Referral of patients from rural primary care clinics to telemedicine vendors for opioid use disorder treatment: A mixed-methods study.

INTRODUCTION: Rural primary care clinics can expand their medication treatment for opioid use disorder (MOUD) capacity by coordinating care with external telemedicine (TM) vendors specializing in addiction medicine. This study used mixed methods to identify factors that influence patient referrals from rural primary care clinics to TM vendors for MOUD. METHODS: Between July/August 2020 and January/February 2021, 582 patients with OUD were identified across six primary care sites; that included 68 referred to an external TM vendor to receive MOUD. Mixed effects logistic regression identified individual and site-level factors associated with being referred to the TM vendor. Clinic providers and staff participated in in-depth interviews and focus groups to discuss their considerations for referring patients to the TM vendor. RESULTS: Patient referrals were positively associated with local household broadband coverage (OR = 2.55, p < 0.001) and negatively associated with local population density (OR = 0.01, p = 0.003) and the number of buprenorphine prescribers in the county (OR = 0.85, p < 0.001). Clinic personnel expressed appreciation for psychiatric expertise and the flexibility to access MOUD brought by the TM vendor. Perceived concerns about TM referral included a lack of trust with external providers, uncertainty about TM service quality, workflow delays, and patients' technological and insurance challenges. CONCLUSION: This study revealed several clinic-level factors that may potentially influence patient referral to TM vendor services for MOUD. To facilitate the referral process and utilization of TM vendors, efforts should be made to foster open communication and trust between clinic providers and TM vendors, streamline workflows, and improve Internet access for patients.

Stakeholder perspectives on a telemedicine referral and coordination model to expand medication treatment for opioid use disorder in rural primary care clinics.

INTRODUCTION: Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor. METHODS: We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale. RESULTS: Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff. CONCLUSIONS: Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

Care coordination between rural primary care and telemedicine to expand medication treatment for opioid use disorder: Results from a single-arm, multisite feasibility study.

PURPOSE: The use of telemedicine (TM) has accelerated in recent years, yet research on the implementation and effectiveness of TM-delivered medication treatment for opioid use disorder (MOUD) has been limited. This study investigated the feasibility of implementing a care coordination model involving MOUD delivered via an external TM provider for the purpose of expanding access to MOUD for patients in rural settings. METHODS: The study tested a care coordination model in 6 rural primary care sites by establishing referral and coordination between the clinic and a TM company for MOUD. The intervention spanned approximately 6 months from July/August 2020 to January 2021, coinciding with the peak of the COVID-19 pandemic. Each clinic tracked patients with OUD in a registry during the intervention period. A pre-/post-intervention design (N = 6) was used to assess the clinic-level outcome as patient-days on MOUD based on patient electronic health records. FINDINGS: All clinics implemented critical components of the intervention, with an overall TM referral rate of 11.7% among patients in the registry. Five of the 6 sites showed an increase in patient-days on MOUD during the intervention period compared to the 6-month period before the intervention (mean increase per 1,000 patients: 132 days, P = .08, Cohen's d = 0.55). The largest increases occurred in clinics that lacked MOUD capacity or had a greater number of patients initiating MOUD during the intervention period. CONCLUSIONS: To expand access to MOUD in rural settings, the care coordination model is most effective when implemented in clinics that have negligible or limited MOUD capacity.

An Experimental Study of a Peer-Facilitated Violence Prevention Program for Women in Prison.

The literature has shown a strong correlation between victimization and violence. As the majority of treatment programs for violence and the associated research have been focused on men, it is vital that services are also oriented to the needs of women who perpetrate violence. Beyond Violence (BV) was developed to fill the gap in violence prevention programming for justice-involved women with histories of violence victimization and perpetration. This randomized controlled trial reports the results of a peer-facilitated model of the BV program implemented in a women's prison. Women volunteered for the intervention and the study. Participants were randomized to either the 20-session BV condition or to a waitlist control (WC) condition. All 145 participants were asked to complete a preintervention (Time 1) and postintervention (Time 2) survey that included validated measures to assess for depression, anxiety, PTSD, anger/aggression, and emotional dysregulation. Preliminary analyses of the background characteristics and preintervention outcome scores showed no significant differences between the groups at Time 1, indicating that randomization was successful. Separate ANCOVAs were run for 13 outcomes measured using the pretest scores from study participants as the covariate and group assignment as the independent variable. Hypotheses were predominantly supported, and findings showed that the BV participants had significant reductions in the majority of the outcome measures at the postintervention assessment when compared to the WC participants. Future research should continue to explore the advantages of peer-facilitated program models and should incorporate postrelease outcomes to assess change over time.

The clinician-patient working alliance: Is it a significant predictor of psychiatric medication adherence in a sample of recently released parolees?

Persistent psychiatric symptoms can serve as a major barrier to the successful reintegration of parolees with mental illness. Thus, it is important to identify factors that might impact their mental health recovery, such as low adherence to their treatment regimen. Although many studies have examined the issue of psychiatric medication nonadherence, very few studies have focused specifically on justice-involved individuals. The strength of the clinician/patient working alliance has been found to be significantly associated with psychiatric medication adherence in prior research, but this relationship has not been assessed in a parolee population. Logistic regression analysis was used to determine if patient-rated working alliance was a significant predictor of low psychiatric medication adherence while taking into account alcohol/illegal drug use, age, and ethnicity in a sample of recently released parolees with mental illness (N=49). Patient-rated working alliance, age, and ethnicity were not significant predictors of low adherence. Alcohol/illegal drug use during the follow-up period was associated with a significantly increased likelihood of meeting the criteria for low medication adherence (OR=8.36; 95% CI=1.60, 43.66). The findings from this study highlight the importance of addressing alcohol and illegal drug use issues as part of the psychiatric treatment plan for returning prisoners with mental illness.

Tracking and Locating Itinerant Subjects With a Rechargeable Incentive Card: Results of a Randomized Trial.

BACKGROUND: High attrition among research participants undermines the validity and generalizability of field research. This study contrasted two incentivizing methods--money orders (MOs) or rechargeable incentive cards (RICs)--with regard to rates of participants' study engagement and follow-up contact over a 6-month period. METHODS: Substance abusers (N = 303) in Los Angeles, California were recruited and randomized to either an MO (control) or RIC (experimental) condition. All participants were asked to call the researchers at the beginning of each calendar month for the ensuing 5 months to update their locator information, even if nothing had changed. Each call resulted in a $10 payment, issued immediately via the RIC system or by MO by mail. Research staff located and interviewed all participants at Month 6. Contact logs assessed level of effort required to locate participants and conduct follow-up interviews. RESULTS: Relative to controls, RIC participants, especially those with low ability to defer gratification, initiated more monthly calls. Six-month follow-up rates did not differ between RIC (75%) and controls (79%), though the RIC condition was associated with an average staff time savings of 39.8 minutes per study participant. DISCUSSION: For longitudinal public health research involving itinerant study participants, the RIC method produces a modest benefit in study engagement and reduced staff time devoted to participant tracking and payments. However, the overall cost-effectiveness of this approach will depend on the pricing model of the card-issuing vendor (which in turns depends on the scale of the project, with per-unit costs falling for larger projects).

Epidermal carbonic anhydrase activity and exoskeletal metal content during the molting cycle of the blue crab, Callinectes sapidus.

During the crustacean molting cycle, the exoskeleton is first mineralized in postmolt and intermolt and then presumably demineralized in premolt in order for epidermal retraction to occur. The mineralization process calls for divalent metal ions, such as Ca(2+) and Mg(2+) , and bicarbonate ions whereas protons are necessary for dissolution of carbonate salts. Carbonic anhydrase (CA) has been suggested to be involved in exoskeletal mineralization by providing bicarbonate ions through catalyzing the reaction of carbon dioxide hydration. However, results of earlier studies on the role of epidermal CA in metal incorporation in crustacean exoskeleton are not consistent. This study was aimed to provide further evidence to support the notion that epidermal CA is involved in exoskeletal mineralization using the blue crab, Callinectes sapidus (Rathbun 1896), as the model crustacean. Significant increases first in calcium and magnesium then in manganese post-ecdysis indicate significant metal deposition during postmolt and intermolt. Significant positive correlation between calcium or magnesium content and epidermal CA activity in postmolt and intermolt constitutes evidence that CA is involved in the mineralization of the crustacean exoskeleton. Additionally, we proposed a hypothetical model to describe the role of epidermal CA in both mineralization and demineralization of the exoskeleton based on the results of epidermal CA activity and exoskeletal metal content during the molting cycle. Furthermore, we found that the pattern of epidermal CA activity during the molting cycle of C. sapidus is similar to that of ecdysteroids reported for the same species, suggesting that epidermal CA activity may be under control of the molting hormones.

An Experimental Comparison of Telepsychiatry and Conventional Psychiatry for Parolees.

OBJECTIVE: Many offenders treated for psychiatric disorders while incarcerated are paroled to counties where psychiatric care is limited, leading some correctional departments to offer psychiatric treatment via videoconferencing ("telepsychiatry"). However, the effectiveness of telepsychiatry for offenders with psychiatric disorders has not been rigorously evaluated. METHODS: In this randomized field experiment, the authors compared the effectiveness of telepsychiatry and in-person psychiatric sessions (treatment as usual) among 71 parolees receiving outpatient psychiatric treatment over a six-month period. Satisfaction with treatment, therapeutic alliance, medication adherence, and psychological functioning were measured. Follow-up data were collected from 60 of the 71 (85%) patients (N=20, telepsychiatry; N=40, control condition). RESULTS: Findings revealed high satisfaction with telepsychiatry overall and no significant group differences in medication adherence or psychological functioning. However, telepsychiatry patients reported lower levels of therapeutic alliance at follow-up. CONCLUSIONS: Telepsychiatry appeared to be an acceptable and effective approach for providing psychiatric care for this population.

Improving the outcomes of children affected by parental substance abuse: a review of randomized controlled trials.

Substance abuse is a major public health concern that impacts not just the user but also the user's family. The effect that parental substance abuse has on children has been given substantial attention over the years. Findings from the literature suggest that children of substance-abusing parents have a high risk of developing physical and mental health and behavioral problems. A number of intervention programs have been developed for parents who have a substance abuse problem. There have also been a number of interventions that have been developed for children who have at least one parent with a substance abuse problem. However, it remains unclear how we can best mitigate the negative effects that parental substance abuse has on children due to the scarcity of evaluations that utilize rigorous methodologies such as experimental designs. The purpose of this study is to review randomized controlled trials of intervention programs targeting parents with substance abuse problems and/or children with at least one parent with a substance abuse problem in order to identify programs that show some promise in improving the behavioral and mental health outcomes of children affected by parental substance abuse. Four randomized controlled trials that met our eligibility criteria were identified using major literature search engines. The findings from this review suggest that interventions that focus on improving parenting practices and family functioning may be effective in reducing problems in children affected by parental substance abuse. However, further research utilizing rigorous methodologies are needed in order to identify other successful interventions that can improve the outcomes of these children long after the intervention has ended.

Trauma-informed treatment decreases posttraumatic stress disorder among women offenders.

Traumatic experiences among women offenders can impact their psychological well-being and patterns of substance use and offending. However, rigorous research in this area for women offenders with a history of trauma is sparse. This study combined data from 2 previous studies of women offenders in order to provide greater statistical power in examining the psychological trends found in the individual studies. Specifically, women in gender-responsive treatment (GRT; n = 135) were compared to women in non-GRT (n = 142) in regard to their change in posttraumatic stress disorder (PTSD) and related symptomatology from baseline to follow-up. The pooled sample of women were predominantly White (58%) or Hispanic (22%), and many had never been married (47%); their mean age was 36 years (SD = 8.9), and, on average, they had 12 years (SD = 1.8) of education. Methamphetamine was their primary drug (71%). Moreover, 55% of the women reported histories of sexual abuse and 37% physical abuse. Finally, 31% had a diagnosis of PTSD. Using generalized estimation equations, we detected significant Group × Time interactions in PTSD (odds ratio [OR] = 0.17) and some related symptomatology (reexperiencing: OR = 0.42; and avoidance: OR = 0.24). Given the aggregate impact of trauma in the lives of women offenders, these women, their families, and their communities could benefit from research on how trauma influences their lives and on services that mitigate the negative impact of such histories.

GENDER-RESPONSIVE DRUG COURT TREATMENT: A Randomized Controlled Trial.

This pilot study compared outcomes for 94 women offenders in San Diego County, California, who participated in four drug court programs. Women were randomized to gender-responsive (GR) programs using Helping Women Recover and Beyond Trauma or standard mixed-gender treatment. Data were collected at program entry, during treatment, and approximately 22 months after treatment entry. Bivariate and multivariate analyses were conducted. Results showed that GR participants had better in-treatment performance, more positive perceptions related to their treatment experience, and trends indicating reductions in posttraumatic stress disorder (PTSD) symptomology. Both groups improved in their self-reported psychological well-being and reported reductions in drug use (p < .06) and arrest (a diagnosis of PTSD was the primary predictor of reductions in rearrest, p < .04). Findings show some beneficial effects of adding treatment components oriented toward women's needs. Significant questions remain, particularly around PTSD and whether it should be targeted to improve substance use outcomes for women.