Examining Access to Primary Care for People With Opioid Use Disorder in Ontario, Canada: A Randomized Clinical Trial

Popularity of HIV self-tests may say more about the state of our primary care system than about the device itself

Background

In Canada, HIV transmission continues to disproportionately affect the same communities of gay men, bisexual men and men who have sex with men (gbMSM); members of African, Caribbean or Black communities (ACB); people who use injection drugs; Indigenous people; and women who belong to the aforementioned groups. While primary care is an ideal location for HIV testing for members of these groups, many people do not have access to such healthcare services. In response, we launched GetaKit to distribute HIV self-tests.

Methods

In light of reduced access to healthcare services as a result of the pandemic and in anticipation of Health Canada's approval of an HIV self-test, a clinician-scientist research team at the University of Ottawa developed GetaKit: an online platform to provide access to sexual health services. When GetaKit first launched in Ottawa in July 2020 with funding from the Ontario Ministry of Health, its objectives were to ensure that access to the newly approved device remained 1) clinically appropriate, 2) accessible and 3) linked to care.

Results

Over the course of the study, there were a stable number of individuals who reported having never been tested for HIV before. These individuals tended to be younger and more likely to be members of racialized minority groups; similar characteristics to those who also face the most barriers to primary care access.

Conclusion

With new reports indicating that nearly six million Canadians are without a primary care provider, it was proposed that the popularity of the HIV self-test may tell more about this lack of access than about the utility of the device itself. While projects like GetaKit should be part of the broader strategy to overcome historic testing barriers, such as geographic distance and inconvenient clinic hours, it is important that this occurs in an environment where a strong primary care health system can support treatment, follow-up and specialist referrals, as required.

Popularity of HIV self-tests may say more about the state of our primary care system than about the device itself

Background

In Canada, HIV transmission continues to disproportionately affect the same communities of gay men, bisexual men and men who have sex with men (gbMSM); members of African, Caribbean or Black communities (ACB); people who use injection drugs; Indigenous people; and women who belong to the aforementioned groups. While primary care is an ideal location for HIV testing for members of these groups, many people do not have access to such healthcare services. In response, we launched GetaKit to distribute HIV self-tests.

Methods

In light of reduced access to healthcare services as a result of the pandemic and in anticipation of Health Canada's approval of an HIV self-test, a clinician-scientist research team at the University of Ottawa developed GetaKit: an online platform to provide access to sexual health services. When GetaKit first launched in Ottawa in July 2020 with funding from the Ontario Ministry of Health, its objectives were to ensure that access to the newly approved device remained 1) clinically appropriate, 2) accessible and 3) linked to care.

Results

Over the course of the study, there were a stable number of individuals who reported having never been tested for HIV before. These individuals tended to be younger and more likely to be members of racialized minority groups; similar characteristics to those who also face the most barriers to primary care access.

Conclusion

With new reports indicating that nearly six million Canadians are without a primary care provider, it was proposed that the popularity of the HIV self-test may tell more about this lack of access than about the utility of the device itself. While projects like GetaKit should be part of the broader strategy to overcome historic testing barriers, such as geographic distance and inconvenient clinic hours, it is important that this occurs in an environment where a strong primary care health system can support treatment, follow-up and specialist referrals, as required.

Hospitalists' Attitudes and Experiences With Posthospitalization Care Transitions for Patients With Substance Use Disorders: A Cross-sectional Analysis

BACKGROUND

Medical hospitalizations are relatively common among individuals who have substance use disorders (SUDs) and represent opportunities for patient engagement and treatment. Posthospitalization transitions of care are an important element of providing full-spectrum inpatient SUD care; however, little is known about clinicians' experiences with postdischarge care transitions.

METHODS

We conducted a cross-sectional study surveying hospital-based medical clinicians (ie, "hospitalists") across 2 large health systems in the state of Utah to assess current practices, barriers, facilitators, and perceptions toward posthospitalization care transitions for patients with SUDs. We used Wilcoxon signed-rank tests to identify the most impactful barriers and facilitators among all respondents. We used logistic regression models to explore the influence of hospitalists' attitudes toward providing SUD care on perceived barriers and facilitators.

RESULTS

The survey was distributed to 429 individuals across 15 hospitals. Eighty-two hospitalists responded to the survey (response rate, 21.4%). Most respondents frequently cared for hospitalized patients with SUDs (n = 63, 77%) and prescribed medications for SUDs (n = 44, 56%). Four respondents (5%) felt that patients received adequate support during care transitions. Lack of social support ( P < 0.001) and social factors such as lack of transportation ( P < 0.001) were perceived as the largest barriers to successful care transitions. Conversely, a partnering outpatient clinic/clinician ( P < 0.001) and outpatient-based care coordination ( P < 0.001) were perceived as the strongest facilitators. Respondents' attitudes toward people with SUDs had a modest effect on perceived barriers and facilitators.

CONCLUSIONS

Hospitalists perceived increased outpatient SUD treatment infrastructure and transitional care supports as most important in facilitating posthospitalization care transitions for patients with SUDs.

Barriers and facilitators for family physicians prescribing opioid agonist therapy in Saskatchewan

OBJECTIVE

To explore barriers and facilitators for family physicians in Saskatchewan prescribing opioid agonist therapy (OAT).

DESIGN

Self-administered postal survey.

SETTING

Family medicine practices in Saskatchewan.

PARTICIPANTS

A total of 218 Saskatchewan family physicians who were not authorized to prescribe OAT as of June 2022.

MAIN OUTCOME MEASURES

Descriptive and inferential statistics of physicians' self-reported barriers to and facilitators of prescribing OAT for opioid use disorder (OUD).

RESULTS

Most respondents (84.8%) had some comfort with diagnosing OUD. However, more than half (58.3%) did not feel confident or knowledgeable about prescribing OAT. Barriers to OAT prescribing included lack of time, incomplete training requirements, lack of interest, insufficient funding or support, feeling overwhelmed, and perceiving that OAT does not work and thus is not necessary. Physicians working in core neighbourhoods and those receiving fee-for-service compensation reported the least available time to prescribe OAT. Conversely, physicians working in interdisciplinary team settings had increased time for OAT prescribing compared with physicians in other settings. Having a close personal relationship with someone with OUD was correlated with increased comfort in diagnosing OUD as well as with knowledge about and confidence in prescribing OAT. Themes identified as facilitators to increasing OAT prescribing included the addition of resources and supports, increased training, more awareness about OUD and OAT, enhanced compensation, and altered prescribing regulations.

CONCLUSION

Despite the presence of several real and perceived barriers limiting OAT prescribing by Saskatchewan family physicians, there are family physicians interested in providing this therapy. Increased clinical resources and support, including increased interdisciplinary practice, are actionable steps that should be considered by policy decision makers to address this issue. Additionally, increased OUD and OAT education, which includes the perspectives of those with lived experience of OUD, would help address physician confidence, knowledge, and awareness in this area.

Post-hospitalization Care Transition Strategies for Patients with Substance Use Disorders: A Narrative Review and Taxonomy

Hospitalizations represent important opportunities to engage individuals with substance use disorders (SUD) in treatment. For those who engage with SUD treatment in the hospital setting, tailored supports during post-discharge transitions to longitudinal care settings may improve care linkages, retention, and treatment outcomes. We updated a recent systematic review search on post-hospitalization SUD care transitions through a structured review of published literature from January 2020 through June 2023. We then added novel sources including a gray literature search and key informant interviews to develop a taxonomy of post-hospitalization care transition models for patients with SUD. Our updated literature search generated 956 abstracts not included in the original systematic review. We selected and reviewed 89 full-text articles, which yielded six new references added to 26 relevant articles from the original review. Our search of five gray literature sources yielded four additional references. Using a thematic analysis approach, we extracted themes from semi-structured interviews with 10 key informants. From these results, we constructed a taxonomy consisting of 10 unique SUD care transition models in three overarching domains (inpatient-focused, transitional, outpatient-focused). These models include (1) training and protocol implementation; (2) screening, brief intervention, and referral to treatment; (3) hospital-based interdisciplinary consult team; (4) continuity-enhanced interdisciplinary consult team; (5) peer navigation; (6) transitional care management; (7) outpatient in-reach; (8) post-discharge outreach; (9) incentivizing follow-up; and (10) bridge clinic. For each model, we describe design, scope, approach, and implementation strategies. Our taxonomy highlights emerging models of post-hospitalization care transitions for patients with SUD. An established taxonomy provides a framework for future research, implementation efforts, and policy in this understudied, but critically important, aspect of SUD care.

Integrating Opioid Use Disorder Treatment Into Primary Care Settings

Importance

Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist.

Objective

To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD.

Design, Setting, and Participants

This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022.

Exposure

Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services.

Measures

Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods.

Results

Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care.

Conclusions and Relevance

The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.

Barriers to Assessing and Treating Trauma in Primary Care and Opportunities for Improvement: Perspectives from Prescribers of Medications for Opioid Use Disorder

Background: Medication for Opioid Use Disorder (MOUD) is a best practice for treating individuals with opioid use disorder (OUD), and primary care-based MOUD management can reduce treatment barriers among OUD patients. Individuals with OUD experience disproportionately high rates of trauma and violence, highlighting the importance of addressing trauma, mental health, and substance use concurrently. However, clear guidelines for trauma-informed treatment in a primary care setting remain poorly established. Methods: A qualitative approach was engaged to explore primary care providers' perceptions of barriers and facilitators to assessing and treating trauma among MOUD patients. Twenty in-depth interviews were conducted in 2021 with Baltimore-based MOUD prescribers, including primary care physicians and nurse practitioners. Interview questions assessed experiences with identifying and treating trauma among MOUD patients, including challenges and opportunities. Results: Providers reported extensive histories of trauma experienced by MOUD patients. Barriers to addressing trauma include a lack of standardized protocols/procedures for identifying trauma, insufficient training/time to assess and treat trauma, and the limited availability of external mental health providers and specialty services. Opportunities included building strong, mutually respectful patient-provider relationships, providing individualized, person-centered care, and establishing connections to coordinated multidisciplinary treatment networks. Conclusions: MOUD treatment within primary care is an important way to increase OUD treatment access, but clearer standards are needed for the treatment of trauma within this patient population. These findings demonstrate opportunities to improve standards and systems such that primary care providers are better equipped to assess and treat the complex histories of trauma experienced by individuals with OUD.