A Quantitative Examination of Illness Models Among People With Opioid Use Disorder Receiving Methadone Treatment.

BACKGROUND: Few studies have examined illness models among people with addiction. We investigated illness models and their associations with demographics and treatment beliefs among patients receiving methadone treatment for opioid use disorder. METHODS: From January 2019 to February 2020, patients receiving methadone treatment at outpatient opioid treatment programs provided demographics and rated using 1 to 7 Likert-type scales agreement with addiction illness models (brain disease model, chronic medical condition model [CMCM], and no explanation [NEM]) and treatment beliefs. Pairwise comparisons and multivariate regressions were used to examine associations between illness models, demographics, and treatment beliefs. Statistical significance was set at P < 0.05. RESULTS: A total of 450 patients participated in the study. Forty percent self-identified as female, 13% as Hispanic, and 78% as White; mean age was 38.5 years. Brain disease model was the most frequently endorsed illness model (46.2%), followed by CMCM (41.7%) and NEM (21.9%). In multivariate analyses, agreement with brain disease model was significantly positively associated with beliefs that methadone treatment would be effective, counseling is important, and methadone is lifesaving, whereas agreement with CMCM was significantly positively associated with beliefs that methadone treatment would be effective, counseling is important, 12-step is the best treatment, taking methadone daily is important, and methadone is lifesaving. In multivariate analyses, agreement with NEM was negatively significantly associated with beliefs that methadone would be effective, counseling is important, taking methadone daily is important, and methadone is lifesaving. DISCUSSION: Many patients in methadone treatment endorsed medicalized addiction models. Agreement with addiction illness models appear to be related to treatment beliefs.

Perceptions of Community Corrections and Treatment Experience: A Qualitative Study Among People With Incarceration Histories Receiving Outpatient Methadone Treatment.

BACKGROUND: Community correctional experiences among individuals receiving methadone treatment (MT) for opioid use disorder (OUD) are poorly understood. We qualitatively investigated perceptions of community corrections and treatment experiences among individuals with criminal-legal system experience currently receiving outpatient MT. METHODS: From January to December 2017, we recruited 42 individuals with history of criminal-legal system involvement enrolled in outpatient MT at a low-barrier nonprofit organization operating multiple clinics in Connecticut. An experienced qualitative research team conducted one-to-one, in-person, semistructured interviews about incarceration and treatment experiences with individuals receiving MT. Participants completed a demographics survey. The interviews were audiorecorded, transcribed, de-identified, and independently coded using NVivo. RESULTS: Participants described the community corrections system as restrictive and abstinence-focused. Most participants described positive perceptions of and experiences with community corrections officers (CCOs), yet described negative perceptions of and experiences with the community corrections system overall. Participants perceived CCOs to have limited knowledge of OUD and MT. Participants described a range of CCO judgment toward their OUD, with some appearing understanding and nonjudgmental while others were perceived to have stigma and prejudice. Few participants noted assistance from CCOs with seeking MT or community-based substance use disorder care. Some participants desired improved treatment facilitation, but viewed forced or coercive treatment negatively. CONCLUSION: To our knowledge, this is the first qualitative study to examine community corrections experience among people receiving outpatient medication for OUD. While individuals receiving MT have negative experiences with the community corrections system, they perceive individual CCOs positively. Interventions addressing gaps in CCOs knowledge of OUD and MT are needed to optimize support for individuals on probation or parole with OUD. Provision of OUD treatment facilitation appears desirable to some individuals in community supervision.

Correlates of Perceived Discrimination Related to Substance Use Disorders Among Patients in Methadone Maintenance Treatment.

This study sought to examine demographic, treatment-related, and diagnosis-related correlates of substance use disorder (SUD)-related perceived discrimination among patients receiving methadone maintenance treatment (MMT). Participants were 164 patients at nonprofit, low-barrier-to-treatment-access MMT programs. Participants completed measures of demographics, diagnosis-related characteristics (Brief Symptom Inventory (BSI-18) and Depressive Experiences Questionnaire (DEQ)), and treatment-related characteristics. Perceived discrimination was measured on a seven-point Likert-type scale ranging from 1 ("Not at all") to 7 ("Extremely") in response to the item: "I often feel discriminated against because of my substance abuse." Given the variable's distribution, a median split was used to categorize participants into "high" and "low" discrimination groups. Correlates of high and low discrimination were analyzed with bivariate and logistic regression models. Ninety-four participants (57%) reported high SUD-related perceived discrimination. Bivariate analyses identified six statistically significant correlates of SUD-related perceived discrimination (P < .05): age, race, age of onset of opioid use disorder, BSI-18 Depression, DEQ Dependency, and DEQ Self-Criticism. In the final logistic regression model, those with high (versus low) SUD-related perceived discrimination were more likely to report depressive symptoms and be self-critical. Patients in MMT with high compared to low SUD-related perceived discrimination may be more likely to report being depressed and self-critical.

A National Study of Homelessness, Social Determinants of Health, and Treatment Engagement Among Outpatient Medication for Opioid Use Disorder-Seeking Individuals in the United States.

BACKGROUND: Homelessness is an important social determinant of health (SDOH), impacting health outcomes for many medical conditions. Although homelessness is common among people with opioid use disorder (OUD), few studies systematically evaluate homelessness and other SDOH among people enrolled in standard of care treatment for OUD, medication for opioid use disorder (MOUD), or examine whether homelessness affects treatment engagement. METHODS: Using data from the 2016 to 2018 U.S. Treatment Episode Dataset Discharges (TEDS-D), patient demographic, social, and clinical characteristics were compared between episodes of outpatient MOUD where homelessness was reported at treatment enrollment versus independent housing using pairwise tests adjusted for multiple testing. A logistic regression model examined the relationship between homelessness and treatment length and treatment completion while accounting for covariates. RESULTS: There were 188 238 eligible treatment episodes. Homelessness was reported in 17 158 episodes (8.7%). In pairwise analysis, episodes involving homelessness were significantly different from those involving independent living on most demographic, social, and clinical characteristics, with significantly greater social vulnerability in most SDOH variables (P's < .05). Homelessness was significantly and negatively associated with treatment completion (coefficient = -0.0853, P < 0.001, 95% CI = [-0.114, -0.056], OR = 0.918) and remaining in treatment for greater than 180 days (coefficient = -0.3435, P < 0.001, 95% CI = [-0.371, -0.316], OR = 0.709) after accounting for covariates. CONCLUSIONS: Patients reporting homelessness at treatment entry in outpatient MOUD in the U.S. represent a clinically distinct and socially vulnerable population from those not reporting homelessness. Homelessness independently predicts poorer engagement in MOUD confirming that homelessness may be an independent predictor for MOUD treatment discontinuation nationally.

"Just fighting for my life to stay alive": a qualitative investigation of barriers and facilitators to community re-entry among people with opioid use disorder and incarceration histories.

BACKGROUND: During the period of community re-entry immediately following release from jail or prison, individuals with opioid use disorder (OUD) face structural barriers to successful re-entry and high risk of overdose. Few published studies investigate experiences in the immediate period (i.e., first 24 h) of re-entry among people with OUD. AIM: To understand the barriers and facilitators to treatment and reintegration of people with OUD during the initial transition from carceral settings back into the community. METHODS: From January-December 2017, we conducted 42 semi-structured qualitative interviews with patients with a history of incarceration who were receiving methadone at a not-for-profit, low-barrier opioid treatment program. Interviews probed participants' community re-entry experiences immediately following incarceration. Interviews were transcribed and analyzed using a Thematic Analysis approach. RESULTS: The main themes described the experiences during the 24 h following release, reacclimating and navigating re-entry barriers, and re-entry preparedness and planning. Participants noted the initial 24 h to be a period of risk for returning to substance use or an opportunity to engage with OUD treatment as well as a tenuous period where many lacked basic resources such as shelter or money. When discussing the subsequent re-entry period, participants noted social challenges and persistent barriers to stable housing and employment. Participants overall described feeling unprepared for release and suggested improvements including formal transition programs, improved education, and support to combat the risk of overdose and return to substance use after incarceration. CONCLUSIONS: In this study that qualitatively examines the experiences of people with incarceration histories and OUD enrolled in methadone treatment, we found that participants faced many barriers to community re-entry, particularly surrounding basic resources and treatment engagement. Participants reported feeling unprepared for release but made concrete suggestions for interventions that might improve the barriers they encountered. Future work should examine the incorporation of these perspectives of people with lived experience into the development of transition programs or re-entry classes.

A cohort study examining the relationship among housing status, patient characteristics, and retention among individuals enrolled in low-barrier-to-treatment-access methadone maintenance treatment.

BACKGROUND: Few studies have directly compared patient characteristics and retention among those enrolled in methadone maintenance treatment (MMT) based on housing status. Low-barrier-to-treatment-access programs may be particularly effective at attracting patients experiencing homelessness into MMT; however, the literature on retention in such settings is limited. METHODS: We performed a retrospective chart review of 488 consecutive patients enrolled from April to October 2017 at low-barrier-to-treatment-access MMT programs in southern New England. Patients completed measures of demographics, social isolation, trauma, chronic pain, smoking behavior, and psychiatric distress. The study investigated associations between housing status and correlates with chi-square and Mann-Whitney U tests while controlling the False Discovery Rate. A two-sample log-rank test examined the relationship between retention and housing status. The study further scrutinized this association by regressing retention on all covariates using a Cox proportional hazards model. RESULTS: Forty-six patients (9.4%) reported experiencing homelessness and 442 (90.6%) reported being housed. Thirty-seven percent of patients self-identified as female and 20% as non-white. Compared to patients who were housed, those experiencing homelessness had lower rates of recent employment; higher rates of social isolation, trauma, current chronic pain, and recent cannabis use; and higher overall psychiatric distress (all p < 0.01). At one year, overall retention was 51.8%, and retention was 32.6% in the unhoused group and 53.8% in the housed group. A significant negative association occurred between retention and housing status (p = 0.006). After regressing on all covariates, homelessness was associated with a 69% increase in one-year treatment discontinuation (HR = 1.69 for homelessness, CI = 1.14-2.50). CONCLUSIONS: Patients entering MMT experiencing homelessness have multiple clinical vulnerabilities and are at increased risk for 12-month MMT discontinuation. Low-barrier-to-treatment-access MMT programs are an important venue for identifying and addressing vulnerabilities associated with homelessness.

Middle school meets MedEd: Five K-12 teaching strategies medical educators should know.

While the COVID-19 pandemic has challenged the way medical educators develop and deliver content, it has also presented an opportunity for innovation. As students, trainees, and faculty design new curricula and employ new learning modalities, primary and secondary school offer a wealth of teaching strategies and ideas for medical education. In this Personal View, the authors share their experience as former middle school teachers and current medical students to offer five valuable teaching strategies - backwards planning, the 5E model, setting norms, scaffoldings, and checks for understanding (CFUs) - for medical educators to incorporate into their practice.