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Bromberg DJ, Madden LM, Fraenkel L, Muthulingam D, Rhoades D, Dvoriak S, Dumchev K, Pykalo I, Altice FL. Preferences and decisional considerations relating to opioid agonist therapy among Ukrainian people who use drugs: A conjoint analysis survey. PLOS Glob Public Health 2024; 4:e0002725. [PMID: 38277422 PMCID: PMC10817130 DOI: 10.1371/journal.pgph.0002725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 11/28/2023] [Indexed: 01/28/2024]
Abstract
Scaling up opioid agonist therapies (OAT) is the most effective strategy to control combined HIV and opioid epidemics, especially in Eastern Europe and Central Asia (EECA), where HIV incidence and mortality continue to increase. Patient concerns about OAT, however, have undermined scale-up. The objective of this study is to understand Ukrainian opioid use disorder patient preferences about OAT to guide the development of an evidence-informed decision aid for clinical decision-making. We conducted a conjoint-based choice (CBC) survey. Participants were asked to about their preferences relating to 7 attributes of OAT (cost, dosing frequency, concerns about withdrawal symptoms, adverse side effects, improvements in quality of life, precipitation of withdrawal and legislative requirements to be registered as a drug dependent person) and 20 attribute levels for receiving OAT under differing potential treatment constraints. Data were analyzed using Hierarchical Bayesian models. Using respondent-driven sampling and random sampling, we recruited 2,028 people who inject drugs with opioid use disorder. Relative importance (RIS) and partial-worth utility scores (PWUS) were used to assess preferences for attributes and thresholds within each attribute. Cost and dosing frequency were the most important attributes (RIS = 39.2% and RIS = 25.2%, respectively) to potential patients, followed by concerns about withdrawal symptoms (RIS = 10.8%), adverse side effects (RIS = 9.0%), quality-of-life improvement (RIS = 7.5%), precipitation of euphoria (5.2%) and requirement to be registered as a drug- dependent person (RIS = 3.1%). The monthly cost-threshold for willingness-to-pay was 1,900 UAH ($70 USD). In Ukraine, where both governmental and private OAT clinics have emerged and provide markedly different delivery strategies, preferences are mostly driven by out-of-pocket expenses, despite many patients being willing to pay for OAT. Programmatic demands (flexibility and ease of acquiring medications) remain an important consideration while for a minority, clinical concerns about withdrawal symptoms, adverse side effects and OAT impact on life play a smaller role.
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Affiliation(s)
- Daniel J. Bromberg
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Lynn M. Madden
- APT Foundation, New Haven, Connecticut, United States of America
- Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Liana Fraenkel
- Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Dharushana Muthulingam
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, United States of America
| | - Delaney Rhoades
- Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Sergii Dvoriak
- European Institute of Public Health Policy, Kyiv, Ukraine
| | | | - Iryna Pykalo
- European Institute of Public Health Policy, Kyiv, Ukraine
| | - Frederick L. Altice
- APT Foundation, New Haven, Connecticut, United States of America
- Division of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
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Muthulingam D, Hassett TC, Madden LM, Bromberg DJ, Fraenkel L, Altice FL. Preferences in medications for patients seeking treatment for opioid use disorder: A conjoint analysis. J Subst Use Addict Treat 2023; 154:209138. [PMID: 37544510 DOI: 10.1016/j.josat.2023.209138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 07/05/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION The opioid epidemic continues to be a public health crisis that has worsened during the COVID-19 pandemic. Medications for opioid use disorder (MOUD) are the most effective way to reduce complications from opioid use disorder (OUD), but uptake is limited by both structural and individual factors. To inform strategies addressing individual factors, we evaluated patients' preferences and trade-offs in treatment decisions using conjoint analysis. METHOD We developed a conjoint analysis survey evaluating patients' preferences for FDA-approved MOUDs. We recruited patients with OUD presenting to initiate treatment. This survey included five attributes: induction, location and route of administration, impact on mortality, side effects, and withdrawal symptoms with cessation. Participants performed 12 choice sets, each with two hypothetical profiles and a "none" option. We used Hierarchical Bayes to identify relative importance of each attribute and part-worth utility scores of levels, which we compared using chi-squared analysis. We used the STROBE checklist to guide our reporting of this cross-sectional observational study. RESULTS Five-hundred and thirty participants completed the study. Location with route of administration was the most important attribute. Symptom relief during induction and withdrawal was a second priority. Mortality followed by side effects had lowest relative importance. Attribute levels with highest part-worth utilities showed patients preferred monthly pick-up from a pharmacy rather than daily supervised dosing; and oral medications more than injection/implants, despite the latter's infrequency. CONCLUSION We measured treatment preferences among patients seeking to initiate OUD treatment to inform strategies to scale MOUD treatment uptake. Patients prioritize the route of administration in treatment preference-less frequent pick up, but also injections and implants were less preferred despite their convenience. Second, patients prioritize symptom relief during the induction and withdrawal procedures of medication. These transition periods influence the sustainability of treatment. Although health professionals prioritize mortality, it did not drive decision-making for patients. To our knowledge, this is the largest study on patients' preferences for MOUD among treatment-seeking people with OUD to date. Future analysis will evaluate patient preference heterogeneity to further target program planning, counseling, and decision aid development.
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Affiliation(s)
- Dharushana Muthulingam
- Washington University School of Medicine, Division of Infectious Disease, 4523 Clayton Ave., CB 8051, St. Louis, MO, 63110, United States of America.
| | - Thomas C Hassett
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States of America
| | - Lynn M Madden
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States of America; APT Foundation, New Haven, CT, United States of America
| | - Daniel J Bromberg
- Yale School of Public Health, New Haven, CT, United States of America
| | - Liana Fraenkel
- Yale School of Medicine, Section of Rheumatology, New Haven, CT, United States of America
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States of America; APT Foundation, New Haven, CT, United States of America; Yale School of Public Health, New Haven, CT, United States of America; University of Malaya, Kuala Lumpur, Malaysia
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Ibrahim S, Nallapaneni NN, Muthulingam D. Liver Abscess Caused by Klebsiella Pneumoniae in the Absence of Hepatobiliary Disease. Cureus 2022; 14:e29789. [PMID: 36340565 PMCID: PMC9618281 DOI: 10.7759/cureus.29789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2022] [Indexed: 11/28/2022] Open
Abstract
Klebsiella pneumoniae is notorious for causing abscesses in patients without any previous hepatobiliary disease and is a cause of liver abscesses. We report the case of a 70-year-old man with a past medical history of hypertension and benign prostatic hyperplasia who presented with a cough and fever lasting two weeks. The findings from his physical examination were unremarkable, but his laboratory investigations were significant for elevated inflammatory markers. A computed tomography scan of his abdomen revealed a complex septated cyst in the right lobe of his liver, and his blood culture was positive for K. pneumoniae. He responded well to drainage and intravenous and oral antibiotics. His abscess resolved fully. Cases of K. pneumoniae in the United States are rare, and studies are necessary to explore its epidemiology. Atypical symptoms make diagnosis a challenge, and physicians are urged to retain high levels of suspicion to diagnose and treat such cases early.
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Oberleitner LMS, Madden LM, Muthulingam D, Marcus R, Oberleitner DE, Beitel M, Gaeta M, Tamberelli JF, Barry DT. A qualitative investigation of addiction counselors' perceptions and experiences implementing an open-access model for treating opioid use disorder. J Subst Abuse Treat 2020; 121:108191. [PMID: 33357602 DOI: 10.1016/j.jsat.2020.108191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 09/18/2020] [Accepted: 10/22/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine addiction counselors' perceptions and experiences of implementing an open-access model for methadone maintenance treatment (MMT), in which the program rapidly enrolled prospective patients, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options. Between 2006, when the treatment program initially implemented this model, and 2020, the census of clients receiving methadone maintenance at the study site grew from 1431 to 4500. METHODS Participants were 31 addiction counselors employed at a treatment organization that implemented an open-access model to scale up MMT. We examined counselors' perceptions and experiences of working in programs that employed this model, using individual semi-structured interviews, which an interdisciplinary team audiotaped, transcribed, and systematically coded using grounded theory. The team reviewed themes and reconciled disagreements (rater agreement was 98%). We describe themes that more than 10% of participants reported. RESULTS Counselors described perceived advantages of the open-access model for clients (e.g., "individualized to client needs"), clinicians (e.g., "fewer demands"), and the community (e.g., "crime reduced"). Counselors also described perceived disadvantages of the open-access model for clinicians (e.g., "uneven workload") and clients (e.g., "need for more intensive services for some clients"), as well as program-level concerns (e.g., "perceived lack of structure"). CONCLUSIONS Counselors who work in opioid treatment programs that use an open-access framework described multiple benefits to themselves, their clients, and the public; they also outlined disadvantages for themselves and clients, which research should further explore and address to facilitate MMT scale up.
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Affiliation(s)
- Lindsay M S Oberleitner
- Yale School of Medicine, Department of Psychiatry, New Haven, CT 06510, USA; Western Connecticut State University, Department of Psychology, Danbury, CT 06810, USA; The APT Foundation, Inc., New Haven, CT 06519, USA
| | - Lynn M Madden
- The APT Foundation, Inc., New Haven, CT 06519, USA; Yale School of Medicine, Department of Internal Medicine, New Haven, CT 06510, USA
| | - Dharushana Muthulingam
- The APT Foundation, Inc., New Haven, CT 06519, USA; Yale School of Medicine, Department of Internal Medicine, New Haven, CT 06510, USA; Washington University, Division of Infectious Disease, St. Louis, MO 63112, USA
| | - Ruthanne Marcus
- The APT Foundation, Inc., New Haven, CT 06519, USA; Yale School of Medicine, Department of Internal Medicine, New Haven, CT 06510, USA
| | - David E Oberleitner
- The APT Foundation, Inc., New Haven, CT 06519, USA; University of Bridgeport, Department of Psychology, Bridgeport, CT 06604, USA
| | - Mark Beitel
- Yale School of Medicine, Department of Psychiatry, New Haven, CT 06510, USA; The APT Foundation, Inc., New Haven, CT 06519, USA; Yale School of Medicine, Child Study Center, New Haven, CT 06510, USA
| | - Marina Gaeta
- Yale School of Medicine, Department of Psychiatry, New Haven, CT 06510, USA; The APT Foundation, Inc., New Haven, CT 06519, USA
| | - Joseph F Tamberelli
- Western Connecticut State University, Department of Psychology, Danbury, CT 06810, USA; The APT Foundation, Inc., New Haven, CT 06519, USA
| | - Declan T Barry
- Yale School of Medicine, Department of Psychiatry, New Haven, CT 06510, USA; The APT Foundation, Inc., New Haven, CT 06519, USA; Yale School of Medicine, Child Study Center, New Haven, CT 06510, USA.
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Marks LR, Liang SY, Muthulingam D, Schwarz ES, Liss DB, Munigala S, Warren DK, Durkin MJ. Evaluation of Partial Oral Antibiotic Treatment for Persons Who Inject Drugs and Are Hospitalized With Invasive Infections. Clin Infect Dis 2020; 71:e650-e656. [PMID: 32239136 PMCID: PMC7745005 DOI: 10.1093/cid/ciaa365] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/31/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Persons who inject drugs (PWID) are at risk of invasive infections; however, hospitalizations to treat these infections are frequently complicated by against medical advice (AMA) discharges. This study compared outcomes among PWID who (1) completed a full course of inpatient intravenous (IV) antibiotics, (2) received a partial course of IV antibiotics but were not prescribed any antibiotics on AMA discharge, and (3) received a partial course of IV antibiotics and were prescribed oral antibiotics on AMA discharge. METHODS A retrospective, cohort study of PWID aged ≥18 years admitted to a tertiary referral center between 01/2016 and 07/2019, who received an infectious diseases consultation for an invasive bacterial or fungal infection. RESULTS 293 PWID were included in the study. 90-day all-cause readmission rates were highest among PWID who did not receive oral antibiotic therapy on AMA discharge (n = 46, 68.7%), compared with inpatient IV (n = 43, 31.5%) and partial oral (n = 27, 32.5%) antibiotics. In a multivariate analysis, 90-day readmission risk was higher among PWID who did not receive oral antibiotic therapy on AMA discharge (adjusted hazard ratio [aHR], 2.32; 95% confidence interval [CI], 1.41-3.82) and not different among PWID prescribed oral antibiotic therapy on AMA discharge (aHR, .99; 95% CI, .62-1.62). Surgical source control (aHR, .57; 95% CI, .37-.87) and addiction medicine consultation (aHR, .57; 95% CI, .38-.86) were both associated with reduced readmissions. CONCLUSIONS Our single-center study suggests access to oral antibiotic therapy for PWID who cannot complete prolonged inpatient IV antibiotic courses is beneficial.
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Affiliation(s)
- Laura R Marks
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Division of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Dharushana Muthulingam
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Evan S Schwarz
- Division of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Section of Medical Toxicology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - David B Liss
- Division of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Section of Medical Toxicology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Satish Munigala
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - David K Warren
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
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Marks LR, Nolan NS, Jiang L, Muthulingam D, Liang SY, Durkin MJ. Use of ICD-10 Codes for Identification of Injection Drug Use-Associated Infective Endocarditis Is Nonspecific and Obscures Critical Findings on Impact of Medications for Opioid Use Disorder. Open Forum Infect Dis 2020; 7:ofaa414. [PMID: 33094117 PMCID: PMC7566393 DOI: 10.1093/ofid/ofaa414] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 09/03/2020] [Indexed: 12/02/2022] Open
Abstract
Background No International Classification of Diseases, 10th revision (ICD-10), diagnosis code exists for injection drug use–associated infective endocarditis (IDU-IE). Instead, public health researchers regularly use combinations of nonspecific ICD-10 codes to identify IDU-IE; however, the accuracy of these codes has not been evaluated. Methods We compared commonly used ICD-10 diagnosis codes for IDU-IE with a prospectively collected patient cohort diagnosed with IDU-IE at Barnes-Jewish Hospital to determine the accuracy of ICD-10 diagnosis codes used in IDU-IE research. Results ICD-10 diagnosis codes historically used to identify IDU-IE were inaccurate, missing 36.0% and misclassifying 56.4% of patients prospectively identified in this cohort. Use of these nonspecific ICD-10 diagnosis codes resulted in substantial biases against the benefit of medications for opioid use disorder (MOUD) with relation to both AMA discharge and all-cause mortality. Specifically, when data from all patients with ICD-10 code combinations suggestive of IDU-IE were used, MOUD was associated with an increased risk of AMA discharge (relative risk [RR], 1.12; 95% CI, 0.48–2.64). In contrast, when only patients confirmed by chart review as having IDU-IE were analyzed, MOUD was protective (RR, 0.49; 95% CI, 0.19–1.22). Use of MOUD was associated with a protective effect in time to all-cause mortality in Kaplan-Meier analysis only when confirmed IDU-IE cases were analyzed (P = .007). Conclusions Studies using nonspecific ICD-10 diagnosis codes for IDU-IE should be interpreted with caution. In the setting of an ongoing overdose crisis and a syndemic of infectious complications, a specific ICD-10 diagnosis code for IDU-IE is urgently needed.
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Affiliation(s)
- Laura R Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Nathanial S Nolan
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Linda Jiang
- Division of Medical Education, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dharushana Muthulingam
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
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Beitel M, Oberleitner L, Muthulingam D, Oberleitner D, Madden LM, Marcus R, Eller A, Bono MH, Barry DT. Experiences of burnout among drug counselors in a large opioid treatment program: A qualitative investigation. Subst Abus 2019. [PMID: 29522381 DOI: 10.1080/08897077.2018.1449051] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Little is known about possible experiences of burnout among drug counselors in opioid treatment programs that are scaling up capacity to address the current opioid treatment gap. METHODS Participants in this quality improvement study were 31 drug counselors employed by large opioid treatment programs whose treatment capacities were expanding. Experiences of burnout and approaches for managing and/or preventing burnout were examined using individual semi-structured interviews, which were audiotaped, transcribed, and systematically coded by a multidisciplinary team using grounded theory. RESULTS Rates of reported burnout (in response to an open-ended question) were lower than expected, with approximately 26% of participants reporting burnout. Counselor descriptions of burnout included cognitive, affective, behavioral, and physiological symptoms; and job-related demands were identified as a frequent cause. Participants described both self-initiated (e.g., engaging in pleasurable activities, exercising, taking breaks during workday) and system-supported strategies for managing or preventing burnout (e.g., availing of supervision and paid time off). Counselors provided recommendations for system-level changes to attenuate counselor risk of burnout (e.g., increased staff-wide encounters, improved communication, accessible paid time off, and increased clinical supervision). CONCLUSIONS Findings suggest that drug counselor burnout is not inevitable, even in opioid treatment program settings whose treatment capacities are expanding. Organizations might benefit from routinely assessing counselor feedback about burnout and implementing feasible recommendations to attenuate burnout and promote work engagement.
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Affiliation(s)
- Mark Beitel
- a Department of Psychiatry , Yale School of Medicine , New Haven , Connecticut , USA.,b Pain Treatment Services , The APT Foundation , Inc., New Haven , Connecticut , USA
| | - Lindsay Oberleitner
- a Department of Psychiatry , Yale School of Medicine , New Haven , Connecticut , USA
| | - Dharushana Muthulingam
- c Department of Internal Medicine , Yale School of Medicine , New Haven , Connecticut , USA
| | - David Oberleitner
- d Department of Psychology , University of Bridgeport , Bridgeport , Connecticut , USA
| | - Lynn M Madden
- a Department of Psychiatry , Yale School of Medicine , New Haven , Connecticut , USA.,b Pain Treatment Services , The APT Foundation , Inc., New Haven , Connecticut , USA
| | - Ruthanne Marcus
- c Department of Internal Medicine , Yale School of Medicine , New Haven , Connecticut , USA
| | - Anthony Eller
- b Pain Treatment Services , The APT Foundation , Inc., New Haven , Connecticut , USA.,f Yale School of Public Health , New Haven , Connecticut , USA
| | - Madeline H Bono
- b Pain Treatment Services , The APT Foundation , Inc., New Haven , Connecticut , USA.,e Department of Psychology , New York University, New York , New York , USA
| | - Declan T Barry
- a Department of Psychiatry , Yale School of Medicine , New Haven , Connecticut , USA.,b Pain Treatment Services , The APT Foundation , Inc., New Haven , Connecticut , USA
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Oberleitner DE, Marcus R, Beitel M, Muthulingam D, Oberleitner LMS, Madden LM, Eller A, Barry DT. "Day-to-day, it's a roller coaster. It's frustrating. It's rewarding. It's maddening and it's enjoyable": A qualitative investigation of the lived experiences of addiction counselors. Psychol Serv 2019; 18:287-294. [PMID: 31580103 DOI: 10.1037/ser0000394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Psychologists in medication for addiction treatment (MAT) settings routinely oversee the work of addiction counselors as supervisors, administrators, and human resource specialists. Limited research has explored the lived experiences of counselors who work in programs that have scaled-up MAT in response to the opioid crisis in the U.S. Thirty-one addiction counselors who worked in MAT programs that had scaled-up treatment capacity were interviewed about 3 facets of their lived experiences: work roles, work motivation, and perceived responses of others to their work. Interviews were taped and transcribed. An interdisciplinary team reviewed and coded the transcripts using grounded theory analysis. The main work roles that emerged were counselor, educator, and advocate. Counselors described multiple factors related to intrinsic motivation for their work: family and personal history, altruism, enjoyment of challenges and client complexity, and witnessing and facilitating change. Factors related to extrinsic motivation were workplace opportunities and positive feedback. The main themes concerning responses of nonclients were positive feedback; others' narratives; negative feedback focused on the stigma associated with the treatment, the clients who receive it, and the counselors who provide it; and responses to anticipated negative feedback. Responses from clients were largely positive and focused on appreciation and respect. Psychologists in MAT settings can enhance the lived experiences of addiction counselors by helping them to savor positive feedback from clients and others, to recognize and appreciate their unique skillsets, and to recognize and address (not internalize) the multiple sources of stigma they encounter as addiction counselors. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
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Affiliation(s)
| | | | - Mark Beitel
- Department of Psychiatry and Child Study Center, Yale School of Medicine
| | | | | | - Lynn M Madden
- Department of Internal Medicine, Yale School of Medicine
| | | | - Declan T Barry
- Department of Psychiatry and Child Study Center, Yale School of Medicine
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Muthulingam D, Bia J, Madden LM, Farnum SO, Barry DT, Altice FL. 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. J Subst Abuse Treat 2019; 100:18-28. [PMID: 30898324 DOI: 10.1016/j.jsat.2019.01.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 01/18/2019] [Accepted: 01/25/2019] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Dharushana Muthulingam
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA.
| | - Joshua Bia
- Frank H. Netter MD School of Medicine at Quinnipiac University, North Haven, CT, USA
| | - Lynn M Madden
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA; APT Foundation, Inc, New Haven, CT, USA
| | - Scott O Farnum
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA; APT Foundation, Inc, New Haven, CT, USA
| | - Declan T Barry
- APT Foundation, Inc, New Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Frederick L Altice
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA; APT Foundation, Inc, New Haven, CT, USA; Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
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Muthulingam D. Health Insurance and the Promise of Incrementalism. J Womens Health (Larchmt) 2017; 26:1263-1264. [DOI: 10.1089/jwh.2017.6696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Marcus JL, Baxter R, Leyden WA, Muthulingam D, Yee A, Horberg MA, Klein DB, Towner WJ, Chao CR, Quesenberry CP, Silverberg MJ. Invasive Pneumococcal Disease Among HIV-Infected and HIV-Uninfected Adults in a Large Integrated Healthcare System. AIDS Patient Care STDS 2016; 30:463-470. [PMID: 27749111 DOI: 10.1089/apc.2016.0165] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
It is unclear whether HIV-infected individuals remain at higher risk of invasive pneumococcal disease (IPD) compared with HIV-uninfected individuals. We conducted a cohort study of HIV-infected and demographically matched HIV-uninfected adults within Kaiser Permanente Northern California during the period 1996-2011. We used Poisson models to obtain rate ratios (RRs) for incident IPD associated with HIV infection and other risk factors. Among 13,079 HIV-infected and 137,643 HIV-uninfected adults, the IPD rate per 100,000 person-years was 160 (n = 109 events) for HIV-infected and 8 (n = 75 events) for HIV-uninfected subjects, with an adjusted RR of 13.0 [95% confidence interval (CI): 9.1-18.7]. For HIV-infected individuals, IPD incidence per 100,000 person-years decreased by 71% during study follow-up, from 305 in 1996-1999 to 88 in 2010-2011 (p < 0.001), with an adjusted RR of 6.6 (95% CI: 2.7-16.1) compared with HIV-uninfected subjects in 2010-2011. Risk factors for IPD among HIV-infected individuals included black compared with white race/ethnicity, smoking, cancer, and higher HIV RNA levels. The 23-valent pneumococcal polysaccharide vaccination was not associated with a reduced risk of IPD in HIV-infected or HIV-uninfected individuals. Among HIV-infected IPD cases, the most common serotype was 19A (33%), and 59% of serotypes were covered by the 13-valent pneumococcal conjugate vaccine (PCV13). Despite a dramatic decline in IPD incidence for HIV-infected adults since 1996, IPD rates were nearly sevenfold higher compared with HIV-uninfected adults in recent years, even after adjustment for risk factors. Timely antiretroviral therapy initiation, risk reduction strategies, and recent guidelines recommending PCV13 use may further reduce IPD incidence among HIV patients.
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Affiliation(s)
- Julia L. Marcus
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Roger Baxter
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Wendy A. Leyden
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Arnold Yee
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Michael A. Horberg
- Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Research Institute, Rockville, Maryland
| | - Daniel B. Klein
- Kaiser Permanente Northern California, San Leandro Medical Center, San Leandro, California
| | - William J. Towner
- Kaiser Permanente Southern California, Los Angeles Medical Center, Los Angeles, California
| | - Chun R. Chao
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California
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Muthulingam D, Yee A, Leyden W, Silverberg M, Baxter R. 1578Clinical Features, Vaccine Status and S. Pneumoniae Serotypes among HIV-positive and HIV-negative Individuals Diagnosed with Invasive Pneumococcal Disease. Open Forum Infect Dis 2014. [PMCID: PMC5781793 DOI: 10.1093/ofid/ofu052.1124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Dharushana Muthulingam
- Internal Medicine, Kaiser Permanente Northern California, Oakland Medical Center, Oakland, CA
| | - Arnold Yee
- Kaiser Permanente Vaccine Study Center, Oakland, CA
| | - Wendy Leyden
- Division of Research, Kaiser Permanente, Oakland, CA
| | | | - Roger Baxter
- Kaiser Permanente Vaccine Study Center, Oakland, CA
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13
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Muthulingam D, Chin J, Hsu L, Scheer S, Schwarcz S. Disparities in engagement in care and viral suppression among persons with HIV. J Acquir Immune Defic Syndr 2013; 63:112-9. [PMID: 23392459 DOI: 10.1097/qai.0b013e3182894555] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Engagement across the spectrum of HIV care can improve health outcomes and prevent HIV transmission. We used HIV surveillance data to examine these outcomes. METHODS San Francisco residents who were diagnosed with HIV between 2009 and 2010 were included. We measured the characteristics and proportion of persons linked to care within 6 months of diagnosis, retained in care for second and third visits, and virally suppressed within 12 months of diagnosis. RESULTS Of 862 persons included, 750 (87%) entered care within 6 months of diagnosis; of these, 72% had a second visit in the following 3-6 months; and of these, 80% had a third visit in the following 3-6 months. Viral suppression was achieved in 50% of the total population and in 76% of those retained for 3 visits. Lack of health insurance and unknown housing status were associated with not entering care (P < 0.01). Persons with unknown insurance status were less likely to be retained for a second visit; those younger than 30 years were less likely to be retained for a third visit. Independent predictors of failed viral suppression included age <40 years, homelessness, unknown housing status, and having a single or 2 medical visits compared with 3 visits. CONCLUSIONS Socioeconomic resources and age, not race or gender, are associated with disparities in engagement in HIV care in San Francisco.
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