Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study.

BACKGROUND: Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients. METHODS: We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics. RESULTS: There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation. CONCLUSIONS: Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.

Radical hospitality: Innovative programming to build community and meet the needs of people who use drugs at a government-sanctioned overdose prevention site in San Francisco, California.

BACKGROUND: The Tenderloin Center (TLC), a multi-service center where people could receive or be connected to basic needs, behavioral health care, housing, and medical services, was open in San Francisco for 46 weeks in 2022. Within a week of operation, services expanded to include an overdose prevention site (OPS), also known as safe consumption site. OPSs have operated internationally for over three decades, but government-sanctioned OPSs have only recently been implemented in the United States. We used ethnographic methods to understand the ways in which a sanctioned OPS, situated in a multi-service center, impacts the lives of people who use drugs (PWUD). METHODS: We conducted participant observation and in-depth interviews June-December 2022. Extensive field notes and 39 in-depth interviews with 24 TLC guests and 15 TLC staff were analyzed using an inductive analysis approach. Interviewees were asked detailed questions about their experiences using and working at the TLC. RESULTS: TLC guests and staff described an atmosphere where radical hospitality-welcoming guests with extraordinary warmth, generosity, and unconditional acceptance-was central to the culture. We found that the co-location of an OPS within a multi-service agency (1) allowed for the culture of radical hospitality to flourish, (2) yielded a convenient one-stop shop model, (3) created a space for community building, and (4) offered safety and respite to guests. CONCLUSIONS: The co-location of an OPS within a multi-service drop-in center is an important example of how such an organization can build positive sociality among PWUD while protecting autonomy and reducing overdose mortality. Overdose response and reversal is an act of relational accountability in which friends, peers, and even strangers intervene to protect and revive one another. This powerful intervention was operationalized as an anti-oppressive, horizontal activity through radical hospitality with a built environment that allowed PWUD to be both social and safe.

Loneliness among homeless-experienced older adults with cognitive or functional impairments: qualitative findings from the HOPE HOME study.

BACKGROUND: Loneliness is more common in older adults and those who face structural vulnerabilities, including homelessness. The homeless population is aging in the United States; now, 48% of single homeless adults are 50 and older. We know little about loneliness among older adults who have experienced homelessness. We aimed to describe the loneliness experience among homeless-experienced older adults with cognitive and functional impairments and the individual, social, and structural conditions that shaped these loneliness experiences. METHODS: We purposively sampled 22 older adults from the HOPE HOME study, a longitudinal cohort study among adults aged 50 years or older experiencing homelessness in Oakland, California. We conducted in-depth interviews about participants perceived social support and social isolation. We conducted qualitative content analysis. RESULTS: Twenty participants discussed loneliness experience, who had a median age of 57 and were mostly Black (80%) and men (65%). We developed a typology of participants' loneliness experience and explored the individual, social, and structural conditions under which each loneliness experience occurred. We categorized the loneliness experience into four groups: (1) "lonely- distressed", characterized by physical impairment and severe isolation; (2) "lonely- rather be isolated", reflecting deliberate social isolation as a result of trauma, marginalization and aging-related resignation; (3) "lonely- transient", as a result of aging, acceptance and grieving; and (4) "not lonely"- characterized by stability and connection despite having experienced homelessness. CONCLUSIONS: Loneliness is a complex and heterogenous social phenomenon, with homeless-experienced older adults with cognitive or functional impairments exhibiting diverse loneliness experiences based on their individual life circumstances and needs. While the most distressing loneliness experience occurred among those with physical impairment and mobility challenges, social and structural factors such as interpersonal and structural violence during homelessness shaped these experiences.

Using alone at home: What's missing in housing-based responses to the overdose crisis?

BACKGROUND: Against the backdrop of North America's overdose crisis, most overdose deaths are occurring in housing environments, largely due to individuals using drugs alone. Overdose deaths in cities remain concentrated in marginal housing environments (e.g., single-room occupancy housing, shelters), which are often the only forms of housing available to urban poor and drug-using communities. This commentary aims to highlight current housing-based overdose prevention interventions and to situate them within the broader environmental contexts of marginal housing. In doing so, we call attention to the need to better understand marginal housing as sites of overdose vulnerability and public health intervention to optimize responses to the overdose crisis. HARM REDUCTION AND OVERDOSE PREVENTION IN HOUSING: In response to high overdose rates in marginal housing environments several interventions (e.g., housing-based supervised consumption rooms, peer-witnessed injection) have recently been implemented in select jurisdictions. However, even with the growing recognition of marginal housing as a key intervention site, housing-based interventions have yet to be scaled up in a meaningful way. Further, there have been persistent challenges to tailoring these approaches to address dynamics within housing environments. Thus, while it is critical to expand coverage of housing-based interventions across marginal housing environments, these interventions must also attend to the contextual drivers of risks in these settings to best foster enabling environments for harm reduction and maximize impacts. CONCLUSION: Emerging housing-focused interventions are designed to address key drivers of overdose risk (e.g., using alone, toxic drug supply). Yet, broader contextual factors (e.g., drug criminalization, housing quality, gender) are equally critical factors that shape how structurally vulnerable people who use drugs navigate and engage with harm reduction interventions. A more comprehensive understanding of these contextual factors within housing environments is needed to inform policy and programmatic interventions that are responsive to the needs of people who use drugs in these settings.

Barriers and Facilitators to Resolving Older Adult Homelessness through Stays with Family: Qualitative findings from the HOPE HOME Study.

Living with family and friends is a common strategy used to prevent or exit homelessness, but little is known about structural barriers that impede family and friends' ability to provide temporary or permanent housing for older homeless adults. We conducted semi-structured interviews with 46 homeless participants from the HOPE HOME study, a cohort of 350 community-recruited homeless adults age 50 or older in Oakland, CA, who reported having stayed with housed family/friends for 1 or more nights in the prior 6 months. We conducted semi-structured interviews with 19 hosts of homeless participants and 11 stakeholders in housing and homelessness. We found that homeless older adults and hosts perceived staying with family or friends as a form of temporary housing rather than as a permanent exit to homelessness. Structural barriers to family and friends providing housing for temporary stays or permanent exits from homelessness included housing regulations restricting visitors and changing rent obligations; decreased eligibility and priority for shelter and permanent housing; geographic and transportation challenges; and environments inconducive to older adults. We suggest four areas for policy reform: providing subsidies to hosts and homeless individuals, removing disincentives for homeless older adults to stay with family, changing lease regulations, and expanding the supply of affordable housing.

Loneliness among older adults who have experienced homelessness: qualitative findings from the HOPE HOME study.

Background: Loneliness is more common in older adults and those who face structural vulnerabilities, including homelessness. The homeless population is aging. We know little about loneliness among older adults who have experienced homelessness. We aimed to describe the loneliness experience among older adults who have experienced homelessness and the individual, social, and structural conditions that shaped these loneliness experiences. Methods: We purposively sampled 22 older adults from the HOPE HOME study, a longitudinal cohort study among adults aged 50 years or older experiencing homelessness in Oakland, California. We conducted in-depth interviews about participants' perceived social support and social isolation. We conducted qualitative content analysis. Results: Twenty participants discussed loneliness experience, who had a median age of 57 and were mostly Black (80%) and men (65%). We developed a typology of participants' loneliness experience and explored the individual, social, and structural conditions under which each loneliness experience occurred. We categorized the loneliness experience into four groups: 1) "lonely - distressed", characterized by physical impairment and severe isolation; 2) "lonely - rather be isolated", reflecting deliberate social isolation as a result of trauma, marginalization and aging-related resignation; 3) "lonely - transient", as a result of aging, acceptance and grieving; and 4) "not lonely" - characterized by stability and connection despite having experienced homelessness. Conclusions: Loneliness is a complex and heterogenous social phenomenon, with older adults who have experienced homelessness exhibiting diverse loneliness experiences based on their individual life circumstances and needs. While the most distressing loneliness experience occurred among those with physical impairment and mobility challenges, social and structural factors such as interpersonal and structural violence during homelessness shaped these experiences.

"Get in and get out, get on with life": Patient and provider perspectives on methadone van implementation for opioid use disorder treatment.

BACKGROUND: Expanding access to opioid use disorder (OUD) treatment, including methadone, is imperative to address the US overdose crisis. In June 2021, the Drug Enforcement Administration announced new regulations allowing all opioid treatment programs (OTPs) to deploy mobile medication units, or methadone vans, to dispense OUD medication treatment outside of clinic walls, ending a 13-year moratorium. We conducted a qualitative study evaluating one opioid treatment program's experience, including benefits and challenges with implementing a methadone van, to inform future policy and clinical practice. METHODS: We recruited staff and patients receiving OUD medication treatment from an OTP in San Francisco, CA. The OTP had one operating van before March 2020 and began operating an additional van in response to COVID-19-related efforts to de-populate clinic settings. We interviewed 10 providers and 20 patients from August to November 2020. We transcribed, coded, and analyzed all interviews using modified grounded theory methodologies. RESULTS: Both patients and providers perceived significant benefits with receiving OUD medications using methadone vans. Patients preferred dosing at the van over the clinic because they were able to "get in and out" faster. Both staff and patients appreciated being able to use phone counseling to connect with counselors which helped reduce in-person visits and streamline workflows. Providers also noted van implementation challenges, including daily van set up, urine drug testing, and delivering counseling to patients who lacked phones. CONCLUSIONS: Eased restrictions on methadone van implementation represent a new strategy for expanding OUD treatment access. In our qualitative study, patients and staff were satisfied with methadone van implementation, though the OTP still faced implementation challenges. Audio-only counseling and other workflow solutions helped facilitate implementation, and several policy considerations like maintaining audio-only counseling flexibilities are key to ensuring future van success. Methadone vans offer the potential to expand treatment uptake, while prioritizing patient-centered care.

The intersection of drug use discrimination and racial discrimination in the management of chronic non-cancer pain in United States primary care safety-net clinics: Implications for healthcare system and clinic-level changes.

BACKGROUND: Clinicians' bias related to patients' race and substance use history play a role in pain management. However, patients' or clinicians' understandings about discriminatory practices and the structural factors that contribute to and exacerbate these practices are underexamined. We report on perceptions of discrimination from the perspectives of patients with chronic non-cancer pain (CNCP) and a history of substance use and their clinicians within the structural landscape of reductions in opioid prescribing in the United States. METHODS: We interviewed 46 clinicians and 94 patients, using semi-structured interview guides, from eight safety-net primary care clinics across the San Francisco Bay Area from 2013 to 2020. We used a modified grounded theory approach to code and analyze transcripts. RESULTS: Clinicians discussed using opioid prescribing guidelines with the goals of increased opioid safety and reduced bias in patient monitoring. While patients acknowledged the validity of clinicians' concerns about opioid safety, they indicated that clinicians made assumptions about opioid misuse towards Black patients and patients suspected of substance use. Clinicians discussed evidence of discrimination in opioid prescribing at the clinic-wide level; racialized stereotypes about patients likely to misuse opioids; and their own struggles to overcome discriminatory practices regarding CNCP management. CONCLUSION: While clinicians and patients acknowledged opioid safety concerns, the practical application of opioid prescribing guidelines impacted how patients perceived and engaged with CNCP care particularly for patients who are Black and/or report a history of substance use. We recommend healthcare system and clinic-level interventions that may remediate discriminatory practices and associated disparities.

"It's no foundation, there's no stabilization, you're just scattered": A qualitative study of the institutional circuit of recently-evicted people who use drugs.

People who use drugs (PWUD) commonly experience housing instability due to intersecting structural vulnerabilities (e.g., drug prohibition, discriminatory housing policies), and prejudicial or illegal evictions are common. In Vancouver, Canada, evictions have proliferated in the Downtown Eastside, a historically low-income neighbourhood with high rates of drug use and housing instability, resulting in many PWUD being evicted into homelessness. This study characterizes housing trajectories of recently-evicted PWUD through the lens of the institutional circuit of homelessness, and explores how wider contexts of structural vulnerability shape experiences within this. Qualitative interviews were conducted with PWUD recently evicted in the Downtown Eastside (<60 days). Peer research assistants recruited 58 PWUD through outreach activities. All PWUD participated in baseline interviews on the causes and contexts of evictions. Follow-up interviews were completed with 41 participants 3-6 months later, focusing on longer-term impacts of eviction, including housing trajectories. Most participants were evicted into homelessness, remaining so at follow-up. Participants described patterns of residential instability consisting of frequent cycling between shelters, streets, and kin-based networks. While participants normalized this cycling as characteristic of their marginalized social positions, narratives revealed how the demands of the institutional circuit deepened vulnerabilities and prolonged experiences of homelessness. Experiences were framed by participants' (in)ability to navigate survival needs (e.g., shelter, drug use), with tensions and trade-offs between needs increasing participants' and their peers' risks of harms. Constructions of agency further shaped experiences; accounts highlighted tensions between the control inherent to indoor spaces and participants' need for autonomy. Findings demonstrate how the demands of the institutional circuit foregrounded structural vulnerabilities to perpetuate cycles of instability. Interventions that address survival needs and preserve agency will be necessary to mitigate risks within the institutional circuit, in tandem with upstream interventions that target housing vulnerability and broader social-structural conditions (e.g., poverty, affordability) that entrap recently-evicted PWUD in the institutional circuit.

Temporary stays with housed family and friends among older adults experiencing homelessness: Qualitative findings from the HOPE HOME study.

Background: The proportion of adults age 50 and older experiencing homelessness is growing. People at risk for homelessness may stay with family and friends to prevent homelessness. Moving in with housed family and friends is a strategy used to exit homelessness. Little is known about these stays with family and friends. This study examined the motivations for and challenges of older adults experiencing homelessness staying with or moving in with family or friends. Methods: We purposively sampled 46 participants from the HOPE HOME study, a cohort of 350 community-recruited adults experiencing homelessness age ≥50 in Oakland, CA. Inclusion criteria included having stayed with housed family/friends for ≥1 nights in the prior 6 months. We sampled 19 family/friends who had hosted participants experiencing homelessness. We conducted separate, semi-structured interviews, summarized, memoed and coded data consistent using a grounded theory approach. Results: Older adults experiencing homelessness reported primarily temporary stays. Motivations for stays on the part of participants included a need for environmental, physical, and emotional respite from homelessness. Both individuals experiencing homelessness and hosts cited the mutual benefits of stays. Barriers to stays included feelings of shame, concerns about burdening the hosts, and interpersonal conflicts between older adults experiencing homelessness and host participants. Conclusions: There are potential opportunities and concerns surrounding temporary stays between older adults experiencing homelessness and their family or friends. Policy solutions should support the potential mutual benefits of temporary stays, while addressing interpersonal barriers to strengthen kinship and friendship networks and mediate the negative impacts of homelessness.

"The idea is to help people achieve greater success and liberty": A qualitative study of expanded methadone take-home access in opioid use disorder treatment.

Background: Prior to the COVID-19 pandemic, the United States (US) was already facing an epidemic of opioid overdose deaths. Overdose deaths continued to surge during the pandemic. To limit COVID-19 spread and to avoid disruptions in access to medications for opioid use disorder (MOUD), including buprenorphine and methadone, US federal and state agencies granted unprecedented exemptions to existing MOUD guidelines for Opioid Treatment Programs (OTPs), including loosening criteria for unsupervised take-home doses. We conducted a qualitative study to evaluate the impact of these policy changes on MOUD treatment experiences for providers and patients at an OTP in California. Methods: We interviewed 10 providers (including two physicians, five social worker associates, and three nurse practitioners) and 20 patients receiving MOUD. We transcribed, coded, and analyzed all interviews to identify emergent themes. Results: Patient participants were middle-aged (median age 51 years) and were predominantly men (53%). Providers discussed clinical decision-making processes and experiences providing take-homes. Implementation of expanded take-home policies was cautious. Providers reported making individualized decisions, using patient factors to decide if benefits outweighed risks of overdose and misuse. Decision-making factors included patient drug use, overdose risk, housing status, and vulnerability to COVID-19. New patient groups started receiving take-homes and providers noted few adverse events. Patients who received take-homes reported increased autonomy and treatment flexibility, which in turn increased likelihood of treatment stabilization and engagement. Patients who remained ineligible for take-homes, usually due to ongoing non-prescribed opioid or benzodiazepine use, desired greater transparency and shared decision-making. Conclusion: Federal exemptions in response to COVID-19 led to the unprecedented expansion of access to MOUD take-homes within OTPs. Providers and patients perceived benefits to expanding access to take-homes and experienced few adverse outcomes, suggesting expanded take-home policies should remain post-COVID-19. Future studies should explore whether these findings are generalizable to other OTPs and assess larger samples to quantify patient-level outcomes resulting from expanded take-home policies.

"I wanted something that was more flexible": A qualitative study of patient preferences on choosing buprenorphine over methadone in a large, safety-net hospital opioid treatment program.

Background: Buprenorphine availability for the treatment of opioid use disorders (OUD) has expanded in the United States. Programs that previously offered only methadone treatment to patients with OUD now offer an equal choice between buprenorphine and methadone at the same location, yet little is known about patient preferences for buprenorphine over methadone in these settings. We sought to understand the decision-making factors and motivations underlying why patients opt for buprenorphine over methadone for the treatment of OUD when both are offered in a safety-net hospital-based opioid treatment program (OTP). Methods: We conducted semi-structured, qualitative interviews with patients receiving buprenorphine, in which we asked about substance use and treatment history, reasons for choosing buprenorphine, advantages, and disadvantages of choosing buprenorphine, and what they would like to change in their treatment experience. Results: Participants had varied exposure to buprenorphine prior to their current treatment, ranging from none to years of experience in multiple settings. Increased flexibility with take-home doses was a widespread motivation for choosing buprenorphine over methadone. Participants described decreased sedation and greater effectiveness in preventing opioid use compared to methadone as advantages during their treatment with buprenorphine. Difficulty with the transition to buprenorphine was a noteworthy challenge for many. Conclusions: Overall, patients maintained on buprenorphine at an urban safety-net hospital OTP viewed their treatment favorably compared to methadone. Increased autonomy in light of federal regulation differences and an improved physical profile were significant decision-making factors, although the number of patients choosing buprenorphine at the OTP remained low. Targeted patient education about induction and focus on improving structural barriers such as dosing efficiency may enhance patient experiences.

Ground-Truthing the Experiences of Homeless Older Adults' Recent Stays with Family and Friends: A Case Study of Participatory Data Analysis.

Many older homeless adults have recently stayed with family or friends, yet little is understood about these experiences. We conducted a multimethod qualitative study of older unhoused adults in Oakland, California. First, we conducted in-depth interviews among older adults experiencing homelessness with recent stays with a housed family member or friend (n=46), hosts (n=19), and program key informants (n=11). Second, we developed thematic summaries in the form of character-based composite stories, which were presented to a Council of Elders with lived experiences of homelessness, to explore reactions, referred to as ground-truthing, a form of participatory data analysis. Predominantly, participants were African American men. Barriers included structural factors (discrimination), policy (lease restrictions), community (violence), interpersonal factors (power dynamics), and individual factors (health problems). Factors enhancing stays included inter-generational support and leveraging resources. Ground-truthing discussions reinforced and expanded upon findings (e.g., importance of neighborhood identity, training needs, how self-improvement affects readiness to live with others).

Structural competency and global health education.

Structural competency is a new curricular framework for training health professionals to recognise and respond to disease and its unequal distribution as the outcome of social structures, such as economic and legal systems, healthcare and taxation policies, and international institutions. While extensive global health research has linked social structures to the disproportionate burden of disease in the Global South, formal attempts to incorporate the structural competency framework into US-based global health education have not been described in the literature. This paper fills this gap by articulating five sub-competencies for structurally competent global health instruction. Authors drew on their experiences developing global health and structural competency curricula-and consulted relevant structural competency, global health, social science, social theory, and social determinants of health literatures. The five sub-competencies include: (1) Describe the role of social structures in producing and maintaining health inequities globally, (2) Identify the ways that structural inequalities are naturalised within the field of global health, (3) Discuss the impact of structures on the practice of global health, (4) Recognise structural interventions for addressing global health inequities, and (5) Apply the concept of structural humility in the context of global health.

COVID-19: A catalyst for change in telehealth service delivery for opioid use disorder management.

BACKGROUND: COVID-19 has exacerbated income inequality, structural racism, and social isolation-issues that drive addiction and have previously manifested in the epidemic of opioid-associated overdose. The co-existence of these epidemics has necessitated care practice changes, including the use of telehealth-based encounters for the diagnosis and management of opioid use disorder (OUD). METHODS: We describe the development of the "Addiction Telehealth Program" (ATP), a telephone-based program to reduce treatment access barriers for people with substance use disorders staying at San Francisco's COVID-19 Isolation and Quarantine (I&Q) sites. Telehealth encounters were documented in the electronic medical record and an internal tracking system for the San Francisco Department of Public Health (SFDPH) COVID-19 Containment Response. Descriptive statistics were collected on a case series of patients initiated on buprenorphine at I&Q sites and indicators of feasibility were measured. RESULTS: Between April 10 and May 25, 2020, ATP consulted on the management of opioid, alcohol, GHB, marijuana, and stimulant use for 59 I&Q site guests. Twelve patients were identified with untreated OUD and newly prescribed buprenorphine. Of these, all were marginally housed, 67% were Black, and 58% had never previously been prescribed medications for OUD. Four self-directed early discharge from I&Q-1 prior to and 3 after initiating buprenorphine. Of the remaining 8 patients, 7 reported continuing to take buprenorphine at the time of I&Q discharge and 1 discontinued. No patients started on buprenorphine sustained significant adverse effects, required emergency care, or experienced overdose. CONCLUSIONS: ATP demonstrates the feasibility of telephone-based management of OUD among a highly marginalized patient population in San Francisco and supports the implementation of similar programs in areas of the U.S. where access to addiction treatment is limited. Legal changes permitting the prescribing of buprenorphine via telehealth without the requirement of an in-person visit should persist beyond the COVID-19 public health emergency.

Responding to the Opioid Epidemic: Educational Competencies for Pain and Substance Use Disorder from the Medical Schools of the University of California.

OBJECTIVE: The University of California (UC) leadership sought to develop a robust educational response to the epidemic of opioid-related deaths. Because the contributors to this current crisis are multifactorial, a comprehensive response requires educating future physicians about safe and effective management of pain, safer opioid prescribing, and identification and treatment of substance use disorder (SUD). METHODS: The six UC medical schools appointed an opioid crisis workgroup to develop educational strategies and a coordinated response to the opioid epidemic. The workgroup had diverse specialty and disciplinary representation. This workgroup focused on developing a foundational set of educational competencies for adoption across all UC medical schools that address pain, SUD, and public health concerns related to the opioid crisis. RESULTS: The UC pain and SUD competencies were either newly created or adapted from existing competencies that addressed pain, SUD, and opioid and other prescription drug misuse. The final competencies covered three domains: pain, SUD, and public health issues related to the opioid crisis. CONCLUSIONS: The authors present a novel set of educational competencies as a response to the opioid crisis. These competencies emphasize the subject areas that are fundamental to the opioid crisis: pain management, the safe use of opioids, and understanding and treating SUD.