APT Foundation

Within Canadian federal prisons, the "Threat Risk Assessment" (TRA) appears to be a structural process obstacle within the prison needle exchange program (PNEP) policy that fails to provide low threshold access to PNEPs due to the prioritization of institutional safety at the cost of public health. Alternative options to the current TRA process clarify actionable levels for policy refinement that preserve safety, improve access and better align with evidence and public health goals.

The Food and Drug Administration's warning that transmucosal buprenorphine, a partial opioid agonist used to treat opioid use disorder and chronic pain, may cause dental disease opens questions about potential class-wide adverse effects involving more widely prescribed opioid analgesics. This was a retrospective matched national cohort study of patients in care at the Department of Veterans Affairs (VA) between October 2010-September 2019. Patients prescribed LTOT were matched 1:2 to patients not prescribed LTOT on age, sex, service region, and VA dental coverage. Cox regression models estimated the association between LTOT and a composite infection-related dental outcome (CIDO). Sensitivity analyses excluded patients with cancer, restricted to patients with comprehensive dental coverage, and to patients with ≥180 days of follow-up time, respectively. The cohort comprised 2,173,435 patients including 787,825 (36%) receiving LTOT; 612,101 (28%) experienced CIDO. In both simple and multivariable regression models, LTOT exposure was associated with greater CIDO risk; HR (95% CI) =1.24 (1.23, 1.25); aHR (95% CI) =1.08 (1.07, 1.08), respectively; p < 0.001. Sensitivity analyses showed similar results except among patients with full dental coverage for whom CIDO rates were substantially higher and LTOT was not statistically significantly associated with risk. he observed positive association between LTOT and CIDO in this large VA sample may inform patient-provider discussions and decision-making around use of LTOT. High CIDO rates among patients with full VA dental coverage may reflect their unique vulnerability to dental infection associated with service-related dental or disabling conditions. Limitations include risk for ascertainment bias, unclear generalizability to a broader clinical population, and the potential for residual confounding.

Community correctional experiences among individuals receiving methadone treatment (MT) for opioid use disorder (OUD) are poorly understood. We qualitatively investigated perceptions of community corrections and treatment experiences among individuals with criminal-legal system experience currently receiving outpatient MT. From January to December 2017, we recruited 42 individuals with history of criminal-legal system involvement enrolled in outpatient MT at a low-barrier nonprofit organization operating multiple clinics in Connecticut. An experienced qualitative research team conducted one-to-one, in-person, semistructured interviews about incarceration and treatment experiences with individuals receiving MT. Participants completed a demographics survey. The interviews were audiorecorded, transcribed, de-identified, and independently coded using NVivo. Participants described the community corrections system as restrictive and abstinence-focused. Most participants described positive perceptions of and experiences with community corrections officers (CCOs), yet described negative perceptions of and experiences with the community corrections system overall. Participants perceived CCOs to have limited knowledge of OUD and MT. Participants described a range of CCO judgment toward their OUD, with some appearing understanding and nonjudgmental while others were perceived to have stigma and prejudice. Few participants noted assistance from CCOs with seeking MT or community-based substance use disorder care. Some participants desired improved treatment facilitation, but viewed forced or coercive treatment negatively. To our knowledge, this is the first qualitative study to examine community corrections experience among people receiving outpatient medication for OUD. While individuals receiving MT have negative experiences with the community corrections system, they perceive individual CCOs positively. Interventions addressing gaps in CCOs knowledge of OUD and MT are needed to optimize support for individuals on probation or parole with OUD. Provision of OUD treatment facilitation appears desirable to some individuals in community supervision.

HIV incidence and mortality are increasing in Eastern Europe and Central Asia and are concentrated in people who inject drugs. Maintenance with opioid agonist therapies (OAT) like methadone or buprenorphine is the best treatment for opioid use disorder and a key HIV-prevention strategy in the region. In Kazakhstan, the scale-up of methadone has been minimal since methadone&rsquo;s introduction in 2008 and has been supported through international charitable organizations. As the Republic of Kazakhstan is designated to assume financial and administrative oversight of OAT, legislative gains can ensure treatment continuity and scale-up. Here, we review legislative barriers to OAT scale-up in Kazakhstan using an implementation science lens. We review legislative, political, and cultural barriers that undermine the efficient distribution and allocation of medications and impose burdensome clinical and administrative demands on patients and clinicians. Legislative reform is required to support further OAT expansion. We therefore provide policy recommendations to overcome these barriers to increase access to this life-saving, life-prolonging, evidence-based medical treatment. Minimally, these include increased numbers of clinical sites and patients at these sites; re-engineering OAT delivery across the country and directly to patients; introducing newer formulations of OAT; and creating an open bidding process to procure treatment medications.

BackgroundOrganizational coaching to promote the implementation of evidence-informed interventions is becoming more popular in healthcare organizations. In order to open the “black box” of coaching for implementation, we first developed, then tested the rigor and utility of a model of coaching for implementation.MethodsInterviews with nine experienced coaches were conducted and inductively coded to develop a model of coaching for implementation. Later, forty coaching calls with behavioral health organizations in Ohio, Wisconsin, and Florida were analyzed with directed content analysis using a priori codes based on this model.ResultsThe coaching work that occurred during these calls aligned closely with the model of coaching for implementation developed by our team. Most coaching work was devoted to building capacity; almost as much work focused on building relationships. Very little coaching work was dedicated to building sustainability. Use of tools for organizational change and implementation remained relatively consistent across all coaching periods.ConclusionUnderstanding what occurs during a successful coaching intervention will improve the effectiveness of coaching as an implementation strategy. Future research should focus on which processes and patterns make coaching more likely to promote specific implementation outcomes.

Homelessness is an important social determinant of health (SDOH), impacting health outcomes for many medical conditions. Although homelessness is common among people with opioid use disorder (OUD), few studies systematically evaluate homelessness and other SDOH among people enrolled in standard of care treatment for OUD, medication for opioid use disorder (MOUD), or examine whether homelessness affects treatment engagement. Using data from the 2016 to 2018 U.S. Treatment Episode Dataset Discharges (TEDS-D), patient demographic, social, and clinical characteristics were compared between episodes of outpatient MOUD where homelessness was reported at treatment enrollment versus independent housing using pairwise tests adjusted for multiple testing. A logistic regression model examined the relationship between homelessness and treatment length and treatment completion while accounting for covariates. There were 188 238 eligible treatment episodes. Homelessness was reported in 17 158 episodes (8.7%). In pairwise analysis, episodes involving homelessness were significantly different from those involving independent living on most demographic, social, and clinical characteristics, with significantly greater social vulnerability in most SDOH variables (P's < .05). Homelessness was significantly and negatively associated with treatment completion (coefficient = -0.0853, P < 0.001, 95% CI = [-0.114, -0.056], OR = 0.918) and remaining in treatment for greater than 180 days (coefficient = -0.3435, P < 0.001, 95% CI = [-0.371, -0.316], OR = 0.709) after accounting for covariates. Patients reporting homelessness at treatment entry in outpatient MOUD in the U.S. represent a clinically distinct and socially vulnerable population from those not reporting homelessness. Homelessness independently predicts poorer engagement in MOUD confirming that homelessness may be an independent predictor for MOUD treatment discontinuation nationally.

Introduction The micro-induction method of initiating buprenorphine is becoming a popular method for initiating buprenorphine in patients with Opioid Use Disorder, who are on full opioid agonists, either prescribed or non-prescribed, in order to avoid precipitated withdrawal. Given the rising concerns around illicit fentanyl use, this method of initiating buprenorphine has become another tool for clinicians to help patients with Opioid Use Disorder, even when multiple full opioid agonists are involved. While the process for initiating buprenorphine through this process is well studied, the characteristics of patients who are able to tolerate this initiation method in an outpatient setting is not. Case(s) We present the cases of two patients with Opioid Use Disorder in a community-based methadone maintenance program in whom micro-induction methods were used to initiate buprenorphine without lowering the methadone dose. Both patients successfully transitioned to buprenorphine without precipitated withdrawal. One of the patients was also using fentanyl at the time of induction and was able to abstain from fentanyl use following the induction process. Conclusion Initiating Buprenorphine using micro-induction strategies in a community based outpatient clinic in patients who are already on full opioid agonists is feasible, in these particular cases, the methadone dose or concurrent fentanyl use did not affect the outcome. We present the characteristics of the patient and the community clinic hoping that this helps more clinicians in replicating this induction strategy.

BackgroundEfficient and linguistically appropriate instruments are needed to assess response to addiction treatment, including severity of addiction/mental health status. This is critical for Russian-speaking persons in Eastern Europe and Central Asia (EECA) where Medications for Opioid Use Disorder (MOUD) remain underscaled to address expanding and intertwined opioid, HIV, HCV and tuberculosis epidemics. We developed and conducted a pilot validation of a Russian version of the 24-item Behavior and Symptom Identification Scale (BASIS-24), an addiction/mental health severity instrument with six subscales, previously validated in English.MethodsUsing the Mapi approach, we reviewed, translated, and back-translated the content to Russian, pilot-tested the Russian-version (BASIS-24-R) among new MOUD patients in Ukraine (N = 283). For a subset of patients (n = 44), test-rest was performed 48 h after admission to reassess reliability of BASIS-24-R. Exploratory principal component analysis (PCA) assessed underlying structure of BASIS-24-R.ResultsCronbach alpha coefficients for overall BASIS-24-R and 5 subscales exceeded 0.65; coefficient for Relationship subscale was 0.42. The Pearson correlation coefficients for overall score and all subscales on the BASIS-24-R exceeded 0.8. Each item loaded onto factors that corresponded with English BASIS-24 subscales ≥ 0.4 in PCA.ConclusionInitial version of BASIS-24-R appears statistically valid in Russian. Use of the BASIS-24-R has potential to guide MOUD treatment delivery in the EECA region and help to align addiction treatment with HIV prevention goals in a region where HIV is concentrated in people who inject opioids and where healthcare professionals have not traditionally perceived MOUD as effective treatment, particularly for those with mental health co-morbidities.