Identifying unique barriers to implementing rural emergency department-based peer services for opioid use disorder through qualitative comparison with urban sites.

BACKGROUND: In an effort to address the current opioid epidemic, a number of hospitals across the United States have implemented emergency department-based interventions for engaging patients presenting with opioid use disorder. The current study seeks to address gaps in knowledge regarding implementation of a sub-type of such interventions, emergency department-based peer support services, in rural areas by comparing implementation of rural and urban programs that participated in Indiana's Recovery Coach and Peer Support Initiative (RCPSI). METHODS: We conducted a secondary analysis of qualitative semi-structured implementation interviews collected as part of an evaluation of 10 programs (4 rural and 6 urban) participating in the RCPSI. We conducted interviews with representatives from each program at 3 time points over the course of the first year of implementation. Our deductive coding process was guided by the Consolidated Framework for Implementation Research (CFIR) and an external context taxonomy. RESULTS: We identified key differences for rural programs corresponding to each of the 5 primary constructs in the coding scheme. (1) Intervention characteristics: rural sites questioned intervention fit with their context, required more adaptations, and encountered unexpected costs. (2) External context: rural sites were not appropriately staffed to meet patient needs, encountered logistical and legal barriers regarding patient privacy, and had limited patient transportation options. (3) Inner setting: rural sites lacked strong mechanisms for internal communication and difficulties integrating with pre-existing culture and climate. (4) Characteristics of individuals: some rural providers resisted working with peers due to pre-existing attitudes and beliefs. (5) Implementation process: rural sites spent more time identifying external partners and abandoned more components of their initial implementation plans. CONCLUSIONS: Findings demonstrate how rural programs faced greater challenges implementing emergency department-based peer services over time. These challenges required flexible adaptations to originally intended plans. Rural programs likely require flexibility to adapt interventions that were developed in urban settings to ensure success considering local contextual constraints that were identified by our analysis.

Navigating intersecting public health crises: a qualitative study of people with opioid use disorders' experiences during the COVID-19 pandemic.

BACKGROUND: The decades-long opioid epidemic and the more recent COVID-19 pandemic are two interacting events with significant public health impacts for people with opioid use disorder (OUD). Most published studies regarding the intersection of these two public health crises have focused on community, state, or national trends using pre-existing data. There is a need for complementary qualitative research aimed at identifying how people with opioid use disorder (OUD) are understanding, experiencing, and navigating this unprecedented time. The current study examines understandings and experiences of people with OUD while they have navigated these crises. METHODS: The study was guided by a pragmatic lens. We conducted brief semi-structured qualitative interviews with 25 individuals in Chicago, the majority of which had received methadone treatment during the pandemic. Thematic inductive analysis was guided by primary interview questions. RESULTS: The sample represents a high-risk group, being composed mostly of older non-Hispanic African American males and having considerable socioeconomic barriers. Themes demonstrate how individuals are keeping safe despite limited knowledge of COVID-19, how the pandemic has increased treatment motivation for some, how adaptations impacted treatment and recovery supports, how the availability social support had been reduced, and difficulties individuals had keeping or obtaining financial support. CONCLUSIONS: The findings can be useful for informing future public health response to ensure appropriate treatment access and supports are available. In particular are the need for treatment providers to ensure people with OUD receive appropriate and understandable health crisis-related information and ensuring funds are appropriately allocated to address mental health impacts of social isolation. Finally, there is a need for appropriate financial and infrastructure supports to ensure health and treatment access disparities are not exacerbated for those in greatest need.

Variation in brief treatment for substance use disorder: a qualitative investigation of four federally qualified health centers with SBIRT services.

BACKGROUND: Brief treatment (BT) can be an effective, short-term, and low-cost treatment option for many people who misuse alcohol and drugs. However, inconsistent implementation is suggested to result in BT that often looks and potentially costs similar to regular outpatient care. Prior research is also rife with inconsistent operationalizations regarding the measurement of BT received by patients. As such, there is a need to more explicitly identify and document variations in BT practice. METHODS: A qualitative investigation of BT in four Federally Qualified Health Centers (FQHC) was undertaken as a sub study of a larger clinical trial. Researchers interviewed 12 staff (administrators and clinicians) involved in BT oversight, referral, or delivery within the four FQHCs. Data were analyzed following an inductive approach guided by the primary research questions. RESULTS: Findings demonstrate considerable differences in how BT was conceptualized and implemented within the FQHCs. This included a variety of ways in which BT was presented and described to patients that likely impacts how they perceive the BT they receive, including potentially not understanding they received substance use disorder treatment at all. CONCLUSIONS: The findings raise questions regarding the validity of prior research, demonstrating more objective definitions of BT and fidelity checklists are needed to ensure integrity of results. Future work in this area should seek to understand BT as practiced among a larger sample of providers and the direct experiences and perspectives of patients. There is also a need for more consistent implementation, quality assurance guidelines, and standardized stage of change assessments to aid practitioners.

Adaptations to Indiana's 21st Century Cures-funded recovery coaching initiative in the wake of COVID-19.

This brief commentary discusses how provider organizations from Indiana's Recovery Coach and Peer Support Initiative (RCPSI) adapted their practices in response to the COVID-19 pandemic and associated restrictions. The RCPSI, which is funded through the 21st Century Cures Act, placed peer recovery coaches (PRCs) in emergency departments (EDs) to link opioid overdose patients to medication for opioid use disorder. This commentary discusses how COVID-19 restrictions increased use of telehealth to replace in-person PRC contacts with patients, affected the timing of initial PRC contacts with patients, and led to allowances for Medicaid billing of recovery coach support sessions conducted via telehealth. Future research should further determine the effects of these changes on PRC services in the ED.

Syringe service program-based telemedicine linkage to opioid use disorder treatment: protocol for the STAMINA randomized control trial.

BACKGROUND: A key strategy for mitigating the current opioid epidemic is expanded access to medications for treating opioid use disorder (MOUD). However, interventions developed to expand MOUD access have limited ability to engage opioid users at higher levels of overdose risk, such as those who inject opioids. This paper describes the study protocol for testing STAMINA (Syringe Service Telemedicine Access for Medication-assisted Intervention through NAvigation), an intervention that engages high-risk opioid users at community-based syringe service programs (SSP) and quickly links them to MOUD using a telemedicine platform. METHODS: This randomized control trial will be conducted at three SSP sites in Chicago. All participants will complete an initial assessment with a provider from a Federally Qualified Health Center who can prescribe or refer MOUD services as appropriate. The control arm will receive standard referral to treatment and the intervention arm will receive immediate telemedicine linkage to the provider and (depending on the type of MOUD prescribed) provided transportation to pick up their induction prescription (for buprenorphine or naltrexone) or attend their intake appointment (for methadone). We aim to recruit a total of 273 participants over two years to provide enough power to detect a difference in our primary outcome of MOUD treatment linkage. Secondary outcomes include treatment engagement, treatment retention, and non-MOUD opioid use. Data will be collected using structured interviews and saliva drug tests delivered at baseline, three months, and six months. Fixed and mixed effects generalized linear regression analyses and survival analysis will be conducted to compare the probabilities of a successful treatment linkage between the two arms, days retained in treatment, and post-baseline opioid and other drug use. DISCUSSION: If successful, STAMINA's telemedicine approach will significantly reduce the amount of time between SSP clients' initial indication of interest in the medication and treatment initiation. Facilitating this process will likely lead to stronger additional treatment- and recovery-oriented outcomes. This study is also timely given the need for more rigorous testing of telemedicine interventions in light of temporary regulatory changes that have occurred during the COVID-19 pandemic. TRIAL REGISTRATION: ClinicalTrials.gov (Clinical Trials ID: NCT04575324 and Protocol Number: 1138-0420). Registered 29 September 2020. The study protocol is also registered on the Open Science Framework (DOI 10.17605/OSF.IO/4853 M).

Implementation of peer recovery coach services for opioid overdose patients in emergency departments in Indiana: findings from an informal learning collaborative of stakeholders.

The Recovery Coach and Peer Support Initiative (RCPSI) in Indiana focused on implementing peer recovery coaches (PRCs) to engage opioid overdose patients in emergency department (ED) settings and promote entry into recovery services. State workers and researchers organized an informal learning collaborative primarily through teleconference meetings with representatives of 11 health service vendors to support implementation. This study presents qualitative analysis of the teleconference meeting discussions that guided RCPSI implementation to display how the informal learning collaborative functioned to support implementation. This informal learning collaborative model can be applied in similar situations where there is limited guidance available for a practice being implemented by multidisciplinary teams. Authors conducted a thematic analysis of data from 32 stakeholder teleconference meetings held between February 2018 and April 2020. The analysis explored the function of these collaborative teleconferences for stakeholders. Major themes representing functions of the meetings for stakeholders include: social networking; executing the implementation plan; identifying and addressing barriers and facilitators; educating on peer recovery services and target population; and working through data collection. During the last 2 months of meetings, stakeholders discussed how the COVID-19 pandemic created multiple barriers but increased use of telehealth for recovery services. Teleconference meetings served as the main component of an informal learning collaborative for the RCPSI through which the vendor representatives could speak with each other and with organizers as they implemented the use of PRCs in EDs.