A qualitative examination of recent increases in methamphetamine use in a cohort of rural people who use drugs.

INTRODUCTION: Rising rates of methamphetamine use among populations using opioids is an escalating public health concern. The purpose of this manuscript is to identify socioecologic factors driving increases in methamphetamine use among Appalachian Kentucky adults with a history of opioid use. METHODS: Semi-structured qualitative interviews were conducted among 20 Appalachian Kentuckians in the Social Network of Appalachian Peoples (SNAP) cohort who reported lifetime opioid use and past 30-day methamphetamine use. Interviews focused on initiation of methamphetamine use, factors that influence methamphetamine use at the individual, interpersonal, community and society levels. RESULTS: Participants reported using methamphetamine to self-treat underlying issues, including withdrawal from opioids, chronic pain, and emotional distress. Initiation of use was most often facilitated through their drug networks. Participants reported that methamphetamine was widely available and affordable in their community. Several participants with extensive histories of non-medical prescription opioid (NMPO) use described transitioning to methamphetamine as their drug of choice as opioids became less available in their community. Participants also reported economic distress and lack of recreational opportunities as drivers of increased methamphetamine use. DISCUSSION: Recent increases in methamphetamine use among those with a history of opioid use is facilitated by methamphetamine's relative availability and affordability. Methamphetamine use was also highly influenced by societal factors such as economic deprivation and policies that decreased availability of NMPOs. Surging methamphetamine use exacerbates inequities in addiction care brought to light by the opioid epidemic. Interventions aimed at addressing the socioecological drivers of methamphetamine use among people who use opioids are warranted.

How Physicians Prepare for Maintenance of Certification Exams: A Qualitative Study.

PURPOSE: Little is known about how board-certified physicians prepare for their periodic maintenance of certification (MOC) examinations. This qualitative study explores how physicians experience MOC exam preparation: how they prepare for the exams and decide what to study and how exam preparation compares with what they normally do to keep their medical knowledge current. METHOD: Between September 2016 and March 2017, the authors interviewed 80 primary care physicians who had recently taken either the American Board of Family Medicine or American Board of Internal Medicine MOC exam. They analyzed transcripts and notes from these interviews looking for patterns and emergent themes, using the constant comparative method and a social practice theory perspective. RESULTS: Most interviewees studied for their MOC exams by varying from their routines for staying current with medical knowledge, both by engaging with a different scope of information and by adopting different study methods. Physicians described exam preparation as returning to a student/testing mindset, which some welcomed and others experienced negatively or with ambivalence. CONCLUSIONS: What physicians choose to study bounds what they can learn from the MOC exam process and, therefore, also bounds potential improvements to their patient care. Knowing how physicians actually prepare, and how these activities compare with what they do when not preparing for an exam, can inform debates over the value of requiring such exams, as well as conversations about how certification boards and other key stakeholders in physicians' continuing professional development could improve the MOC process.