Integrated Models of Care for Individuals with Opioid Use Disorder: How Do We Prevent HIV and HCV?

Purpose of Review

To describe models of integrated and co-located care for opioid use disorder (OUD), hepatitis C (HCV), and HIV.

Recent Findings

The design and scale-up of multidisciplinary care models that engage, retain, and treat individuals with HIV, HCV, and OUD are critical to preventing continued spread of HIV and HCV. We identified 17 models within primary care (N = 3), HIV specialty care (N = 5), opioid treatment programs (N = 6), transitional clinics (N = 2), and community-based harm reduction programs (N = 1), as well as two emerging models.

Summary

Key components of such models are the provision of (1) medication-assisted treatment for OUD, (2) HIV and HCV treatment, (3) HIV pre-exposure prophylaxis, and (4) behavioral health services. Research is needed to understand differences in effectiveness between co-located and fully integrated care, combat the deleterious racial and ethnic legacies of the “War on Drugs,” and inform the delivery of psychiatric care. Increased access to harm reduction services is crucial.

Electronic supplementary material

The online version of this article (10.1007/s11904-018-0396-x) contains supplementary material, which is available to authorized users.

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.

Effect of pelleting on survival of porcine epidemic diarrhea virus-contaminated feed

Porcine epidemic diarrhea virus (PEDV) is a heat-sensitive virus that has devastated the U.S. swine industry. Because of its heat sensitivity, we hypothesized that a steam conditioner and pellet mill mimicking traditional commercial thermal processing may mitigate PEDV infectivity. Pelleting, a common feed processing method, includes the use of steam and shear forces, resulting in increased temperature of the processed feed. Two thermal processing experiments were designed to determine if different pellet mill conditioner retention times and temperatures would impact PEDV quantity and infectivity by analysis of quantitative reverse transcription PCR and bioassay. In Exp. 1, a 3 × 3 × 2 factorial design was used with 3 pelleting temperatures (68.3, 79.4, and 90.6°C), 3 conditioning times (45, 90, or 180 s), and 2 doses of viral inoculation (low, 1 × 10 tissue culture infectious dose (the concentration used to see cytopathic effect in 50% of the cells)/g, or high, 1 × 10 tissue culture infectious dose/g). Noninoculated and PEDV-inoculated unprocessed mash were used as controls. The low-dose PEDV-infected mash had 6.8 ± 1.8 cycle threshold (Ct) greater ( < 0.05) PEDV than the high-dose mash. Regardless of time or temperature, pelleting reduced ( < 0.05) the quantity of detectable viral PEDV RNA compared with the PEDV-inoculated unprocessed mash. Fecal swabs from pigs inoculated with the PEDV-positive unprocessed mash, regardless of dose, were clinically PEDV positive from 2 to 7 d (end of the trial) after inoculation. However, if either PEDV dose of inoculated feed was pelleted at any of the 9 tested conditioning time × temperature combinations, no PEDV RNA was detected in fecal swabs or cecum content. Based on Exp. 1 results, a second experiment was developed to determine the impact of lower processing temperatures on PEDV quantity and infectivity. In Exp. 2, PEDV-inoculated feed was pelleted at 1 of 5 conditioning temperatures (37.8, 46.1, 54.4, 62.8, and 71.1°C) for 30 s. The 5 increasing processing temperatures led to feed with respective mean Ct values of 32.5, 34.6, 37.0, 36.5, and 36.7, respectively. All samples had detectable PEDV RNA. However, infectivity was detected by bioassay only in pigs from the 37.8 and 46.1°C conditioning temperatures. Experiment 2 results suggest conditioning and pelleting temperatures above 54.4°C could be effective in reducing the quantity and infectivity of PEDV in swine feed. However, additional research is needed to prevent subsequent recontamination after pelleting as it is a point-in-time mitigation step.

Approaches to Predicting Outcomes in Patients with Acute Kidney Injury

Despite recognition that Acute Kidney Injury (AKI) leads to substantial increases in morbidity, mortality, and length of stay, accurate prognostication of these clinical events remains difficult. It remains unclear which approaches to variable selection and model building are most robust. We used data from a randomized trial of AKI alerting to develop time-updated prognostic models using stepwise regression compared to more advanced variable selection techniques. We randomly split data into training and validation cohorts. Outcomes of interest were death within 7 days, dialysis within 7 days, and length of stay. Data elements eligible for model-building included lab values, medications and dosages, procedures, and demographics. We assessed model discrimination using the area under the receiver operator characteristic curve and r-squared values. 2241 individuals were available for analysis. Both modeling techniques created viable models with very good discrimination ability, with AUCs exceeding 0.85 for dialysis and 0.8 for death prediction. Model performance was similar across model building strategies, though the strategy employing more advanced variable selection was more parsimonious. Very good to excellent prediction of outcome events is feasible in patients with AKI. More advanced techniques may lead to more parsimonious models, which may facilitate adoption in other settings.