Statin use for cardiovascular disease prevention: perceptions among people living with HIV in the United States.

BACKGROUND: People living with HIV (PLWH) may be at heightened risk for cardiovascular disease (CVD). Statin use and lifestyle changes reduce the risk of CVD but remain under-prescribed among PLWH. The objective of this study was to characterize knowledge of CVD and statin use, current usage, barriers to taking statins, and information desired by PLWH to improve statin uptake among PLWH in Los Angeles, CA. METHODS: Between April 2019 and April 2020, we conducted four focus group discussions (n = 37) with patients across three public community health clinics that serve PLWH in Los Angeles County, California. All clinics participated in a larger study to improve statin prescribing for PLWH. We asked about knowledge of statins, willingness to take a statin, possible barriers to statin usage, preferred information sources for health information, and desired information about statins. We utilized standard qualitative content analysis methods to identify themes. RESULTS: We found a range in the awareness of statins, with some participants reporting never having heard of statins while others had a history of statin use. There were concerns about the potential long-term effect of statin use, but participants expressed willingness to use CVD medications generally and statins specifically, especially if recommended by their healthcare provider. Participants also expressed interest in potential alternatives to statin usage such as exercising regularly and nutritious eating. CONCLUSIONS: More interventions are needed to increase statin use among PLWH to improve CVD outcomes, which also has implications for HIV progression. Clinics should aim to increase patient and provider knowledge about CVD risk and statin use for PLWH and provide shared decision-making tools that are easy to use and culturally appropriate.

Contextual barriers and enablers to establishing an addiction-focused consultation team for hospitalized adults with opioid use disorder.

BACKGROUND: Hospitalization presents an opportunity to begin people with opioid use disorder (OUD) on medications for opioid use disorder (MOUD) and link them to care after discharge; regrettably, people admitted to the hospital with an underlying OUD typically do not receive MOUD and are not connected with subsequent treatment for their condition. To address this gap, we launched a multi-site randomized controlled trial to test the effectiveness of a hospital-based addiction consultation team (the Substance Use Treatment and Recovery Team (START)) consisting of an addiction medicine specialist and care manager team that provide collaborative care and a specified intervention to people with OUD during the inpatient stay. Successful implementation of new practices can be impacted by organizational context, though no previous studies have examined context prior to implementation of addiction consultation services (ACS). This study assessed pre-implementation context for implementing a specialized ACS and tailoring it accordingly. METHODS: We conducted semi-structured interviews with hospital administrators, physicians, physician assistants, nurses, and social workers at the three study sites between April and August 2021 before the launch of the pragmatic trial. Using an analytical framework based on the Consolidated Framework for Implementation Research, we completed a thematic analysis of interview data to understand potential barriers or enablers and perceptions about acceptability and feasibility. RESULTS: We interviewed 28 participants across three sites. The following themes emerged across sites: (1) START is an urgently needed model for people with OUD; (2) Intervention adaptations are recommended to meet local and cultural needs; (3) Linking people with OUD to community clinicians is a highly needed component of START; (4) It is important to engage stakeholders across departments and roles throughout implementation. Across sites, participants generally saw a need for change from usual care to support people with OUD, and thought the START was acceptable and feasible to implement. Differences among sites included tailoring the START to support the needs of varying patient populations and different perceptions of the prevalence of OUD. CONCLUSIONS: Hospitals planning to implement an ACS in the inpatient setting may wish to engage in a systematic pre-implementation contextual assessment using a similar framework to understand and address potential barriers and contextual factors that may impact implementation. Pre-implementation work can help ensure the ACS and other new practices fit within each unique hospital context.

It takes a village: A pilot study of a group telehealth intervention for support persons affected by opioid use disorder.

INTRODUCTION: Opioid use disorder (OUD) has devastating effects on individuals, families, and communities. The Community Reinforcement and Family Training (CRAFT) is a Support Person (SP)-focused intervention that aims to increase SPs' communication strategies, positive reinforcement/rewards, and social support. This pilot study, called eINSPIRE (INtegrating Support Persons Into REcovery), adapted CRAFT for delivery via group telehealth. The aims were to evaluate the feasibility, acceptability, and preliminary effectiveness of this intervention on patient buprenorphine retention and SP mental health. METHODS: The study recruited patients receiving buprenorphine treatment in a primary care setting across five community health centers with their SP (N = 100 dyads). SP participants were randomly assigned to receive usual care (UC) or the eINSPIRE intervention. We interviewed Patients and SPs at baseline and three months later. The study collected patient buprenorphine retention data from the electronic medical record three months post-baseline. RESULTS: About 88 % (656/742) of potentially eligible patients were able to nominate a SP and 69 % (100/145) of nominated SPs were eligible and consented to the study. eINSPIRE groups had low reach (25 % of SPs attended), but high exposure (M = 7 of 10 sessions attended) and acceptability (classes helped them with their patient's OUD). The proportion of eINSPIRE patients (68 %) and UC patients (53 %) retained on buprenorphine at follow-up were similar (p = 0.203). SPs in both conditions reported similar reductions in their depression, anxiety, and impairment symptoms. CONCLUSIONS: Preliminary data suggest that eINSPIRE groups may not be feasible in primary care without further adaptations for this population. A future study with a larger sample size is needed to elucidate the observed distribution differences in buprenorphine retention. Future research should also explore methods to reduce barriers to SP session attendance to improve the reach of this evidence-based intervention.

Findings from an Organizational Context Survey to Inform the Implementation of a Collaborative Care Study for Co-occurring Disorders.

Primary care is an opportune setting to deliver treatments for co-occurring substance use and mental health disorders; however, treatment delivery can be challenging due multi-level implementation barriers. Documenting organizational context can provide insight into implementation barriers and the adaptation of new processes into usual care workflows. This study surveyed primary care and behavioral health staff from 13 clinics implementing a collaborative care intervention for opioid use disorders co-occurring with PTSD and/or depression as part of a multisite randomized controlled trial. A total of 323 completed an online survey for a 60% response rate. The Consolidated Framework for Implementation Research guided this assessment of multi-level factors that influence implementation. Most areas for improvement focused on inner setting (organizational level) constructs whereas individual-level constructs tended to be strengths. This work addresses a research gap regarding how organizational analyses can be used prior to implementation and provides practical implications for researchers and clinic leaders.

Stakeholder perspectives on a telemedicine referral and coordination model to expand medication treatment for opioid use disorder in rural primary care clinics.

INTRODUCTION: Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor. METHODS: We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale. RESULTS: Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff. CONCLUSIONS: Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

Pilot randomized controlled trial of a hospital-based substance use treatment and recovery team (START) to improve initiation of medication for alcohol or opioid use disorder and linkage to follow-up care.

OBJECTIVES: We conducted a pilot randomized controlled trial (RCT) to explore whether a hospital inpatient addiction consult team (Substance Use Treatment and Recovery Team [START]) based on collaborative care was feasible, acceptable to patients, and whether it could improve uptake of medication in the hospital and linkage to care after discharge, as well as reduce substance use and hospital readmission. The START consisted of an addiction medicine specialist and care manager who implemented a motivational and discharge planning intervention. METHODS: We randomized inpatients age ≥ 18 with a probable alcohol or opioid use disorder to receive START or usual care. We assessed feasibility and acceptability of START and the RCT, and we conducted an intent-to-treat analysis on data from the electronic medical record and patient interviews at baseline and 1-month postdischarge. The study compared RCT outcomes (medication for alcohol or opioid use disorder, linkage to follow-up care after discharge, substance use, hospital readmission) between arms by fitting logistic and linear regression models. FINDINGS: Of 38 START patients, 97 % met with the addiction medicine specialist and care manager; 89 % received ≥8 of 10 intervention components. All patients receiving START found it to be somewhat or very acceptable. START patients had higher odds of initiating medication during the inpatient stay (OR 6.26, 95 % CI = 2.38-16.48, p < .001) and being linked to follow-up care (OR 5.76, 95 % CI = 1.86-17.86, p < .01) compared to usual care patients (N = 50). The study found no significant differences between groups in drinking or opioid use; patients in both groups reported using fewer substances at the 1-month follow-up. CONCLUSIONS: Pilot data suggest START and RCT implementation are feasible and acceptable and that START may facilitate medication initiation and linkage to follow-up for inpatients with an alcohol or opioid use disorder. A larger trial should assess effectiveness, covariates, and moderators of intervention effects.

Changes in In-Person, Audio-Only, and Video Visits in California's Federally Qualified Health Centers, 2019-2022.

This study assesses telehealth visit trends among California federally qualified health centers from 2019 to 2022.

Perspectives Regarding Medications for Opioid Use Disorder Among Individuals with Mental Illness.

Most people with co-occurring opioid use disorder (OUD) and mental illness do not receive effective medications for treating OUD. To investigate perspectives of adults in a publicly-funded mental health system regarding medications for OUD (MOUD), we conducted semi-structured telephone interviews with 13 adults with OUD (current or previous diagnosis) receiving mental health treatment. Themes that emerged included: perceiving or using MOUDs as a substitute for opioids or a temporary solution to prevent withdrawal symptoms; negative perceptions about methadone/methadone clinics; and viewing MOUD use as "cheating". Readiness to quit was important for patients to consider MOUDs. All participants were receptive to discussing MOUDs with their mental health providers and welcomed the convenience of receiving care for their mental health and OUD at the same location. In conclusion, clients at publicly-funded mental health clinics support MOUD treatment, signaling a need to expand access and build awareness of MOUDs in these settings.

Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic: Results from the Connected Care Accelerator Initiative.

In early 2020, as the coronavirus disease 2019 (COVID-19) pandemic emerged, widespread social-distancing efforts suspended much of the delivery of nonurgent health care. Telehealth proved to be a viable alternative to in-person care, at least on a temporary basis, and utilization skyrocketed. Many Federally Qualified Health Centers (FQHCs) serving low-income patients started delivering telehealth visits in high volume in March 2020 to help maintain access to care. This sudden and dramatic change in health care delivery posed numerous challenges. Health centers had to quickly make changes to technology, workflows, and staffing to accommodate telehealth visits. To support health centers in these efforts, the California Health Care Foundation established the Connected Care Accelerator (CCA) program, a quality improvement initiative that was launched in July 2020. RAND researchers evaluated the progress of FQHCs that participated in the CCA initiative by investigating changes in telehealth utilization and health center staff experiences with implementation. In this research, researchers review recent literature on telehealth implementation in safety net settings. They also present new information on the experiences of the 45 CCA health centers, drawing from data on visit trends, interviews with health center leaders, and surveys of health center providers and staff. Telehealth has the potential to increase access to care and deliver care that is more convenient and patient-centered; however, ongoing research is needed to ensure that telehealth is implemented in a way that ensures high-quality care and health equity.

The Substance Use Treatment and Recovery Team (START) study: protocol for a multi-site randomized controlled trial evaluating an intervention to improve initiation of medication and linkage to post-discharge care for hospitalized patients with opioid use disorder.

BACKGROUND: People with opioid use disorder experience high burden of disease from medical comorbidities and are increasingly hospitalized with medical complications. Medications for opioid use disorder are an effective, life-saving treatment, but patients with an opioid use disorder admitted to the hospital seldom initiate medication for their disorder while in the hospital, nor are they linked with outpatient treatment after discharge. The inpatient stay, when patients may be more receptive to improving their health and reducing substance use, offers an opportunity to discuss opioid use disorder and facilitate medication initiation and linkage to treatment after discharge. An addiction-focus consultative team that uses evidence-based tools and resources could address barriers, such as the need for the primary medical team to focus on the primary health problem and lack of time and expertise, that prevent primary medical teams from addressing substance use. METHODS: This study is a pragmatic randomized controlled trial that will evaluate whether a consultative team, called the Substance Use Treatment and Recovery Team (START), increases initiation of any US Food and Drug Administration approved medication for opioid use disorder (buprenorphine, methadone, naltrexone) during the hospital stay and increases linkage to treatment after discharge compared to patients receiving usual care. The study is being conducted at three geographically distinct academic hospitals. Patients are randomly assigned within each hospital to receive the START intervention or usual care. Primary study outcomes are initiation of medication for opioid use disorder in the hospital and linkage to medication or other opioid use disorder treatment after discharge. Outcomes are assessed through participant interviews at baseline and 1 month after discharge and data from hospital and outpatient medical records. DISCUSSION: The START intervention offers a compelling model to improve care for hospitalized patients with opioid use disorder. The study could also advance translational science by identifying an effective and generalizable approach to treating not only opioid use disorder, but also other substance use disorders and behavioral health conditions. TRIAL REGISTRATION: Clinicaltrials.gov: NCT05086796, Registered on 10/21/2021. https://www. CLINICALTRIALS: gov/ct2/results?recrs=ab&cond=&term=NCT05086796&cntry=&state=&city=&dist = .

Implementation and evaluation of a syringe vending machine trial in Tbilisi, Georgia.

BACKGROUND: Syringe vending machines (SVM) have proven to be an effective vehicle for providing an uninterrupted supply of sterile equipment to PWID, but they have not been implemented or disseminated broadly. The aim of this study was to implement and evaluate outcomes of introducing SVM in Tbilisi, Georgia. METHODS: We installed SVM at five HIV prevention sites in 10 locations in Tbilisi, Georgia and studied implementation over 20 months. We used the RE-AIM framework to assess outcomes across four RE-AIM domains: reach, effectiveness at providing syringe access, adoption and implementation. RESULTS: Reach. SVM reached 8% of the target population. Effectiveness at Providing Syringe Access. SVM dispensed 14% of all syringes distributed by HIV prevention services. Using SVM was associated with PWID receiving more sterile syringes from HIV prevention outlets. Adoption. All HIV prevention sites (N=5) invited to implement SVM agreed to participate. Sixty one percent of PWID who received SVM access cards used SVM at least once. Women and young PWID were more likely to use SVM compared to other PWID. IMPLEMENTATION: At some sites adherence of the outreach staff to the operational protocol was suboptimal. CONCLUSIONS: SVM are an acceptable, feasible and effective intervention for improving access to sterile injection equipment for PWID. Future research will need to elaborate approaches to build the sense of ownership and improve motivation of the field staff to engage with the new intervention, and to examine strategies for attracting groups of PWID who are not in contact with prevention and treatment services.

Observational "go-alongs" of follow-up HIV care visits of two virally suppressed Black sexual minority men.

PURPOSE: This study explored potentially underreported healthcare contexts, clinical experiences, and motivations for adherence in care among virally suppressed Black sexual minority men (BSMM) living with HIV (LWHIV) in Baltimore, MD. METHODS: Go-alongs with two virally suppressed BSMM LWHIV supplemented 27 in-depth interviews of a larger qualitative study guided by Positive Deviance and Life Course Theory. The go-alongs involved accompanying participants' follow-up HIV care visit to obtain a better account of contextual healthcare factors. Observations focused on (1) clinic location and resources, (2) sources of HIV and sexuality stigma or support in the clinic, and (3) patient-provider interactions. RESULTS: We found that facilitators and barriers to viral suppression for BSMM LWHIV included structural factors (i.e., healthcare setting, facility, and services), quality of patient-provider interactions, and personal motivations to achieve viral suppression. CONCLUSION: Clinic accessibility, co-located clinical services, and rapport with clinicians and healthcare staff could be key contextual conditions that facilitate retention in care among BSMM LWHIV.

Opioid Use Disorder Among Clients of Community Mental Health Clinics: Prevalence, Characteristics, and Treatment Willingness.

OBJECTIVE: The authors examined the prevalence of co-occurring opioid use disorder and willingness to engage in treatment among clients of eight Los Angeles County Department of Mental Health outpatient clinics. METHODS: Adults presenting for an appointment over a 2-week period were invited to complete a voluntary, anonymous health survey. Clients who indicated opioid use in the past year were offered a longer survey assessing probable opioid use disorder. Willingness to take medication and receive treatment also was assessed. RESULTS: In total, 3,090 clients completed screening. Among these, 8% had a probable prescription (Rx) opioid use disorder and 2% a probable heroin use disorder. Of the clients with probable Rx opioid use or heroin use disorder, 49% and 25% were female, respectively. Among those with probable Rx opioid use disorder, 43% were Black, 33% were Hispanic, and 12% were White, and among those with probable heroin use disorder, 24% were Black, 22% were Hispanic, and 39% were White. Seventy-eight percent of those with Rx opioid use disorder had never received any treatment, and 82% had never taken a medication for this disorder; 39% of those with heroin use disorder had never received any treatment, and 39% had never received a medication. The strongest predictor of willingness to take a medication was believing that it would help stop opioid use (buprenorphine, ß=13.54, p=0.003, and naltrexone long-acting injection, ß=15.83, p<0.001). CONCLUSIONS: These findings highlight the need to identify people with opioid use disorder and to educate clients in mental health settings about medications for these disorders.

HIV Treatment Adherence Strategies Among Virally Suppressed Black Sexual Minority Men in Baltimore, Maryland, and Los Angeles, California: A Theory-Based Qualitative Study.

ABSTRACT: The goals and strategies of Black sexual minority men living with HIV (BSMMLWH) who achieve viral suppression require further investigation. This study explored treatment adherence strategies among BSMMLWH with sustained viral suppression. We conducted 27 in-depth qualitative interviews with BSMMLWH in Baltimore, Maryland, and Los Angeles, California, between December 2018 and May 2019. Interviews included questions guided by Positive Deviance and Life Course theoretical frameworks regarding multilevel factors and explicit strategies for antiretroviral therapy adherence. Themes regarding intentional, age group-specific strategies such as using technology (among younger men) and taking HIV medications with other daily pills (among older men) were identified. Participants also reported symbiotic goals and values that encouraged adherence, such as having a desire to live, strong familial relationships with clinicians, and support networks. Identifying personal goals and having supportive clinical and social relationships could be key to improving treatment adherence and viral suppression among BSMMLWH.

Smart Syringe Vending Machines: Research Capabilities and Implications for Research Data Collection.

OBJECTIVE: Syringe vending machines (SVMs) are intended to supplement the standard syringe exchange programs to access hard-to-reach groups and to cover unserved geographical areas. This report describes how we adapted SVMs to deliver interventions and collect research data as part of a study of smart SVMs (SSVMs) in Tbilisi, Georgia. METHOD: To create SSVMs, we upgraded commercial vending machines and developed a computer program to track and record interactions and to display messages related to study procedures. Preferred locations for SSVMs, product specifications, and the mode of operation were determined through formative input from people who inject drugs (PWID). SSVMs were installed near pharmacies and serve both the general population and PWID. The "hidden" interactive menu for the PWID prevention kits was displayed on the screen only when a special plastic card was used. The plastic cards were distributed to the clients of fixed syringe exchange programs and to their peers who were not in contact with harm-reduction services. RESULTS: Ten SSVMs were operational in Tbilisi as of March 2021, with more than 800 PWID using them on a regular basis. More than half of sterile equipment kits were distributed during weekends and night hours. CONCLUSIONS: Our innovative SSVM integrates features for intervention delivery and research data collection. It can be used for testing a variety of interventions beyond syringes (e.g., distribution of HIV/hepatitis C virus self-tests) and provides opportunities for serving various at-risk groups that might not otherwise access these products and services (e.g., men who have sex with men, commercial sex workers).

Factors affecting statin uptake among people living with HIV: primary care provider perspectives.

BACKGROUND: Cardiovascular disease (CVD) is a major cause of morbidity and mortality among people living with HIV (PLWH), but statin therapy, safe and effective for PLWH, is under-prescribed. This study examined clinic leadership and provider perceptions of factors associated with statin prescribing for PLWH receiving care in eight community health clinics across Los Angeles, California. METHODS: We conducted semi-structured telephone interviews with clinic leadership and providers across community health clinics participating in a larger study (INSPIRE) aimed at improving statin prescribing through education and feedback. Clinics included federally qualified health centers (N = 5), community clinics (N = 1) and county-run ambulatory care clinics (N = 2). Leadership and providers enrolled in INSPIRE (N = 39) were invited to participate in an interview. We used the Consolidated Framework for Implementation Research (CFIR) to structure our interview guide and analysis. We used standard qualitative content analysis methods to identify themes within CFIR categories; we also assessed current CVD risk assessment and statin-prescribing practices. RESULTS: Participants were clinic leaders (n = 6), primary care physicians with and without an HIV specialization (N = 6, N = 6, respectively), infectious diseases specialists (N = 12), nurse practitioners, physician assistants and registered nurses (N = 7). Ninety-five percent of providers from INSPIRE participated in an interview. We found that CVD risk assessment for PLWH is standard practice but that there is variation in risk assessment practices and that providers are unsure whether or how to adjust the risk threshold to account for HIV. Time, clinic and patient priorities impede ability to conduct CVD risk assessment with PLWH. CONCLUSIONS: Providers desire more data and standard practice guidance on prescribing statins for PLWH, including estimates of the effect of HIV on CVD, how to adjust the CVD risk threshold to account for HIV, which statins are best for people on antiretroviral therapy and on shared decision-making around prescribing statins to PLWH. While CVD risk assessment and statin prescribing fits within the mission and workflow of primary care, clinics may need to emphasize CVD risk assessment and statins as priorities in order to improve uptake.

Primary Care Providers' Knowledge, Attitudes, and Beliefs About HIV Pre-Exposure Prophylaxis (PrEP): Informing Network-Based Interventions.

Increasing access to pre-exposure prophylaxis (PrEP) in primary care settings for patients who may be at risk for HIV could help to increase PrEP uptake, which has remained low among certain key risk populations. The current study conducted interviews with primary care providers identified from national claims data as having either high or low likelihood of serving PrEP-eligible patients based on their prescribing practices for other sexually transmitted infections. The study yielded important information about primary care providers' knowledge, attitudes, and beliefs about PrEP, as well as the barriers and facilitators to prescribing PrEP. Key recommendations for a provider-focused intervention to increase PrEP prescribing among primary care providers, including increasing patient education to increase demand from providers, enhancing provider education, leveraging technology, and instituting standardized sexual health checks, are provided with the goal of informing network-based interventions.

Community perspectives on supervised consumption sites: Insights from four U.S. counties deeply affected by opioids.

BACKGROUND: To address the overdose crisis in the United States, expert groups have been nearly unanimous in calls for increasing access to evidence-based treatment and overdose reversal drugs. In some places there have also been calls for implementing supervised consumption sites (SCSs). Some cities-primarily in coastal urban areas-have explored the feasibility and acceptability of introducing them. However, the perspectives of community stakeholders from more inland and rural areas that have also been hard hit by opioids are largely missing from the literature. METHODS: To examine community attitudes about implementing SCSs for people who use opioids (PWUO) in areas with acute opioid problems, the research team conducted in-depth interviews and focus groups in four counties: Ashtabula and Cuyahoga Counties in Ohio, and Carroll and Hillsborough Counties in New Hampshire, two states with high rates of opioid overdose. Participants were policy, treatment, and criminal justice professionals, frontline harm reduction and service providers, and PWUO. RESULTS: Key informants noted benefits to SCSs, but also perceived potential drawbacks such as that they may enable opioid use, and potential practical barriers, including lack of desire among PWUO to travel to an SCS after purchasing opioids and fear of arrest. Key informants generally believed their communities likely would not currently accept SCSs due to cultural, resource, and practical barriers. They viewed publication of evidence on SCSs and community education as essential for fostering acceptance. CONCLUSIONS: Despite cultural and other barriers, implementation of SCSs may be more feasible in urban communities with existing (and perhaps more long-standing) harm reduction programs, greater treatment resources, and adequate transportation, particularly if there is strong evidence to support them.

Is telemedicine the answer to rural expansion of medication treatment for opioid use disorder? Early experiences in the feasibility study phase of a National Drug Abuse Treatment Clinical Trials Network Trial.

Telemedicine (TM) enabled by digital health technologies to provide medical services has been considered a key solution to increasing health care access in rural communities. With the immediate need for remote care due to the COVID-19 pandemic, many health care systems have rapidly incorporated digital technologies to support the delivery of remote care options, including medication treatment for individuals with opioid use disorder (OUD). In responding to the opioid crisis and the COVID-19 pandemic, public health officials and scientific communities strongly support and advocate for greater use of TM-based medication treatment for opioid use disorder (MOUD) to improve access to care and have suggested that broad use of TM during the pandemic should be sustained. Nevertheless, research on the implementation and effectiveness of TM-based MOUD has been limited. To address this knowledge gap, the National Drug Abuse Treatment Clinical Trials Network (CTN) funded (via the NIH HEAL Initiative) a study on Rural Expansion of Medication Treatment for Opioid Use Disorder (Rural MOUD; CTN-0102) to investigate the implementation and effectiveness of adding TM-based MOUD to rural primary care for expanding access to MOUD. In preparation for this large-scale, randomized controlled trial incorporating TM in rural primary care, a feasibility study is being conducted to develop and pilot test implementation procedures. In this commentary, we share some of our experiences, which include several challenges, during the initial two-month period of the feasibility study phase. While these challenges could be due, at least in part, to adjusting to the COVID-19 pandemic and new workflows to accommodate the study, they are notable and could have a substantial impact on the larger, planned pragmatic trial and on TM-based MOUD more broadly. Challenges include low rates of identification of risk for OUD from screening, low rates of referral to TM, digital device and internet access issues, workflow and capacity barriers, and insurance coverage. These challenges also highlight the lack of empirical guidance for best TM practice and quality remote care models. With TM expanding rapidly, understanding implementation and demonstrating what TM approaches are effective are critical for ensuring the best care for persons with OUD.

Clinician perspectives on methadone service delivery and the use of telemedicine during the COVID-19 pandemic: A qualitative study.

OBJECTIVES: During the COVID-19 pandemic, opioid treatment programs (OTPs) in the U.S. were granted new flexibility in methadone dispensing and the use of telemedicine. To explore the impact of the pandemic and accompanying policy changes on service delivery, we asked OTP clinicians about changes in care patterns and perceptions of impacts on access and quality. METHODS: In May-June 2020, we completed semistructured telephone interviews with 20 OTP clinicians (physicians, physician assistants, and nurse practitioners) from 13 U.S. states. The study recruited participants through Medscape, an online platform where clinicians access clinical content. We used rapid thematic analysis, a qualitative approach, to summarize participants' expressed views related to the research objectives. RESULTS: Clinicians identified a range of changes to methadone and ancillary service delivery as a result of COVID-19. Most clinicians reported that OTPs were prescribing more take-home doses of methadone and providing psychosocial services and medication management via telemedicine. Many also reported reducing the frequency of urine toxicology screening and accepting fewer new patients. While some clinicians expressed support for the increased flexibility around dosing and use of telemedicine, others expressed concern about increased risk of medication diversion and overdose. Clinicians reported several advantages and disadvantages of the changes due to the pandemic and that continued reimbursement would be required to maintain telemedicine services. CONCLUSIONS: The COVID-19 pandemic dramatically altered the delivery of methadone treatment in the U.S. This study's findings suggest that OTPs may have reduced their methadone treatment during the early months of the pandemic and that the flexibilities that policy changes offered may not have resulted in changes in care delivery for all patients. Careful consideration and additional analysis should inform which changes OTPs should maintain long-term.