorphine care follow up appointments, but rather they go in-person to the clinic or per usual standard care protocols. Feasibility and acceptability of the library telehealth intervention and conduct of the randomized controlled trial are determined by the participants' use of the library telehealth intervention for buprenorphine treatment, and quantitative and qualitative measures assessing their perceptions of the library telehealth intervention, collected over a 12-week period.

Discussion: The design of this pilot study may support the adoption of library-facilitated telehealth treatment as a feasible and acceptable strategy to engage and retain people experiencing homelessness with OUD in buprenorphine treatment.

Trial registration: This trial was registered prospectively at ClinicalTrials.gov (registration number NCT05872386) on May 24, 2023.

Background: People with opioid use disorders (OUD) living in the South and Midwest are under-prescribed pre-exposure prophylaxis (PrEP) despite an increasing number of providers writing PrEP prescriptions in other regions of the United States. Greater research is needed into attitudes toward integrating harm reduction strategies into primary care and PrEP prescribing among prescribers working in rural primary care settings. The objective of this paper was to examine relationships between providers' attitudes toward buprenorphine and methadone, comprehensive harm reduction (e.g., fentanyl test strips) and self-reported PrEP prescribing in the past year.

Methods: Relationships were examined between attitudes toward buprenorphine and harm reduction services, and PrEP prescribing among 409 rural primary health care providers (PCPs) treating at least one person with OUD or HIV in several EHE priority states. A Qualtrics panel survey was administered to primary care providers residing in the U.S. South and Midwest and worked in a Federally Qualified Health Center, Rural Health Clinic or other HRSA-eligible health center. Chi-square tests were used to explore significant differences between PrEP prescribers and non-Prescribers on attitudes toward integrating MOUD, drug-related harm reduction into primary care.

Results: Overall, 62.1% (n = 254) of the sample of providers reported writing at least one prescription for PrEP in the past year. Providers who believed that reforming buprenorphine waiver laws made their jobs easier or who expressed interest in integrating naloxone distribution and syringe exchange into primary care were more likely to write prescriptions for PrEP compared to providers who did not have these beliefs. Providers who were from larger facilities and who had specialty training in infectious diseases were more likely to write prescriptions for PrEP.

Conclusions: Findings from this study suggest that providers who are more open to integrating harm reduction services into primary care are more likely to prescribe PrEP in the past year. PCPs with more positive attitudes toward naloxone, syringe exchange, and buprenorphine were more likely to prescribe PrEP in the past year. Combination interventions may be a promising avenue of reducing the harms of drug use including overdose and HIV infection among populations of people who use drugs.

Background: Routine use of brief, structured screening tools is essential to detect and provide support for Australians who drink above recommended levels. However, detecting drinking above recommended levels in Aboriginal and Torres Strait Islander Australian primary care settings is complex. Inaccuracies in completing a screening tool such as Alcohol Use Disorders Identification Test - Consumption, can lead to errors in estimating drinking in First Nations contexts where group sharing and episodic drinking make it difficult to accurately estimate alcohol consumption with tools that assume regular drinking patterns. This can lead to under-detection of drinking and a mismatch with the subsequent care that is offered. Hence, screening tools that consider these contextual factors are needed to make it easier for First Nations Australian primary care services to screen for alcohol consumption above recommended levels. Electronic screening tools offer the technical flexibility to consider the drinking contexts Furthermore, for sensitive topics such as alcohol and other drugs, computer-based screening in the general population has been shown to provide more accurate and comprehensive responses compared with face-to-face interviews.

Aim: To facilitate alcohol screening and brief intervention in First Nations Australian primary care settings by adapting the Grog App - a community survey tool validated in Aboriginal and Torres Strait Islander populations for use in primary care.

Methods: The project will use mixed-methods techniques across five study stages: 1 - Interest-holder consultation; 2 - technical development; 3 - re-validation and user interface acceptability; 4 - implementation in an Aboriginal and Torres Strait Islander primary care setting; 5 - acceptability study, six months after implementation.

Discussion: The project will produce a novel, culturally appropriate digital health tool and implementation resources to make it easier to conduct routine alcohol screening in primary care contexts for a priority population, which may lead to increased screening and alcohol care rates. It will also provide first-ever contextual data about implementation of new health service improvement strategy focused on an electronic alcohol consumption screening tool, which is lacking in peer-reviewed literature. This study will also provide an important evidence base for using continuous quality improvement as an implementation approach in primary care settings.

Background: There is increasing attention in clinician care to the importance of using person-first language. Clinicians' words can reinforce clinicians' pre-existing stigmas and biases. People who use drugs (PWUD) continue to face stigma from clinicians. Person-first language is a way to reduce stigma and perpetuation of bias.

Methods: Through specific structured in-person interviews, we examined the usage of stigmatizing language in the care of PWUD by surveying key clinicians- such as physicians, nurses, and social workers-and patients who self-identified as PWUD at Tufts Medical Center (Boston, MA) between July 2022-September 2022. Interview guides were created using the Consolidated Framework for Implementation Research (CFIR) 2.0 as a framework. We evaluated perceptions of person-first language and barriers to using person-first language amongst participants. Interviews were coded with Dedoose Software and inductive thematic analysis (ITA) methods were used until all themes were captured; CFIR 2.0 determinants used during interview guide creation were used as preliminary themes and modified as needed.

Results: We interviewed thirty-four people, including eleven PWUD at time of interview. Most clinicians agreed that language is important and matters when talking to patients and during documentation. Almost all patients agreed that language was important to them and impacted their relationship with their provider. However, there were responders that felt that person-first language was unnecessary, ineffective, and overly verbose in the medical setting. Major barriers to using person-first language were unawareness, lack of formal training, and perceived generational differences in appropriate language.

Conclusion: Addressing language usage is a critical opportunity to promote inclusion and reduce bias amongst PWUD. As medical charts become increasingly accessible by patients, the use of language by the clinician becomes increasingly important. To create and maintain equitable systems of care, it is important to meet clinicians where they are at and to work with them to address these issues. This can include targeted educational sessions and resources informing clinicians on preferred language use and curriculum for providers-in-training.

Background: Incorporating clinicians' perspectives is essential for the successful implementation of novel interventions in health care. This study aimed to explore clinicians' experiences of using smartphone-derived data in alcohol dependency treatment, and factors affecting implementation into routine care.

Methods: Two focus group discussions were conducted in April 2023, including 10 clinicians working at a specialist addiction clinic in Stockholm, Sweden. The clinicians had various levels of experience using smartphone-based data, which was available through two online portals, as part of a randomised controlled trial evaluating two smartphone-based interventions. Data were analysed using Thematic Framework Analysis, guided by Normalisation Process Theory.

Results: Two main themes were identified: The patient as the driving force and Cultivating commitment, competence and credibility. The first theme highlighted a person-centred approach that permeated the practice and how the patients' engagement with the app-based interventions guided the clinicians' own involvement. Benefits of the interventions for both patients (i.e., increased awareness and control) and clinicians (i.e. supportive during treatment sessions) were also acknowledged. Clinicians believed that the interventions offered an opportunity for patients to become more actively involved in treatment and noted that clinician access to the app-derived data was less important. The second theme covered clinician discussions on the need for support and guidance to make better use of the interventions, continuity in the work, and additional work time. Moreover, the use of external portals made the intervention less accessible. Potential risks and concerns with the interventions were raised, including technical instability and data security.

Discussion and conclusions: The results of this study indicate that a breathalyser-coupled and a drink-counting smartphone application have potential to be supportive complements to alcohol dependency treatment. According to the clinicians, the app-based interventions enhanced patient accountability in the change process and supported treatment delivery. To be effectively implemented into routine care, using a person-centred approach is key, as well as ensuring optimal conditions for clinicians to effectively use the systems. Technical issues constitute a barrier to acceptance, why technical robustness must be ensured.

Introduction: Increasingly, services for the management of substance use disorders have been developed or adapted for remote delivery. Limited research has investigated service user experience of these services. We undertook a qualitative sub-study, embedded within a pilot feasibility study of remote symptom-triggered alcohol withdrawal management, to better understand the experiences of participants. Our aim was to determine the acceptability of the intervention and refine intervention procedures.

Methods: Eligible participants were enrolled in the parent study and completed at least one day of telemedicine-delivered symptom-triggered alcohol withdrawal management. Individuals were adults with alcohol use disorder recruited using intensity sampling. Participants completed an audio-recorded, semi-structured interview. Thematic analysis was conducted using Braun and Clarke interpretive methodology.

Results: Fourteen individuals were enrolled in the study. Six themes were identified: benefits of being in the home environment, technological tensions, intervention-specific feedback, personal motivations for participation, post-program achievements and changes and navigating the 'system'. Participants identified numerous benefits of being in the home environment including: increased comfort, privacy and security, normalizing abstinence in the home, flexibility to engage in other tasks, and the convenience of not travelling. Intervention-specific feedback included positive aspects of the intervention (interactions with staff, accountability, counselling, use of medication), areas for improvement (preparation, scheduling, medication logistics, and aftercare), and the meaning and role of having a support person available during treatment.

Conclusion: Participants found remote alcohol withdrawal management to be satisfactory and associated with several benefits including increased comfort, privacy, normalizing abstinence in the home, flexibility and convenience. They also provided important feedback for refinement of the intervention. Findings suggest that remote alcohol withdrawal management could play an important role in improving access to medical management of alcohol withdrawal, particularly in rural, remote or underserved areas.

Background: Amphetamine-type stimulant use and overdoses have increased sharply across the US in recent years, largely driven by methamphetamine. Increased access to treatments for amphetamine-type stimulant use disorder (AT-StUD), including in primary care settings, is needed to mitigate these problems, yet effective behavioral treatments are often inaccessible and there are no FDA-approved medications for AT-StUD. In the current study, we characterize how often patients with clinically documented AT-StUD in predominantly rural-serving Pacific Northwest primary care clinics received medications that have been conditionally recommended in practice guidelines for treatment of AT-StUD.

Methods: Electronic health record data from 23 primary care clinics in the Pacific Northwest US were obtained through the Data QUEST network. Adult patients with clinically documented "other stimulant abuse" or "other stimulant dependence" diagnoses typically reflecting AT-StUD between 01/2017 and 12/2021 were included. Prescription records were used to identify orders for bupropion, mirtazapine, topiramate, naltrexone-bupropion combination, methylphenidate, dextroamphetamine, and modafinil. Statistical analyses quantified the percentage of patients with medication orders placed within one year after any documented AT-StUD diagnosis.

Results: Patients (N = 963) were predominantly female (53.3%), White (81.7%), and non-Hispanic (70.5%). In total, 14.3% of patients received orders for a non-stimulant medication conditionally recommended in practice guidelines; 2.7% received orders for a stimulant medication. Consistent with clinical guidelines, medications were more often prescribed when patients had documented co-occurring disorders for which the medications could also be effective.

Conclusions: In this sample of rural-serving primary care clinics, approximately 1 in 7 primary care patients with AT-StUD received orders for medications with preliminary evidence of effectiveness. Efforts are needed to increase access to AT-StUD treatments within primary care. These efforts could include training health professionals to consider judicious use of pharmacotherapy consistent with clinical guidelines, increasing capacity for behavioral health services including contingency management, and continuing research on pharmacologic agents.