Mobile service delivery in response to the opioid epidemic in Philadelphia.

BACKGROUND: The harms of opioid use disorder (OUD) and HIV infection disproportionately impact marginalized populations, especially people experiencing homelessness and people who inject drugs (PWID). Mobile OUD service delivery models are emerging to increase access and reduce barriers to OUD care. While there is growing interest in these models, there is limited research about the services they provide, how they operate, and what barriers they face. We characterize the capacity, barriers, and sustainment of mobile OUD care services in a large city with a high incidence of OUD and HIV. METHODS: From May to August 2022, we conducted semi-structured interviews with leadership from all seven mobile OUD care units (MOCU) providing a medication for OUD or other substance use disorder services in Philadelphia. We surveyed leaders about their unit's services, staffing, operating location, funding sources, and linkages to care. Leaders were asked to describe their clinical approach, treatment process, and the barriers and facilitators to their operations. Interview recordings were coded using rapid qualitative analysis. RESULTS: MOCUs are run by small, multidisciplinary teams, typically composed of a clinician, one or two case managers, and a peer recovery specialist or outreach worker. MOCUs provide a range of services, including medications for OUD, wound care, medical services, case management, and screening for infectious diseases. No units provide methadone, but all units provide naloxone, six write prescriptions for buprenorphine, and one unit dispenses buprenorphine. The most frequently reported barriers include practical challenges of working on a MOCU (e.g. lack of space, safety), lack of community support, and patients with substantial medical and psychosocial needs. Interviewees reported concerns about funding and specifically as it relates to providing their staff with adequate pay. The most frequently reported facilitators include positive relationships with the community, collaboration with other entities (e.g. local nonprofits, the police department, universities), and having non-clinical staff (e.g. outreach workers, peer recovery specialists) on the unit. CONCLUSIONS: MOCUs provide life-saving services and engage marginalized individuals with OUD. These findings highlight the challenges and complexities of caring for PWID and demonstrate a need to strengthen collaborations between MOCU providers and the treatment system. Policymakers should consider programmatic funding for permanent mobile OUD care services.

Implementing a resilience coach program to support first year housestaff during the COVID-19 pandemic: early pilot results and comparison with non-housestaff sessions.

BACKGROUND: In response to the COVID-19 pandemic, we launched the Penn Medicine Coping First Aid program to provide psychosocial supports to our health system community. Our approach leveraged lay health worker volunteers trained in principles of Psychological First Aid to deliver coaching services through a centralized virtual platform. METHODS: We emailed all (n = 408) first year housestaff (i.e., residents and fellows) with an invitation to schedule a session with a resilience coach. We compared the mental health concerns, symptoms, and Psychological First Aid techniques recorded in (n = 67) first year housestaff sessions with (n = 91) sessions of other employees in the health system. RESULTS: Between June and November 2020, forty-six first year housestaff attended at least one resilience coaching session. First year housestaff most commonly presented with feelings of anxiety and sadness and shared concerns related to the availability of social support. Resilience coaches most frequently provided practical assistance and ensured safety and comfort to first year housestaff. First year housestaff reported fewer physical or mental health symptoms and held shorter sessions with resilience coaches than non-housestaff. CONCLUSIONS: This work offers insights on how to address psychosocial functioning through low-intensity interventions delivered by lay personnel. More research is needed to understand the efficacy of this program and how best to engage housestaff in wellness and resilience programs throughout training, both during and beyond COVID-19.

"There's absolutely no downside to this, I mean, except community opposition:" A qualitative study of the acceptability of vending machines for harm reduction.

BACKGROUND: Vending machines for harm reduction (VMHR) are an innovative approach to deliver life-saving materials, information, and treatment for hard-to-reach populations, particularly for persons who inject drugs. The current study explores stakeholders' perspectives on the feasibility and acceptability of VMHR in Philadelphia. METHODS: From October 2021 to February 2022, we conducted 31 semi-structured interviews with potential end users, staff, and leadership at a local federally qualified health center, and community members. Trained coders extracted themes from interview transcripts across four key domains: materials and logistics, location, access, and community introduction. RESULTS: Interviewees from all stakeholder groups endorsed using VMHR to provide supplies for wound care, fentanyl test strips, naloxone, and materials to connect individuals to treatment and other services. Dispensing syringes and medications for opioid use disorder were commonly endorsed by health center staff but were more controversial among potential end users. Even within stakeholder groups, views varied with respect to where to locate the machines, but most agreed that the machine should be placed in the highest drug use areas. Across stakeholder groups, interviewees suggested several strategies to introduce and gain community acceptance of VMHR, including community education, one-on-one conversations with community members, and coupling the machine with safe disposal of syringes and information to link individuals to treatment. CONCLUSIONS: Stakeholders were generally receptive to VMHR. The current study findings are consistent with qualitative analyses from outside of the USA and contribute new ideas regarding the anticipated community response and best methods for introducing these machines to a community. With thoughtful planning and design, VMHR could be a feasible and acceptable modality to reduce death and disease transmission associated with the opioid and HIV epidemics in cities like Philadelphia.

Not in my treatment center: Leadership's perception of barriers to MOUD adoption.

INTRODUCTION: Despite their well-established effectiveness, medications for opioid use disorder (MOUD) are widely underutilized across the United States. In the context of a large publicly funded behavioral health system, we examined the relationship between a range of implementation barriers and a substance use disorder treatment agency's level of adoption of MOUD. METHODS: We surveyed leadership of publicly funded substance use disorder treatment centers in Philadelphia about the significance of barriers to implementing MOUD related to their workforce, organization, funding, regulations, and beliefs about MOUD's efficacy and safety. We queried leaders on the percentage of their patients with opioid use disorder who receive MOUD and examined associations between implementation barriers and MOUD adoption. RESULTS: Ratings of regulatory, organizational, or funding barriers of respondents who led high MOUD adopting agencies (N = 20) were indistinguishable from those who led agencies that were low adopting of MOUD (N = 23). In contrast, agency leaders who denied MOUD-belief or workforce barriers were significantly more likely to lead high-MOUD-adopting organizations. CONCLUSIONS: These findings suggest that leadership beliefs about MOUD may be a key factor of the organizational decision to adopt and should be a target of implementation efforts to increase direct provision of these medications.

A systematic review of brief, freely accessible, and valid self-report measures for substance use disorders and treatment.

BACKGROUND: Self-report measures can improve evidence-based assessment practices in substance use disorder treatment, but many measures are burdensome and costly, limiting their utility in community practice and non-specialty healthcare settings. This systematic review identified and evaluated the psychometric properties of brief, free, and readily accessible self-report measures of substance use and related factors. METHODS: We searched two electronic databases (PsycINFO and PubMed) in May 2021 for published literature on scales, measures, or instruments related to substance use, substance use treatment, and recovery, and extracted the names of all measures. Measures were included if they were: (1) brief (25 items or fewer), (2) freely accessible in a ready-to-use format, and (3) had published psychometric data. RESULTS: An initial search returned 411 measures, of which 73 (18%) met criteria for inclusion. Included measures assessed a variety of substances (e.g., alcohol, nicotine, opioids, cannabinoids, cocaine) and measurement domains (e.g., use, severity, expectancies, withdrawal). Among these measures, 14 (19%) were classified as psychometrically "excellent," 27 (37%) were rated as "good," 32 (44%) were "adequate." CONCLUSIONS: Despite the shift toward evidence-based assessment in substance use disorder treatment in the last twenty years, key areas of public health concern are lacking pragmatic, psychometrically valid measures. Among the brief measures we reviewed, less than a fifth met criteria for psychometric "excellence" and most of these instruments fell into one measurement domain: screening for problematic substance use. Future research should focus both on improving the evidence base for existing brief self-report measures and creating new low-burden measures for specific substances and treatment constructs.