Non-prescribing clinicians' treatment orientations and attitudes toward treatments for opioid use disorder: Rural differences

INTRODUCTION

The United States has experienced substantial increases in opioid use for more than two decades. This growth has impacted rural areas where overdoses have risen drastically during this time period and more often involve prescription opioids than in urban areas. Medications for opioid use disorders (MOUDs) are highly underutilized in rural settings due to lack of access, inadequate prescribing, and stigma.

METHODS

The study collected data using a cross-sectional online survey of nonprescribing clinicians (NPCs) involved in the treatment of substance use disorders (SUDs) in the United States. The study used multiple recruitment methods to obtain a purposive sample of NPCs from a variety of geographical contexts across the nation. The survey assessed demographic and practice characteristics including rurality of practice location, exposure and training related to MOUDs, treatment orientation, treatment preferences for opioid use disorder (OUD), and attitudes toward MOUDs. The study compared treatment preferences for OUD and attitudes toward MOUDs based on rurality of practice location. We tested a mediation model to determine whether the relationship between rurality of practice setting and attitudes toward MOUDs is mediated by treatment orientation.

RESULTS

Most of the 636 NPCs surveyed favored a combination of MOUDs and psychosocial treatment. Compared to clinicians practicing in suburban or urban areas, self-identified rural clinicians were more likely to favor MOUDs alone as most effective and less likely to endorse a combination of MOUDs and psychosocial treatment. Although most NPCs were supportive of MOUDs overall, many endorsed misconceptions related to MOUDs. Rural clinicians were less likely to perceive MOUDs as effective or acceptable compared to those in urban settings. Results of a mediation analysis indicated that practicing in a rural location compared to in an urban location directly and indirectly influenced attitudes toward MOUDs through an effect on treatment orientation.

CONCLUSIONS

NPCs play important roles in the implementation of MOUDs, and while efforts to increase their knowledge of and exposure to MOUDs have contributed broadly to more favorable attitudes toward MOUDs among NPCs, this study's findings indicate that additional efforts are still needed, particularly among NPCs who work in rural settings. Findings also indicate that, among rural clinicians, increasing knowledge of and exposure to harm reduction principles may be a necessary prerequisite to engaging them in the implementation of specific harm reduction strategies such as MOUDs.

Over the Hills and Through the Hollers: How One Program is Assisting Residents of Appalachian with Opioid Use Recovery

Introduction

The consequences of increasing opioid misuse in the U.S. over the last two decades have been severe, contributing to hundreds of thousands of lives lost and heavy tolls on individuals, families, and society. The Appalachian Region has been hit particularly hard, with its predominantly rural landscape seeing disproportionate increases in opioid misuse and overdoses. These cases have been difficult to address due to poor treatment access and capacity constraints in many areas of Appalachia.

Purpose

The current study focuses on evaluating The Kentucky Access to Recovery Program (KATR), which provides services to individuals recovering from opioid addiction residing in several counties in Eastern Kentucky. Its purpose is to understand the impact of KATR on service recipients' access to recovery services and supports.

Methods

Semi-structured interviews were conducted with 12 service recipients, three service providers, and four vendors of support services related to housing, transportation, medical/dental care, employment, and childcare. Qualitative data were analyzed using thematic analysis.

Results

Themes related to individual-level impacts were identified and discussed, including behavioral changes related to recovery, physical and mental health improvements, relationship repair, regaining custody of children, provision of needed supports, and ability to gain employment and improve finances. Study findings showed that KATR had meaningful impacts on the lives of service recipients by helping meet needs and reducing barriers to their ongoing recovery.

Implications

Through its use of vouchers for support services and basic-needs provision, KATR demonstrates a potentially effective strategy for increasing access to health-related social services for persons in recovery in predominantly rural areas.

Impacts of the COVID-19 Pandemic on a Rural Opioid Support Services Program

During 2020, Kentucky saw the third highest increase in overdose deaths in the U.S. Employment issues, inadequate housing, transportation problems, and childcare needs present barriers to accessing treatment in rural areas. These barriers and others (e.g., technology) arose during the pandemic negatively affecting individuals in recovery and service providers as they adjusted services to provide primarily telehealth and remote services. This study examines the impact of COVID-19 in its early stages on an opioid use disorder (OUD) support services program in a nonprofit located in rural eastern Kentucky, part of the central Appalachia region. A qualitative design was applied, employing semi-structured interviews in early fall 2020. Participants were associated with one OUD support services program, including service recipients, program coordinators, and business vendors. Guided by the Social Determinants of Health framework, two-cycle coding-descriptive coding and pattern coding-was utilized. Codes were sorted into three patterns: changes to daily life; financial impacts; and service access and provision. Overall, early stages of COVID-19 brought increased stress for individuals in recovery, as they were taking on more responsibility and navigating a changing environment. Coordinators were under pressure to provide services in a safe, timely manner. Vendors vocalized their struggles and successes related to finances. These findings can help organizations make realistic adjustments and policymakers set reasonable expectations and consider additional financial support.

Mental Health and Weather Extremes in a Southeastern U.S. City: Exploring Group Differences by Race

The connection between mental health and weather extremes is a public health concern, but less studied to date than physical health. This exploratory study examines the mental health impacts of two kinds of weather extremes increasingly linked to climate change—summer heat waves and extreme winter weather—in a low- to middle-income population in the Southeastern U.S. The distribution of mental health impacts, and potential pathways to them, are examined with a focus on race. Data are from a random-sample survey of 426 participants and are analyzed with bivariate statistics and path analysis. Self-reported mental health impacts, in both seasons, were common in our study, with White participants tending to report worse impacts than participants who identified with other racial groups. Physical health had direct effects on mental health across several models, overall and by racial group. For summer heat waves, concern about climate change and social cohesion had direct and indirect effects, respectively, on mental health in White participants only. For extreme winter weather, preparedness had a direct negative effect on mental health in White, but not Black, participants. Results suggest that there may be racial differences in the influence of human and social capital factors on mental health related to weather extremes, warranting further study of this critical topic and with larger racial subgroup samples.

Pathways to Retention: Job Satisfaction, Burnout, & Organizational Commitment among Social Workers

Purpose: Job satisfaction, burnout, and organizational commitment remain concerns for human service organizations. Few studies have utilized a large sample of social workers to investigate these factors while also considering practice setting. In the present study, work-related burnout, satisfaction with workload, and satisfaction with organizational environment are examined as factors contributing to organizational commitment while comparing the measurement and predictive strength of these factors based on practice setting. Method: Confirmatory factor analyses and structural equation modeling were used to estimate and compare factors related to organizational commitment with a sample of 1,786 social workers practicing in the United States. Results: Satisfaction with organizational environment showed a strong positive relationship with organizational commitment. Work-related burnout was confirmed to have a negative relationship with organizational commitment. No measurement or structural model differences existed between social workers from different types of practice settings. Discussion: Findings suggest that increasing satisfaction with organizational environment is a better target for retaining employees than reducing workloads. Results emphasize the need for human service organizations to foster work environments which provide a climate of wellness, support, and recognition of employees' contributions at work.

Bioventing pilot test results at the low point drain area, Offutt AFB, Nebraska

The purpose of this paper was to describe the application of bioventing technology at the LPD site at Offutt AFB, Nebraska and present the results of the 15-month pilot test. The preliminary tests indicated sufficient hydrocarbon contamination was present with the necessary soil characteristics to warrant an extended bioventing pilot test. The six month in situ respiration test indicated that progress was being made in reducing the TVH concentrations and biological activity was still occurring. Laboratory analysis of the final soil samples confirmed the reduction in TRPH and BTEX concentrations indicating that the site is close to complete remediation. However, owing to reduced air flow at greater distances from the VW, more biodegradation is still needed near MPB. The reduced biodegradation at MPB could also be due to the high water tables resulting from heavy rains during the summer and fall of 1993. The local water table was above the VW and MP screens for several months. The operation of the blower will continue until the site is completely remediated. The single VW pilot test at the LPD site at Offutt AFB has proven the effectiveness of bioventing in reducing TRPH and BTEX contamination in the subsurface. The installation, operation and maintenance costs were minimal. The effectiveness of this application has resulted in three additional bioventing applications at Offutt AFB including the first, full-scale system located in the state of Nebraska.

Response of Schwann cells to mitogens in vitro is determined by pre-exposure to serum, time in vitro, and developmental age

We compared the mitogenic response of Schwann cells freshly isolated from adult, neonatal, and embryonic nerves, and compared these cells with cells that had been cultured in serum for 5 days. DNA synthesis in response to growth factors was measured using bromodeoxyuridine and immunocytochemistry. Freshly isolated adult Schwann cells were unresponsive to growth factors with or without forskolin to elevate intracellular cAMP levels. After 5 days of culture in serum, or alternatively in defined medium containing fibroblast growth factor 2 plus forskolin, or neu-differentiation factor beta2, adult cells were responsive to mitogens, whereas cells cultured in defined medium alone remained unresponsive. Serum also increased expression of type 1 fibroblast growth factor receptor. Freshly isolated embryonic and neonatal Schwann cells in contrast responded to growth factors even in the absence of forskolin. This responsiveness changed with time in culture. Neonatal cells cultured for 5 days in defined medium in the presence or absence of serum no longer responded to FGF alone, but required forskolin for a mitogenic response. Thus, the response of freshly isolated cells to mitogens is developmentally regulated; extrinsic signals are required to render adult cells responsive to mitogens; and with time in culture, neonatal cells develop a requirement for cAMP elevation for mitogenic response.

Presence of exon 5-deleted oestrogen receptor in human breast cancer: functional analysis and clinical significance

A variant form of the human oestrogen receptor (ER) mRNA lacking sequences encoded within exon 5 has been described (Fuqua SAW, Fitzgerald SD, Chamness GC, Tandon AK, McDonnell DP, Nawaz Z, O'Malloy BW, McGuire WL 1991, Cancer Res 51: 105-109). We have examined the expression of the exon 5-deleted ER (HE delta5) mRNA variant in breast biopsies using reverse transcriptase polymerase chain reaction (RT - PCR). HE delta5 mRNA was present in only 13% of non-malignant breast tissues compared with 32% of carcinomas (95% CI, P=0.05). Presence of the HE delta5 mRNA was associated with the presence of immunohistochemically detected ER (P=0.015) and progesterone receptor (PR) (P=0.02). There was a positive correlation between the presence of HE delta5 and disease-free survival (P=0.05), suggesting that the presence of HE delta5 may be an indicator of better prognosis. We have raised a monoclonal antibody specific to the C-terminal amino acids of HE delta5. This antibody recognized the variant but not the wild-type ER protein. We show that HE delta5 protein is present in breast cancer using immunohistochemical techniques. We also analysed trans-activation by HE delta5 in mammalian cells and showed that, in MCF-7 cells, HE delta5 competes with wild-type ER to inhibit ERE-dependent trans-activation. Our results indicate that this variant is unlikely to be responsible for endocrine resistance of breast cancer, but its presence at both the mRNA and protein level suggest that it may, nevertheless, be involved in regulating the expression of oestrogen-responsive genes in breast cancer.

Percutaneous catheter closure of the persistently patent ductus arteriosus in the adult

The USCI patent ductus occluder has been shown to be an effective nonsurgical technique for closure of the persistently patent ductus in a primarily pediatric population. Its clinical impact in the adult has been reported only within small subgroups of larger pediatric studies or for a small population. This study was conducted to determine the feasibility, success rate, and complications of device closure for the persistently patent ductus arteriosus (PDA) in the adult. The population consisted of 55 patients (4 men and 51 women; mean age 38.8 +/- 15.0 years) with follow-up of 2.2 +/- 2.1 years. All patients underwent echocardiography obtained as part of their follow-up assessment. The device was successfully placed in 54 patients, with 75% clinical and echocardiographic closure at the first follow-up assessment 2.4 +/- 2.6 months). One patient with initial clinical and echocardiographic evidence of closure was subsequently found to have an open ductus. Spontaneous closure (2 patients) or second implant (6 patients) resulted in 86% closure at the most recent assessment. Thus, the percutaneous PDA double-umbrella occluder device is a feasible and effective technique for closing persistent PDA in the adult and will result in occlusion of the shunt in most patients without the need for thoracotomy.

Cardiopulmonary function in adult patients late after Fontan repair

OBJECTIVES

The clinical status and exercise assessment of adult patients late after the Fontan operation were reviewed to determine cardiovascular function.

BACKGROUND

The Fontan operation is the final operation for many patients with tricuspid atresia or a single ventricle. Follow-up reports describe most patients to be in Canadian Cardiovascular Society functional class I or II. Objective measures of cardiac performance in the pediatric age group have shown significant dysfunction.

METHODS

Forty-seven adult patients were seen late after the Fontan operation at the Toronto Congenital Cardiac Centre for Adults. Thirty of these underwent cycle ergometry to determine maximal exercise capacity. Maximal ventilation, maximal oxygen uptake and anaerobic threshold were determined from a ramp exercise protocol. Ejection fraction at rest and during exercise was measured with gated radionuclide angiography. Results were compared with those of eight normal volunteers. Results are given as mean +/- SD.

RESULTS

Thirty patients underwent cardiopulmonary exercise testing 6.7 +/- 3.9 years after a first Fontan operation. Clinically 93% were in functional class I or II. The Fontan group patients had a significantly lower maximal work load (548 +/- 171 vs. 1,094 +/- 190 kilopond-meters, p < 0.00001), anaerobic threshold (11.2 +/- 2.9 vs. 23.6 +/- 4.6 ml/kg per min) and maximal oxygen consumption (14.8 +/- 4.5 vs. 42.1 +/- 10.0 ml/kg per min). Systemic ventricular ejection fraction was lower at rest (38 +/- 12% vs. 58 +/- 7%) and during exercise (40 +/- 15% vs. 70 +/- 8%).

CONCLUSIONS

Despite a clinical impression of good function, by objective measures adult patients continue to have significant cardiovascular limitation late after the Fontan operation.

Accuracy of home blood glucose monitors

OBJECTIVE

To determine the accuracy of five home blood glucose monitors (HBGM) in reference to a standard laboratory reference method.

RESEARCH DESIGN AND METHODS

The study took place in the laboratory of a 350-bed private acute-care hospital. Subjects were a sample of convenience of 207 diabetic and nondiabetic adult and pediatric patients scheduled for fasting blood work that included a blood glucose test. Venous blood samples were collected for laboratory determination of blood glucose level. A separate sample was collected for testing on two each of five HBGMs: AccuChek II M, Tracer II, ExacTech, Glucometer II with Memory, and One Touch.

RESULTS

Multiple regression analysis showed that all 10 monitors could be used to predict laboratory blood glucose values. The monitors with the highest predictabilities were One Touch, Tracer II, and AccuChek II M. Consistency between monitors of the same brand was lowest with One Touch. AccuChek II M had the smallest SD between the 2 monitors used in the study.

CONCLUSIONS

HBGM can be used to predict actual laboratory values of blood glucose. However, the controlled environment of the study should be considered and patient education made a high priority when recommending monitors.