Cannabis and opioid perceptions, co-use, and substitution among patients across 4 NCI-Designated Cancer Centers.

Prescription opioids are used for managing pain in persons with cancer, however, there are socioeconomic and racial disparities in medication access. Cannabis is increasingly used for cancer symptom management and as an opioid alternative. Limited data are available about patterns of opioid and cannabis use among patients with cancer. We used survey data from 4 National Cancer Institute-designated cancer centers in 3 states (n = 1220) to assess perceptions, use of cannabis and opioids for pain, their substitution, and racial and ethnic differences in each outcome. Compared with White patients, Black patients were less likely to use opioids for pain (odds ratio [OR] = 0.66; P = .035) and more likely to report that cannabis was more effective than opioids (OR = 2.46; P = .03). Race effects were mitigated (P > .05) after controlling for socioeconomic factors. Further research is needed to understand cannabis and opioid use patterns and how overlapping social determinants of health create a disadvantage in cancer symptom management for Black patients.

Cannabis Use Is Associated with Pain Severity and Interference Among Cancer Survivors.

Context: Cannabis use for symptom management among individuals with cancer is increasingly common. Objectives: We sought to describe the (1) prevalence and characteristics of cannabis use, (2) perceived therapeutic benefits of cannabis use, and (3) examine how use of cannabis was associated with self-reported pain, mood, and general health outcomes in a representative sample of patients treated at a National Cancer Institute (NCI)-designated Oregon Health and Science University Knight Cancer Institute. Methods: We conducted a population-based, cross-sectional survey developed in conjunction with 11 other NCI-designated cancer centers and distributed to eligible individuals. The survey inquired about characteristics of cannabis use, perception of therapeutic benefits, pain, mood, and general health. Responses were population weighted. We examined the association of cannabis use with self-reported pain, mood, and general health using logistic regression controlling for relevant sociodemographic and clinical characteristics. Results: A total of 523 individuals were included in our analytic sample. A total of 54% endorsed using cannabis at any time since their cancer diagnosis and 42% endorsed using cannabis during active treatment. The most commonly endorsed reasons for use included the following: sleep disturbance (54.7%), pain (47.1%), and mood (42.6%). We found that moderate pain was associated with more than a twofold (odds ratio = 2.4 [95% confidence interval = 1.3-4.6], p = 0.002) greater likelihood of self-reported cannabis use. Depressed mood and general health were not associated with cannabis use. Conclusions: In a state that had early adoption of medical and recreational cannabis legislation, a high number of cancer survivors report cannabis use. Moderate or more severe pain was associated with an increased likelihood to use cannabis, while mood and general health were not associated. Oncologists should be aware of these trends and assess use of cannabis when managing long-term symptoms of cancer and its treatments.

Improving access to buprenorphine for rural veterans in a learning health care system.

OBJECTIVE: To describe a learning health care system research process designed to increase buprenorphine prescribing for the treatment of opioid use disorder (OUD) in rural primary care settings within U.S. Department of Veterans Affairs (VA) treatment facilities. DATA SOURCES AND STUDY SETTING: Using national administrative data from the VA Corporate Data Warehouse, we identified six rural VA health care systems that had improved their rate of buprenorphine prescribing within primary care from 2015 to 2020 (positive deviants). We conducted qualitative interviews with leaders, clinicians, and staff involved in buprenorphine prescribing within primary care from these sites to inform the design of an implementation strategy. STUDY DESIGN: Qualitative interviews to inform implementation strategy development. DATA COLLECTION/EXTRACTION METHODS: Interviews were audio-recorded, transcribed verbatim, and coded by a primary coder and secondary reviewer. Analysis utilized a mixed inductive/deductive approach. To develop an implementation strategy, we matched clinical needs identified within interviews with resources and strategies participants had utilized to address these needs in their own sites. PRINCIPAL FINDINGS: Interview participants (n = 30) identified key clinical needs and strategies for implementing buprenorphine in rural, primary care settings. Common suggestions included the need for clinical mentorship or a consult service, buprenorphine training, and educational resources. Building upon interview findings and in partnership with a clinical team, we developed an implementation strategy composed of an engaging case-based training, an audit and feedback process, and educational resources (e.g., Buprenorphine Frequently Asked Questions, Rural Care Model Infographic). CONCLUSIONS: We describe a learning health care system research process that leveraged national administrative data, health care provider interviews, and clinical partnership to develop an implementation strategy to encourage buprenorphine prescribing in rural primary care settings.

Integrating Buprenorphine for Opioid Use Disorder into Rural, Primary Care Settings.

BACKGROUND: Medications for opioid use disorder (MOUD) including buprenorphine are effective, but underutilized. Rural patients experience pronounced disparities in access. To reach rural patients, the US Department of Veterans Affairs (VA) has sought to expand buprenorphine prescribing beyond specialty settings and into primary care. OBJECTIVE: Although challenges remain, some rural VA health care systems have begun offering opioid use disorder (OUD) treatment with buprenorphine in primary care. We conducted interviews with clinicians, leaders, and staff within these systems to understand how this outcome had been achieved. DESIGN: Using administrative data from the VA Corporate Data Warehouse (CDW), we identified rural VA health care systems that had improved their rate of primary care-based buprenorphine prescribing over the period 2015-2020. We conducted qualitative interviews (n = 30) with staff involved in implementing or prescribing buprenorphine in these systems to understand the processes that had facilitated implementation. PARTICIPANTS: Clinicians, staff, and leaders embedded within rural VA health care systems located in the Northwest, West, Midwest (2), South, and Northeast. APPROACH: Qualitative interviews were analyzed using a mixed inductive/deductive approach. KEY RESULTS: Interviews revealed the processes through which buprenorphine was integrated into primary care, as well as processes insufficient to enact change. Implementation was often initially catalyzed through a targeted hire. Champions then engaged clinicians and leaders one-on-one to "pitch" the case, describe concordance between buprenorphine prescribing and existing goals, and delineate the supportive role that they could provide. Sites were prepared for implementation by developing new clinical teams and redesigning clinical processes. Each of these processes was made possible with the active, instrumental support of leadership. CONCLUSIONS: Results suggest that rural systems seeking to improve buprenorphine accessibility in primary care may need to alter primary care structures to accommodate buprenorphine prescribing, whether through new hires, team development, or clinical redesign.

Feasibility and acceptability for LION, a fully remote, randomized clinical trial within the VA for light therapy to improve sleep in Veterans with and without TBI: An MTBI2 sponsored protocol: LION: A remote RCT protocol within VA.

Sleep-wake disturbances frequently present in Veterans with mild traumatic brain injury (mTBI). These TBI-related sleep impairments confer significant burden and commonly exacerbate other functional impairments. Therapies to improve sleep following mTBI are limited and studies in Veterans are even more scarce. In our previous pilot work, morning bright light therapy (MBLT) was found to be a feasible behavioral sleep intervention in Veterans with a history of mTBI; however, this was single-arm, open-label, and non-randomized, and therefore was not intended to establish efficacy. The present study, LION (light vs ion therapy) extends this preliminary work as a fully powered, sham-controlled, participant-masked randomized controlled trial (NCT03968874), implemented as fully remote within the VA (target n=120 complete). Randomization at 2:1 allocation ratio to: 1) active: MBLT (n=80), and 2) sham: deactivated negative ion generator (n=40); each with identical engagement parameters (60-min duration; within 2-hrs of waking; daily over 28-day duration). Participant masking via deception balanced expectancy assumptions across arms. Outcome measures were assessed following a 14-day baseline (pre-intervention), following 28-days of device engagement (post-intervention), and 28-days after the post-intervention assessment (follow-up). Primary outcomes were sleep measures, including continuous wrist-based actigraphy, self-report, and daily sleep dairy entries. Secondary/exploratory outcomes included cognition, mood, quality of life, circadian rhythm via dim light melatonin onset, and biofluid-based biomarkers. Participant drop out occurred in <10% of those enrolled, incomplete/missing data was present in <15% of key outcome variables, and overall fidelity adherence to the intervention was >85%, collectively establishing feasibility and acceptability for MBLT in Veterans with mTBI.

"They Ask Questions, But They Don't Want the Answers"-Perceptions of Clinical Communication Among Veterans Discontinuing Buprenorphine for the Treatment of Opioid Use Disorder.

BACKGROUND: Many patients with opioid use disorder (OUD) discontinue treatment prematurely, increasing their risk of opioid-related overdose and death. While patient-centered care is considered the gold standard in treating chronic illness, it may be practiced less frequently in the context of OUD care. Patient-provider communication can influence patients' care experiences, potentially having an impact on treatment retention and care decision-making. METHODS: This study was conducted at the VA Portland Health Care System from March 2021 to April 2022. We conducted qualitive interviews with patients who had discontinued buprenorphine for the treatment of OUD within the past year. Coding and analysis were guided by inductive qualitative content analysis. Retrospective medical record review identified clinical and demographic characteristics of participants. RESULTS: Twenty patients completed an interview. Participant age ranged from 28 to 74 years (median 63 years). Ninety percent of participants were white and 90% male. Many participants expressed frustration and feelings of disempowerment in OUD care processes. Patients with a history of long-term prescribed opioid use frequently expressed stigmatizing views of OUD, and perceptions of disagreement with providers over diagnosis and care choices. Elderly patients and those with multiple comorbidities expressed confusion over significant aspects of their care, as well as difficulty navigating treatment logistics like appointment requirements and medication dose changes. Some patients reported later restarting buprenorphine in new settings, and described feeling respected and involved in care decisions as a facilitator for continuing treatment. CONCLUSIONS: Prioritizing patient-centered communication in OUD treatment could improve the patient experience and potentially support treatment retention. Subgroups of OUD patients, such as those with a history of long-term prescribed opioid use, elderly patients with multiple comorbidities, or those who express stigmatizing medication views, could particularly benefit from tailored communication strategies that address their individual concerns.

Patients' Perspectives on Discontinuing Buprenorphine for the Treatment of Opioid Use Disorder.

OBJECTIVES: Buprenorphine and other medications for opioid use disorder (OUD) are recommended as standard of care in the treatment of OUD and are associated with positive health and addiction-related outcomes. Despite benefits, discontinuation is common, with half of patients discontinuing in the first year of treatment. Addressing OUD is a major clinical priority, yet little is known about the causes of medication discontinuation from the patient perspective. METHODS: From March 2021 to April 2022, we conducted qualitative interviews with patients who had discontinued buprenorphine for the treatment of OUD within the past 12 months. Eligible participants were selected from 2 Veterans Health Administration Health Care Systems in Oregon. Coding and analysis were guided by conventional qualitative content analysis. RESULTS: Twenty participants completed an interview; 90% were White and 90% were male, and the mean age was 54.2 years. Before discontinuation, participants had received buprenorphine for 8.3 months on average (range, 1-40 months); 80% had received buprenorphine for less than 12 months. Qualitative analysis identified the following themes relating to discontinuation: health system barriers (eg, logistical hurdles, rules and policy violations), medication effects (adverse effects; attributed adverse effects, lack of efficacy in treating chronic pain) and desire for opioid use. Patient description of decisions to discontinue buprenorphine could be multicausal, reflecting provider or system-level barriers in interaction with patient complexity or medication ambivalence. CONCLUSIONS: Study results identify several actionable ways OUD treatment could be modified to enhance patient retention.