Envisioning Minimally Disruptive Opioid Use Disorder Care.

Most people who need and want treatment for opioid addiction cannot access it. Among those who do get treatment, only a fraction receive evidence-based, life-saving medications for opioid use disorder (MOUD). MOUD access is not simply a matter of needing more clinicians or expanding existing treatment capacity. Instead, many facets of our health systems and policies create unwarranted, inflexible, and punitive practices that create life-threatening barriers to care. In the USA, opioid use disorder care is maximally disruptive. Minimally disruptive medicine (MDM) is a framework that focuses on achieving patient goals while imposing the smallest possible burden on patients' lives. Using MDM framing, we highlight how current medical practices and policies worsen the burden of treatment and illness, compound life demands, and strain resources. We then offer suggestions for programmatic and policy changes that would reduce disruption to the lives of those seeking care, improve health care quality and delivery, begin to address disparities and inequities, and save lives.

The Naloxone Component of Buprenorphine/Naloxone: Discouraging Misuse, but at What Cost?

Because opioid overdose deaths in the United States continue to rise, it is critical to increase patient access to buprenorphine, which treats opioid use disorder and reduces mortality. An underrecognized barrier to buprenorphine treatment (both for maintenance and treatment of acute withdrawal) is limited access to buprenorphine monoproduct. In the United States, buprenorphine is primarily prescribed as a combination product also containing naloxone, added to reduce the potential for misuse. Because naloxone has relatively low sublingual bioavailability compared with buprenorphine, adverse effects are generally considered mild and rare. The authors' clinical experience, however, suggests that adverse effects may be less benign than generally accepted and can have negative effects for the patient, the provider-patient relationship, and the health care system as a whole. The insistence on prescribing combination product can foster stigma and mistrust, creating barriers to care and increased risk of overdose and death.

A qualitative study of patient experiences with telemedicine opioid use disorder treatment during COVID-19.

Background: The drug-related overdose crisis worsened during the COVID-19 pandemic. Recent drug policy changes to increase access to medications for opioid use disorder (MOUD) during COVID-19 shifted some outpatient MOUD treatment into virtual settings to reduce the demand for in-person care. The objective of this study was to qualitatively explore what is gained and lost in virtual patient encounters for patients with opioid use disorder at a low-threshold, addiction treatment clinic that offers buprenorphine and harm reduction services. Methods: Patients were included in this study if they received care at the Harm Reduction and BRidges to Care (HRBR) clinic and utilized virtual visits between November 2019 and March 2021. The study was conceptualized using a health care access framework and prior studies of telemedicine acceptability. Semi-structured interviews were completed between March and April 2021. Interviews were dual-coded and analyzed using directed content analysis. Results: Nineteen interviews were conducted. The sample was predominantly White (84%) and stably housed (79%) with comparable gender (male, 53%) and employment status (employed, 42%). The majority (63%) of patients preferred virtual visits compared to in-person visits (16%) or a combination of access to both (21%). Two overarching tandem domains emerged: availability-accommodation and acceptability-appropriateness. Availability-accommodation reflected participants' desires for immediate services and reduced transportation and work or caregiving scheduling barriers, which was facilitated by virtual visits. The acceptable-appropriate domain articulated how participants felt connected to their providers, whether through in-person interactions or the mutual trust experienced during virtual visits. Conclusions: Virtual visits were perceived by participants as a valuable and critical option for accessing treatment for OUD. While many participants preferred virtual visits, some favored face-to-face visits due to relational and physical interactions with providers. Participants desired flexibility and the ability to have a choice of treatment modality depending on their needs.

Low-Threshold Buprenorphine via Community Partnerships and Telemedicine-Case Reports of Expanding Access to Addiction Treatment During COVID-19.

BACKGROUND: To reduce coronavirus disease 2019 (COVID-19) spread, federal agencies eased telemedicine restrictions including audio-only appointments. These changes permitted clinicians to prescribe buprenorphine to patients with opioid use disorder (OUD) without in-person or audio/video assessment. Our clinic utilized existing community collaborations to implement protocols and extend outreach. We describe 3 patients with OUD who engaged with treatment through outreach with trusted community partners and low-threshold telemedicine. CASE PRESENTATIONS: Patient 1-a 40-year-old man with severe OUD who injected heroin and was living outside. A weekend harm reduction organization volunteer the patient previously knew used her mobile phone to facilitate an audio-only intake appointment during clinic hours. He completed outpatient buprenorphine initiation. Patient 2-a 48-year-old man with severe opioid and methamphetamine use disorders who injected both and was living in his recreational vehicle. He engaged regularly with syringe services program (SSP), but utilized no other healthcare services. Initially, an SSP worker connected him to our clinic for audio-only appointment using their landline to initiate buprenorphine; a harm reduction volunteer coordinated follow-up. Patient 3-a 66-year-old man with moderate OUD used non-prescribed pill opioids without prior buprenorphine experience. He lived over 5 hours away in a rural town. He underwent virtual appointment and completed home buprenorphine initiation. CONCLUSION: These 3 cases illustrate examples of how policy changes allowing for telemedicine buprenorphine prescribing can expand availability of addiction services for patients with OUD who were previously disengaged for reasons including geography, lack of housing, transportation difficulties, and mistrust of traditional healthcare systems.

Collaboration in a time of crisis: Adapting a telementoring ECHO for addiction leaders during COVID-19.

Substance use disorder (SUD) organizations are often siloed, with little integration across specialty addictions treatment, primary care and hospitals, harm reduction, policy, and advocacy. COVID-19 introduced a pressing need for collaboration and leadership, given a fast-changing, high-stakes environment; widespread anxiety; and lack of guidance. This research letter describes our approach to convening and supporting leaders across the US state of Oregon's SUD continuum during the pandemic. We rapidly developed and implemented a SUD COVID Response ECHO, adapting ECHO - a telementoring model - to convene leaders across 32 statewide agencies. Our experience allowed participants to lead their agencies to respond to real-time COVID-related needs, address existing barriers within SUD systems, and build relationships and community across statewide SUD leaders. This kind of collaboration - which helped bridge gaps among the diverse agencies, disciplines, and regions addressing SUDs in the state - was long overdue, and sows seeds for long-term advances in care for people with SUD.

"OPTIONS-DC", a feasible discharge planning conference to expand infection treatment options for people with substance use disorder.

BACKGROUND: Serious bacterial infections associated with substance use often result in long hospitalizations, premature discharges, and high costs. Out-of-hospital treatment options in people with substance use disorder (SUD) are often limited. METHODS: We describe a novel multidisciplinary and interprofessional care conference, "OPTIONS-DC," to identify treatment options agreeable to both patients and providers using the frameworks of harm reduction and patient-centered care. We retrospectively reviewed charts of patients who had an OPTIONS-DC between February 2018 and July 2019 and used content analysis to understand the conferences' effects on antibiotic treatment options. RESULTS: Fifty patients had an OPTIONS-DC during the study window. Forty-two (84%) had some intravenous (IV) substance use and 44 (88%) had an active substance use disorder. Participants' primary substances included opioids (65%) or methamphetamines (28%). On average, conferences lasted 28 min. OPTIONS-DC providers recommended out-of-hospital antibiotic treatment options for 34 (68%) of patients. OPTIONS-DC recommended first line therapy of IV antibiotics for 35 (70%) patients, long-acting injectable antibiotics for 14 (28%), and oral therapy for 1 (2%). 35 (70%) patients that had an OPTIONS-DC completed an antibiotic course and 6 (12%) left the hospital prematurely. OPTIONS-DC expanded treatment options by exposing and contextualizing SUD, psychosocial risk and protective factors; incorporating patient preferences; and allowing providers to tailor antibiotic and SUD recommendations. CONCLUSIONS: OPTIONS-DC is a feasible intervention that allows providers to integrate principles of harm reduction and offer patient-centered choices among patients needing prolonged antibiotic treatment.

Low-barrier buprenorphine during the COVID-19 pandemic: A rapid transition to on-demand telemedicine with wide-ranging effects.

Low barrier addiction clinics increase access to medications to treat substance use disorders, while emphasizing harm reduction. The Harm Reduction and BRidges to Care (HRBR) Clinic is an on demand, low barrier addiction clinic that opened in October 2019. In the first three months of operation (November through January 2020), HRBR saw steadily increasing numbers of patients. Oregon saw its first case of novel coronavirus in February, and declared a state of emergency and enacted a formal "Stay at Home" order in March. That same month, the DEA announced that patients could be initiated on buprenorphine through telemedicine visits without an in-person exam. Within a week of being granted the ability to see patients virtually, HRBR had transitioned to over 90% virtual visits, while still allowing patients without technology to access in-person care. Within four weeks, the clinic expanded hours significantly, established workflows with community harm reduction partners, and was caring for patients in rural areas of the state. In response to the COVID-19 crisis, the HRBR clinic was able to quickly transition from in-person to almost completely virtual visits within a week. This rapid pivot to telemedicine significantly increased access to care for individuals seeking low-threshold treatment in multiple contexts. Overarching institutional support, grant funding and a small flexible team were critical. HRBR's increased access and capacity were only possible with the Drug Enforcement Agency loosening restrictions around the use of telehealth for new patients. Keeping these altered regulations in place will be key to improving health and health care equity for people who use drugs, even after the pandemic subsides. Further research is needed in to whether addiction telemedicine impacts medication diversion rates, continued substance use, or provider practices.

Buprenorphine Microdose Induction for the Management of Prescription Opioid Dependence.

Prescription opioid dependence remains a major source of morbidity and mortality in the United States. Patients previously on high-dose opioids may poorly tolerate opioid tapers. Current guidelines support the use of buprenorphine therapy in opioid-tapering protocols, even among patients without a diagnosis of opioid use disorder. Buprenorphine microinduction protocols can be used to transition patients to buprenorphine therapy without opioid withdrawal. From November 2019 to April 2020, we transitioned 8 patients on high-dose prescribed opioids for pain to sublingual buprenorphine-naloxone using a microdose protocol without any evidence of precipitated withdrawal. Six of these patients remain on buprenorphine-naloxone and report improved analgesia. Because of its simplicity, the buprenorphine microinduction protocol can be easily adapted for telemedicine and may help to prevent unnecessary clinic visits and opioid-related admissions in the setting of social distancing regulations during the coronavirus 2019 pandemic.

Understanding the impact of the SARS-COV-2 pandemic on hospitalized patients with substance use disorder.

BACKGROUND: The SARS-COV-2 pandemic rapidly shifted dynamics around hospitalization for many communities. This study aimed to evaluate how the pandemic altered the experience of healthcare, acute illness, and care transitions among hospitalized patients with substance use disorder (SUD). METHODS: We performed a qualitative study at an academic medical center in Portland, Oregon, in Spring 2020. We conducted semi-structured interviews, and conducted a thematic analysis, using an inductive approach, at a semantic level. RESULTS: We enrolled 27 participants, and identified four main themes: 1) shuttered community resources threatened patients' basic survival adaptations; 2) changes in outpatient care increased reliance on hospitals as safety nets; 3) hospital policy changes made staying in the hospital harder than usual; and, 4) care transitions out of the hospital were highly uncertain. DISCUSSION: Hospitalized adults with SUD were further marginalized during the SARS-COV-2 pandemic. Systems must address the needs of marginalized patients in future disruptive events.

Spreading Addictions Care Across Oregon's Rural and Community Hospitals: Mixed-Methods Evaluation of an Interprofessional Telementoring ECHO Program.

BACKGROUND: Despite evidence of effectiveness, most US hospitals do not deliver hospital-based addictions care. ECHO (Extension for Community Healthcare Outcomes) is a telementoring model for providers across diverse geographic areas. We developed and implemented a substance use disorder (SUD) in hospital care ECHO to support statewide dissemination of best practices in hospital-based addictions care. OBJECTIVES: Assess the feasibility, acceptability, and effects of ECHO and explore lessons learned and implications for the spread of hospital-based addictions care. DESIGN: Mixed-methods study with a pre-/post-intervention design. PARTICIPANTS: Interprofessional hospital providers and administrators across Oregon. INTERVENTION: A 10-12-week ECHO that included participant case presentations and brief didactics delivered by an interprofessional faculty, including peers with lived experience in recovery. APPROACH: To assess feasibility and acceptability, we collected enrollment, attendance, and participant feedback data. To evaluate ECHO effects, we used pre-/post-ECHO assessments and performed a thematic analysis of open-ended survey responses and participant focus groups. KEY RESULTS: We recruited 143 registrants to three cohorts between January and September 2019, drawing from 32 of Oregon's 62 hospitals and one southwest Washington hospital. Ninety-six (67.1%) attended at least half of ECHO sessions. Participants were highly satisfied with ECHO. After ECHO, participants were more prepared to treat SUD; however, prescribing did not change. Participants identified substantial gains in knowledge and skills, particularly regarding the use of medications for opioid use disorder; patient-centered communication with people who use drugs; and understanding harm reduction as a valid treatment approach. ECHO built a community of practice and reduced provider isolation. Participants recognized the need for supportive hospital leadership, policies, and SUD resources to fully implement and adopt hospital-based SUD care. CONCLUSIONS: A statewide, interprofessional SUD hospital care ECHO was feasible and acceptable. Findings may be useful to health systems, states, and regions looking to expand hospital-based addictions care.

Perceptions of Nurse Managers and Nurse Preceptors: Are New Graduate Nurses Displaying Competency According to the New Graduate Nurse Performance Survey?

Assessing new graduate nurses' competency is an important outcome of the orientation and evaluation process. Nurse managers and nurse preceptors act as key stakeholders in the transition of new graduate nurses to professional practice and are often charged with the responsibility of assessing the competency of new graduate nurses. This article provides insight in regard to the perception of postorientation competency levels of new graduate nurses.

Recommendations for integrating peer mentors in hospital-based addiction care.

Legislators and health systems have recently begun to explore the use of peer mentors as part of hospital-based addiction teams. Integrating peers into hospitals is a complex undertaking still in its infancy. Peers' lived experience of addiction and its consequences, combined with their distance from medical culture and hierarchy, is at the core of their power - and creates inherent challenges in integrating peers into hospital settings. Successful integration of peers in hospitals has unique challenges for individual providers, health systems, and the peers themselves. We have included peers as part of a hospital-based addiction medicine team at our hospital since 2015. In this article, we outline some unique challenges, share lessons learned, and provide recommendations for integrating peers into hospital-based SUD care. Challenges include the rigid professional hierarchy of hospitals which contrasts with peers' role, which is built on shared life experience and relationship; different expectations regarding professional boundaries and sharing personal information; the intensity of the hospital environment; and, illness severity of hospitalized people which can be emotionally draining and increase peers' own risk for relapse. Recommendations focus on establishing a way to finance the peer program, clearly defining the peer role, creating a home base within hospital settings, creating a collaborative and structured process for hiring and retaining peers, identifying peers who are likely to succeed, providing initial and ongoing training to peers that extends beyond typical peer certification, ways to introduce peer program to hospital staff, and providing regular, meaningful supervision. We hope that our recommendations help other hospital systems capitalize on the practical lessons learned from our experience.

Predictors of Opioid and Alcohol Pharmacotherapy Initiation at Hospital Discharge Among Patients Seen by an Inpatient Addiction Consult Service.

BACKGROUND: Medications for opioid use disorder (MOUD) and alcohol use disorder (MAUD) are effective and under-prescribed. Hospital-based addiction consult services can engage out-of-treatment adults in addictions care. Understanding which patients are most likely to initiate MOUD and MAUD can inform interventions and deepen understanding of hospitals' role in addressing substance use disorders (SUD). OBJECTIVE: Determine patient- and consult-service level characteristics associated with MOUD/MAUD initiation during hospitalization. METHODS: We analyzed data from a study of the Improving Addiction Care Team (IMPACT), an interprofessional hospital-based addiction consult service at an academic medical center. Researchers collected patient surveys and clinical data from September 2015 to May 2018. We used logistic regression to identify characteristics associated with medication initiation among participants with OUD, AUD, or both. Candidate variables included patient demographics, social determinants, and treatment-related factors. RESULTS: Three hundred thirty-nine participants had moderate to severe OUD, AUD, or both and were not engaged in MOUD/MAUD care at admission. Past methadone maintenance treatment (aOR 2.07, 95%CI (1.17, 3.66)), homelessness (aOR 2.63, 95%CI (1.52, 4.53)), and partner substance use (aOR 2.05, 95%CI (1.12, 3.76) were associated with MOUD/MAUD initiation. Concurrent methamphetamine use disorder (aOR 0.32, 95%CI (0.18, 0.56)) was negatively associated with MOUD/MAUD initiation. CONCLUSIONS: The association of MOUD/MAUD initiation with homelessness and partner substance use suggests that hospitalization may be an opportunity to reach highly-vulnerable people, further underscoring the need to provide hospital-based addictions care as a health-system strategy. Methamphetamine's negative association with MOUD/MAUD warrants further study.

"If It Wasn't for Him, I Wouldn't Have Talked to Them": Qualitative Study of Addiction Peer Mentorship in the Hospital.

BACKGROUND: Hospitalizations related to substance use disorders (SUD) are skyrocketing. Hospital providers commonly feel unprepared to care for patients with SUD and patients with SUD commonly feel discriminated against by hospital staff. This tension can lead to provider burnout and poor patient outcomes. Research in ambulatory settings suggests that peer mentors (PMs) can improve substance use outcomes and patient experience. However, no study has examined the role of peer mentorship for patients with SUD in hospitals. OBJECTIVE: Understand how peer mentorship affects care for hospitalized patients with SUD, and how working in a hospital affects PMs' sense of professional identity. DESIGN: Qualitative study utilizing participant observation, individual interviews, and focus groups related to the PM component of the Improving Addiction Care Team (IMPACT), a hospital-based interprofessional addiction medicine consult service. PARTICIPANTS: IMPACT providers, patients seen by IMPACT, PMs, and a PM supervisor. APPROACH: Qualitative thematic analysis. KEY RESULTS: PMs occupy a unique space in the hospital and are able to form meaningful relationships with hospitalized patients based on trust and shared lived experiences. PMs facilitate patient care by contextualizing patient experiences to teams and providers. Reciprocally, PMs "translate" provider recommendations to patients in ways that patients can hear. Respondents described PMs as "cultural brokers" who have the potential to transfer trust that they have earned with patients to providers and systems who may otherwise be viewed as untrustworthy. While PMs felt their role led to professional and personal development, the intensity of the role in the hospital setting also put them at risk for emotional drain and stress. CONCLUSIONS: While integrating PMs into hospital care presents substantial challenges, PMs may act as a "secret weapon" to engage often marginalized hospitalized patients with SUD and improve patient and provider experience.

Dying To Access Methadone.

A cancer patient who uses heroin can't gain reasonable access to methadone to treat his disorder until he qualifies for hospice.