Evaluating the implementation of a prisoner re-entry initiative for individuals with opioid use and mental health disorders: Application of the consolidated framework for implementation research in a cross-system initiative
ارزیابی اجرای ابتکار ورود مجدد زندانی برای افراد دارای مصرف مواد افیونی و اختلالات سلامت روانی: استفاده از چارچوب تلفیقی برای تحقیقات پیاده سازی در یک ابتکار عمل متقابل-2020
Given the interrelated nature of opioid use, criminal justice interaction, and mental health issues, the current opioid crisis has created an urgent need for treatment, including medication assisted treatment, among justiceinvolved populations. Implementation research plays an important role in improving systems of care and integration of evidence-based practices within and outside of criminal justice institutions. The current study is a formative qualitative evaluation of the implementation of a cross-system (corrections and community-based) opioid use treatment initiative supported by Opioid State Targeted Response (STR) funding. The purpose of the study is to assess the fit of the Consolidated Framework for Implementation Research (CFIR) to a cross-system initiative, and to identify key barriers and facilitators to implementation. The process evaluation showed that adaptability of the clinical model and staff flexibility were critical to implementation. Cultural and procedural differences across correctional facilities and community-based treatment programs required frequent and structured forums for cross-system communication. Challenges related to recruitment and enrollment, staffing, MAT, and data collection were addressed through the collaborative development and continuous review of policies and procedures. This study found CFIR to be a useful framework for understanding implementation uptake and barriers. The framework was particularly valuable in reinforcing the use of implementation research as a means for continuous process improvement. CFIR is a comprehensive and flexible framework that may be adopted in future cross-system evaluations.
Keywords: Opioids | Medication assisted treatment | Implementation research | Criminal justice | Co-occurring disorders
New kid on the block: An investigation of the physical, operational, personnel, and service characteristics of recovery community centers in the United States
بچه های جدید در اپارتمان : بررسی خصوصیات جسمی ، عملیاتی ، پرسنلی و خدماتی مراکز جامعه بهبودی در ایالات متحده-2020
Background: Professional treatment and non-professional mutual-help organizations (MHOs) play important roles in mitigating addiction relapse risk. More recently, a third tier of recovery support services has emerged that are neither treatment nor MHO that encompass an all-inclusive flexible approach combining professionals and volunteers. The most prominent of these is Recovery Community Centers (RCCs). RCCs goal is to provide an attractive central recovery hub facilitating the accrual of recovery capital by providing a variety of services (e.g., recovery coaching; medication assisted treatment [MAT] support, employment/educational linkages). Despite their growth, little is known formally about their structure and function. Greater knowledge would inform the field about their potential clinical and public health utility. Method: On-site visits (2015–2016) to RCCs across the northeastern U.S. (K = 32) with semi-structured interviews conducted with RCC directors and online surveys with staff assessing RCCs: physicality and locality; operations and budgets; leadership and staffing; membership; and services. Results: Physicality and locality: RCCs were mostly in urban/suburban locations (90%) with very good to excellent Walk Scores reflecting easy accessibility. Ratings of environmental quality indicated neighborhood/ grounds/buildings were moderate-good attractiveness and quality. Operations: RCCs had been operating for an average of 8.5 years (SD = 6.2; range 1–33 years) with budgets (mostly state-funded) ranging from $17,000–$760,000/year, serving anywhere from a dozen to more than two thousand visitors/month. Leadership and staffing: Center directors were mostly female (55%) with primary drug histories of alcohol (62%), cocaine (19%), or opioids (19%). Most, but not all, directors (90%) and staff (84%) were in recovery. Membership: A large proportion of RCC visitors were male (61%), White (72%), unemployed (50%), criminal-justice system-involved (43%) and reported opioids (35%) or alcohol (33%) as their primary substance. Roughly half were in their first year of recovery (49%), but about 20% had five or more years. Services: RCCs reported a range of services including social/recreational (100%), mutual-help (91%), recovery coaching (77%), and employment (83%) and education (63%) assistance. Medication-assisted treatment (MAT) support (43%) and overdose reversal training (57%) were less frequently offered, despite being rated as highly important by staff. Conclusions: RCCs are easily accessible, attractive, mostly state-funded, recovery support hubs providing an array of services to individuals in various recovery stages. They appear to play a valued role in facilitating the accrual of social, employment, housing, and other recovery capital. Research is needed to understand the relative lack of opioid-specific support and to determine their broader impact in initiating and sustaining remission and cost-effectiveness.
Keywords: Recovery community centers | Recovery | Addiction | Support services | Recovery coaching | Addiction | Substance use disorder
The Negative Affect of Protracted Opioid Abstinence: Progress and Perspectives From Rodent Models
تأثیر منفی پرهیز از مصرف مواد افیونی طولانی: پیشرفت و چشم انداز مدل های جوندگان-2020
Opioid use disorder (OUD) is characterized by the development of a negative emotional state that develops after a history of long-term exposure to opioids. OUD represents a true challenge for treatment and relapse prevention. Human research has amply documented emotional disruption in individuals with an opioid substance use disorder, at both behavioral and brain activity levels; however, brain mechanisms underlying this particular facet of OUD are only partially understood. Animal research has been instrumental in elucidating genes and circuits that adapt to long-term opioid use or are modified by acute withdrawal, but research on long-term consequences of opioid exposure and their relevance to the negative affect of OUD remains scarce. In this article, we review the literature with a focus on two questions: 1) Do we have behavioral models in rodents, and what do they tell us? and 2) What do we know about the neuronal populations involved? Behavioral rodent models have successfully recapitulated behavioral signs of the OUD-related negative affect, and several neurotransmitter systems were identified (i.e., serotonin, dynorphin, corticotropin-releasing factor, oxytocin). Circuit mechanisms driving the negative mood of prolonged abstinence likely involve the 5 main reward–aversion brain centers (i.e., nucleus accumbens, bed nucleus of the stria terminalis, amygdala, habenula, and raphe nucleus), all of which express mu opioid receptors and directly respond to opioids. Future work will identify the nature of these mu opioid receptor–expressing neurons throughout reward–aversion networks, characterize their adapted phenotype in opioid abstinent animals, and hopefully position these primary events in the broader picture of mu opioid receptor–associated brain aversion networks.
Keywords: Mood | Mu opioid receptor (MOR) | Neural circuits | Opioid use disorder (OUD) | Opioid withdrawal | Rodent behavior
Cost-effectiveness analysis of alternative naloxone distribution strategies: First responder and lay distribution in the United States
تجزیه و تحلیل مقرون به صرفه استراتژی های توزیع naloxone جایگزین: اولین پاسخ دهنده و توزیع در ایالات متحده -2020
Background: The U.S. is facing an unprecedented number of opioid-related overdose deaths, and an array of other countries have experienced increases in opioid-related fatalities. In the U.S., naloxone is increasingly distributed to first responders to improve early administration to overdose victims, but its cost-effectiveness has not been studied. Lay distribution, in contrast, has been found to be cost-effective, but rising naloxone prices and increased mortality due to synthetic opioids may reduce cost-effectiveness. We evaluate the cost-effectiveness of increased naloxone distribution to (a) people likely to witness or experience overdose (“laypeople”); (b) police and firefighters; (c) emergency medical services (EMS) personnel; and (d) combinations of these groups. Methods: We use a decision-analytic model to analyze the cost-effectiveness of eight naloxone distribution strategies. We use a lifetime horizon and conduct both a societal analysis (accounting for productivity and criminal justice system costs) and a health sector analysis. We calculate: the ranking of strategies by net monetary benefit; incremental cost-effectiveness ratios; and number of fatal overdoses. Results: High distribution to all three groups maximized net monetary benefit and minimized fatal overdoses; it averted 21% of overdose deaths compared to minimum distribution. High distribution to laypeople and one of the other groups comprised the second and third best strategies. The majority of health gains resulted from increased lay distribution. In the societal analysis, every strategy was cost-saving compared to its next-best alternative; cost savings were greatest in the maximum distribution strategy. In the health sector analysis, all undominated strategies were cost-effective. Results were highly robust to deterministic and probabilistic sensitivity analysis. Conclusions: Increasing naloxone distribution to laypeople and first responder groups would maximize health gains and be cost-effective. If feasible, communities should distribute naloxone to all groups; otherwise, distribution to laypeople and one of the first responder groups should be emphasized.
Keywords: Opioids | Naloxone | Cost-effectiveness analysis | Overdose | First responders | Take-home
Using actor-partner interdependence modeling to understand recent illicit opioid use and injection drug use among men in community supervision and their female partners in New York City
استفاده از مدل وابستگی متقابل بازیگر و شریک زندگی برای درک مصرف غیرقانونی مخدر اخیر و مصرف مواد مخدر تزریقی در مردان تحت نظارت جامعه و شرکای زن آنها در شهر نیویورک-2020
Background: The United States’ opioid crisis disproportionately affects individuals in the criminal justice system. Intimate partners can be a source of social support that helps reduce substance use, or they can serve as a driver of continued or increased substance use. Better understanding of the association between intimate partner characteristics and illicit opioid use and injection drug use among individuals in community supervision could be vital to developing targeted interventions. Methods: Using actor-partner interdependence models, we examined individual and partner characteristics associated with recent illicit opioid use and injection drug use among males in community supervision settings in New York City (n = 229) and their female partners (n = 229). Results: Higher levels of depression (aOR 1.98, 95% CI [1.39–2.82], p ≤ 0.01) and anxiety (aOR 1.98, 95% CI [1.42–2.75], p ≤ 0.01) were associated with recent opioid use among males in community supervision. Females with a partner having higher levels of anxiety were more likely to have recently used opioids (aOR 1.52, 95% CI [1.06–2.16], p ≤ 0.05). Males with a female partner with higher levels of anxiety (aOR 2.16, 95% CI [1.31–3.56], p ≤ 0.01) or depression (aOR 1.70, 95% CI [1.01–2.86], p ≤ 0.05) were more likely to recently inject drugs. Women with a male partner who had been in prison were more likely to have recently injected drugs (aOR 3.71, 95% CI [1.14–12.12], p ≤0.05), but women who had a male partner who had been arrested in the past three months were less likely to have recently injected (aOR 0.08, 95% CI [0.02–0.46], p ≤ 0.01). Conclusions: Results suggest that recent individual illicit opioid use and injection drug use is associated not only with individual-level factors, but also with partner factors, highlighting the need for couple-based approaches to address the opioid epidemic.
Keywords: Opioid use | Injection drug use | Mental health | Criminal justice | Dyads | Actor-partner interdependence model
Methadone maintenance treatment is swapping one drug for another, and thats why it works: Towards a treatment-based critique of the war on drugs
درمان نگهداری متادون یک دارو را با داروی دیگر عوض می کند و به همین دلیل موثر است: به سمت انتقاد مبتنی بر درمان از جنگ با مواد مخدر-2020
The claim that methadone maintenance treatment (MMT) is ‘just swapping one drug for another’ has typically been used to de-legitimize the treatment and attack those who use it. However, this commentary re-positions that argument as a way of bringing analytic focus to the role of structural forces, like criminalization and the war on drugs, in the treatment decisions of people who use illegal drugs. Specifically, I use my experience as a qualitative sociologist who studies MMT as well as my own experience on MMT to demonstrate how criminalization functions as source of harm in the lives of people who use illegal drugs, that drives them towards the legal, and thus comparatively safer, style of substance use made available by MMT. Moreover, I argue that the dominance of individually-focused theories based on addiction and recovery to understand MMT is related to its punitive organizational structure and lack of popularity among people who use illegal opioids. Ultimately, I argue for a paradigm shift, both in policy and scholarship, that acknowledges the pragmatic value of MMT within the structural context of criminalization.
Keywords: Methadone maintenance treatment (MMT) | Recovery | Harm reduction | Criminalization | Addiction
Increasing collaboration on substance use disorder research with primary care practices through the National Drug Abuse Treatment Clinical Trials Network
افزایش همکاری در زمینه تحقیق اختلال در مصرف مواد با اقدامات مراقبت های اولیه از طریق شبکه ملی آزمایش های بالینی درمان سوء مصرف مواد-2020
Background: The National Drug Abuse Treatment Clinical Trials Network (CTN) called for its national nodes to promote the translation of evidence-based interventions from substance use disorder (SUD) research into clinical practices. This collaborative demonstration project engaged CTN-affiliated practice-based research networks (PBRNs) in research that describes aspects of opioid prescribing in primary care. Methods: Six PBRNs queried electronic health records from a convenience sample of 134 practices (84 participants) to identify the percent of adult patients with an office visit who were prescribed an opioid medication from October 1, 2015, to September 30, 2016, and, of those, the percent also prescribed a sedative in that year. Seven PBRNs sent an e-mail survey to a convenience sample of 108 practices (58 participants) about their opioid management policies and procedures during the project year. Results: Of 561,017 adult patients with a visit to one of the 84 clinics in the project year, 22.9% (PBRN range 3.1%–25.4%) were prescribed opioid medications, and 52.1% (PBRN range 8.5%–60.6%) of those were prescribed a sedative in the same year. Of the 58 practices returning a survey (45.3% response rate), 98.1% had formal written treatment agreements for chronic opioid therapy, 68.5% had written opioid prescribing policies, and 43.4% provided reports to providers with feedback on opioid management. Only 24.1% were providing buprenorphine for OUD. Conclusion: CTN-affiliated PBRNs demonstrated their ability to collaborate on a project related to opioid management; results highlight the important role for PBRNs in OUD treatment, research, and the need for interventions and additional policies addressing opioid prescribing in primary care practice.
Keywords: Prescribing patterns | Opioids | Primary care | Electronic health records | Practice-based research
The impact of cannabis access laws on opioid prescribing
تأثیر قوانین دستیابی به حشیش بر تجویز مواد افیونی-2020
While recent research has shown that cannabis access laws can reduce the use of prescrip-tion opioids, the effect of these laws on opioid use is not well understood for all dimensionsof use and for the general United States population. Analyzing a dataset of over 1.5 bil-lion individual opioid prescriptions between 2011 and 2018, which were aggregated to theindividual provider-year level, we find that recreational and medical cannabis access lawsreduce the number of morphine milligram equivalents prescribed each year by 11.8 and 4.2percent, respectively. These laws also reduce the total days’ supply of opioids prescribed,the total number of patients receiving opioids, and the probability a provider prescribesany opioids net of any offsetting effects. Additionally, we find consistent evidence thatcannabis access laws have different effects across types of providers, physician specialties,and payers.
Keywords: Cannabis | Marijuana| Opioids
Imprisonment, opioids and health care reform: The failure to reach a highrisk population
حبس ، مواد افیونی و اصلاح مراقبت های بهداشتی: عدم دستیابی به جمعیت پرخطر-2020
The 2014 National Research Council report on American incarceration optimistically anticipated the Affordable Care Act (ACA) would be “a turning point in the nations health care, and … will provide unprecedented access to care for many people being released from correctional facilities.” However, the ACA was not designed to proactively respond to risks associated with prisoner re-entry into society. Our overarching hypothesis is that unmet health needs among previously incarcerated adults can be more fully understood by analyzing how unprescribed use of drugs, such as opioids, is associated with economic and health problems and health care uninsurance that in turn results in exclusion from needed health care services. Using several waves of the National Longitudinal Study of Adolescent to Adult Health conducted before and after passage and implementation of ACA, our analysis indicates that the above risk factors nearly fully mediate the association between previous incarceration and failure to receive needed health care. We argue that these factors are likely intensified by a reactive approach to health care reform that not only fails to cover many former prisoners, but also is lacking in sufficient outreach programming, and as such is insufficient for adults with health problems and limited economic resources - especially those using un-prescribed opioids. Future work should address the capacity of more proactively organized public health programs to expand coverage to previously incarcerated populations - including un-prescribed opioid users - and thereby reduce their health risks and vulnerability to repeated exposure to law enforcement surveillance and criminal punishment.
Keywords: Incarceration | Opioids | Affordable Care Act | Health care access | Health care policy
Implementation and enforcement of state opioid prescribing laws
پیاده سازی و اجرای قوانین تجویز مواد مخدر دولتی-2020
Background: In response to the role overprescribing has played in the U.S. opioid crisis, in the past decade states have enacted four main types of laws to curb opioid prescribing: mandatory prescription drug monitoring program (PDMP) enrollment laws requiring clinicians to register with a PDMP; mandatory PDMP query laws requiring clinicians to check a PDMP prior to prescribing opioids; pill mill laws regulating pain management clinics; and opioid prescribing cap laws limiting the dose/duration of opioid prescriptions. While 47 states now have one or more of these laws in place, little is known about implementation and enforcement strategies, facilitators, and barriers. Methods: From November 2017 to February 2019, we interviewed 114 professionals involved in state opioid prescribing law implementation and enforcement in 20 states and identified common themes. Results: Implementation efforts focused on awareness campaigns and targeted training of key front-line implementers. Enforcement strategies included active, complaint-based, and automated strategies. Collaboration across agencies and stakeholders, particularly health agencies and law enforcement, was identified as an important facilitator of implementation and enforcement. Two key interrelated barriers were identified: the complexity of state opioid prescribing laws in terms of which providers, patients, and prescriptions they applied to, and IT infrastructure. Conclusion: Despite differing approaches, our findings suggest similar barriers to implementation and enforcement across state opioid prescribing laws. Strategies are needed to ease implementation and enforcement of laws that apply only to specific sub-sets of providers, patients, or prescriptions and address issues of access and data utilization of the PDMP.
Keywords: Opioid | Policy | Implementation | Enforcement