Prioritizing the patient in patient-centered addictions treatment

Patients’ Perspectives on Coming Off Opioid Agonist Treatment: A Qualitative Study

Aims:

Opioid agonist treatment (OAT) programs are life-saving, as they reduce opioid use, overdoses, and criminal activities. Disadvantages reported with long-term OAT include side effects of the medication, especially on cognitive ability and sexual function, which may discourage potential participants. Many of those who participate in OAT have a desire to come off treatment. The aims of this study were to explore patients’ thoughts about coming off OAT and to investigate their perceptions of what support they would need in order to realize a planned withdrawal from OAT.

Methods:

A qualitative interview study with semi-structured interviews, using applied thematic analysis. Persons with experiences of participating in OAT were invited from Swedish programs and a private Facebook community.

Results:

Fifteen persons, with a mean of 9.6 (±6.4) years of treatment experience, were included. The participants underlined the need for a patient-centered focus within the treatment. They wanted to be regarded as capable of deciding if, when, and how a planned ending was to take place. They also called for staff to be supportive in making such decisions. Participants recommended staff to be sensitive to the needs of the specific patient and to have strategies for coming off OAT that could be adjusted for the single person.

Conclusions:

OAT programs need to be continually updated and adapted to the persons who can benefit from them. Applying a person-centered, holistic perspective would enhance the quality of the treatment by emanating from individual goals. Regulatory guidelines need to take into account research on patient experiences and perspectives on coming off.

Improving Treatment Together: a protocol for a multi-phase, community-based participatory, and co-design project to improve youth opioid treatment service experiences in British Columbia

Background

Opioid use is one of the most critical public health issues as highly potent opioids contribute to rising rates of accidental opioid-related toxicity deaths. This crisis has affected people from all age groups, including youth (ages 15–24) who are in a critical developmental period where the stakes of opioid use are especially high. Efforts to reduce the significant harms of opioid use have focused on the expansion of evidence-based treatments, including medications for opioid use disorder (e.g. buprenorphine). While these treatments are unequivocally life saving, recent evidence suggests that they may not align with youths’ needs. Accordingly, the ‘Improving Treatment Together’ (ITT) project has been designed with the aim to improve youths’ opioid treatment service experiences and outcomes by co-developing, implementing, and measuring youth-centred opioid use treatment service innovations. This manuscript describes the protocol for this multi-phase project.

Methods

The ITT project follows community-based participatory research (CBPR) and strategically integrates co-design processes throughout its four phases. Upon establishing a project partnership between national, provincial and community-based organizations, Phase 1 follows four core elements of human-centred co-design (empathy, needs identification, ideation, prototyping) in nine separate workshops. These workshops will be held in four diverse communities with youth, caregivers and service providers who have accessed or delivered opioid treatment services. Phase 1 will culminate in the co-production of opioid treatment service innovations to be considered by the project’s partners for further co-development, pilot testing, and wider implementation during the remaining phases of the project. Throughout each phase, the project will collect and analyse both qualitative and quantitative research and evaluation data to determine the project’s impact.

Discussion

This protocol provides a detailed description of the ITT project, with an emphasis on the project’s application of co-design and CBPR processes, the planned research and implementation procedures, and the establishment of a unique partnership. To our knowledge, this is one of the first projects to integrate these participatory processes to the design, implementation and measurement of youth-centred opioid treatment services. Embedding these processes throughout each phase of the project will strengthen the relevance and feasibility of the project’s service delivery innovations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00261-7.

Three-month outcomes from a patient-centered program to treat opioid use disorder in Iowa, USA

BACKGROUND

Opioid use disorder (OUD), a chronic disease, is a major public health problem. Despite availability of effective treatment, too few people receive it and treatment retention is low. Understanding barriers and facilitators of treatment access and retention is needed to improve outcomes for people with OUD.

OBJECTIVES

To assess 3-month outcomes pilot data from a patient-centered OUD treatment program in Iowa, USA, that utilized flexible treatment requirements and prioritized engagement over compliance.

METHODS

Forty patients (62.5% female: mean age was 35.7 years, SD 9.5) receiving medication, either buprenorphine or naltrexone, to treat OUD were enrolled in an observational study. Patients could select or decline case management, counseling, and peer recovery groups. Substance use, risk and protective factors, and recovery capital were measured at intake and 3 months.

RESULTS

Most participants reported increased recovery capital. The median Assessment of Recovery Capital (ARC) score went from 37 at enrollment to 43 (p < 0.01). Illegal drug use decreased, with the median days using illegal drugs in the past month dropping from 10 to 0 (p < 0.001). Cravings improved: 29.2% reported no cravings at intake and 58.3% reported no cravings at 3 months (p < 0.001). Retention rate was 92.5% at 3 months. Retention rate for participants who were not on probation/parole was higher (96.9%) than for those on probation/parole (62.5%, p = 0.021).

CONCLUSION

This study shows preliminary evidence that a care model based on easy and flexible access and strategies to improve treatment retention improves recovery capital, reduces illegal drug use and cravings, and retains people in treatment.

Increased flexibility in methadone take-home scheduling during the COVID-19 pandemic: Should this practice be incorporated into routine clinical care?

In the context of the COVID-19 pandemic and the state of emergency that the government of Spain declared, the rapid adaptation of health services is of paramount importance to preserve access to and continuity of service delivery. This research note underscores the importance of ensuring a sufficient quantity of methadone take-home doses for patients on methadone maintenance treatment (MMT) to maximize their adherence to government-imposed lockdown restrictions and social distancing measures designed to curtail the spread of SARS-CoV-2. We evaluate the impact of COVID-19 on take-home medication (number of days provided) in a methadone clinic in Barcelona (Catalonia, Spain). This work conveys that we should consider maintaining the take-home practices that we adopted in response to the pandemic, even after the pandemic has abated.

From "Step Away" to "Stand Down": Tailoring a Smartphone App for Self-Management of Hazardous Drinking for Veterans

Background

US military veterans who screen positive for hazardous drinking during primary care visits may benefit from a mobile app. Step Away is an evidence-based mobile intervention system for the self-management of hazardous drinking. However, Step Away was not designed for veterans, and differences between veterans and civilians could limit the reach and effectiveness of the app with this population.

Objective

The primary objective of this study was to repurpose Step Away to address the needs and preferences of the veteran primary care population. The Method for Program Adaptation through Community Engagement (M-PACE) model was used to guide the adaptation process. This model can serve as a generalizable approach that other researchers and intervention developers can follow to systematically tailor mobile health tools for a new population.

Methods

Veteran patients who screened positive for hazardous drinking during a primary care visit (n=12) and peer providers employed by the US Veterans Health Administration (n=11) were recruited to systematically review Step Away and provide feedback on its content and presentation via Web-based surveys and a semistructured interview. Participant feedback was reviewed through an iterative process by key stakeholders who adjudicated which suggested modifications to the app could enhance engagement and effectiveness with veterans while maintaining program integrity.

Results

Usability ratings of the individual modules of Step Away were uniformly positive across patients and peers, as was the perceived utility of the app overall. Personalized feedback on the health consequences and costs of drinking, options for customization, and the measurement-based care capabilities of the app were viewed as facilitators of engagement. Conversely, lengthy text, small font, and a lack of interactive features were viewed as potential barriers with the older primary care population. Modifications to create a veteran version of the app (Stand Down: Think Before You Drink) included altering the appearance of the app to incorporate more veteran-centric content, adding links and options for resources and activities for veterans, and reducing the amount of text and adding veteran-specific references and common concerns and triggers for drinking in this population.

Conclusions

The M-PACE model provided a systematic approach to repurpose Step Away to fit the needs and preferences of veteran primary care patients who engage in hazardous drinking. Stand Down may serve as an innovative, low-cost means of expanding access to care for veterans who engage in hazardous drinking.

Building healthcare provider relationships for patient-centered care: A qualitative study of the experiences of people receiving injectable opioid agonist treatment

Background

Injectable opioid agonist treatment (iOAT) was designed as a pragmatic and compassionate approach for people who have not benefitted from medication assisted treatment with oral opioids (e.g., methadone). While, a substantial body of clinical trial evidence has demonstrated the safety and effectiveness of iOAT, considerably less is known about the patient-centered aspects of this treatment and their role in self-reported treatment goals and outcomes. The aim of this study was to explore participants’ experiences in iOAT as they broadly relate to the domains of patient-centered care. A secondary goal was to explore how these experiences affected participants’ self-reported treatment outcomes.

Methods

A qualitative methodology, and constructivist grounded theory approach, was used to guide sampling, data collection and analysis. A total of 30 in-depth interviews were conducted with people receiving iOAT in North America’s first clinic. Audio-recordings for each semi-structured interview were transcribed and read repeatedly. The strategy of constant comparison was used through iterative stages of line-by-line, focused and theoretical coding until theoretical saturation was achieved.

Results

“Building healthcare provider relationships for patient-centered care in iOAT” was the emergent core concept. Healthcare provider relationships were established through two interrelated processes: ‘Opening up’ was attributed to the positive environment, and to feeling understood and supported by healthcare providers. ‘Being a part of care’ emerged as participants felt safe to ask for what was needed and had opportunities to collaborate in treatment decisions. These processes established a foundation in which participants experienced care that was responsive to their individual dose, health and psychosocial needs.

Conclusions

The core concept suggested that therapeutic relationships were fundamental to experiences of patient-centered care in iOAT. When relationships were respectful and understanding, participants received individualized and holistic care in iOAT. These findings offer a valuable example of how therapeutic relationships can be strengthened in other substance use treatment settings, particularly when responding to the diverse treatment needs of clients.

Quality of life and well-being from the perspective of patients on opioid agonist maintenance treatment: study protocol for a systematic review of qualitative research and a scoping review of measures

BACKGROUND

Opioid agonist maintenance treatment (OAMT) is a first-line treatment for heroin dependence, but its effectiveness has been assessed primarily through clinical outcomes with a limited attention to patient perspectives. Despite the increased use of patient reported outcome measures their patient-centeredness is highly questionable. This is the protocol of a systematic review of qualitative research on how OAMT users construct the meaning of their quality of life and well-being and a scoping review of instruments that measure these domains.

METHODS

We will conduct a systematic review of qualitative research exploring the views of quality of life of patients on OAMT (registration number CRD42018086490). According pre-specified eligibility criteria, we will include studies from a comprehensive search of bibliographical databases from their inception. We will extract data from included studies and assess their risk of bias with the CASP appraisal criteria, and will implement a thematic analysis to generate a set of interpretative analytical themes ascertaining their confidence using the CERQual approach. We will implement similar methods to conduct a scoping review to assess to what extent the existing measures of these domains were focused on user's views, assessing their validity using the COSMIN methodology, and summarizing their characteristics and level of patient centeredness.

CONCLUSION

The findings from the reviews will contribute to obtain a genuine understanding of the perspective from users on OAMT regarding their perception of well-being and quality of life and will likely lead to greater patient centeredness when assessing such variables, which in turn may contribute to a more patient-centered care.

Conceptualizing patient-centered care for substance use disorder treatment: findings from a systematic scoping review

BACKGROUND

Despite ongoing efforts aimed to improve treatment engagement for people with substance-related disorders, evidence shows modest rates of utilization as well as client-perceived barriers to care. Patient-centered care (PCC) is one widely recognized approach that has been recommended as an evidence-based practice to improve the quality of substance use disorder treatment. PCC includes four core principles: a holistic and individualized focus to care, shared decision-making and enhanced therapeutic alliance.

AIMS

This scoping review aimed to explore which PCC principles have been described and how they have defined and measured among people with substance-related disorders.

METHODS

Following the iterative stages of the Arksey and O'Malley scoping review methodology, empirical (from Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references were eligible if they focused on people accessing treatment for substance-related disorders and described PCC. Two reviewers independently screened the title/abstract and full-texts of references. Descriptive analyses and a directed content analysis were performed on extracted data.

FINDINGS

One-hundred and forty-nine references met inclusion from the 2951 de-duplicated references screened. Therapeutic alliance was the most frequent principle of PCC described by references (72%); this was consistently defined by characteristics of empathy and non-judgment. Shared decision-making was identified in 36% of references and was primarily defined by client and provider strategies of negotiation in the treatment planning process. Individualized care was described by 30% of references and included individualized assessment and treatment delivery efforts. Holistic care was identified in 23% of references; it included an integrated delivery of substance use, health and psychosocial services via comprehensive care settings or coordination. Substance use and treatment engagement outcomes were most frequently described, regardless of PCC principle.

CONCLUSIONS

This review represents a necessary first step to explore how PCC has been defined and measured for people accessing substance use disorder treatment. The directed content analysis revealed population and context-specific evidence regarding the defining characteristics of PCC-principles that can be used to further support the implementation of PCC.

Using nominal group technique to identify barriers, facilitators, and preferences among patients seeking treatment for opioid use disorder: A needs assessment for decision making support

BACKGROUND

The opioid crisis requires rapid scale-up of evidence-based interventions to treat opioid use disorder (OUD), of which pharmacologic therapies with methadone, buprenorphine or long-acting naltrexone are most effective. With recently-developed formulations, there are unprecedented treatment options. Even when pharmacologic treatment is accessible, however, uptake remains low, suggesting individual-level barriers. Decision aids are an evidence-based strategy that may overcome these barriers. This study aims to inform such a tool by describing and rank-ordering patients' considerations when deciding whether to start medication and, if starting, choosing a medication.

METHODS

Adults with OUD (N = 81) attending an addiction treatment center or syringe exchange program completed focus groups using nominal group technique, a consensus method that generates and ranks response. The qualitative component generates a broad array of responses, followed by rank-ordering to prioritize responses. Responses to questions about starting any medications and the pros and cons of five specific medications were ranked and coded.

RESULTS

The decision to initiate pharmacologic therapy and choose among medications was influenced by six key attributes in decreasing priority: (1) benefits, (2) side effects of treatment, (3) medication delivery strategies, (4) convenience, (5) how expectations for treatment are met, and (6) how medication (especially methadone) can represents trading one addiction for another.

CONCLUSIONS

Pharmacologic properties, logistical factors, and managing expectations were important themes in decision-making for starting, choosing, and staying on medications, and to a lesser degree, negative views about medications, specifically OAT, as an addiction itself. Desire for more control over treatment persisted in all themes. This study identified specific knowledge gaps, expectations, and priorities which are important for developing a decision aid for OUD treatment relevant to the target group. Nominal group technique is an established mixed-methodology that we have applied to a new population and purpose, that of conducting needs assessment for decision aid development.

Medication-Assisted Treatment for Opioid Addiction in the United States: Critique and Commentary

In the United States, buprenorphine products (namely buprenorphine/naloxone combination) and methadone are the primary forms of medication-assisted treatment (MAT) that are authorized for addressing opioid addiction. Although treatment ideologies differentiate MAT programs, much of the provision in the US reflects a model of "high threshold, low tolerance." This model is discussed with a focus on structural and programmatic barriers that shape access to and retention in MAT. The critique continues with a discussion of multifaceted stigma that reinforces spoiled identities and diffuses into treatment settings. The social control mechanisms that are imposed in MAT are strikingly similar to those reflected in criminal justice settings, namely probation, parole and community corrections more generally. Parallels are drawn between the "addict" and the "felon" and how they are monitored, tracked, and controlled. These factors have major implications for recovery.