Integrated telehealth intervention to reduce chronic pain and unhealthy drinking among people living with HIV: protocol for a randomized controlled trial.

BACKGROUND: Unhealthy alcohol use represents a significant risk for morbidity and mortality among people living with HIV (PLWH), in part through its impact on HIV management. Chronic pain, a common comorbidity, exacerbates suboptimal engagement in the HIV care continuum and has reciprocal detrimental effects on alcohol outcomes. There are no integrated, accessible approaches that address these comorbid conditions among PLWH to date. This paper describes a research study protocol of an integrated telehealth intervention to reduce unhealthy drinking and chronic pain among PLWH (Motivational and Cognitive-Behavioral Management for Alcohol and Pain [INTV]). METHODS: Two-hundred and fifty PLWH with unhealthy drinking and chronic pain will be recruited nationally via online advertisement. Informed consent and baseline assessments occur remotely, followed by 15 days of ecological momentary assessment to assess alcohol use, chronic pain, functioning, and mechanisms of behavior change. Next, participants will be randomized to either the INTV or Control (CTL) condition. Individuals in both conditions will meet with a health counselor through videoconferencing following randomization, and those in the INTV condition will receive 6 additional sessions. At 3- and 6-months post-baseline, participants will complete outcome assessments. It is hypothesized that the INTV condition will result in reduced unhealthy alcohol use and pain ratings compared to the CTL condition. CONCLUSION: This protocol paper describes a randomized controlled trial which tests the efficacy of a novel, integrated telehealth approach to reduce unhealthy alcohol use and chronic pain for PLWH, two common comorbid conditions that influence the HIV treatment cascade. GOV IDENTIFIER: NCT05503173.

Building capacity for local public health: lessons from a mixed-methods evaluation of an academic-public health partnership used in response to COVID-19.

Introduction: The Massachusetts Academic Health Department Consortium (AHD) established the Academic Public Health Volunteer Corps (APHVC) to support Local Health Departments (LHDs, n = 351) to meet rapidly emerging needs during the COVID-19 pandemic through engaging student volunteers. A program evaluation captured lessons learned and informed recommendations for sustainability and future replication. Methods: The mixed-methods evaluation leveraged the Consolidated Framework for Implementation Research (CFIR). Data were stratified by LHD engagement with APHVC. Quantitative surveys informed probes for qualitative focus groups and interviews; findings were categorized into CFIR constructs using a deductive approach. Results: One-fifth of LHDs (n = 76, 27 used APHVC services, 45 did not) completed the survey. Eleven employees participated in follow-up focus groups or interviews. APHVC filled resource gaps, built capacity, and provided high-quality deliverables. LHDs experienced issues with reliability and communication of volunteers and lacked time to train volunteers. Conclusions: CFIR aided in evaluating APHVC in real time, producing actionable recommendations for best practices, dissemination, and future iterations of the program. Results are being used to enhance program effectiveness and sustainability, community health, and health equity across Massachusetts, and may help inform academic practice-based programs across the United States.

The Impact of COVID-19 on Substance Use and Related Consequences among Patients in Office-Based Opioid Use Disorder Treatment.

OBJECTIVES: The COVID-19 pandemic led to increased substance-related morbidity and mortality and transformed care for opioid use disorder (OUD). We assessed the perceived impacts of the pandemic on substance use and related consequences among patients in office-based addiction treatment (OBAT). METHODS: We recruited patients with OUD on buprenorphine from July 2021 to July 2022, with data collection at baseline and 6 months. Exposures of interest were the following 6 domains potentially impacted by COVID-19: personal or family infection, difficulty accessing healthcare/medication, economic stressors, worsening physical or mental health, social isolation, and conflicts/disruptions in the home. Outcomes were past 30-day alcohol and other substance use, increased use, and substance-related consequences at baseline and 6 months. Generalized estimating equations Poisson regression models quantified associations between increasing impact domain scores and relative risks of each outcome. RESULTS: All participants (N = 150) reported at least one domain negatively impacted by COVID-19 at both time points. Higher "worsening physical or mental health" domain scores were associated with increased relative risk of recent alcohol or drug use (adjusted risk ratio [aRR] 1.04, 95% confidence interval [CI]: 1.01-1.07). Relative risks of experiencing substance-related consequences increased with higher scores in the domains of economic stressors (aRR 1.07, 95% CI: 1.02-1.13), difficulty accessing healthcare/medication (aRR 1.11, 95% CI: 1.04-1.19), and worsening physical or mental health (aRR 1.08, 95% CI: 1.04-1.12). CONCLUSIONS: Among patients with OUD, stressors from COVID-19 were common. Three life domains impacted by COVID-19 appeared to be associated with consequential substance use, highlighting opportunities to address barriers to healthcare access and economic stressors.

Design and rationale for a randomized clinical trial testing the efficacy of a lifestyle physical activity intervention for people with HIV and engaged in unhealthy drinking.

BACKGROUND: Among people living with HIV (PLWH), unhealthy drinking presents an increased risk for negative outcomes. Physical inactivity and sedentariness raise additional health risks. Despite evidence that physical activity (PA) is associated with improved physical and mental functioning and reduced alcohol cravings, there have been no PA studies conducted with PLWH engaged in unhealthy drinking. We describe a study protocol of a remote lifestyle physical activity (LPA) intervention to increase PA and reduce alcohol consumption among PLWH. METHODS: Using online advertisements, 220 low-active PLWH engaged in unhealthy drinking will be recruited and randomized nationwide. After providing informed consent and completing a baseline interview, participants will receive a Fitbit. Participants will complete 15 days of ecologic momentary assessment through a phone application and up to 15 days of Fitbit wear time. Following this period, participants will be randomly assigned to a Fitbit-only control condition or a LPA and Fitbit intervention condition. Health counselors meet with control participants once (and have 6 subsequent brief check ins on Fibit use) and with intervention participants 7 times for PA counseling over a 12-week period. Follow-up assessments will be conducted at 3- and 6-months post-randomization. We hypothesize that individuals in the LPA and Fitbit condition will have lower rates of alcohol consumption and higher rates of PA at 6-month follow-up. CONCLUSION: The randomized controlled trial described in this paper investigates remote methods to influence multimorbidity among PLWH using a LPA approach for increasing PA and reducing alcohol consumption.

Patient and Clinician Experiences with the Implementation of Telemedicine and Related Adaptations in Office-Based Buprenorphine Treatment During the COVID-19 Pandemic: A Qualitative Study.

Background: Deaths from opioid overdose have increased dramatically in the past decade, representing an epidemic in the United States. For individuals with opioid use disorder (OUD), agonist medications such as methadone and buprenorphine reduce opioid-related morbidity and mortality. Historically, the provision of buprenorphine treatment in office-based settings has relied on frequent in-person contact, likely influencing patients' access to and retention in care. In response to the COVID-19 pandemic, providers of office-based buprenorphine treatment rapidly adapted their care processes, increasingly relying on telemedicine visits. To date, relatively few prior studies have combined patient and clinician perspectives to examine the implementation of telemedicine and related care adaptations, particularly in safety-net settings. Methods: Qualitative methods were used to explore clinician and patient experiences with telemedicine in an office-based buprenorphine treatment clinic affiliated with an urban safety-net hospital. From this clinic, we interviewed 25 patients and 16 clinicians (including prescribers and non-prescribers) to understand how telemedicine impacted treatment quality and engagement in care, as well as preferences for using telemedicine moving forward. Results: Five themes regarding the implementation of telemedicine and other COVID-19-related care adaptations arose from patient and clinician perspectives: 1) telemedicine integration precipitated openness to more flexibility in care practices, 2) concerns regarding telemedicine-related adaptations centered around safety and accountability, 3) telemedicine encounters required rapport and trust between patients and clinicians to facilitate open communication, 4) safety-net patient populations experienced unique challenges when using telemedicine, particularly in terms of the technology required and the need for privacy, and 5) there is an important role for telemedicine in office-based buprenorphine treatment moving forward, primarily through its use in hybrid models of care. Conclusions: Telemedicine implementation within office-based buprenorphine treatment has the potential to improve patients' engagement in care; however, our findings emphasize the need for tailored approaches to implementing telemedicine in office-based buprenorphine treatment, particularly within safety-net settings. Overall, this study supports the maintenance of changes to policy and practice that facilitate the use of telemedicine in office-based buprenorphine treatment beyond the COVID-19 public health emergency.

A Qualitative Study of A Health Center-Based Mobile Produce Market.

Healthcare-based food assistance programs have the potential to improve patients' food security, but are underutilized. We conducted a qualitative study of user and staff perceptions of an on-site mobile market at a federally-qualified health center (FQHC). Five themes were identified: 1) financial need drives the decision to use the market, 2) people attend specifically to receive healthy food, 3) users feel a connection to the FQHC, which increases participation, 4) social networks increase usage of the program, and 5) long lines, inclement weather, inaccessibility, and inconsistent marketing and communication are attendance barriers. Findings should inform implementation of future healthcare-based food assistance programs.

A Clinical Guide to Support the Implementation of Addiction Consult Services and the Value of Teaching and Technical Assistance.

ABSTRACT: People with substance use disorders (SUDs) are increasingly admitted to general hospitals; however, many hospital systems lack both formal structures and skilled staff to provide high-quality care for inpatients with SUDs. Inpatient addiction consult services (ACSs), which are increasingly being implemented around the country, are an evidence-based strategy to add focused care for people with SUDs into the general medical setting. In 2018, New York City Health + Hospitals (H + H) launched an ACS program called Consult for Addiction Care and Treatment in Hospitals in six hospitals, supported by a team of addiction consult experts to deliver teaching and technical assistance (TTA) for the Consult for Addiction Care and Treatment in Hospitals ACSs. This commentary describes the TTA, which included site visits, introductory educational lectures, case conferences, ad hoc support, implementation assistance, and the creation of an addiction care guide. Similar TTA services could be used in the future when hospitals or systems want to launch novel clinical programs.

Using formative evaluation of a community-based opioid overdose prevention program to inform strategic communication for adoption, implementation, and sustainability.

BACKGROUND: Opioid addiction and overdose is a public health problem in the United States and is expected to remain with substance use increasing due to the COVID-19 pandemic. Communities that approach this issue through multi-sector partnerships experience more positive health outcomes. Understanding motivation for stakeholder engagement in these efforts is essential to successful adoption, implementation, and sustainability particularly in the shifting landscape of needs and resources. METHODS: A formative evaluation was conducted on the C.L.E.A.R. Program in Massachusetts, a state heavily impacted by the opioid epidemic. A stakeholder power analysis identified appropriate stakeholders for the study (n = 9). The Consolidated Framework for Implementation Research (CFIR) guided data collection and analysis. Surveys (n = 8) examined perception and attitudes on the program; motivations and communication for engagement; and, benefits and barriers to collaboration. Stakeholder interviews (n = 6) explored the quantitative findings in more detail. Surveys were analyzed using descriptive statistics and a content analysis with deductive approach was conducted for stakeholder interviews. The Diffusion of Innovation (DOI) Theory guided recommendations for communications to engage stakeholders. RESULTS: Agencies represented a range of sectors and the majority (n = 5) were familiar with the C.L.E.A.R. PROGRAM: Despite the many strengths of the program and existing collaboration, based on the coding densities of each CFIR construct stakeholders identified crucial gaps in the services the program provided and noted that the overall infrastructure of the program could be enhanced. Opportunities for strategic communication to address the stages of DOI align with the gaps identified in the CFIR domains to result in increased agency collaboration and expansion of services into the surrounding communities to ensure sustainability of the C.L.E.A.R. CONCLUSIONS: This study explored factors necessary for ongoing multi-sector collaboration and sustainability of an existing community-based program especially given the changing context from COVID-19. Findings informed both program revisions and communication strategies to promote the program to new and existing collaborating agencies and the community served, and identify effective communication approaches across sectors. This is essential for successful implementation and sustainability of the program, especially as it is adapted and expanded to address post-pandemic times. TRIAL REGISTRATION: This study does not report results of a health care intervention on human participants, however it was reviewed and determined an exempt study with the Boston University Institutional Review Board (IRB #H-42107).