Harm reduction in undergraduate and graduate medical education: a systematic scoping review.

BACKGROUND: Substance use increasingly contributes to early morbidity and mortality, which necessitates greater preparation of the healthcare workforce to mitigate its harm. The purpose of this systematic scoping review is to: 1) review published curricula on harm reduction for substance use implemented by undergraduate (UME) and graduate medical education (GME) in the United States and Canada, 2) develop a framework to describe a comprehensive approach to harm reduction medical education, and 3) propose additional content topics for future consideration. METHODS: PubMed, Scopus, ERIC: Education Resources Information Center (Ovid), and MedEdPORTAL were searched. Studies included any English language curricula about harm reduction within UME or GME in the United States or Canada from 1993 until Nov 22, 2021. Two authors independently reviewed and screened records for data extraction. Data were analyzed on trainee population, curricula objectives, format, content, and evaluation. RESULTS: Twenty-three articles describing 19 distinct educational programs across the United States were included in the final sample, most of which created their own curricula (n = 17). Data on educational content were categorized by content and approach. Most programs (85%) focused on introductory substance use knowledge and skills without an understanding of harm reduction principles. Based on our synthesis of the educational content in these curricula, we iteratively developed a Harm Reduction Educational Spectrum (HRES) framework to describe curricula and identified 17 discrete content topics grouped into 6 themes based on their reliance on harm reduction principles. CONCLUSIONS: Harm reduction is under-represented in published medical curricula. Because the drug supply market changes rapidly, the content of medical curricula may be quickly outmoded thus curricula that include foundational knowledge of harm reduction principles may be more enduring. Students should be grounded in harm reduction principles to develop the advanced skills necessary to reduce the physical harm associated with drugs while still simultaneously recognizing the possibility of patients' ongoing substance use. We present the Harm Reduction Educational Spectrum as a new framework to guide future healthcare workforce development and to ultimately provide the highest-quality care for patients who use drugs.

Bricks and mortar of well-being: exploring the housing-health connection.

Housing is a determinant of health. Increasing housing costs and worsening housing conditions have impacted populations worldwide. This Editorial aims to examine the dynamic connection between housing and health and the role of public health in addressing this relationship for a Collection launched at BMC Public Health on Housing as a determinant of health and well-being.

Improving Research on Racial Disparities in Access to Medications to Treat Opioid Use Disorders.

OBJECTIVES: The aims of the study are to review the current research on the association between access to medications for opioid use disorders (MOUD) and race, to identify gaps in research methods, and to propose new approaches to end racialized disparities in access to MOUD. METHODS: We conducted a literature review of English language peer-reviewed published literature from 2010 to 2021 to identify research studies examining the association between race and use of, or access to, MOUD. RESULTS: We reviewed 21 studies related to access to MOUD for Black and White populations. Of the 21 studies, 16 found that Black individuals had lower use of, or access to, MOUD than White individuals, 2 found the opposite among patients in specialty addiction treatment, 1 found that the difference changed over time, and 2 found that distance to opioid treatment programs was shorter for Black residents than for White residents. CONCLUSIONS: To improve future research, we recommend that researchers (1) be clearer on how race is conceptualized and interpreted; (2) explicitly evaluate the intersection of race and other factors that may influence access such as income, insurance status, and geography; (3) use measures of perceived racism, unconscious bias, and self-identified race; (4) collect narratives to better understand why race is associated with lower MOUD access and identify solutions; and (5) evaluate the effect of policies, programs, and clinical training on reducing racial disparities. A multitude of studies find that Black individuals have lower access to MOUD. Researchers must now identify effective solutions for reducing these disparities.

A Qualitative Analysis of Hospitalist Perceptions of Self-Directed Discharge Among Inpatients with Opioid Use Disorder.

Background: People with opioid use disorder (OUD) have high rates of hospital admissions and high rates of patient-directed discharge, leading to significant morbidity and mortality. In this study, we aimed to understand hospitalist attitudes toward patients with OUD leaving before treatment completion and their willingness to collaborate with patients in future initiatives focused on improving the experience of hospital-based care for patients with OUD. Methods: We conducted semi-structured interviews with hospitalists at two hospitals in Philadelphia, PA to explore their perspectives on social and structural factors that contribute to patients with OUD leaving the hospital before treatment completion. Interviews were recorded, transcribed, and coded with NVivo using conventional content analysis. Results: Twenty-two hospitalists (64% female, 72.7% White, mean age 37) were interviewed between February and April 2021. Hospitalists listed the following as reasons for patients with OUD leaving before treatment completion: untimely and inadequate pain/withdrawal treatment, limited prescribing options in medications for OUD, restrictive visitor and smoking policies, and patient social and other obligations. Twenty out of 22 hospitalists were willing to engage in collaborative patient-centered care but noted institutional barriers. Conclusion: Hospitalists stated willingness to collaborate with patients on identifying and developing systems-level solutions that would allow for patient-centered care. In-hospital access to addiction consult service, staff with lived experience, and other culturally competent resources are key to reducing self-directed discharge, as is training to address stigma and reframe perceptions of appropriate dosing for pain and withdrawal. Hospitalists note a need for transitions to outpatient care after hospital discharge.

Sorting through life: evaluating patient-important measures of success in a medication for opioid use disorder (MOUD) treatment program.

BACKGROUND: Medication for opioid use disorder (MOUD) is the gold standard treatment for opioid use disorder. Traditionally, "success" in MOUD treatment is measured in terms of program retention, adherence to MOUD, and abstinence from opioid and other drug use. While clinically meaningful, these metrics may overlook other aspects of the lives of people with opioid use disorder (OUD) and surprisingly do not reflect the diagnostic criteria for OUD. METHODS: Authors identified items for a pilesorting task to identify participant-driven measures of MOUD treatment success through semi-structured interviews. Interviews were transcribed verbatim and coded in Nvivo using directed and conventional content analysis to identify measures related to treatment success and quality of life goals. Participants of a low-threshold MOUD program were recruited and asked to rank identified measures in order of importance to their own lives. Multidimensional scaling (MDS) compared the similarity of items while non-metric MDS in R specified a two-dimensional solution. Descriptive statistics of participant demographics were generated in SPSS. RESULTS: Sixteen semi-structured interviews were conducted between June and August 2020 in Philadelphia, PA, USA, and 23 measures were identified for a pilesorting activity. These were combined with 6 traditional measures for a total list of 29 items. Data from 28 people were included in pilesorting analysis. Participants identified a combination of traditional and stakeholder-defined recovery goals as highly important, however, we identified discrepancies between the most frequent and highest ranked items within the importance categories. Measures of success for participants in MOUD programs were complex, multi-dimensional, and varied by the individual. However, some key domains such as emotional well-being, decreased drug use, and attendance to basic functioning may have universal importance. The following clusters of importance were identified: emotional well-being, decreased drug use, and human functioning. CONCLUSIONS: Outcomes from this research have practical applications for those working to provide services in MOUD programs. Programs can use aspects of these domains to both provide patient-centered care and to evaluate success. Specifics from the pilesorting results may also inform approaches to collaborative goal setting during treatment.

The association between food insecurity and physical activity in adults with serious mental illness living in supportive housing.

Rates of food insecurity are high among adults with serious mental illness (SMI); this population also engages in less physical activity than the general population. However, the relationship between food insecurity and physical activity in this group has not been explored. We examined food insecurity prevalence and its association with physical activity in 314 adults with SMI living in supportive housing in New York City and Philadelphia and enrolled in an institutional review board-approved randomized controlled trial of a Peer Group Lifestyle Balance (PGLB) program. We analyzed 2014 baseline survey data, including demographic data and self-reported food security, and four self-reported physical activity outcomes: any physical activity per week (yes/no) and 2) total, 3) moderate, or 4) vigorous physical activity minutes per week. A logistic regression model examined food security as a predictor of any physical activity; zero-inflated negative binomial regression models were used for the other three physical activity outcomes; demographic and clinical predictors were assessed for inclusion in models. Over half of participants (51.7%) reported low or very low levels of food security. Relationships between food insecurity and three physical activity measures (any physical activity, total weekly minutes, and moderate weekly minutes) were non-significant; those with lower food security were more likely to engage in vigorous physical activity. The high food insecurity prevalence highlights the importance of measuring and addressing food security in populations experiencing SMI; measuring physical activity is also important for tailored lifestyle recommendations. Future studies should examine longitudinal changes in food security and physical activity.

A Qualitative Exploration of the Functional, Social, and Emotional Impacts of the COVID-19 Pandemic on People Who Use Drugs.

Since 2020, people who use drugs (PWUD) experienced heightened risks related to drug supply disruptions, contamination, overdose, social isolation, and increased stress. This study explored how the lives of PWUD changed in Philadelphia over a one-year period. Using semi-structured interviews with 20 participants in a Housing First, low-barrier medication for opioid use (MOUD) program in Philadelphia, the effects of the first year of the COVID-19 pandemic on the daily lives, resources, functioning, substance use, and treatment of PWUD were explored. Interviews were analyzed using a combination of directed and conventional content analysis. Six overarching themes emerged during data analysis: (1) response to the pandemic; (2) access to MOUD and support services; (3) substance use; (4) impacts on mental health, physical health, and daily functioning; (5) social network impacts; and (6) fulfillment of basic needs. Participants reported disruptions in every domain of life, challenges meeting their basic needs, and elevated risk for adverse events. MOUD service providers offset some risks and provided material supports, treatment, social interaction, and emotional support. These results highlight how there were significant disruptions to the lives of PWUD during the first year of the COVID-19 pandemic and identified critical areas for future intervention and policies.

"It's a place that gives me hope": A qualitative evaluation of a buprenorphine-naloxone group visit program in an urban federally qualified health center.

Background: Medication for opioid use disorder (MOUD) with buprenorphine is effective in treating opioid use disorder yet remains underutilized. Scant research has examined the experience of patients, clinic staff, and providers in a "low-threshold" group-based MOUD program. This study evaluates a "low-threshold" MOUD program at a federally qualified health center (FQHC) in Philadelphia, Pennsylvania through the perspectives of its key stakeholders. Methods: This qualitative study involved focus groups of patients, providers, and clinic staff. Focus groups were conducted between October 2017 and June 2018. Grounded theory was used for analysis. Results: There were a total of 10 focus groups, including 20 patient participants and 26 staff members. Program participants noted that a strength of the program is its person-centered harm reduction approach, which is reflected in the program's policies and design. Program participants discussed the programmatic design choices that facilitated their participation and engagement in the program: ease of access, integration into primary care, and group-based visit model. Challenges in program implementation included varying acceptance and understanding of harm reduction among staff, the unpredictability of clinic volume and workflow, and the need to balance access to primary care and MOUD. Conclusion: This group-based MOUD program's philosophy of person-centered harm reduction, low-barrier approach, the structure of group-based visits, and integrated care contributes to increased patient access and retention. Understanding the strengths and challenges of the program may be useful for other safety-net clinics considering a MOUD program.

Main Outcomes of a Peer-Led Healthy Lifestyle Intervention for People With Serious Mental Illness in Supportive Housing.

OBJECTIVE: The effectiveness of the Peer-led Group Lifestyle Balance (PGLB) intervention, a 12-month manualized healthy lifestyle intervention delivered by peer specialists, was investigated in a sample of persons with serious mental illness who were overweight or obese and living in supportive housing. METHODS: The authors randomly assigned 314 participants from three supportive housing agencies to PGLB or usual care, with assessments at baseline and 6, 12, and 18 months. Outcomes were clinically significant changes from baseline in weight (≥5% weight loss), cardiorespiratory fitness (CRF; increase of ≥50 meters in the 6-minute walk test), and cardiovascular disease (CVD) risk reduction (clinically significant weight loss or CRF improvement). RESULTS: Most participants were from racial-ethnic minority groups (82%, N=255). The mean±SD baseline weight of this sample was 218.8±54.0 pounds, and the body mass index was 33.7±7.2. Compared with the usual care group, a larger proportion of the PGLB group achieved clinically significant changes in study outcomes at 12 and 18 months, but none of these changes was statistically significant. Outcomes differed by site: two sites reported no significant differences between the two groups, and one reported that PGLB significantly outperformed usual care on clinically significant weight loss at 18 months and CVD risk reduction at 6 and 12 months. CONCLUSIONS: The null findings indicate that PGLB was not superior to usual care in helping participants achieve clinically significant changes in weight, CRF, and CVD risk reduction at 12 and 18 months. Questions remain regarding how PGLB works, for whom, and in which settings.

Evaluation of Risk Factors for Hepatitis C Virus Infection Among Philadelphia's Shelter-Bound, Homeless Population: Data from a Student-Run Hepatitis C Virus Screening Initiative.

The objective was to assess risk factors for HCV specific to the shelter-bound homeless population of Philadelphia, Pennsylvania. This is a retrospective analysis of data obtained from 306 patients who received HCV antibody testing at 4 homeless shelters in Philadelphia between March 2017 and June 2019. Risk factors for HCV infection specific to this population were analyzed using Fischer exact tests. Fourteen (4.6%) of 306 patients screened positive for HCV infection. Risk factors for HCV infection among this shelter-bound homeless population included injection drug use, inhalation drug use, and tattoos obtained while incarcerated. Although an estimated 2.8% of the population of Philadelphia is infected with HCV, 4.6% of those screened in this program tested positive, highlighting the increased prevalence of HCV among the shelter-bound homeless population and the importance of assessing risks for HCV infection inherent to this specific population.

'It's common sense that an individual must eat': Advocating for food justice with people with psychiatric disabilities through photovoice.

BACKGROUND: People with SMI have often been excluded in advocacy efforts focused on physical health, health care and health and social policy. OBJECTIVE: Following a Photovoice project focused on barriers to healthy eating and physical activity in urban neighbourhoods, participant-researchers were invited to present their insights in community advocacy settings. The purpose of this study was to explore the feasibility and participant-researchers' experience of these community advocacy activities. DESIGN: We held four focus groups with the eight participant-researchers after each community advocacy activity to explore their experience with public speaking, presenting their experiences and advocating. SETTING AND PARTICIPANTS: People with serious mental illness who were overweight/obese living in supportive housing. ANALYSIS APPROACH: Qualitative analysis of the focus group transcripts, using a modified grounded theory approach followed by structured coding focused on empowerment, participation and non-discrimination. RESULTS: Participant-researchers gave three oral presentations of their photographs at a variety of community-based programmes and settings and participated in a rally to advocate for SNAP benefits. Two themes emerged from analysis: (a) Empowerment (the level of choice, influence and control that users of mental health services can exercise over events in their lives) and (b) Barriers to Empowerment (obstacles to participation and well-being). CONCLUSIONS: This evaluation strengthens the evidence that it is feasible for participant-researchers in Photovoice projects to engage in robust advocacy activities, such as presentations and discussions with local policymakers. During focus groups, participant-researchers demonstrated realistic optimism towards their roles as change agents and influencers in spite of acknowledged systemic barriers.

Retention of Patients With Multiple Vulnerabilities in a Federally Qualified Health Center Buprenorphine Program: Pennsylvania, 2017-2018.

Objectives. To describe and report initial outcomes of a low-threshold, group-based primary care medication for opioid use disorder (OUD) program in a federally qualified health center.Methods. We performed a retrospective chart review of patients enrolled in the program from October 4, 2017, to October 3, 2018, in Philadelphia, Pennsylvania. The main outcome measure was time retained in treatment, defined as time from treatment initiation to unplanned treatment termination. Secondary outcomes were the relationships between treatment retention and cocaine use or housing status. We analyzed retention in treatment using Kaplan-Meier survival estimates.Results. The 3- and 6-month retention rates were 82% and 63%, respectively. The log-rank test showed no significant differences for comparisons between homeless versus not homeless (P = .25) and cocaine use versus no cocaine use (P = .12).Conclusions. The medication for OUD program engaged a large number of patients from marginalized groups. Three- and 6-month retention rates were comparable with those reported of other federally qualified health center populations.Public Health Implications. Integrating treatment of OUD into primary care shows promise for increasing access to and retention in medication for OUD services. The federally qualified health center payment structure supports the sustainability of the group visit model.

Reaching for a Healthier Lifestyle: A Photovoice Investigation of Healthy Living in People with Serious Mental Illness.

BACKGROUND: People with mental illness in the United States are almost twice as likely to be obese compared with those without a mental illness. Lifestyle factors, such as poor dietary choices and physical inactivity, are often cited as causes of obesity in this population, which limits the response to the obesity epidemic primarily to behavioral change interventions. In response, this project is grounded in a human rights framework to assure that the people most affected by the problem are included in understanding and addressing the problem. We sought to investigate social and structural factors that affect weight loss in partnership with community co-researchers enrolled in a group lifestyle program for overweight/obese people with serious mental illness (SMI) living in supportive housing settings. METHODS: Using Photovoice methodology, eight co-researchers identified barriers and facilitators to healthy living in their community over seven weekly sessions. RESULTS: Co-researchers selected 33 photos reflecting two overarching themes: 1) structural barriers, such as poor-quality food, high transportation costs, limited SNAP benefits, limits of food pantries, easy availability of tobacco and alcohol products, and limited places for exercise and 2) strategies for overcoming structural barriers. CONCLUSIONS: Co-researchers highlighted structural barriers that were a cause or consequence of food insecurity and situations that threaten the right to healthy food and opportunities for a healthy life. Co-researchers reported examples of knowledge and skills they learned through participation in the project that were used to overcome structural barriers to healthy eating and physical activity, and likely contributed to weight loss.

Medical Cannabis: A guide to the clinical and legal landscapes.

If your patient expresses interest in medical marijuana, you'll find evidence on maximizing benefit while minimizing risk. But be cautious: Data are often contradictory.

Feasibility Pilot Outcomes of a Mammography Decision Support and Navigation Intervention for Women With Serious Mental Illness Living in Supportive Housing Settings.

Objective: People with serious mental illness (SMI) experience significant disparities in morbidity and mortality from preventable and treatable medical conditions. Women with SMI have low mammography screening rates. SMI, poverty, and poor access to care can have a significant effect on a woman's opportunity to learn about and discuss breast cancer screening with health care providers. This study examines the feasibility pilot outcomes of mammography decision support and patient navigation intervention (DSNI) for women with SMI living in supportive housing settings. The primary research question was: Does the DSNI increase knowledge, promote favorable attitudes, and decrease decisional conflict relating to screening mammography? Methods: We developed the intervention with the community using participatory methods. Women (n = 21) with SMI who had not undergone screening mammography in the past year participated in an educational module and decision counseling session and received patient navigation over a 6-month period. We conducted surveys and interviews at baseline and follow-ups to assess mammography decisional conflict. Results: Among study participants, 67% received a mammogram. The mammogram DSNI was feasible and acceptable to women with SMI living in supportive housing settings. From baseline to 1-month follow-up, decisional conflict decreased significantly (P = .01). The patient navigation process resulted in 270 attempted contacts (M = 12.86, SD = 10.61) by study staff (phone calls and emails with patient and/or case manager) and 165 navigation conversations (M = 7.86, SD = 4.84). A barrier to navigation was phone communication, with in-person navigation being more successful. Participants reported they found the intervention helpful and made suggestions for further improvement. Conclusions: The process and outcomes evaluation support the feasibility and acceptability of the mammography DSNI. This project provides initial evidence that an intervention developed with participatory methods can improve cancer screening outcomes in supportive housing programs for people with SMI.

Attitudes Surrounding a Community-Based Fitness Intervention at an Urban FQHC.

BACKGROUND AND OBJECTIVES: The population surrounding an urban federally qualified health center (FQHC) in Philadelphia has poorer health than Philadelphia overall. Community residents identified aerobics and dance classes as very important services or programs that an FQHC might provide. We sought to measure the impact of participation in a resident physician-led, patient-centered fitness and nutrition class on participants' attitudes, knowledge, and self-efficacy regarding their health. METHODS: An urban line dancing class and brief healthy eating intervention for adults was held at a YMCA adjacent to a residency-affiliated FQHC weekly for 8 weeks. Pre/postsurveys were administered to assess attitudes and confidence toward physical activity and healthy lifestyles. RESULTS: Participants' self-assessment of health and levels of physical activity improved. Confidence in performing everyday activities, doing regular exercise and exercising without making symptoms worse increased. A significant decrease in participants' physical activity gratification was observed. Participants' confidence improved in reading food labels for health, but confidence in eating a balanced diet did not improve. CONCLUSIONS: A resident-led fitness and nutrition class, tailored to perceived community needs, generated significant interest and sustained participation. This pilot study furthered development of community infrastructure addressing health, nutrition, and overall fitness, and the results reflect opportunities and challenges of engaging communities in physical fitness.

Cancer screening, prevention, and treatment in people with mental illness.

People with mental illness die decades earlier in the United States compared with the general population. Most of this disparity is related to preventable and treatable chronic conditions, with many studies finding cancer as the second leading cause of death. Individual lifestyle factors, such as smoking or limited adherence to treatment, are often cited as highly significant issues in shaping risk among persons with mental illness. However, many contextual or systems-level factors exacerbate these individual factors and may fundamentally drive health disparities among people with mental illness. The authors conducted an integrative review to summarize the empirical literature on cancer prevention, screening, and treatment for people with mental illness. Although multiple interventions are being developed and tested to address tobacco dependence and obesity in these populations, the evidence for effectiveness is quite limited, and essentially all prevention interventions focus at the individual level. This review identified only one published article describing evidence-based interventions to promote cancer screening and improve cancer treatment in people with mental illness. On the basis of a literature review and the experience and expertise of the authors, each section in this article concludes with suggestions at the individual, interpersonal, organizational, community, and policy levels that may improve cancer prevention, screening, and treatment in people with mental illness.

Peer-led healthy lifestyle program in supportive housing: study protocol for a randomized controlled trial.

BACKGROUND: The risk for obesity is twice as high in people with serious mental illness (SMI) compared to the general population. Racial and ethnic minority status contribute additional health risks. The aim of this study is to describe the protocol of a Hybrid Trial Type 1 design that will test the effectiveness and examine the implementation of a peer-led healthy lifestyle intervention in supportive housing agencies serving diverse clients with serious mental illness who are overweight or obese. METHODS: The Hybrid Trial Type 1 design will combine a randomized effectiveness trial with a mixed-methods implementation study. The effectiveness trial will test the health impacts of a peer-led healthy lifestyle intervention versus usual care in supportive housing agencies. The healthy lifestyle intervention is derived from the Group Lifestyle Balanced Program, lasts 12 months, and will be delivered by trained peer specialists. Repeated assessments will be conducted at baseline and at 6, 12, and 18 months post randomization. A mixed-methods (e.g., structured interviews, focus groups, surveys) implementation study will be conducted to examine multi-level implementation factors and processes that can inform the use of the healthy lifestyle intervention in routine practice, using data from agency directors, program managers, staff, and peer specialists before, during, and after the implementation of the effectiveness trial. DISCUSSION: This paper describes the use of a hybrid research design that blends effectiveness trial methodologies and implementation science rarely used when studying the physical health of people with SMI and can serve as a model for integrating implementation science and health disparities research. Rigorously testing effectiveness and exploring the implementation process are both necessary steps to establish the evidence for large-scale delivery of peer-led healthy lifestyle intervention to improve the physical health of racial/ethnic minorities with SMI. TRIAL REGISTRATION: www.clinicaltrials.gov; NCT02175641, registered 24 June 2014.

Using Concept Mapping to Explore Barriers and Facilitators to Breast Cancer Screening in Formerly Homeless Women with Serious Mental Illness.

Women with serious mental illness (SMI) have disproportionately worse breast cancer profiles than those of other women. The purpose of this project was to examine barriers to and facilitators of breast cancer screening, specifically in formerly homeless women with SMI using the participatory methodology of concept mapping. A series of three concept mapping focus groups were held with 27 women over the age of 40 with a diagnosis of a SMI who live in supportive housing programs, and with 16 housing program staff. Data from the focus groups were combined through multidimensional scaling to create a visual cluster map. Barriers and facilitators to mammography screening generated by the participants clustered into eight categories. Participants rated addressing educational issues as most important and feasible. Interventions designed to improve mammogram screening in this population should address patients' perception of personal risk and should target education and support systems as modifiable factors.