"You're Always Jumping Through Hoops": Journey Mapping the Care Experiences of Individuals With Opioid Use Disorder-associated Endocarditis.

OBJECTIVES: Serious infectious complications of opioid use disorder (OUD), and specifically endocarditis, are becoming more common in the US. Individuals with OUD-associated endocarditis require long periods of complex medical care, often face recurrent addiction- and infection-related complications, and have dismal clinical outcomes. The objective of this study was to perform journey mapping analysis to capture common trajectories and patterns of care for people with OUD-associated endocarditis. METHODS: This was an analysis of qualitative semi-structured interviews of individuals who received care for OUD-associated endocarditis. Interviews were conducted among individuals receiving care at a single academic healthcare system in Boston, Massachusetts. Ten participants meeting DSM-5 criteria for at least mild OUD and a culture-positive diagnosis of endocarditis who had previously completed care for OUD-associated endocarditis were recruited from inpatient and ambulatory settings. Details of participant's care episodes were extracted and visualized in an iterative journey mapping process. A grounded theory approach was then used to identify shared themes and care patterns among participants' journey maps. RESULTS: Common patterns of care included early addiction treatment and intensive outpatient care preceding periods without rehospitalization, while leaving outpatient care and return to drug use often directly preceded rehospitalization. Participants frequently left care by choice and proactively reengaged with care. CONCLUSIONS: Journey mapping is a novel, patient-centered approach to capturing the care experiences and trajectories of a patient population experiencing significant stigma, who engage with the healthcare system in unexpected and fragmented ways. For individuals with OUD-associated endocarditis, we identified critical moments to support and engage patients to prevent return to drug use and rehospitalization.

Opioid and Amphetamine Treatment Trends Among American Indians in the Great Plains.

OBJECTIVES: Traditionally underserved populations in the United States, particularly rural and American Indian/Alaska Native (AI/AN) communities, are disproportionately impacted by the opioid and amphetamine epidemics and have a higher risk for substance use disorders. AI/AN communities in the American Great Plains face exceptional health risks. We aim to describe recent trends in opioid and amphetamine treatment admissions for AI/ANs living in the Great Plains relative to that of the general population. METHODS: We used data from the 2014 to 2016 Substance Abuse and Mental Health Services Administration (SAMHSA) Drug and Alcohol Services Information System (DASIS) Treatment Episode Data Set (TEDS) for Admissions. We extracted opioid and amphetamine treatment admissions for self-identified AI/AN and non-AI/AN patients living in the Great Plains: North Dakota, South Dakota, Nebraska, and Iowa. Average annual admission rates were calculated and compared from 2014 to 2016 for AI/AN versus non-AI/AN populations. RESULTS: While opioid and amphetamine treatment admissions from 2014 to 2016 increased in both AI/AN (49 vs 80 per 10,000) and non-AI/AN (20 vs 26 per 10,000) populations, the rate of increase was significantly greater among AI/ANs (64% vs 32%; P < 0. 01). These trends are largely reflective of increased amphetamine use treatment admissions observed in both AI/AN and non-AI/AN populations. CONCLUSIONS: Treatment admissions for opioid and amphetamine use have increased from 2014 to 2016 for both AI/AN and non-AI/AN individuals in the Great Plains, driven largely by amphetamine use. AI/AN individuals were observed to seek care at a much higher rate. This increase in treatment admissions suggests increasing demand for services, which, in turn, necessitates greater investment of resources into AI/AN health facilities to address opioid and amphetamine use disorder in this underserved population.

Experiences of care among individuals with opioid use disorder-associated endocarditis and their healthcare providers: Results from a qualitative study.

PURPOSE: Infectious complications of opioid use disorder (OUD), including endocarditis, are rising. Patients with OUD-associated endocarditis have poor clinical outcomes but their care is not well understood. We aimed to elucidate the prior experiences of care for patients with OUD-associated endocarditis and the healthcare providers who deliver that care. STUDY DESIGN: This qualitative study was conducted through semi-structured interviews of patients and providers at a single academic hospital using a grounded theory approach. Patients meeting DSM-5 criteria for at least mild OUD who had previously completed an episode of care for OUD-associated endocarditis were recruited from inpatient and ambulatory settings. Multidisciplinary care providers who regularly care for patients with OUD-associated endocarditis were also recruited. Interviews were conducted until thematic saturation was achieved. PRINCIPLE RESULTS: Of 11 patient participants, six were recruited from outpatient settings. Of 12 provider participants, seven cared for patients with OUD "almost always." Five major themes emerged across patient and provider interviews: stigma-related inequity and delays in care, the social and medical comorbidities of individuals with OUD-associated endocarditis, addiction as a chronic and relapsing disease, differing experiences of prolonged hospitalizations between patients and providers, and a lack of integration or discontinuity of care. Opportunities for care innovation and improvement were identified. CONCLUSIONS: This qualitative analysis highlights multiple patient and health system factors that may explain poor clinical outcomes experienced by individuals with OUD-associated endocarditis. A sick, complex, stigmatized patient population was noted, with new physical and mental comorbidities often developing on top of pre-existing ones. Perceived barriers to effective treatment of OUD-associated endocarditis included the complexity of managing two life threatening illness simultaneously, external stigma towards individuals with OUD, and discontinuity in longitudinal care.

Smoking cessation after engagement in HIV care in rural Uganda.

People living with HIV (PLWH) are more likely to smoke compared to HIV-uninfected counterparts, but little is known about smoking behaviors in sub-Saharan Africa. To address this gap in knowledge, we characterized smoking cessation patterns among people living with HIV (PLWH) compared to HIV-uninfected individuals in rural Uganda. PLWH were at least 40 years of age and on antiretroviral therapy for at least three years, and HIV-uninfected individuals were recruited from the clinical catchment area. Our primary outcome of interest was smoking cessation, which was assessed using an adapted WHO STEPS smoking questionnaire. We fit Cox proportional hazards models to compare time to smoking cessation between PLWH pre-care, PLWH in care, and HIV-uninfected individuals. We found that, compared to HIV-uninfected individuals, PLWH in care were less likely to have ever smoked (40% vs. 49%, p = 0.04). The combined sample of 267 ever-smokers had a median age of 56 (IQR 49-68), 56% (n = 150) were male, and 26% (n = 70) were current smokers. In time-to-event analyses, HIV-uninfected individuals and PLWH prior to clinic enrollment ceased smoking at similar rates (HR 0.8, 95% CI 0.5-1.2). However, after enrolling in HIV care, PLWH had a hazard of smoking cessation over twice that of HIV-uninfected individuals and three times that of PLWH prior to enrollment (HR 2.4, 95% CI 1.3-4.6, p = 0.005 and HR 3.0, 95% CI 1.6-5.5, p = 0.001, respectively). In summary, we observed high rates of smoking cessation among PLWH after engagement in HIV care in rural Uganda. While we hypothesize that greater access to primary care services and health counseling might contribute, future studies should better investigate the mechanism of this association.