Reimagining patient-centered care in opioid treatment programs: Lessons from the Bronx during COVID-19.

Opioid treatment programs (OTPs) operate within a rigid set of clinical guidelines and regulations that specify the number of required OTP visits for supervised administration of methadone. To ensure physical distancing in light of COVID-19, the federal government loosened regulations to allow for additional flexibility. As OTP providers in the Bronx, NY, caring for more than 3600 patients in the epicenter of both the overdose and COVID-19 pandemics, we describe how our clinical practice changed with COVID-19. We halted toxicology testing, and to promote physical distancing and prevent interruptions in access to treatment for medications for opioid use disorder (MOUD), we drastically increased unsupervised take-home doses of MOUD. Within two weeks, we reduced the proportion of patients with 5-6 OTP visits per week from 47.2% to 9.4%. To guide treatment decision-making, we shifted focus from toxicology tests to other patient-centered measures, such as engagement in care and patient goals. In the initial three months, our patients experienced six nonfatal overdoses, no fatal overdoses, and 20 deaths attributable to COVID-19. This experience provides an opportunity to re-imagine care in OTPs going forward. We advocate that OTPs rely less on toxicology testing and more on the other patient-centered measures to guide decisions about distribution of take-home doses of MOUD. To minimize financial risk to OTPs and facilitate their transition to a more flexible model of care, we advocate for the reassessment of OTP reimbursement models.

Evidence of fentanyl use is common and frequently missed in a cross-sectional study of emergency department patients in Baltimore, Maryland.

Objective: Fentanyl-associated deaths have risen in Maryland, but the prevalence of illicit fentanyl use is unknown. Our objective was to measure whether fentanyl is present among emergency department (ED) patients seeking care for a drug overdose.Design: The prevalence of fentanyl use was determined using a cross-sectional study of a convenience sample of adult ED patients with complaints of apparent opioid overdose, withdrawal from opioids, and/or requesting treatment for their substance use disorder (SUD) between February and April, 2018. Subjects were consented, interviewed, and underwent urine point-of-care (POC) fentanyl testing.Results: A total of 102 patients met inclusion criteria and were approached, 76 consented, 63 (83%) of whom tested positive for recent fentanyl use. 60 (80%) were male, 26 (34%) had overdosed, 41 (54%) were seeking SUD treatment, and 13 (17%) were in withdrawal (4 had multiple complaints). Of those who underwent both standard hospital urine drug screen and POC fentanyl testing, 56% (22/39) were positive for fentanyl and negative for opiates. Only 5% (4/76) reported knowledge of using fentanyl.Conclusions: Fentanyl use was common and frequently missed among these ED patients. Hospitals who treat patients taking illicit fentanyl should consider adding fentanyl to their urine drugs of abuse panel.

Conhecimento, atitudes e práticas dos profissionais da equipe de saúde da família na atenção aos usuários de substâncias psicoativas / Knowledge, attitudes and practice of family health team professionals in the attention to psychoactive substances users

O abuso do álcool e outras drogas é um problema de saúde pública, e as equipes de saúde da família devem estar capacitadas e qualificadas para cuidar dessa população. Desse modo, o presente estudo teve como objetivo geral: Avaliar o conhecimento, as atitudes e as práticas dos profissionais que integram as Equipes de Saúde da Família na atenção à saúde dos usuários com problemas relacionados ao uso de substâncias psicoativas; e teve como objetivos específicos: Descrever o conhecimento, as atitudes e as práticas frente ao uso de substâncias psicoativas dos profissionais de saúde que integram as Equipes de Saúde da Família; Realizar capacitação em serviço sobre as substâncias psicoativas baseadas na Intervenção Breve par aos profissionais da Equipe de Saúde da Família; Analisar o impacto da capacitação em serviço sobre o conhecimento dos profissionais das Equipes de Saúde da Família nas perspectivas da Intervenção Breve. Metodologia: Trata-se de uma pesquisa seccional do tipo inquérito Conhecimento, Atitudes e Práticas, seguido de um estudo quase- experimental. Para o estudo seccional foram entrevistados 318 profissionais que atuavam nas Equipes de Saúde da Família em uma área de planejamento do município do Rio de Janeiro. O instrumento de coleta de dados foi um questionário autoaplicável com questões referentes a perfil sociodemográfico, conhecimento, atitudes e práticas relacionadas à atenção à saúde dos usuários de substâncias psicoativas. Para o desenho quase-experimental foi realizada uma capacitação em serviço com 17 profissionais das Equipes de Saúde da Família, sendo utilizado um questionário autoaplicável antes e após a intervenção. Todos os dados foram analisados pelo programa Statistical Package for the Social Sciences (IBM SPSS, v. 23,0). Resultados: Evidenciou-se que a maior parte dos entrevistados foram do sexo feminino, adultos (mediana= 38), cristãos, agentes comunitários de saúde e que trabalhavam na Estratégia de Saúde da Família de 1 a 5 anos. Houve predomínio de conhecimento, atitudes e práticas não adequadas relacionadas à atenção à saúde dos usuários de substâncias psicoativas, houve diferença estatística significativa entre atitudes não adequadas e práticas não adequadas. Após a capacitação em serviço observou-se melhora no conhecimento adequado. Conclusão: Observou-se que ainda existe fragilidade no conhecimento, nas atitudes e nas práticas ofertadas pelos profissionais da Estratégia de Saúde da Família para as pessoas com uso/abuso de substâncias psicoativas. Desse modo, recomenda-se maior oferta de cursos de capacitação em serviço sobre álcool e outras drogas para que o mesmo possa influenciar em atitudes e práticas adequadas.

The abuse of alcohol and other drugs is a public health problem, which family health teams must be trained and qualified for the care of this population. Thus, the present study had the general objective of: Assessing the knowledge, attitudes and practices of the professionals who are part of the Family Health Teams in the health care of users with problems related to the use of psychoactive substances; and had as specific objectives: To describe the knowledge, attitudes and practices regarding the use of psychoactive substances by health professionals who are part of the Family Health Teams; Conduct in-service training on psychoactive substances based on Brief Intervention for professionals in the Family Health Team; To analyse the impact of in-service training on the knowledge of the professionals of the Family Health Teams in the perspective of Brief Intervention. Methodology: This is a Knowledge, Attitudes and Practices sectional survey followed by a quasi-experimental study. For the sectional study, 318 professionals who worked in Family Health Teams in a planning area in the city of Rio de Janeiro were interviewed. The data collection instrument was a self- administered questionnaire with questions related to the socio-demographic profile, knowledge, attitudes and practices related to the health care of psychoactive substances users. For the quasi-experimental design, in-service training was carried out with 17 professionals from the Family Health Teams, using a self-administered questionnaire before and after the intervention. All data was analysed using the Statistical Package for the Social Sciences program (IBM SPSS, v.23.0). Results: It was evident that most of the interviewees were female, adults (median = 38), Christians, community health workers and who worked on the Family Health Strategy for 1 to 5 years. There was a predominance of inappropriate knowledge, attitudes and practices related to the health care of psychoactive substances users, there was a statistically significant difference between inappropriate attitudes and inappropriate practices. After in-service training, there was an improvement in adequate knowledge. Conclusion: It was observed that there is still a weakness in the knowledge, attitudes and practices offered by professionals of the Family Health Strategy for people with use/abuse psychoactive substances. Thus, a greater offer of in-service training courses on alcohol and other drugs is recommended so that it can influence appropriate attitudes and practices.

El abuso de alcohol y otras drogas es un problema de salud pública en el que los equipos de salud familiar deben estar capacitados y calificados para atender a esta población. Por lo tanto, el presente estudio tuvo el objetivo general de: evaluar los conocimientos, las actitudes y las prácticas de los profesionales que forman parte de los Equipos de Salud Familiar en la atención de la salud de los usuarios con problemas relacionados con el uso de sustancias psicoactivas; y tenía como objetivos específicos: describir el conocimiento, las actitudes y las prácticas con respecto al uso de sustancias psicoactivas por parte de los profesionales de la salud que forman parte de los Equipos de Salud Familiar; Realizar capacitación en el servicio sobre sustancias psicoactivas basada en la Intervención Breve para profesionales del Equipo de Salud Familiar; Analizar el impacto de la capacitación en el servicio sobre el conocimiento de los profesionales de los Equipo de Salud Familiar en la perspectiva de la intervención breve. Metodología: Esta es una encuesta seccional Conocimiento, Actitudes y Prácticas seguida de un estudio cuasi-experimental. Para el estudio seccional, se entrevistó a 318 profesionales que trabajaron en Equipos de Salud Familiar en un área de planificación en la ciudad de Río de Janeiro. El instrumento de recopilación de datos fue un cuestionario autoadministrado con preguntas sobre el perfil sociodemográfico, el conocimiento, las actitudes y las prácticas relacionadas con la atención de la salud de los usuarios de sustancias psicoactivas. Para el diseño cuasiexperimental, se llevó a cabo capacitación en el servicio con 17 profesionales de los equipos de salud familiar, utilizando un cuestionario autoadministrado antes y después de la intervención. Todos los datos se analizaron utilizando el Paquete Estadístico para el programa de Ciencias Sociales (IBM SPSS, v.23.0). Resultados: fue evidente que la mayoría de los entrevistados eran mujeres, adultos (mediana = 38), cristianos, trabajadores de salud comunitarios y que trabajaron en la Estrategia de Salud Familiar hace de 1 a 5 años. Predominaran el conocimiento, las actitudes y las prácticas inapropiadas relacionadas con la atención de la salud de los usuarios de sustancias psicoactivas, hubo una diferencia estadísticamente significativa entre las actitudes inapropiadas y las prácticas inapropiadas. Después de la capacitación en servicio, hubo una mejora en el conocimiento adecuado. Conclusión: se observó que todavía existe debilidad en el conocimiento, las actitudes y las prácticas ofrecidas por los profesionales de la Estrategia de Salud Familiar para las personas con uso/abuso de substancias psicoactivas. Por lo tanto, se recomienda mayor oferta de cursos de capacitación en servicio sobre alcohol y otras drogas para que pueda influir en las actitudes y prácticas apropiadas.