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1.
Int J Drug Policy ; 121: 104214, 2023 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-37778132

RESUMO

BACKGROUND: Expanding access to opioid use disorder (OUD) treatment, including methadone, is imperative to address the US overdose crisis. In June 2021, the Drug Enforcement Administration announced new regulations allowing all opioid treatment programs (OTPs) to deploy mobile medication units, or methadone vans, to dispense OUD medication treatment outside of clinic walls, ending a 13-year moratorium. We conducted a qualitative study evaluating one opioid treatment program's experience, including benefits and challenges with implementing a methadone van, to inform future policy and clinical practice. METHODS: We recruited staff and patients receiving OUD medication treatment from an OTP in San Francisco, CA. The OTP had one operating van before March 2020 and began operating an additional van in response to COVID-19-related efforts to de-populate clinic settings. We interviewed 10 providers and 20 patients from August to November 2020. We transcribed, coded, and analyzed all interviews using modified grounded theory methodologies. RESULTS: Both patients and providers perceived significant benefits with receiving OUD medications using methadone vans. Patients preferred dosing at the van over the clinic because they were able to "get in and out" faster. Both staff and patients appreciated being able to use phone counseling to connect with counselors which helped reduce in-person visits and streamline workflows. Providers also noted van implementation challenges, including daily van set up, urine drug testing, and delivering counseling to patients who lacked phones. CONCLUSIONS: Eased restrictions on methadone van implementation represent a new strategy for expanding OUD treatment access. In our qualitative study, patients and staff were satisfied with methadone van implementation, though the OTP still faced implementation challenges. Audio-only counseling and other workflow solutions helped facilitate implementation, and several policy considerations like maintaining audio-only counseling flexibilities are key to ensuring future van success. Methadone vans offer the potential to expand treatment uptake, while prioritizing patient-centered care.


Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Humanos , Metadona/uso terapêutico , Analgésicos Opioides/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Acessibilidade aos Serviços de Saúde , Buprenorfina/uso terapêutico
2.
Matern Child Health J ; 27(Suppl 1): 143-152, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-37204587

RESUMO

OBJECTIVES: Many cisgender women affected by homelessness and substance use desire pregnancy and parenthood. Provider discomfort with patient-centered counseling about reproductive choices and supporting reproductive decisions of these women poses barriers to reproductive healthcare access. METHODS: We used participatory research methods to develop a half-day workshop for San Francisco-based medical and social service providers to improve reproductive counseling of women experiencing homelessness and/or who use substances. Guided by a stakeholder group comprising cisgender women with lived experience and providers, goals of the workshop included increasing provider empathy, advancing patient-centered reproductive health communication, and eliminating extraneous questions in care settings that perpetuate stigma. We used pre/post surveys to evaluate acceptability and effects of the workshop on participants' attitudes and confidence in providing reproductive health counseling. We repeated surveys one month post-event to investigate lasting effects. RESULTS: Forty-two San Francisco-based medical and social service providers participated in the workshop. Compared to pre-test, post-test scores indicated reduced biases about: childbearing among unhoused women (p < 0.01), parenting intentions of pregnant women using substances (p = 0.03), and women not using contraception while using substances (p < 0.01). Participants also expressed increased confidence in how and when to discuss reproductive aspirations (p < 0.01) with clients. At one month, 90% of respondents reported the workshop was somewhat or very beneficial to their work, and 65% reported increased awareness of personal biases when working with this patient population. CONCLUSIONS FOR PRACTICE: A half-day workshop increased provider empathy and improved provider confidence in reproductive health counseling of women affected by homelessness and substance use.


Assuntos
Comunicação em Saúde , Pessoas Mal Alojadas , Transtornos Relacionados ao Uso de Substâncias , Humanos , Feminino , Gravidez , Saúde Reprodutiva , São Francisco
3.
Womens Health (Lond) ; 19: 17455057231152374, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36939096

RESUMO

BACKGROUND: Women experiencing homelessness with substance use disorders face unique and intersecting barriers to realizing their reproductive goals. OBJECTIVE: This study explored the reproductive aspirations of this population, as well as the barriers to accessing reproductive services from the perspectives of affected individuals, and the healthcare providers who serve them. DESIGN: This mixed-methods study included surveys and interviews with women experiencing homelessness with substance use disorders and healthcare providers. METHODS: We conducted surveys and semi-structured interviews with women recruited from opiate treatment programs and homeless encampments in San Francisco, California in 2018. We also conducted interviews and focus groups with healthcare providers in reproductive health and substance use treatment settings. Interviews were recorded, transcribed, and coded. Descriptive statistics of survey results were performed. RESULTS: Twenty-eight women completed surveys, 96% of whom reported current substance use. Ten women participated in interviews. One-third (9/28) reported desiring pregnancy in the next year; over half (16/28) reported they would be somewhat or very happy to learn they were pregnant. A majority used no contraception at last intercourse (14/28). Twenty-six healthcare providers participated in interviews (n = 15) and focus groups (n = 2). Patients and providers identified similar barriers to care access, including discrimination, logistical and financial challenges, and delayed pregnancy awareness. While providers proposed solutions focused on overcoming logistical challenges, patients emphasized the importance of transforming the healthcare environment to treat patients affected by substance use and homelessness with dignity and respect. CONCLUSION: Women experiencing homelessness with substance use disorders face intersecting and compounding barriers to accessing reproductive health services. For patients, the impact of stigma and bias on treatment experiences are particularly salient, in contrast to logistical barriers emphasized by providers. Improving access will require structural and individual-level solutions to address stigma and create person-centered, trauma-informed, and respectful care environments.


Assuntos
Pessoas Mal Alojadas , Transtornos Relacionados ao Uso de Substâncias , Gravidez , Humanos , Feminino , São Francisco/epidemiologia , Acessibilidade aos Serviços de Saúde , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Grupos Focais
5.
Addict Sci Clin Pract ; 12(1): 19, 2017 08 22.
Artigo em Inglês | MEDLINE | ID: mdl-28826401

RESUMO

BACKGROUND: Persons living with HIV and unhealthy substance use are often less engaged in HIV care, have higher morbidity and mortality and are at increased risk of transmitting HIV to uninfected partners. We developed a quality-improvement tracking system at an urban methadone clinic to monitor patients along the HIV care continuum and identify patients needing intervention. OBJECTIVE: To evaluate patient outcomes along the HIV Care Continuum at an urban methadone clinic and explore the relationship of HIV primary care site and patient demographic characteristics with retention in HIV treatment and viral suppression. METHODS: We reviewed electronic medical record data from 2015 for all methadone clinic patients with known HIV disease, including age, gender, race, HIV care sites, HIV care visit dates and HIV viral load. Patients received either HIV primary care at the methadone clinic, an HIV specialty clinic located in the adjacent building, or a community clinic. Retention was defined as an HIV primary care visit in both halves of the year. Viral suppression was defined as an HIV viral load <40 copies/ml at the last lab draw. RESULTS: The population (n = 65) was 63% male, 82% age 45 or older and 60% non-Caucasian. Of these 65 patients 77% (n = 50) were retained in care and 80% (n = 52) were virologically suppressed. Viral suppression was significantly higher for women (p = .022) and patients 45 years or older (p = .034). There was a trend towards greater retention in care and viral suppression among patients receiving HIV care at the methadone clinic (93, 93%) compared to the HIV clinic (74, 79%) or community clinics (62, 62%). CONCLUSIONS: Retention in HIV care and viral suppression are high in an urban methadone clinic providing integrated HIV services. This quality improvement analysis supports integrating HIV primary care with methadone treatment services for this at-risk population.


Assuntos
Instituições de Assistência Ambulatorial/organização & administração , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Adulto , Fatores Etários , Continuidade da Assistência ao Paciente/organização & administração , Registros Eletrônicos de Saúde , Feminino , Infecções por HIV/virologia , Humanos , Masculino , Metadona/uso terapêutico , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos/métodos , Atenção Primária à Saúde/organização & administração , Melhoria de Qualidade/organização & administração , Fatores Sexuais , Fatores Socioeconômicos , Serviços Urbanos de Saúde/organização & administração , Carga Viral
6.
Addict Res Theory ; 24(6): 490-498, 2016.
Artigo em Inglês | MEDLINE | ID: mdl-28503120

RESUMO

30-60% of patients receiving methadone for opioid use disorder (OUD) actively use cocaine. Cocaine use disorder (CUD) has no FDA-approved pharmacological treatment; existing psychosocial treatments are inadequate. Oxytocin, a social neuropeptide, has preclinical promise as an adjunctive treatment for both OUD and CUD. Twenty-two individuals receiving methadone for OUD with co-occurring CUD were randomized to receive oxytocin or placebo intranasally 40 IU twice daily for two weeks. A priori aims were feasibility and safety. Exploratory effectiveness aims included laboratory-based measures of drug craving, drug-related implicit cognition, and drug use. High retention rates (93.5%), the absence of study-related adverse events, and the fact that oxytocin was well tolerated in this population support the feasibility of larger trials. Two weeks of oxytocin (but not placebo) significantly reduced cocaine craving at day 15 compared to baseline (mean change±SD: OT=-0.23±0.19, p=0.004; PL=-0.16±0.29, p=0.114). For heroin craving, the placebo group reported a trend-level increase over time while the oxytocin group remained unchanged - with medium to large effect sizes between the groups (Cohen's d=0.71-0.90). Oxytocin led to a significant switch from implicit self-association with drugs to implicitly associating drugs with others (mean change±SD: 0.25±0.35, p=0.037) and a trend-level reduction in self-reported cocaine use over time (Z=-1.78, p=0.075). Furthermore, oxytocin significantly increased the accuracy of self-reported cocaine use when correlated with quantitative urine levels of cocaine metabolite. This proof-of-concept study provides promising early evidence that oxytocin may be an effective adjunct to the treatment of co-occurring CUD and OUD. Further investigation with larger trials is warranted.

7.
Drug Alcohol Depend ; 153: 236-41, 2015 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-26051162

RESUMO

BACKGROUND: Clinical, experimental, and ethnographic research suggests that cannabis may be used to help manage pain. Ethnographic research has revealed that some people are using cannabis to temper their illicit opioid use. We seek to learn if there is an association between cannabis use and the frequency of nonmedical opioid use among people who inject drugs (PWID). METHODS: PWID were recruited using targeted sampling methods in Los Angeles and San Francisco, California, 2011-2013. We limited analysis to people who used opioids in past 30 days (N=653). OUTCOME VARIABLE: number of times used any opioids non-medically in past 30 days. Explanatory variable: any cannabis use past 30 days. STATISTICS: multivariable linear regression with a log-transformed outcome variable. RESULTS: About half reported cannabis use in the past 30 days. The mean and median number of times using opioids in past 30 days were significantly lower for people who used cannabis than those who did not use cannabis (mean: 58.3 vs. 76.4 times; median: 30 vs 60 times, respectively; p<0.003). In multivariable analysis, people who used cannabis used opioids less often than those who did not use cannabis (Beta: -0.346; 95% confidence interval: -0.575, -0.116; p<0.003). CONCLUSIONS: There is a statistical association between recent cannabis use and lower frequency of nonmedical opioid use among PWID. This may suggest that PWID use cannabis to reduce their pain and/or nonmedical use of opioids. However, more research, including prospective longitudinal studies, is needed to determine the validity of these findings.


Assuntos
Fumar Maconha/epidemiologia , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Abuso de Substâncias por Via Intravenosa/epidemiologia , Adolescente , Adulto , Feminino , Humanos , Los Angeles/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , São Francisco/epidemiologia , Adulto Jovem
8.
Drug Alcohol Depend ; 150: 92-7, 2015 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-25754939

RESUMO

BACKGROUND: Concomitant use of opioids and promethazine has been reported in various subpopulations, including methadone maintenance patients, injection drug users, and at-risk teenagers. Promethazine is thought to potentiate the "high" from opioids. However, to date, the prevalence of promethazine use has not been determined among patients prescribed opioids for chronic pain. METHODS: Urine samples from 921 patients prescribed opioids for chronic pain were analyzed for promethazine. Demographic data, toxicology results, and opioid prescription information were obtained through medical record abstraction. We assessed the prevalence and factors associated with promethazine use with bivariable and multivariable statistics. RESULTS: The prevalence of promethazine-positive urine samples among chronic pain patients was 9%. Only 50% of promethazine-positive patients had an active prescription for promethazine. Having benzodiazepine-positive urine with no prescription for a benzodiazepine was statistically associated with promethazine use. Also, having a prescription for methadone for pain or being in methadone maintenance for the treatment of opioid dependence were both statistically associated with promethazine use. Chronic pain patients prescribed only a long-acting opioid were more likely to have promethazine-positive urines than patients prescribed a short-acting opioid. CONCLUSIONS: The study provides compelling evidence of significant promethazine use in chronic pain patients. Promethazine should be considered as a potential drug of abuse that could cause increased morbidity in opioid-using populations.


Assuntos
Dor Crônica/tratamento farmacológico , Antagonistas dos Receptores Histamínicos H1/uso terapêutico , Uso Indevido de Medicamentos sob Prescrição/estatística & dados numéricos , Prometazina/uso terapêutico , Adolescente , Adulto , Idoso , Analgésicos Opioides/uso terapêutico , Feminino , Humanos , Masculino , Metadona/uso terapêutico , Pessoa de Meia-Idade , Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/reabilitação , Adulto Jovem
9.
Am Fam Physician ; 88(2): 113-21, 2013 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-23939642

RESUMO

Substance misuse is common among patients in primary care settings. Although it has a substantial health impact, physicians report low levels of preparedness to identify and assist patients with substance use disorders. An effective approach to office-based treatment includes a coherent framework for identifying and managing substance use disorders and specific strategies to promote behavior change. Brief validated screening tools allow rapid and efficient identification of problematic drug use, including prescription medication misuse. After a positive screening, a brief assessment should be performed to stratify patients into three categories: hazardous use, substance abuse, or substance dependence. Patients with hazardous use benefit from brief counseling by a physician. For patients with substance abuse, brief counseling is also indicated, with the addition of more intensive ongoing follow-up and reevaluation. In patients with substance dependence, best practices include a combination of counseling, referral to specialty treatment, and pharmacotherapy (e.g., drug tapering, naltrexone, buprenorphine, methadone). Comorbid mental illness and intimate partner violence are common in patients with substance use disorders. The use of a motivational rather than a confrontational communication style during screening, counseling, and treatment is important to improve patient outcomes.


Assuntos
Atenção Primária à Saúde/métodos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Aconselhamento Diretivo , Violência Doméstica/psicologia , Feminino , Humanos , Masculino , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Substâncias/psicologia , Transtornos Relacionados ao Uso de Substâncias/terapia
10.
J Addict Med ; 7(2): 96-101, 2013.
Artigo em Inglês | MEDLINE | ID: mdl-23385449

RESUMO

OBJECTIVE: Promethazine has been reported to be misused in conjunction with opioids in several settings. Promethazine misuse by itself or in conjunction with opioids may have serious adverse health effects. To date, no prevalence data for the nonmedical use of promethazine have been reported. This study examines the prevalence and correlates of promethazine use in 2 different populations in San Francisco, California: methadone maintenance clinic patients and community-based injection drug users (IDUs). METHODS: We analyzed urine samples for the presence of promethazine and reviewed the clinical records for 334 methadone maintenance patients at the county methadone clinic. Separately, we used targeted sampling methods to recruit and survey 139 community-based opioid IDUs about their use of promethazine. We assessed prevalence and factors associated with promethazine use with bivariate and multivariate statistics. RESULTS: The prevalence of promethazine-positive urine samples among the methadone maintenance patients was 26%. Only 15% of promethazine-positive patients had an active prescription for promethazine. Among IDUs reporting injection of opiates in the community-based survey, 17% reported having used promethazine in the past month; 24% of the IDUs who reported being enrolled in methadone treatment reported using promethazine in the past month. CONCLUSIONS: The finding that one-quarter of methadone maintenance patients in a clinic or recruited in community settings have recently used promethazine provides compelling evidence of significant nonmedical use of promethazine in this patient population. Further research is needed to establish the extent and nature of nonmedical use of promethazine.


Assuntos
Analgésicos Opioides/uso terapêutico , Metadona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Prometazina/urina , Abuso de Substâncias por Via Intravenosa/tratamento farmacológico , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Antagonistas dos Receptores Histamínicos H1/urina , Humanos , Masculino , Pessoa de Meia-Idade , Tratamento de Substituição de Opiáceos/métodos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/urina , Prevalência , Fatores de Risco , São Francisco/epidemiologia , Centros de Tratamento de Abuso de Substâncias/estatística & dados numéricos , Abuso de Substâncias por Via Intravenosa/epidemiologia , Abuso de Substâncias por Via Intravenosa/urina , Transtornos Relacionados ao Uso de Substâncias/tratamento farmacológico , Transtornos Relacionados ao Uso de Substâncias/urina , Adulto Jovem
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