Access and care for people with opioid use disorder in U.S. skilled nursing facilities: A policy commentary.

Referrals for people with opioid use disorder (OUD) to skilled nursing facilities (SNFs) are increasing in the United States (U.S.). Further, legal guidance from the U.S. Department of Justice states that people with OUD cannot be discriminated against by health care institutions because of OUD or treatment with medications for OUD (MOUD). As such, SNFs are an important touchpoint for initiating or continuing MOUD, particularly amid rising drug-related overdose deaths among older adults and because people with OUD experience frailty and other geriatric syndromes at younger chronological ages. Informed by research, clinical expertise, and lived experience, this commentary describes policy and practice opportunities to help address challenges faced by people with OUD in gaining access to care and MOUD in SNFs. We propose opportunities to intervene against barriers that impede SNF placement and access to MOUD for people with OUD, including further revisions to 42 CFR Part 8 regulations to extend waivers for certification as opioid treatment programs (OTPs) to SNFs, allowing them to administer and dispense methadone in the same way as hospitals. If passed, proposed federal changes under the Modernizing Opioid Treatment Act would eliminate the requirement for methadone to be dispensed through OTPs, offering another opportunity to improve access to methadone for SNF residents. Also, we propose national and state-level investment in mobile substance use disorder services and partnerships with OTPs and hospital-based addiction consult services. We also recognize the need for more compassionate attitudes toward people with OUD in healthcare settings and discuss opportunities to address stigma. Although people with OUD are referred to SNFs for skilled care needs and not specifically for OUD care, it is essential for SNFs to be prepared to continue MOUD. It is both legally mandated and imperative that people with OUD have access to high quality and equitable SNF care.

Perspectives on Admissions and Care for Residents With Opioid Use Disorder in Skilled Nursing Facilities.

Importance: Skilled nursing facilities (SNFs) are being referred more individuals with opioid use disorder (OUD), even when their medical needs are not directly associated with OUD. Objective: To characterize factors that influence SNF admission for individuals with OUD and identify strategies for providing medications for OUD (MOUD) in SNFs. Design, Setting, and Participants: In this semistructured qualitative study, interviews were conducted with SNF administrators from 27 SNFs in Rhode Island from November 5, 2021, to April 27, 2022. Data analysis occurred from August 22, 2022, to May 31, 2023. Main Outcomes and Measures: Themes and subthemes on administrator perspectives on admissions and care for people with OUD in SNFs. Audio interviews were transcribed, coded, and analyzed using codebook thematic analysis and guided by community-engaged and participatory research principles. Results: The study included 29 participants representing 27 SNFs in Rhode Island. Participant roles were administrators (17 participants [59%]), directors of nursing (6 participants [21%]), directors of admissions (5 participants [17%]), and unit managers (1 participant [3%]). Participants described active substance use, Medicaid insurance, housing instability, and younger age as potential barriers to SNF admission for individuals with OUD. The lack of formal guidelines for OUD management, staff shortages, facility liability, state regulations, and skills and training deficits among staff were cited among challenges of effectively meeting the needs of residents with OUD. Many participants reported inadequate institutional capacity as a source of negative outcomes for people with OUD yet expressed their concerns by characterizing individuals with OUD as potentially violent, nonadherent, or likely to bring undesirable elements into facilities. Participants also shared strategies they used to better serve residents with OUD, including providing transportation to support group meetings in the community, delivery in advance of resident arrival of predosed methadone, and telemedicine through the state's hotline to prescribe buprenorphine. Conclusions and Relevance: In this qualitative study of administrator perspectives about admissions and care for individuals with OUD in SNFs, gaps in institutional capacity overlapped with stigmatizing beliefs about OUD; such beliefs perpetuate discrimination of individuals with OUD. Adequate SNF funding and staffing combined with OUD-specific interventions (eg, antistigma training, community partnerships for MOUD and recovery support) could incentivize SNFs to serve individuals with OUD and facilitate OUD care consistent with practice guidelines.

'We need to get paid for our value': Work-place experiences and role definitions of peer recovery specialists/community health workers.

Despite growing research on peer recovery specialists and community health workers (CHWs) in fields such as substance use disorder (SUD) treatment and recovery support, their workplace experiences are little understood. Through semi-structured interviews with 21 CHWs and peer recovery specialists working within substance use disorder treatment and/or traditional health care settings, we identified six prevalent themes: Benefits/Pleasures of the Role; Reciprocity; Challenges; Duality of Lived Experience; Relationships with Medical Professionals and Supervisors; and Defining Metrics. These themes reveal a complex narrative of system failures, organizational hierarchies, and experiential realities in which shared experiences and personal connections with clients undergird both positive and negative aspects of the role. In the words of one study participant: "We have not taken a vow of poverty, we need to get paid for our value."

Barriers to Buprenorphine Prescribing Among Attending Physicians in an Academic Residency Program - Implications for Increased Buprenorphine Usage.

The need for outpatient management of opioid use disorder with medication-assisted treatment has continued to rise yet physician comfort with prescribing buprenorphine remains low. A survey assessing comfort prescribing was disseminated to attending physicians in the Division of General Internal Medicine at an academic medical center followed by semi-structured qualitative interviews. The majority of respondents (71%) reported that they had not prescribed buprenorphine in an outpatient setting despite being trained and 67% stated that they felt "uncomfortable" or "very uncomfortable" doing so. However, almost all survey respondents (89%) reported comfort precepting residents prescribing buprenorphine. Attending physicians attribute this differential comfort to structural forces including a lack of team-based care, time, and psychosocial support services in their own practice as compared to the academic residency clinic. These findings highlight the barriers to prescribing buprenorphine and challenge the existing notion that academic centers are not suitable places for substance use treatment.

"It's a revolving door": understanding the social determinants of mental health as experienced by formerly incarcerated people.

BACKGROUND: This qualitative study seeks to understand how formerly incarcerated individuals in Rhode Island conceptualize their mental health and perceive obstacles to accessing and utilizing mental health services following recent incarceration. METHODS: We conducted in-depth semi-structured interviews from 2021 to 2022 with 25 people who had been released from incarceration within the past five years. We identified participants using voluntary response and purposive sampling. We analyzed the data using a modified form of grounded theory developed to capitalize on insights drawn from the lived experience of research team members, including a team member with experience of incarceration, and refined initial findings with a community advisory board with lived experience of incarceration and/or mental health issues similar to the study's sample. RESULTS: Participants overwhelmingly identified social determinants of health such as housing, employment, transport, and insurance coverage as the main obstacle to both accessing and maintaining engagement with mental health care. They also reported a level of opacity in the mental health system as they attempted to navigate it with limited systems literacy and support. Participants discussed alternative strategies that they employed when they believed formal mental health failed to meet their needs. Importantly, the majority of participants perceived a lack of empathy or understanding from their providers regarding the impact of SDOH on their mental health. CONCLUSIONS: Despite growing efforts to address social determinants among formerly incarcerated people, the majority of participants believed that providers neither understood nor addressed these dimensions of their lives. Participants reported two social determinants of mental health that have not yet been adequately explored in the literature: mental health systems literacy and systems opacity. We offer some strategies for how behavioral health professionals can develop stronger relationships with this population.

Reflections From Rhode Island's Safe Consumption Sites Regulations Committee: A Lesson in Racial Equity.

In July 2021, a statewide measure to create Harm Reduction Centers (also known as safe consumption sites [SCS]) was signed into law in Rhode Island. Convincing evidence shows that SCS can reduce premature death in the surrounding neighborhood. Although SCS have had success around the globe for approaching 40 years, implementing a harm reduction center of this kind in the United States requires consideration of this country's unique racial and geographic politics. In this manuscript, we describe a series of discussions at the Regulations Committee meetings in Rhode Island around the question of whether or not to mandate the presence of inhalation rooms. Through this vignette, we aim to convey how, at the highest level of government, citizens of Rhode Island were able to promote and prioritize racial equity.