"My Goal is to get Through the Day Without Pain": A Qualitative Study on Chronic Pain Experiences and Treatment Needs Among Child Caregiving Women.

INTRODUCTION: We aimed to understand connections between pain, caregiving, physical and behavioral health treatment needs, and motivations for prescription opioid use among child caregiving women with chronic pain. METHODS: We conducted in-depth, semi-structured interviews with 12 women (average age 48 years; 58% Black) in child caregiving roles, including women who were pregnant or trying to become pregnant and were caring for children or grandchildren < 18 years, and who received treatment at an outpatient pain management clinic. We used thematic text analysis to identify qualitative themes related to caregiving, pain, treatment, substance use, coping strategies, and sources of support. RESULTS: A diverse sample of women reported high levels of stress and pain, substance use, interpersonal violence, depression, and financial strain. Most described difficulties at work, interacting with children or grandchildren, and engaging routine, daily activities due to their pain. Most indicated that they spent less time with family and friends due to their pain and had limited sources of support to help them navigate both caregiving and pain. Many described barriers to receiving appropriate healthcare, including prescription opioids, due to stigma or logistics, though most also reported positive healthcare experiences. Women also reported added daily-life, physical, mental health, and interpersonal stressors and difficulty navigating the healthcare system to receive needed care. DISCUSSION: For women with chronic pain in child caregiver roles, results highlight the importance of care tailored to the physical needs of child caregiving and of trauma-informed approaches given the prevalence of comorbid conditions and trauma.

Type of household firearm ownership and firearm suicide among adolescents, 1976-2018.

After declining steadily for almost two decades, the rate of firearm suicide among adolescents (aged 15-19 years) has increased nearly every year since 2007. At the same time, overall levels of household firearm ownership have been declining. In this paper, we examined whether and how types of firearms in the homes of adolescents have changed over time, and the extent to which such changes are associated with trends in firearm suicides among adolescents. Our analyses focused on understanding these trends among Black and White male and female adolescents to better understand longstanding race-gender differences in firearm ownership and firearm suicide. With combined data from the General Social Survey (GSS) and the National Center for Health Statistics (NCHS), the findings show that handgun ownership in Black and White households increased over the last four decades, while overall levels of firearm ownership declined. Increases in handgun ownership were predictive of increased firearm suicide rates among White adolescents, especially among males. We found no significant relationship between firearm suicide among Black adolescents and firearm ownership among Black households, regardless of gun type, which is potentially unsurprising given that firearm ownership is substantially lower in Black households compared to White households. Possibly reflecting race and gender differences in household gun ownership, our findings also show that rates of firearm suicide were lower for Black and female adolescents and highest for White male adolescents. Taken together, these findings provide new evidence on the relationship between trends in firearm ownership and adolescent firearm suicide and address important questions about the influence of race and gender for understanding firearm suicide among adolescents.

COVID-19 Adaptations in the Care of Patients with Opioid Use Disorder: a Survey of California Primary Care Clinics.

BACKGROUND: With the onset of the COVID-19 crisis, many federal agencies relaxed policies regulating opioid use disorder treatment. The impact of these changes has been minimally documented. The abrupt nature of these shifts provides a naturalistic opportunity to examine adaptations for opioid use disorder treatment in primary care. OBJECTIVE: To examine change in medical and behavioral health appointment frequency, visit type, and management of patients with opioid use disorder in response to COVID-19. DESIGN: A 14-item survey queried primary care practices that were enrolled in a medications for opioid use disorder statewide expansion project. Survey content focused on changes in service delivery because of COVID-19. The survey was open for 18 days. PARTICIPANTS: We surveyed 338 clinicians from 57 primary care clinics located in California, including federally qualified health centers and look-alikes. A representative from all 57 clinics (100%) and 118 staff (34.8% of all staff clinicians) participated in the survey. MAIN MEASURES: The survey consisted of seven dimensions of practice: medical visits, behavioral health visits, medication management, urine drug screenings, workflow, perceived patient demand, and staff experience. KEY RESULTS: A total of 52 of 57 (91.2%) primary care clinics reported practice adaptations in response to COVID-19 regulatory changes. Many clinics indicated that both medical (40.4%) and behavioral health visits (53.8%) were now exclusively virtual. Two-thirds (65.4%) of clinics reported increased duration of buprenorphine prescriptions and reduced urine drug screenings (67.3%). The majority (56.1%) of clinics experienced an increase in patient demand for behavioral health services. Over half (56.2%) of clinics described having an easier or unchanged experience retaining patients in care. CONCLUSIONS: Many adaptations in the primary care approach to patients with opioid use disorder may be temporary reactions to COVID-19. Further evaluation of the impact of these adaptations on patient outcomes is needed to determine whether changes should be maintained post-COVID-19.

Virtual quality improvement collaborative with primary care practices during COVID-19: a case study within a clinically integrated network.

INTRODUCTION: Quality improvement collaboratives (QICs) are a common approach to facilitate practice change and improve care delivery. Attention to QIC implementation processes and outcomes can inform best practices for designing and delivering collaborative content. In partnership with a clinically integrated network, we evaluated implementation outcomes for a virtual QIC with independent primary care practices delivered during COVID-19. METHODS: We conducted a longitudinal case study evaluation of a virtual QIC in which practices participated in bimonthly online meetings and monthly tailored QI coaching sessions from July 2020 to June 2021. Implementation outcomes included: (1) level of engagement (meeting attendance and poll questions), (2) QI capacity (assessments completed by QI coaches), (3) use of QI tools (plan-do-check-act (PDCA) cycles started and completed) and (4) participant perceptions of acceptability (interviews and surveys). RESULTS: Seven clinics from five primary care practices participated in the virtual QIC. Of the seven sites, five were community health centres, three were in rural counties and clinic size ranged from 1 to 7 physicians. For engagement, all practices had at least one member attend all online QIC meetings and most (9/11 (82%)) poll respondents reported meeting with their QI coach at least once per month. For QI capacity, practice-level scores showed improvements in foundational, intermediate and advanced QI work. For QI tools used, 26 PDCA cycles were initiated with 9 completed. Most (10/11 (91%)) survey respondents were satisfied with their virtual QIC experience. Twelve interviews revealed additional themes such as challenges in obtaining real-time data and working with multiple electronic medical record systems. DISCUSSION: A virtual QIC conducted with independent primary care practices during COVID-19 resulted in high participation and satisfaction. QI capacity and use of QI tools increased over 1 year. These implementation outcomes suggest that virtual QICs may be an attractive alternative to engage independent practices in QI work.

Patient navigation for perinatal substance use disorder treatment: A systematic review.

BACKGROUND: Substance use during the perinatal period (i.e., pregnancy through the first year postpartum) can pose significant maternal and infant health risks. However, access to lifesaving medications and standard care remains low for perinatal persons who use substances. This lack of substance use disorder treatment access stems from fragmented services, stigma, and social determinants of health-related barriers that could be addressed using patient navigators. This systematic review describes patient navigation models of care for perinatal people who use substances and associated outcomes. METHODS: We conducted a structured search of peer-reviewed, US-focused, English- or Spanish-language articles from 2000 to 2023 focused on 1) patient navigation, 2) prenatal and postpartum care, and 3) substance use treatment programs using PubMed, Scopus, PsycINFO, and CINAHL databases. RESULTS: After meeting eligibility criteria, 17 studies were included in this review. The majority (n=8) described outpatient patient navigation programs, with notable hospital (n=4) and residential (n=3) programs. Patient navigation was associated with reduced maternal substance use, increased receipt of services, and improved maternal and neonatal health. Findings were mixed for engagement in substance use disorder treatment and child custody outcomes. Programs that co-located care, engaged patients across the perinatal period, and worked to build trust and communication with family members and service providers were particularly successful. CONCLUSION: Patient navigation may be a promising strategy for improving maternal and infant health outcomes among perinatal persons who use substances. More experimental research is needed to test the effect of patient navigation programs for perinatal persons who use substances compared to other models of care.

Desire, acceptability, and expected resolution: A latent class analysis of current pregnancy orientation in the United States.

BACKGROUND: Scant research has examined latent and contextual dimensions of pregnancy intentions, conventionally classifying unintended pregnancies as mistimed (wanted later) or unwanted (not wanted at all). Being at risk of mistimed pregnancy likely encompasses a broad spectrum of emotions and expectations regarding pregnancy and merits further exploration. METHOD: Using a national sample from GfK's online KnowledgePanel of women aged 15-39 considered at risk of mistimed pregnancy in 2017 (n = 1278), we conducted a latent class analysis to assess underlying patterns of current pregnancy orientation using three items: pregnancy desire, pregnancy acceptability, and expected pregnancy resolution. As class structure varied by relationship status (serious or not), we stratified analyses by relationship status. RESULTS: Among women in serious relationships, three classes emerged: "No," "Slightly okay," and "Acceptable." For those not in serious relationships, there were two classes: "Strong no" and "Ambiguous." Overall, the classes indicate varied patterns of wantedness, acceptability, and anticipated resolution to potential pregnancy. CONCLUSIONS: This analysis reinforces that the construct of mistimed pregnancy is too restrictive to reflect the inherent diversity of prospective pregnancy orientation. The combination of relationship type as a grouping variable for stratified analyses, financial hardships' impact, and the overall effect of increasing age on increasing interest in pregnancy suggest the importance of locating pregnancy intentions within the broader reproductive life course. Scholars, clinicians, and public health programs should allow for multidimensionality of pregnancy perspectives, locate them within the broader life course, and acknowledge the potential impacts of stratified relationship formation on eventual pregnancy intentions.

Sustainability planning in the US response to the opioid crisis: An examination using expert and text mining approaches.

Between January 2016 and June 2020, the Substance Abuse and Mental Health Services Administration rapidly distributed $7.5 billion in response to the U.S. opioid crisis. These funds are designed to increase access to medications for addiction treatment, reduce unmet treatment need, reduce overdose death rates, and provide and sustain effective prevention, treatment and recovery activities. It is unclear whether or not the services developed using these funds will be sustained beyond the start-up period. Based on 34 (64%) State Opioid Response (SOR) applications, we assessed the states' sustainability plans focusing on potential funding sources, policies, and quality monitoring. We found variable commitment to sustainability across response plans with less than half the states adequately describing sustainability plans. States with higher proportions of opioid prescribing, opioid misuse, and poverty had somewhat higher scores on sustainment. A text mining/machine learning approach automatically rated sustainability in SOR applications with an 82% accuracy compared to human ratings. Because life saving evidence-based programs and services may be lost, intentional commitment to sustainment beyond the bolus of start-up funding is essential.

The Integrating Medications for Addiction Treatment (IMAT) Index: A measure of capability at the organizational level.

Primary care provides a treatment opportunity for many persons with opioid use disorder (OUD). The push to integrate and expand reach and adoption of medications for opioid use disorder (MOUD) within primary care has been a major focus of national, state and health systems endeavors. To guide high capability MOUD practice, we introduce the Integrating Medications for Addiction Treatment (IMAT) Index. The research team has developed IMAT along similar lines to other organizational measures of integrated services capability. We present the development and validation of the measure, and suggest its applicability for systems and organizations, as well as for process improvement and implementation research. Forty-one primary care clinics completed the IMAT at two time points: baseline and 9-month follow-up. Findings support the IMAT Index as psychometrically acceptable and pragmatically useful. It has good internal consistency, as well as concurrent and predictive validity. Changes in IMAT scores between baseline and follow-up significantly predicted increases in proportion of patients on MOUD. The IMAT has the potential to support both scientific and public health care activities.

Opening the "black box": Four common implementation strategies for expanding the use of medications for opioid use disorder in primary care.

Background: Despite the persistent increase in overdose deaths, access to medications for opioid use disorders remains limited. Recent federal funding aimed at increasing access prompts a need to understand if implementation strategies improve access. Methods: This is an analysis of data from 174 primary care clinics enrolled in a state-wide medications for opioid use disorders (MOUD) implementation effort in California. We examined clinic use of one of four implementation strategies: learning collaboratives, Project Extension for Community Health care Outcomes (ECHO), didactic webinars, and clinical skills trainings. The primary implementation outcome was categorical change in new patients prescribed buprenorphine. Univariate and multivariate logistic regressions were used to determine the impact of clinic attendance in all or individual implementation strategies, respectively, on patient growth. Results: Clinics attending learning collaboratives, Project ECHO, and clinical skills trainings had significantly higher odds of patient growth (odds ratio [OR] = 3.56; 95% confidence interval [CI] = 1.78, 7.10, p < .001), (OR = 3.39; 95% CI = 1.59, 7.24, p < .01), (OR = 3.90, 95% CI = 1.64, 9.23, p < .01) than non-attending clinics. The impact of attendance at learning collaboratives (OR = 5.81, 95% CI = 1.89, 17.85; p < .01), didactic webinars (OR = 3.59; 95% CI = 1.04, 12.35; p < .05), and clinical skills trainings (OR = 3.53, 95% CI = 1.06, 11.78, p < .05) on patient growth was greater for Federally Qualified Health Centers. When comparing strategies in multivariate models, only the relationship between learning collaborative attendance and new patients prescribed buprenorphine remained significant (OR = 2.57; 95% CI = 1.12, 5.88; p < .05). Conclusions: This study reported on a large, statewide, implementation-as-usual project offering four typical implementation strategies. Clinic attendance at learning collaboratives, a multi-component strategy, had the most consistent impact on new patients prescribed buprenorphine. These results suggest that while a broad array of strategies was initially reasonable, optimizing the selection of implementation strategies could be more effective. Plain Language Summary: Access to life-saving medications for opioid use disorder, such as buprenorphine, remains limited despite strong evidence of effectiveness. Systems and organizations often select from a variety of implementation strategies aimed at expanding access to these medications. However, scant research exists to enable these organizations to select the most effective and efficient strategies. Our study-within a large state-wide system of care-examined the impact of primary care clinic attendance in four common implementation strategies on new patients prescribed buprenorphine. Learning collaboratives were the strategy that most consistently improved outcomes. These results highlight the challenges to strategy selection inherent in implementation-as-usual systems-level approaches. The field needs evidence-based information on which implementation strategies are most likely to yield desired implementation outcomes.

The prospects for sustaining evidence-based responses to the US opioid epidemic: state leadership perspectives.

BACKGROUND: The US 21st Century Cures Act provided $7.5 billion in grant funding to states and territories for evidence-based responses to the opioid epidemic. Currently, little is known about optimal strategies for sustaining these programs beyond this start-up funding. METHODS: Using an inductive, conventional content analysis, we conducted key informant interviews with former and current state leaders (n = 16) about barriers/facilitators to sustainment and strategies for sustaining time-limited grants. RESULTS: Financing and reimbursement, service integration, and workforce capacity were the most cited barriers to sustainment. Status in state government structure, public support, and spending flexibility were noted as key facilitators. Effective levers to increase chances for sustainment included strong partnerships with other state agencies, workforce and credentialing changes, and marshalling advocacy through public awareness campaigns. CONCLUSIONS: Understanding the strategies that leaders have successfully used to sustain programs in the past can inform how to continue future time-limited, grant-funded initiatives.

Implementation of the hub and spoke model for opioid use disorders in California: Rationale, design and anticipated impact.

As part of the State Targeted Response to the opioid epidemic, California has adopted the Hub and Spoke model to expand access to medications for opioid use disorder, particularly buprenorphine, throughout the state. By aligning opioid treatment programs as hubs with primary care, office-based practitioners, and other health care settings as spokes, a broader treatment model can reach more people with opioid use disorder, improve access to medications for opioid use disorders, and decrease overdose deaths. Expanding access requires expanding knowledge and intensive implementation support of new practices. This paper describes the rationale, specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and capacity of waivered prescribers; enhance skills of prescribers and multidisciplinary teams; and create systems change. Activities include buprenorphine waiver trainings and provider support, a practice facilitator program, Project ECHO sessions, webinars, clinical skills trainings, and regional learning collaboratives. This overview highlights the steps California is taking to build treatment capacity to address the opioid epidemic.

Planned, unplanned and in-between: the meaning and context of pregnancy planning for young people.

OBJECTIVE: To understand how young people conceptualize planned, unplanned and "in-between" pregnancies. METHODS: We conducted individual qualitative interviews with 50 young (ages 18-24) women and their male partners (n=100) in the San Francisco Bay Area to investigate prospective pregnancy intentions. In this analysis, we focused on participants' conceptualization of planned and unplanned pregnancies, as well as a status in between planned and unplanned. RESULTS: Conceptualizations of pregnancy planning were influenced by personal experiences and life circumstances, including previous unplanned pregnancies. While many participants held up planned pregnancies as an ideal, the majority of participants (n=71) also felt that a status in between planned and unplanned pregnancy existed. Many described this in-between stage occurring when someone is "not not trying" or would find an unplanned pregnancy acceptable. Notably, a few participants mentioned that pregnancy planning was not possible because either it was uncommon among their peers or they felt a general lack of control over pregnancy. CONCLUSION: Our analysis suggests that binary operationalization of pregnancies as "planned" and "unplanned" neglects the complexity of young people's lived experiences and perspectives. Contraceptive counseling approaches that allow patients the flexibility to express their considerations and feelings toward a potential future pregnancy could improve the quality of family planning visits and patient-provider interactions. IMPLICATIONS: The traditional binary conceptualization of pregnancies as planned and unplanned may not holistically capture the diverse perspectives of young people. Increased understanding of the complexities in young people's conceptualizion of pregnancy planning can inform family planning care that is inclusive, relevant and supportive of a variety of perspectives.