Patient Barriers and Facilitators to Medications for Opioid Use Disorder in Primary Care.

Introduction: This study explored factors influencing patient access to medications for opioid use disorder (OUD), particularly for individuals eligible but historically suboptimal follow-up with in-house referrals to office-based opioid treatment (OBOT). Objectives: In-depth qualitative interviews among a mostly underserved sample of adults with OUD elicited: 1) knowledge and experiences across the OUD treatment cascade; and 2) more nuanced elements of patient-centered care, including shared decision making with providers, experiences in OBOT versus specialty addiction treatment, transitioning from methadone to buprenorphine or extended-release naltrexone (XR-NTX), and voluntary discontinuation of medications for OUD. Methods: We conducted semi-structured qualitative interviews between January and February of 2018 among adult inpatient detoxification program patients with OUD (n = 23). Preliminary analysis of interviews yielded key themes and ideas that were coded from a grounded theory approach. Results: Willingness to engage with OBOT was influenced by a complex array of practical considerations, including access to patient-centered care in OBOT settings, positive experiences with illicitly obtained buprenorphine, and differential experiences pertaining to OBOT versus specialty addiction treatment. Responses were generally favorable towards OBOT with buprenorphine, yet knowledge regarding extended-release naltrexone was limited. Respondents were often frustrated by clinicians when requesting to transition from methadone to buprenorphine or XR-NTX. Lastly, participants elucidated limited access to OBOT programs in underserved neighborhoods and suburban settings. Conclusion: Limited access to patient-centered care in OBOT with buprenorphine and extended-release naltrexone may exacerbate challenges to retention and/or reengagement with OUD care.

LVAD-DT: Culture of Rescue and Liminal Experience in the Treatment of Heart Failure.

The purpose of this article is to investigate how cultural meanings associated with the left ventricular assist device (LVAD) inform acceptance and experience of this innovative technology when it is used as a destination therapy. We conducted open-ended, semistructured interviews with family caregivers and patients who had undergone LVAD-DT procedures at six U.S. hospitals. A grounded theory approach was used for the analysis. Thirty-nine patients and 42 caregivers participated. Participants described a sense of obligation to undergo the procedure because of its promise for salvation. However, once the device was implanted, patients described being placed into a liminal state of being neither sick nor healthy, with no culturally scripted role. Consideration of end-of-life decisions was complicated by the uncertainties about how patients with LVADs die. Pre-implantation communications among patient, family, and clinicians should take into account the impact of the technology on meaning, identity, and patient experience.

Barriers and facilitators to implementing CareConnect: A telehealth, low-barrier buprenorphine bridge clinic in Philadelphia.

INTRODUCTION: Rates of fatal overdose continue to rise in the United States, and most people with opioid use disorder (OUD) are not engaged in evidence-based treatment with medications. In Philadelphia, a city with one of the highest fatal overdose rates in the country, many residents face significant care access barriers. The COVID-19 pandemic - which destabilized the street drug supply and forced many clinics to limit services - worsened this crisis, but also led to regulatory changes that allowed for buprenorphine induction and maintenance visits via telehealth in the U.S. To increase access to buprenorphine across the Philadelphia area and reach individuals who struggle to access care, Penn Medicine developed the CareConnect Warmline in October 2021. CareConnect is embedded in an existing virtual urgent care practice. Staffed by advanced practice providers and substance use navigators (SUNs), CareConnect provides same-day buprenorphine bridge (i.e., short-term) prescriptions and linkage to longitudinal OUD care. OBJECTIVE: To examine barriers and facilitators to implementing CareConnect from the perspective of key stakeholders, including CareConnect leadership, clinicians, and staff, and attitudes and beliefs about providing care for patients with OUD via this model. METHODS: In this qualitative descriptive study, we interviewed 14 participants and used thematic analysis to analyze the data. The sample included CareConnect prescribing clinicians, SUNs, and administrative staff. RESULTS: Our analysis yielded four themes: 1/ CareConnect is a unique program that fills an important care gap; 2/ Benefits of leveraging existing infrastructure; 3/ Importance of an interdisciplinary team; and 4/ Necessity of relationships with outside stakeholders. Prescribing clinicians and administrative staff - most of whom had little experience with OUD care before CareConnect - stressed how embedding the model within an existing virtual clinic and involving experienced SUNs increased their comfort prescribing buprenorphine. However, all participants highlighted how the program's effectiveness is contingent upon buy-in from outside stakeholders, including pharmacists who fill the prescriptions and longitudinal care providers in the community. CONCLUSIONS: Innovative delivery models can help expand OUD care access to individuals who are poorly served by traditional treatment infrastructure. Our findings provide valuable insight to improve and sustain CareConnect and can guide the development and implementation of future programs nationally.

Substance use policy and practice in the COVID-19 pandemic: Learning from early pandemic responses through internationally comparative field data.

The COVID-19 pandemic has created an unprecedented natural experiment in drug policy, treatment delivery, and harm reduction strategies by exposing wide variation in public health infrastructures and social safety nets around the world. Using qualitative data including ethnographic methods, questionnaires, and semi-structured interviews with people who use drugs (PWUD) and Delphi-method with experts from field sites spanning 13 different countries, this paper compares national responses to substance use during the first wave of the COVID-19 pandemic. Field data was collected by the Substance Use x COVID-19 (SU x COVID) Data Collaborative, an international network of social scientists, public health scientists, and community health practitioners convened to identify and contextualise health service delivery models and social protections that influence the health and wellbeing of PWUD during COVID-19. Findings suggest that countries with stronger social welfare systems pre-COVID introduced durable interventions targeting structural drivers of health. Countries with fragmented social service infrastructures implemented temporary initiatives for PWUD led by non-governmental organisations. The paper summarises the most successful early pandemic responses seen across countries and ends by calling for greater systemic investments in social protections for PWUD, diversion away from criminal-legal systems toward health interventions, and integrated harm reduction, treatment and recovery supports for PWUD.