Lessons Learned Serving Pregnant, Postpartum, and Parenting People with Substance Use Disorders in Massachusetts: The Moms Do Care Program.

PURPOSE: The purpose of this paper is to describe the design and implementation of a multidisciplinary, integrated approach to supporting pregnant, postpartum, and parenting people (PPPP) and their families affected by substance use disorders (SUD). DESCRIPTION: Between 2015 and 2022, the Moms Do Care (MDC) Program, sponsored by the Massachusetts Department of Public Health Bureau of Substance Addiction Services, established or expanded 11 co-located medical and behavioral health teams in locations across Massachusetts. These teams provided trauma-informed primary and obstetrical health care, SUD treatment and recovery services, parenting support, and case management for approximately 1048 PPPP with SUD. ASSESSMENT: By enhancing the capacity of medical and behavioral health providers offering integrated care across the perinatal health care continuum, MDC created a network of support for PPPP with SUD. Lessons learned include the need to continually invest in staff training to foster teambuilding and improve integrated service delivery, uplift the peer recovery coach role within the care team, improve engagement with and access to services for communities of color, and conduct evaluation and sustainability planning. CONCLUSION: MDC prioritizes trauma-informed integrated care, peer recovery, and commits to addressing inequities and stigma; thus, this program represents a promising approach to supporting PPPP impacted by SUD. The MDC model is relevant for those working to build multidisciplinary, integrated systems of health care and perinatal SUD services for marginalized populations.

A Thematic Analysis of Overdose Prevention and Response Efforts in States Experiencing Declines in Rates of Opioid-Involved Overdose Deaths.

OBJECTIVE: To address the opioid overdose epidemic, it is important to understand the broad scope of efforts under way in states, particularly states in which the rate of opioid-involved overdose deaths is declining. The primary objective of this study was to examine core elements of overdose prevention activities in 4 states with a high rate of opioid-involved overdose deaths that experienced a decrease in opioid-involved overdose deaths from 2016 to 2017. METHODS: We identified 5 states experiencing decreases in age-adjusted mortality rates for opioid-involved overdoses from 2016 to 2017 and examined their overdose prevention programs via program narratives developed with collaborators from each state's overdose prevention program. These program narratives used 10 predetermined categories to organize activities: legislative policies; strategic planning; data access, capacity, and dissemination; capacity building; public-facing resources (eg, web-based dashboards); training resources; enhancements and improvements to prescription drug monitoring programs; linkage to care; treatment; and community-focused initiatives. Using qualitative thematic analysis techniques, core elements and context-specific activities emerged. RESULTS: In the predetermined categories of programmatic activities, we identified the following core elements of overdose prevention and response: comprehensive state policies; strategic planning; local engagement; data access, capacity, and dissemination; training of professional audiences (eg, prescribers); treatment infrastructure; and harm reduction. CONCLUSIONS: The identification of core elements and context-specific activities underscores the importance of implementation and adaptation of evidence-based prevention strategies, interdisciplinary partnerships, and collaborations to address opioid overdose. Further evaluation of these state programs and other overdose prevention efforts in states where mortality rates for opioid-involved overdoses declined should focus on impact, optimal timing, and combinations of program activities during the life span of an overdose prevention program.

Engagement and Substance Dependence in a Primary Care-Based Addiction Treatment Program for People Infected with HIV and People at High-Risk for HIV Infection.

To improve outcomes for people with substance dependence and HIV infection or at risk for HIV infection, patients were enrolled in a primary care-based addiction treatment program from 2008-2012 that included a comprehensive substance use assessment, individual and group counseling, addiction pharmacotherapy and case management. We examined whether predisposing characteristics (depression, housing status, polysubstance use) and an enabling resource (buprenorphine treatment) were associated with engagement in the program and persistent substance dependence at 6 months. At program enrollment 61% were HIV-infected, 53% reported heroin use, 46% reported alcohol use, 37% reported cocaine use, and 28% reported marijuana use in the past 30 days, 72% reported depression, 19% were homeless, and 53% had polysubstance use. Within 6-months 60% had been treated with buprenorphine. Engagement (defined as 2 visits in first 14 days and 2 additional visits in next 30 days) occurred in 64%; 49% had substance dependence at 6-months. Receipt of buprenorphine treatment was associated with engagement (Adjusted Odds Ratio (AOR) 8.32 95% CI: 4.13-16.77). Self-reported depression at baseline was associated with substance dependence at 6-months (AOR 3.30 95% CI: 1.65-6.61). Neither housing status nor polysubstance use was associated with engagement or substance dependence. The FAST PATH program successfully engaged and treated patients in a primary care-based addiction treatment program. Buprenorphine, a partial opioid agonist, was a major driver of addiction treatment engagement. Given depression's association with adverse outcomes in this clinical population, including mental health treatment as part of integrated care holds potential to improve addiction treatment outcomes.

Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study.

BACKGROUND: One approach to preventing opioid overdose, a leading cause of premature, preventable mortality, is to provide overdose education and naloxone distribution (OEND). Two outstanding issues for OEND implementation include 1) the dissemination of OEND training from trained to untrained community members; and 2) the concern that OEND provides active substance users with a false sense of security resulting in increased opioid use. METHODS: To compare overdose rescue behaviors between trained and untrained rescuers among people reporting naloxone rescue kit use; and determine whether heroin use changed after OEND, we conducted a retrospective cohort study among substance users in the Massachusetts OEND program from 2006 to 2010. We used chi square and t-test statistics to compare the differences in overdose management characteristics among overdoses managed by trained versus untrained participants. We employed Wilcoxon signed rank test to compare median difference among two repeated measures of substance use among participants with drug use information collected more than once. RESULTS: Among 4,926 substance-using participants, 295 trained and 78 untrained participants reported one or more rescues, resulting in 599 rescue reports. We found no statistically significant differences in help-seeking (p = 0.41), rescue breathing (p = 0.54), staying with the victim (p = 0.84) or in the success of naloxone administration (p = 0.69) by trained versus untrained rescuers. We identified 325 OEND participants who had drug use information collected more than once. We found no significant overall change in the number of days using heroin in past 30 days (decreased 38%, increased 35%, did not change 27%, p = 0.52). CONCLUSION: Among 4926 substance users who participated in OEND, 373(7.6%) reported administering naloxone during an overdose rescue. We found few differences in behavior between trained and untrained overdose rescuers. Prospective studies will be needed to determine the optimal level of training and whether naloxone rescue kits can meet an over-the-counter standard. With no clear evidence of increased heroin use, this concern should not impede expansion of OEND programs or policies that support them.

Patient perspectives of an integrated program of medical care and substance use treatment.

The benefits of integrating primary care and substance use disorder treatment are well known, yet true integration is difficult. We developed and evaluated a team-based model of integrated care within the primary care setting for HIV-infected substance users and substance users at risk for contracting HIV. Qualitative data were gathered via focus groups and satisfaction surveys to assess patients' views of the program, evaluate key elements for success, and provide recommendations for other programs. Key themes related to preferences for the convenience and efficiency of integrated care; support for a team-based model of care; a feeling that the program requirements offered needed structure; the importance of counseling and education; and how provision of concrete services improved overall well-being and quality of life. For patients who received buprenorphine/naloxone for opioid dependence, this was viewed as a major benefit. Our results support other studies that theorize integrated care could be of significant value for hard-to-reach populations and indicate that having a clinical team dedicated to providing substance use disorder treatment, HIV risk reduction, and case management services integrated into primary care clinics has the potential to greatly enhance the ability to serve a challenging population with unmet treatment needs.

Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis.

OBJECTIVE: To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts. DESIGN: Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation. SETTING: 19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006. PARTICIPANTS: OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users. INTERVENTION: OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone. MAIN OUTCOME MEASURES: Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals. RESULTS: Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100,000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100,000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant. CONCLUSIONS: Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.