Barriers and Facilitators to Establishing Partnerships for Substance Use Disorder Care Transitions Between Safety-Net Hospitals and Community-Based Organizations.

BACKGROUND: The effectiveness of hospital-based transitional opioid programs (TOPs), which aim to connect patients with substance use disorders (SUD) to ongoing treatment in the community following initiation of medication for opioid use disorder (MOUD) treatment in the hospital, hinges on successful patient transitions. These transitions are enabled by strong partnerships between hospitals and community-based organizations (CBOs). However, no prior study has specifically examined barriers and facilitators to establishing SUD care transition partnerships between hospitals and CBOs. OBJECTIVE: To identify barriers and facilitators to developing partnerships between hospitals and CBOs to facilitate care transitions for patients with SUDs. DESIGN: Qualitative study using semi structured interviews conducted between November 2022-August 2023. PARTICIPANTS: Staff and providers from hospitals affiliated with four safety-net health systems (n=21), and leaders and staff from the CBOs with which they had established partnerships (n=5). APPROACH: Interview questions focused on barriers and facilitators to implementing TOPs, developing partnerships with CBOs, and successfully transitioning SUD patients from hospital settings to CBOs. KEY RESULTS: We identified four key barriers to establishing transition partnerships: policy and philosophical differences between organizations, ineffective communication, limited trust, and a lack of connectivity between data systems. We also identified three facilitators to partnership development: strategies focused on building partnership quality, strategic staffing, and organizing partnership processes. CONCLUSIONS: Our findings demonstrate that while multiple barriers to developing hospital-CBO partnerships exist, stakeholders can adopt implementation strategies that mitigate these challenges such as using mediators, cross-hiring, and focusing on mutually beneficial services, even within resource-limited safety-net settings. Policymakers and health system leaders who wish to optimize TOPs in their facilities should focus on adopting implementation strategies to support transition partnerships such as inadequate data collection and sharing systems.

Reducing perceived barriers to scaling up overdose education and naloxone distribution and medications for opioid use disorder in the United States in the HEALing (helping end addiction long-term®) communities study.

BACKGROUND: Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues. METHODS: The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested. RESULTS: Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status. DISCUSSION: The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.

Application of an opioid use disorder cascade of care in a large public health system.

Background: Over the past decade, hospitals and health systems have increasingly adopted interventions to address the needs of patients with substance use disorders. The Opioid Use Disorder (OUD) Cascade of Care provides a framework for organizing and tracking patient health milestones over time and can assist health systems in identifying areas of intervention to maximize the impact of evidence-based services. However, detailed protocols are needed to guide health systems in how to operationalize the OUD Cascade and track outcomes using electronic health records.Objective: In this paper, we describe the process of operationalizing and applying the OUD Cascade in a large, urban, public hospital system.Methods: Through this case example, we describe the technical processes around data mining, as well as the decision-making processes, challenges encountered, lessons learned from compiling preliminary patient data and defining stages and outcome measures for the OUD Cascade of Care, and preliminary dataResults: We identified 33,616 (26.17% female) individuals with an OUD diagnosis. Almost half (48%) engaged with addiction services, while only 10.7% initiated medication-based treatment in an outpatient setting, 6.7% had timely follow-up, and 3.5% were retained for a minimum of 6 months.Conclusion: The current paper serves as a primer for other health systems seeking to implement data-informed approaches to guide more efficient care and improved substance use-related outcomes. An OUD Cascade of Care must be tailored to local systems based on inherent data limitations and services design with an emphasis on early stages wherein drop-off is the greatest.

Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland.

BACKGROUND: Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs. METHODS: People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services. RESULTS: The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors). CONCLUSIONS: Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.

Providing medication for opioid use disorder and HIV pre-exposure prophylaxis at syringe services programs via telemedicine: a pilot study.

BACKGROUND: People who inject drugs (PWID) are at high risk for opioid overdose and infectious diseases including HIV. We piloted PARTNER UP, a telemedicine-based program to provide PWID with medication for opioid use disorder (MOUD) with buprenorphine/naloxone (bup/nx) and oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine through two syringe services programs (SSP) in North Carolina. We present overall results from this project, including participant retention rates and self-reported medication adherence. METHODS: Study participants met with a provider for an initial in-person visit at the SSP, followed by weekly telemedicine visits in month 1 and then monthly until program end at month 6. Participants were asked to start both MOUD and PrEP at initiation but could choose to discontinue either at any point during the study. Demographics and health history including substance use, sexual behaviors, and prior use of MOUD/PrEP were collected at baseline. Follow-up surveys were conducted at 3- and 6-months to assess attitudes towards MOUD and PrEP, change in opioid use and sexual behaviors, and for self-reported medication adherence. Participant retention was measured by completion of visits; provider notes were used to assess whether the participant reported continuation of medication. RESULTS: Overall, 17 persons were enrolled and started on both bup/nx and PrEP; the majority self-identified as white and male. At 3 months, 13 (76%) remained on study; 10 (77%) reported continuing with both MOUD and PrEP, 2 (15%) with bup/nx only, and 1 (8%) with PrEP only. At 6 months, 12 (71%) remained on study; 8 (67%) reported taking both bup/nx and PrEP, and 4 (33%) bup/nx only. Among survey participants, opioid use and HIV risk behaviors decreased. Nearly all reported taking bup/nx daily; however, self-reported daily adherence to PrEP was lower and declined over time. The most common reason for not continuing PrEP was feeling not at risk for acquiring HIV. CONCLUSIONS: Our study results show that MOUD and PrEP can be successfully administered via telemedicine in SSPs. PrEP appears to be a lower priority for participants with decreased continuation and adherence. Low perception of HIV risk was a reason for not continuing PrEP, possibly mitigated by MOUD use. Future studies including helping identify PWID at highest need for PrEP are needed. TRIAL REGISTRATION: Providing Suboxone and PrEP Using Telemedicine, NCT04521920. Registered 18 August 2020. https://clinicaltrials.gov/study/NCT04521920?term=mehri%20mckellar&rank=2 .

Understanding Healthcare Providers' Care for Patients with Medications Treating Opioid Use Disorder in the Emergency Department: A Scoping Review.

BACKGROUND: There is limited research exploring the changing clinical practices among healthcare providers (HPs) care for patients with Emergency Department (ED)-initiated Medication for Opioid Use Disorder (MOUD). METHODS: This scoping review followed the methodological framework of Arksey and O'Malley to map relevant evidence and synthesize the findings. We searched PubMed, EMBASE, CINAHL, Web of Science, and Scopus for related studies from inception through October 12, 2022. Following the application of inclusion and exclusion criteria, 16 studies were included. Subsequently, they were charted and analyzed thematically based on ecological systems theory. RESULTS: The main determinants in the four ecological systems were generated as follows: (1) microsystem: willingness and attitude, professional competence, readiness, and preference; (2) mesosystem: ED clinical practices, departmental factors; (3) exosystem: multidisciplinary approaches, discharge planning, and (4) macrosystem: stigma, health insurance, policy. The findings have implications for HPs and researchers, as insufficient adoption, implementation, and retention of MOUD in the ED affect clinical practices. CONCLUSIONS: Across the four ecological systems, ED-initiated MOUD is shaped by multifaceted determinants. The microsystem underscores pivotal patient-HP trust dynamics, while the mesosystem emphasizes interdepartmental synergies. Exosystemically, resource allocation and standardized training remain paramount. The macrosystem reveals profound effects of stigma, insurance disparities, and evolving policies on treatment access and efficacy. Addressing these interconnected barriers is crucial for optimizing patient outcomes in the context of MOUD.

Telehealth Utilization for Opioid Use Disorder: A Nationwide Analysis Before and After the COVID-19 Public Health Emergency Declaration.

Introduction: The COVID-19 pandemic has led to the rapid and widespread adoption of telehealth services. Telehealth may aid in bridging gaps in access to care. The specific impact of telehealth on opioid use disorder (OUD) and its treatment remains uncertain. Methods: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of(a) OUD treatments with and without telehealth support and (b) prescriptions for medications for opioid use disorder (MOUD) with and without telehealth support among individuals diagnosed with OUD. Results: In a study population of 1,340,506 individuals, OUD diagnosis rates were 5 per 1,000 in-person and 1 per 1,000 via telehealth. COVID-19 decreased in-person OUD diagnoses by 0.89 per 1,000, while telehealth diagnoses increased by 0.83 per 1,000. In-person MOUD treatment rates increased by 0.07 per 1,000 during COVID-19, while telehealth rates remained low. The onset of COVID-19 saw a 1.13 per 1,000 higher increase in telehealth-supported MOUD treatment compared to solely in-person treatment. Conclusions: A retrospective review of commercial insurance claim records within the United States was conducted to investigate the association between the COVID-19 pandemic and changes in the rates of (a) OUD treatments with and without telehealth support and (b) prescriptions for MOUD with and without telehealth support among individuals diagnosed with OUD.

Invited Commentary: On the Mathematization of Epidemiology as a Socially Engaged Quantitative Science.

Ensuring that patients with opioid use disorder (OUD) have access to optimal medication therapies is a critical challenge in substance use epidemiology. Rudolph et al. (Am J Epidemiol. 2023;XXX(X):XXXX-XXXX) demonstrated that sophisticated data-adaptive statistical techniques can be used to learn optimal, individualized treatment rules that can aid providers in choosing a medication treatment modality for a particular patient with OUD. This important work also highlights the effects of the mathematization of epidemiologic research. Here, we define mathematization and demonstrate how it operates in the context of effectiveness research on medications for OUD using the paper by Rudolph et al. as a springboard. In particular, we address the normative dimension of mathematization and how it tends to resolve a fundamental tension in epidemiologic practice between technical sophistication and public health considerations in favor of more technical solutions. The process of mathematization is a fundamental part of epidemiology; we argue not for eliminating it but for balancing mathematization and technical demands equally with practical and community-centric public health needs.

Exploring Barriers and Facilitators to Integrating a Harm Reduction Approach to Substance Use in Three Medical Settings.

BACKGROUND: Evidence suggests that harm reduction, a public health strategy aimed at reducing the negative consequences of a risky health behavior without requiring elimination of the behavior itself, may be a promising approach for minimizing drug-related harms while engaging individuals with substance use disorders (SUDs) in care. However, philosophical clashes between the medical and harm reduction models may pose barriers to adopting harm reduction approaches within medical settings. OBJECTIVE: To identify barriers and facilitators to implementing a harm reduction approach toward care within healthcare settings. We conducted semi-structured interviews with providers and staff at three integrated harm reduction and medical care sites in New York. DESIGN: Qualitative study using in-depth and semi-structured interviews. PARTICIPANTS: Twenty staff and providers across three integrated harm reduction and medical care sites across New York state. APPROACH: Interview questions focused on how harm reduction approaches were implemented and demonstrated in practice and barriers and facilitators to implementation, as well as questions based on the five domains of the Consolidated Framework for Implementation Research (CFIR). KEY RESULTS: We identified three key barriers to the adoption of the harm reduction approach that surrounded resource constraints, provider burnout, and interacting with external providers that do not have a harm reduction orientation. We also identified three facilitators to implementation, which included ongoing training both within and external to the clinic, team-based and interdisciplinary care, and affiliations with a larger healthcare system. CONCLUSIONS: This study demonstrated that while multiple barriers to implementing harm reduction informed medical care existed, health system leaders can adopt practices to mitigate barriers to adoption, such as value-based reimbursement models and holistic models of care that address the full spectrum of patient needs.

Total cost of care associated with opioid use disorder treatment.

The opioid epidemic in the United States disproportionately affects Medicaid beneficiaries than other groups. This results in a significant financial burden on state Medicaid programs. In this analysis, we investigate the association of medication for opioid use disorder (MOUD) treatment initiation and linkage to ongoing care on overall healthcare costs of Medicaid Fee-for-Service patients. We conducted a retrospective study among adult patients diagnosed with opioid use disorder (OUD) and who had a clinical encounter at a safety-net institution in Denver Colorado in 2020. Three categories of MOUD status of patients were defined: 1) identified with OUD but did not receive MOUD; 2) initiated MOUD but not linked to ongoing treatment and 3) received MOUD and linked to ongoing treatment. Our outcome variable was per-member per-month total healthcare cost. We estimated a multivariable model to test the association between healthcare cost and MOUD status, while controlling for demographic and risk classification variables. We found that in individuals with OUD who initiated MOUD treatment but were not linked to ongoing care had the highest healthcare cost, while those who were linked to ongoing MOUD treatment had the lowest healthcare cost. MOUD treatment is not only effective at addressing the significant morbidity and mortality burden of OUD but also associated with decreased financial cost, which is disproportionately incurred by Medicaid. Additional policy and care delivery changes are needed to focus efforts to improve linkage to ongoing treatment.

A call to action: Contingency management to improve post-release treatment engagement among people with opioid use disorder who are incarcerated.

People with opioid use disorder (OUD) are overrepresented in US correctional facilities and experience disproportionately high risk for illicit opioid use and overdose after release. A growing number of correctional facilities offer medication for OUD (MOUD), which is effective in reducing these risks. However, a recent evaluation found that <50% of those prescribed MOUD during incarceration continued MOUD within 30 days after release, demonstrating a need to improve post-release continuity of care. We describe available evidence on contingency management (CM), an intervention wherein patients receive incentives contingent on behavior change, to achieve this goal. A prior systematic review reported strong evidence in support of CM for increasing treatment adherence in MOUD programs, but the trials reviewed did not include incarcerated participants. Research on CM to increase treatment adherence among participants in the criminal justice system is limited with mixed findings. However, in comparison to the trials that supported CM's efficacy in the community, CM trials in the criminal justice system provided smaller rewards with greater delays in the delivery of rewards to patients, which likely contributed to null findings. Indeed, a prior meta-analysis demonstrates a dose-response relationship between the magnitude and immediacy of reward and CM effectiveness. Thus, CM involving larger and more immediately delivered rewards are likely necessary to improve MOUD adherence during the critical period following release from incarceration. Future research on the effectiveness and implementation of CM to improve MOUD retention after release from incarceration is warranted.

Rationale, evidence, and steps for implementation of medication for opioid use disorder treatment programs in HIV primary care settings.

As the opioid crisis continues to escalate, the management of patients with opioid use disorder has crossed over to the care of patients with chronic infectious diseases, specifically HIV, HBV, and HCV, typically managed in the primary care setting. Consensus guidelines recommend testing for HIV and hepatitis in persons who inject drugs at least annually, but high-risk sexual activity may put other patients at risk as well. Significant barriers to robust care of these patient populations include low rates of HIV and hepatitis testing, limited access to methadone treatment programs, lack of widespread knowledge of how to prescribe office-based opioid treatment, and ongoing stigma surrounding prescribing of HIV treatment and prophylaxis medications. Clinical pharmacists across ambulatory, infectious diseases, and opioid stewardship specialties have the opportunity to play a key role in the implementation and support of harm reduction and medication for opioid use disorder services in the outpatient setting. The goal of this article is to discuss the rationale and evidence for these services and provide a framework for implementation.

Variability in opioid use disorder clinical presentations and treatment in the emergency department: A mixed-methods study.

BACKGROUND: There is strong evidence for emergency department (ED)-initiated treatment of opioid use disorder (OUD). However, implementation is variable, and ED management of OUD may differ by clinical presentation. Our aim was to use mixed methods to explore variation in ED-based OUD care by patient clinical presentation and understand barriers and facilitators to ED implementation of OUD treatment across scenarios. METHODS: We analyzed treatment outcomes in OUD-related visits within three urban, academic EDs from 12/2018 to 7/2020 following the implementation of interventions to increase ED-initiated OUD treatment. We assessed differences in treatment with medications for OUD (MOUDs) by clinical presentation (overdose, withdrawal, others). These data were integrated with results from 5 focus groups conducted with 28 ED physicians and nurses January to April 2020 to provide a richer understanding of clinician perspectives on caring for ED patients with OUD. RESULTS: Of the 1339 total opioid-related visits, there were 265 (20%) visits for overdose, 123 (9%) for withdrawal, and 951 (71%) for other OUD-related conditions. 23% of patients received MOUDs during their visit or at discharge. Treatment with MOUDs was least common in overdose presentations (6%) and most common in withdrawal presentations (69%, p < 0.001). Buprenorphine was prescribed at discharge in 15% of visits, including 42% of withdrawal visits, 14% of other OUD-related visits, and 5% of overdose visits (p < 0.001). In focus groups, clinicians highlighted variation in ED presentations among patients with OUD. Clinicians also highlighted key aspects necessary for successful treatment initiation including perceived patient receptivity, provider confidence, and patient clinical readiness. CONCLUSIONS: ED-based treatment of OUD differed by clinical presentation. Clinician focus groups identified several areas where targeted guidance or novel approaches may improve current practices. These results highlight the need for tailored clinical guidance and can inform health system and policy interventions seeking to increase ED-initiated treatment for OUD.

Patient Engagement in a Multimodal Digital Phenotyping Study of Opioid Use Disorder.

BACKGROUND: Multiple digital data sources can capture moment-to-moment information to advance a robust understanding of opioid use disorder (OUD) behavior, ultimately creating a digital phenotype for each patient. This information can lead to individualized interventions to improve treatment for OUD. OBJECTIVE: The aim is to examine patient engagement with multiple digital phenotyping methods among patients receiving buprenorphine medication for OUD. METHODS: The study enrolled 65 patients receiving buprenorphine for OUD between June 2020 and January 2021 from 4 addiction medicine programs in an integrated health care delivery system in Northern California. Ecological momentary assessment (EMA), sensor data, and social media data were collected by smartphone, smartwatch, and social media platforms over a 12-week period. Primary engagement outcomes were meeting measures of minimum phone carry (≥8 hours per day) and watch wear (≥18 hours per day) criteria, EMA response rates, social media consent rate, and data sparsity. Descriptive analyses, bivariate, and trend tests were performed. RESULTS: The participants' average age was 37 years, 47% of them were female, and 71% of them were White. On average, participants met phone carrying criteria on 94% of study days, met watch wearing criteria on 74% of days, and wore the watch to sleep on 77% of days. The mean EMA response rate was 70%, declining from 83% to 56% from week 1 to week 12. Among participants with social media accounts, 88% of them consented to providing data; of them, 55% of Facebook, 54% of Instagram, and 57% of Twitter participants provided data. The amount of social media data available varied widely across participants. No differences by age, sex, race, or ethnicity were observed for any outcomes. CONCLUSIONS: To our knowledge, this is the first study to capture these 3 digital data sources in this clinical population. Our findings demonstrate that patients receiving buprenorphine treatment for OUD had generally high engagement with multiple digital phenotyping data sources, but this was more limited for the social media data. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.3389/fpsyt.2022.871916.

The rising threat of illicit amphetamine-type stimulant use among methadone maintenance treatment patients in East Coast Malaysia: a retrospective observational study.

Background: In recent years, amphetamine-type-stimulants (ATS) have been extensively misused in South-East Asia, inducing major problems among methadone-maintenance-treatment (MMT) patients.Objective: We examine ATS-misuse prevalence and its determinants among MMT patients in East-Coast-Malaysia.Methods: A retrospective-observational study was conducted on government-subsidized medication for opioid-use-disorder (MOUD) treatment clinics involving 292 MMT-patients (98% males) who were selected using a multilevel-proportional-stratified random sampling technique. Information obtained during the mandatory monitoring procedure from January 1 to December 31 2019, was utilized to determine ATS misuse prevalence from consecutive random urine drug screening. The determinants associated with its use, namely sociodemographics, social networks, comorbidities, and pharmacological assessments were analyzed via a logistic model.Results: Overall, 52.2% of the MMT-patients (95% CI: 0.42-0.54) had misused ATS at least once during their methadone treatment. These misusing patients were active smokers, hepatitis B and C seronegative, concurrently misused opioids, and had received suboptimum prescribed doses of methadone. Multiple logistic regression analysis demonstrated that the odds of misusing ATS during methadone treatment were 37 times higher among those who concurrently misused opioids (AOR: 37.60, 95% CI: 14.03-100.74) and 12 times higher among those who received suboptimal methadone doses (<60 mg/day) (AOR: 12.24, 95% CI: 5.58-25.43).Conclusion: This study demonstrated the significant prevalence of ATS misuse among MMT-patients in East-Coast-Malaysia, especially among patients who were prescribed suboptimal doses of methadone and/or demonstrated concomitant opioid-misuse. Stringent urine-monitoring is crucial to prevent diversion to ATS misuse. Nonetheless, to avoid negligence and improve physician engagement, the relevant authorities should immediately plan a comprehensive national-standard training module comprising support activities for professional methadone-prescribers.

Ultrasound-guided phlebotomy in primary care for people who inject drugs.

OBJECTIVES: Persons who inject drugs (PWID) commonly experience venous degradation as a complication of prolonged injection, which makes routine phlebotomy difficult. Clients may decline care due to the perceived lack of skilled phlebotomy services, and this contributes to significant delays in infectious disease screening and treatment. In this study, we investigated ultrasound-guided phlebotomy in clients with difficult venous access receiving care at two low-threshold buprenorphine clinics. Our objectives were to increase the accuracy of vascular access, expedite infectious disease treatment for hepatitis C virus (HCV) and human immunodeficiency virus (HIV), and increase client satisfaction with phlebotomy services. METHODS: PWID who declined routine phlebotomy at two clinic sites were offered ultrasound-guided vascular access by a trained clinician. Participants completed a survey to collect data regarding acceptability of the intervention. RESULTS: Throughout a 14-month period, 17 participants were enrolled. Of the total 30 procedures, 41.2% of clients returned for more than one phlebotomy visit, and 88.2% of clients achieved vascular access within 1 attempt. Of participating clients, 52.9% described themselves as having difficult venous access and at conclusion of the study, 58.8% expressed more willingness to have phlebotomy performed with an ultrasound device. CONCLUSIONS: Offering ultrasound-guided phlebotomy for PWID with difficult venous access resulted in decreased access attempts, increased patient satisfaction, and expedited screening and treatment for HIV and HCV point-of-care ultrasound technology is an effective approach to improving care for persons who inject drugs.

Barriers to Assessing and Treating Trauma in Primary Care and Opportunities for Improvement: Perspectives from Prescribers of Medications for Opioid Use Disorder.

Background: Medication for Opioid Use Disorder (MOUD) is a best practice for treating individuals with opioid use disorder (OUD), and primary care-based MOUD management can reduce treatment barriers among OUD patients. Individuals with OUD experience disproportionately high rates of trauma and violence, highlighting the importance of addressing trauma, mental health, and substance use concurrently. However, clear guidelines for trauma-informed treatment in a primary care setting remain poorly established. Methods: A qualitative approach was engaged to explore primary care providers' perceptions of barriers and facilitators to assessing and treating trauma among MOUD patients. Twenty in-depth interviews were conducted in 2021 with Baltimore-based MOUD prescribers, including primary care physicians and nurse practitioners. Interview questions assessed experiences with identifying and treating trauma among MOUD patients, including challenges and opportunities. Results: Providers reported extensive histories of trauma experienced by MOUD patients. Barriers to addressing trauma include a lack of standardized protocols/procedures for identifying trauma, insufficient training/time to assess and treat trauma, and the limited availability of external mental health providers and specialty services. Opportunities included building strong, mutually respectful patient-provider relationships, providing individualized, person-centered care, and establishing connections to coordinated multidisciplinary treatment networks. Conclusions: MOUD treatment within primary care is an important way to increase OUD treatment access, but clearer standards are needed for the treatment of trauma within this patient population. These findings demonstrate opportunities to improve standards and systems such that primary care providers are better equipped to assess and treat the complex histories of trauma experienced by individuals with OUD.

Treatment Initiation, Substance Use Trajectories, and the Social Determinants of Health in Persons Living With HIV Seeking Medication for Opioid Use Disorder.

BACKGROUND: People living with HIV and opioid use disorder (OUD) are disproportionally affected by adverse socio-structural exposures negatively affecting health, which have shown inconsistent associations with uptake of medications for OUD (MOUD). This study aimed to determine whether social determinants of health (SDOH) were associated with MOUD uptake and trajectories of substance use in a clinical trial of people seeking treatment. METHODS: Data are from a 2018 to 2019 randomized trial comparing the effectiveness of different MOUD to achieve viral suppression among people living with HIV and OUD. SDOH were defined by variables mapping to Healthy People 2030 domains: education (Education Access and Quality), income (Economic Stability), homelessness (Neighborhood and Built Environment), criminal justice involvement (Social and Community Context), and recent SUD care (Health Care Access and Quality). Associations between SDOH and MOUD initiation were assessed with Cox proportional hazards models, and SDOH and substance use over time with generalized estimating equation models. RESULTS: Participants (N = 114) averaged 47 years old, 63% were male, 56% were Black, and 12% Hispanic. Participants reported an average of 2.3 out of 5 positive SDOH indicators (SD = 1.2). Stable housing was the most commonly reported SDOH (61%), followed by no recent criminal justice involvement (59%), having a high-school level education or greater (56%), income stability (45%), and recent SUD care (13%). Each additional favorable SDOH was associated with a 25% increase in the likelihood of MOUD initiation during the study period [adjusted HR = 1.25, 95% CI = (1.01, 1.55), P = .044]. Positive SDOH were also associated with a decrease in the odds of baseline opioid use and a greater reduction in opioid use during subsequent weeks of the study (P < .001 for a joint test of baseline and slope differences). CONCLUSIONS: Positive social determinants of health, in aggregate, may increase the likelihood of MOUD treatment initiation among people living with HIV and OUD.

METHADONE INITIATION IN THE EMERGENCY DEPARTMENT FOR OPIOID USE DISORDER: A CASE SERIES.

BACKGROUND: In an era of fentanyl and continually rising rates of opioid overdose deaths, increasing access to evidence-based treatment for opioid use disorder (OUD) should be prioritized. Emergency department (ED) buprenorphine initiation for patients with OUD is considered best-practice. Methadone, though also evidence-based and effective, is under-utilized due to strict federal regulation, significant stigma, and lack of physician training. We describe the novel utilization of CFR Title 21 1306.07 (b), also known as the "72-hour rule," to initiate methadone for OUD in the ED. CASE SERIES: We describe the cases of 3 patients with a history of OUD who were initiated on methadone for OUD in the ED, linked to an opioid treatment program, and attended an intake appointment. Why Should an Emergency Physician Be Aware of This? The ED can be a crucial point of intervention for vulnerable patients with OUD who may not interact with the health care system in other settings. Methadone and buprenorphine are both first-line options for medication for OUD, and methadone may be preferred in patients who have been unsuccessful with buprenorphine in the past or those at higher risk of treatment dropout. Patients may also prefer methadone to buprenorphine based on previous experience or understanding of the medications. ED physicians may utilize the "72-hour rule" to administer and initiate methadone for up to 3 consecutive days while arranging referral to treatment. EDs can develop methadone initiation and bridge programs utilizing similar strategies to those that have been described in developing buprenorphine programs.

Centering culture in the treatment of opioid use disorder with American Indian and Alaska Native Communities: Contributions from a National Collaborative Board.

American Indian/Alaska Native (AI/AN) communities are disproportionally impacted by the opioid overdose epidemic. There remains a dearth of research evaluating methods for effectively implementing treatments for opioid use disorder (OUD) within these communities. We describe proceedings from a 2-day Collaborative Board (CB) meeting tasked with developing an implementation intervention for AI/AN clinical programs to improve the delivery of medications to treat OUD (MOUD). The CB was comprised of Elders, cultural leaders, providers, individuals with lived experience with OUD, and researchers from over 25 communities, organizations, and academic institutions. Conversations were audio-recorded, transcribed, and coded by two academic researchers with interpretation oversight provided by the CB. These proceedings provided a foundation for ongoing CB work and a frame for developing the program-level implementation intervention using a strength-based and holistic model of OUD recovery and wellbeing. Topics of discussion posed to the CB included engagement and recovery strategies, integration of extended family traditions, and addressing stigma and building trust with providers and clients. Integration of traditional healing practices, ceremonies, and other cultural practices was recommended. The importance of centering AI/AN culture and involving family were highlighted as priorities for the intervention.