"Narcan encounters:" overdose and naloxone rescue experiences among people who use opioids.

BACKGROUND: Communities across the United States are confronting the precipitous rise in opioid overdose fatalities that has occurred over the past decade. Naloxone, an opioid antagonist, is a safe rescue medication that laypeople can administer to reverse an overdose. Community naloxone training programs have been well-documented. Less is known about overdose survivors' subjective experiences with naloxone reversal and its impacts on drug use behavior.Methods: Semi-structured interviews were conducted with 35 community-dwelling adults who had been reversed at least once with naloxone. Inductive thematic content analysis incorporating Atlas.ti software was used to identify themes.Results: Four broad thematic categories were identified. (1) Overdose experience and memory: Most participants remembered taking the drugs one minute and waking up the next-sometimes in different surroundings; (2) Naloxone rescue-waking up: Participants described acute withdrawal symptoms, disorientation, and volatile emotions; (3) Reasons for overdose: Polypharmacy; changes in opioid tolerance, or presence of fentanyl were the most common explanations. (4) Impacts of naloxone rescue: A variety of contextual factors influenced participants' responses to naloxone rescue, especially acute withdrawal symptoms. While some participants altered or tempered their opioid use, others resumed opioid use-especially to mitigate withdrawal. Participants overwhelmingly emphasized that naloxone saved their lives.Conclusion: Results suggest that a naloxone rescue may not be a wake-up call for many people who use opioids, but access to naloxone is an effective overdose harm reduction option, supporting its widespread implementation. The study findings underscore the importance of ongoing community overdose prevention and harm reduction initiatives, including take-home naloxone (THN) and medication assisted treatment in the Emergency Department.

Treatment Experiences Among People Who Use Opioids: A Social Ecological Approach.

The prevalence of opioid use disorder (OUD) and surge in overdose deaths remain key public health concerns. Despite evidence supporting the efficaciousness of medications for opioid use disorder, most people with OUD do not receive treatment. In this qualitative study, semi-structured interviews were conducted with 35 adults in a northeastern city to learn about their experiences with substance use treatment. Qualitative data were analyzed using an inductive thematic content analysis approach, and a social ecological model was applied to examine contextual factors affecting participants' experiences accessing and engaging in treatment. While we organized our findings following the individual, interpersonal, community, and society levels of the socio-ecological model, we also observed overlap and interconnectedness between and across these levels. Our findings suggest that retention in treatment often depends upon personal motivation, treatment availability, the match of the treatment modality to an individual's needs, and social support. A person-centered approach is needed to promote individualized care and tailor treatment components to the patient's needs.

A parenting education program for women in treatment for opioid-use disorder at an outpatient medical practice.

Opioid use during pregnancy poses serious risks for the mother and the unborn child. Opioid-use disorder may be managed with medication-assisted treatment (MAT) in an outpatient setting, but few MAT practices specifically address the challenges faced by pregnant women. This article describes a medical office-based educational support group for women in MAT for opioid-use disorder who were pregnant and/or parenting young children. Focus groups were conducted to elicit patient feedback. Women indicated that they found the educational support groups beneficial and offered suggestions. In-office educational support groups for pregnant women in treatment for opioid-use disorder are feasible and well received.

"Living well with diabetes": evaluation of a pilot program to promote diabetes prevention and self-management in a medically underserved community.

A substantial disparity exists in the prevalence and effective self-management of diabetes among African Americans in the United States. Community-level programs have the potential to affect self-efficacy and may be helpful in overcoming common barriers to self-management. The Neighborhood Health Talker Program used community members trained as cultural health brokers to engage their communities in conversations about "living diabetes well." Program evaluators used mixed methods to analyze post-conversation surveys and Health Talker field notes. These indicated an increase in diabetes-related knowledge and increased confidence among conversation participants. Conversations included discussion of barriers and facilitators to lifestyle changes and effective self-management that are frequently overlooked in a clinical setting.

Longitudinal trajectories in recovery capital and associations with substance use among adult drug treatment court clients.

BACKGROUND: Recovery capital (RC) refers to the resources individuals use to support substance use disorder (SUD) recovery. Individuals with SUD who are involved with the criminal justice system often have limited RC. Drug treatment courts (DTCs), including traditional drug treatment courts (tDTCs) and opioid intervention courts (OICs), can link clients to important sources of RC in the short-term, but few studies have assessed RC longitudinally. METHODS: The current study analyzed five waves of data from a one-year longitudinal study on substance use and RC collected from clients of tDTCs and OICs (n=165, 52% male, 75% non-Hispanic White, Age=21-67 years). Mixed-effects models examined (1) within-person trends over time in RC, (2) individual characteristics associated with differences and changes in RC, and (3) patterns of relationships between RC and substance use over time. We also tested differences by court type. RESULTS: First, OIC participants had lower RC at baseline relative to tDTC participants, and there was considerable within-person variability in RC over time. Second, the effect of a high school diploma/GED at baseline on RC change over time was greater for OIC relative to tDTC participants. Third, there was a negative concurrent within-person association between drug use and RC that became stronger over time for OIC relative to tDTC participants. CONCLUSIONS: This study is among the first to examine longitudinal, within-person trajectories in RC. Results revealed important within-person variability over time in RC that was linked to education and drug use, particularly among OIC clients. Findings could help inform DTC treatment approaches.

Implementing a Novel Statewide Network to Support Emergency Department-initiated Buprenorphine Treatment.

INTRODUCTION: Medications for opioid use disorder (MOUD), including buprenorphine, represent an evidence-based treatment that supports long-term recovery and reduces risk of overdose death. Patients in crisis from opioid use disorder (OUD) often seek care from emergency departments (ED). The New York Medication for Addiction Treatment and Electronic Referrals (MATTERS) network is designed to support ED-initiated buprenorphine and urgent referrals to long-term care for patients suffering from OUD. METHODS: Using the PRECEDE-PROCEED implementation science framework, we provide an overview of the creation of the MATTERS network in Western New York. We also include an explanation of how the network was designed and launched as a response to the opioid epidemic. Finally, we analyzed the program's outputs and outcomes, thus far, as it continues to grow across the state. RESULTS: The New York MATTERS network was created and implemented in 2019 with a single hospital referring patients with OUD to three local clinics. In the social assessment and situational analysis phase, we describe the opioid epidemic and available resources in the region at the outset of the program. In the epidemiological assessment phase, we quantify the epidemic on the state and regional levels. In the educational and ecological assessment, we review local ED practices and resources. In the administrative and policy assessment and intervention alignment phase, the program's unique framework is reviewed. In the piloting phase, we describe the initial deployment of New York MATTERS. Finally, in the process evaluation phase, we depict the early lessons we learned. By the beginning of 2021, the New York MATTERS network included 35 hospitals that refer to 47 clinics throughout New York State. CONCLUSION: The New York MATTERS network provides a structured approach to reduce barriers to ED-initiated buprenorphine and urgent referral to long-term care. An implementation framework provides a structured means of evaluating this best practice model.

Challenges and Lessons Learned in the Regional Implementation of MISSION-CJ in Drug Treatment Courts.

This column discusses lessons learned during a regional implementation of the evidence-based MISSION-CJ (Maintaining Independence and Sobriety through Systems Integration, Outreach, and Networking-Criminal Justice) case management program across multiple drug treatment courts, including discussion of key components, implementation challenges encountered, and strategies that helped address these challenges. The authors' experiences may assist other programs in planning for similar implementations and suggest that programs can enhance success among drug court participants with the MISSION-CJ model but that the programs may need to be flexible with regard to implementation fidelity and to establishing and communicating their specific role within the court.

High prevalence of undetected vitamin D deficiency in an urban minority primary care practice.

OBJECTIVES: To assess the prevalence of vitamin D deficiency among patients in an inner-city practice with a large African American population, and to evaluate the efficacy of vitamin D replacement as part of routine care. METHODS: A chart review was undertaken to identify patients aged 18 years and more with at least one 25-hydroxyvitamin D level. When patients were found to be deficient (vitamin D < 20) they were placed on 50000 units ergocalciferol monthly or over-the-counter calcium supplements with vitamin D. Descriptive statistics were used to calculate the prevalence rate, and paired t tests were used to compare the vitamin D levels pre and post treatment. RESULTS: A total of 369 (65%) out of 570 patients were found to be vitamin D deficient, and 253 were treated with ergocalciferol or vitamin D supplements. For patients deficient at baseline and treated with vitamin D supplementation (n = 253), significant differences were found between baseline and follow-up vitamin D levels (t(1,120) = 11.56, p < .001). Among 253 patients deficient at baseline and treated, 201 were corrected with oral vitamin D (79%), leaving 52 patients (21%) deficient after vitamin D supplementation. CONCLUSIONS: The results of this study show that there is a very high prevalence of vitamin D deficiency in an urban, mostly African American population. This can be readily improved with the addition of oral vitamin D. The study also suggests that routine vitamin D screening may be helpful for the detection and treatment of vitamin D deficiency, especially in urban minority populations.

Metabolic syndrome and major depressive disorder: co-occurrence and pathophysiologic overlap.

The metabolic syndrome and its components are associated with depressive symptomatology. This article discusses the rate of co-occurrence and the points of pathophysiologic commonality between the metabolic syndrome and major depressive disorder.

A retrospective analysis of treatment and retention outcomes of pregnant and/or parenting women with opioid use disorder.

AIM: To determine factors associated with positive outcomes of buprenorphine maintenance treatment for opioid use disorder among pregnant women and women with children under the age of five years. METHODS: This retrospective, de-identified electronic health record review of a cohort of 108 female patients at a suburban primary care outpatient clinic followed patients for one year of treatment at the clinic. Positive outcomes were defined as 1) treatment retention and 2) urine toxicology at 12 months free of all substances other than buprenorphine. This study also evaluated a variety of potential correlates of treatment retention and toxicology, including patient demographics, medical and social history, and clinical factors (i.e., participation in a women's group and assigned treatment provider). RESULTS: Patient retention was 73.2% at 12 months. Compared to those retained in treatment, patients not retained were more likely to have received past treatment for a psychiatric illness (65.4% vs. 38.2%; p < 0.02) or have prior criminal history of a misdemeanor conviction (56.0% vs. 27.9%; p < 0.02). There was a significant association between time in treatment and reduction in opiate use (p < 0.01). CONCLUSIONS: In this population, certain baseline characteristics were predictive of failure to be retained in treatment. As such, specific patients may need more intensive treatment. These findings have important public health and child welfare implications and may offer insight for providers to tailor treatment and refer for comprehensive services.

Atypical depression, somatic depression and anxious depression in women: are they gender-preferred phenotypes?

BACKGROUND: Both depression and anxiety disorders affect women at rates significantly greater than men. Women also have a documented higher frequency of comorbid depression and anxiety disorders, and a three-fold higher prevalence of atypical depression. HYPOTHESES: These gender differences are mainly due to specific depressive phenotypes including anxious depression and atypical depression. The prevalence of comorbid anxiety and depression strongly suggests overlap of pathophysiological mechanisms-which in women are also affected by fluctuations in gonadal hormones. Similar efficacy of serotonergic antidepressants as treatment for anxiety disorders as well as depressions further underscores the blurred boundaries between these two descriptive entities. CONCLUSIONS: Symptoms of depression and anxiety may be a departure point for differential diagnosis in which dimensionally-based phenotypes substantiated by pathobiology would replace current descriptive entities. It is suggested that at least some biologically-based dysphorias may be specific to women, ensuing from the combination of specific vulnerabilities, and complex interactions between brain mechanisms and gonadal hormones.

An adaptation of the diabetes prevention program for use with high-risk, minority patients with type 2 diabetes.

PURPOSE: The purpose of this pilot study was to determine the effectiveness of an edited Diabetes Prevention Program (DPP) Lifestyle Resources Core Teaching Plan for managing patients with type 2 diabetes in an urban underserved setting. Modifications were made to attempt to cut to the bare essentials to work within the constrained budgets of safety net providers. The primary aim was to achieve a mean absolute reduction in HbA1c level of 1 percentage point. METHODS: The authors conducted a randomized controlled trial of 9 months' duration for patients with type 2 diabetes with an HbA1c>or=8.0%. A total of 67 patients randomized into usual-care and case management groups were evaluated with an intention-to-treat analysis. A modified DPP workbook was used during 7 monthly visits with a nurse case manager. RESULTS: As compared with the usual-care group, those in the case management group experienced a greater reduction in HbA1c level (-1.87 vs -0.54; P=.011) and weight (-2.47 kg vs +0.88 kg; P=.011). CONCLUSION: Use of an edited version of the DPP workbook in an urban, low-income, minority population with type 2 diabetesproduced a significant absolute reduction in HbA1c percentage and weight.

Facilitating quality improvement in physician management of comorbid chronic disease in an urban minority practice.

CONTEXT: Increasing numbers of patients with multiple chronic conditions present in the primary care setting and pose a challenge to physicians who must cope with competing demands while adhering to clinical practice guidelines. PURPOSE: We tested a chart audit tool to assess how physicians are managing patients with multiple comorbidities in an inner-city family medicine practice serving minority patients. METHODS: We developed an evidence-based comorbidity chart audit tool that captures the number of diagnosed, coexisting general medical conditions and adherence to key clinical practice guidelines for each condition. A randomized chart audit was undertaken, with one in every five charts selected, yielding a total of 314 patient charts. FINDINGS: The majority of patients (59%) had > or = 2 comorbid chronic conditions, and 32% had > or = 3 comorbid chronic conditions. The highest overall adherence to guidelines was for chronic obstructive pulmonary disease (90%) and asthma (80%), followed by congestive heart failure (75%) and coronary artery disease (58%). For all other conditions, overall adherence to guidelines was < or = 50%. CONCLUSIONS: The chart review tool identified inconsistencies in adherence to guidelines across multiple diagnosed conditions, suggesting the importance of adopting a patient-centered approach to management as well as prevention.

The impacts of subsidized health insurance on employees' use of preventive health services.

This study presents an uncontrolled preliminary evaluation of a pilot health insurance subsidy program and addresses whether provision of subsidized insurance that required employee contribution had an impact upon preventive health utilization among small businesses and their employees. Self-report questionnaires were mailed to the employees; these included questions on use of preventive health services before and after enrollment in the subsidy program. The analysis was stratified by self-reported prior enrollment in an insurance program to compare employees with and without prior health insurance. The findings suggest significant increases in health service utilization among the previously uninsured. Regular checkups more than doubled (p < .0001), as did the number of individuals receiving regular blood work (p < .0001). Nearly twice the number of individuals filled regular prescriptions after enrollment in the subsidy program as compared with before (p < .0001). This study suggests that employees of small businesses are willing to contribute to the cost of a health insurance premium, and once insured are more likely to use preventive services. A model of shared cost responsibility is an effective way to provide affordable insurance to small-business employees, thus increasing preventive services in these populations.

Nurse perspectives on the implementation of routine telemonitoring for high-risk diabetes patients in a primary care setting.

Aims The purpose of this qualitative evaluation was to explore the experience of implementing routine telemonitoring (TM) in real-world primary care settings from the perspective of those delivering the intervention; namely the TM staff, and report on lessons learned that could inform future projects of this type. BACKGROUND: Routine TM for high-risk patients within primary care practices may help improve chronic disease control and reduce complications, including unnecessary hospital admissions. However, little is known about how to integrate routine TM in busy primary care practices. A TM pilot for diabetic patients was attempted in six primary care practices as part of the Beacon Community in Western New York. METHODS: Semi-structured interviews were conducted with representatives of three TM agencies (n=8) participating in the pilot. Interviews were conducted over the phone or in person and lasted ~30 min. Interviews were audio-taped and transcribed. Analysis was conducted using immersion-crystallization to identify themes. Findings TM staff revealed several themes related to the experience of delivering TM in real-world primary care: (1) the nurse-patient relationship is central to a successful TM experience, (2) TM is a useful tool for understanding socio-economic context and its impact on patients' health, (3) TM staff anecdotally report important potential impacts on patient health, and (4) integrating TM into primary care practices needs to be planned carefully. CONCLUSIONS: This qualitative study identified challenges and unexpected benefits that might inform future efforts. Communication and integration between the TM agency and the practice, including the designation of a point person within the office to coordinate TM and help address the broader contextual needs of patients, are important considerations for future implementation. The role of the TM nurse in developing trust with patients and uncovering the social and economic context within which patients manage their diabetes was an unexpected benefit.

Extracting Deep Phenotypes for Chronic Kidney Disease Using Electronic Health Records.

INTRODUCTION: As chronic kidney disease (CKD) is among the most prevalent chronic diseases in the world with various rate of progression among patients, identifying its phenotypic subtypes is important for improving risk stratification and providing more targeted therapy and specific treatments for patients having different trajectories of the disease progression. PROBLEM DEFINITION AND DATA: The rapid growth and adoption of electronic health records (EHR) technology has created a unique opportunity to leverage the abundant clinical data, available as EHRs, to find meaningful phenotypic subtypes for CKD. In this study, we focus on extracting disease severity profiles for CKD while accounting for other confounding factors. PROBABILISTIC SUBTYPING MODEL: We employ a probabilistic model to identify precise phenotypes from EHR data of patients who have chronic kidney disease. Using this model, patient's eGFR trajectory is decomposed as a combination of four different components including disease subtype effect, covariate effect, individual long-term effect and individual short-term effect. EXPERIMENTAL RESULTS: The discovered disease subtypes obtained by Probabilistic Subtyping Model for CKD are presented and their clinical relevance is analyzed. DISCUSSION: Several clinical health markers that were found associated with disease subtypes are presented with suggestion for further investigation on their use as risk predictors. Several assumptions in the study are also clarified and discussed. CONCLUSION: The large dataset of EHRs can be used to identify deep phenotypes retrospectively. Directions for further expansion of the model are also discussed.

Developing a Smoking Cessation Intervention for Low Income and Minority Women.

OBJECTIVE: The objective of this qualitative pilot study was to elicit patient and provider feedback on how to develop a smoking cessation program for low income women with cervical dysplasia in an urban Women's Health Center. METHODS: A community-based participatory research project incorporating a focus group and structured interviews was utilized to elicit feedback on how to develop a culturally appropriate smoking cessation program appealing to low-income and minority women smokers. RESULTS: Qualitative data from 13 patients, 4 nurses, and 6 staff members collected between January 2012-August 2012 described the challenges of finding effective mechanisms for cessation interventions that met the schedules and needs of low income and minority patients. Input from office staff indicated insufficient educational resources to offer patients, limited skills to assist patients and the importance of perceived patient readiness to quit as barriers to creating an effective smoking cessation program. CONCLUSION: Smoking cessation services targeting low-income and minority female smokers can be enhanced by providing clinic staff with patient education materials and smoking cessation training.

Chronic Kidney Disease Guideline Implementation in Primary Care: A Qualitative Report from the TRANSLATE CKD Study.

BACKGROUND: Primary care physicians (PCPs) are optimally situated to identify and manage early stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national, mixed-methods, cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. METHODS: As part of the mixed-methods process evaluation, semistructured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the 4 domains of Normalization Process Theory (NPT). RESULTS: Identified themes illuminated the complex work undertaken to manage CKD in primary care practices. Barriers to guideline implementation were identified in each of the 4 NPT domains, including (1) lack of knowledge and understanding around CKD (coherence), (2) difficulties engaging providers and patients in CKD management (cognitive participation), (3) limited time and competing demands (collective action), and (4) challenges obtaining and using data to monitor progress (reflexive monitoring). CONCLUSIONS: Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care.