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Provider perspectives on care coordination for people living with HIV who use drugs
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Abstracts / Drug and Alcohol Dependence 171 (2017) e2–e226
Remifentanil vs. food choice under a dependent schedule Jonathan J. Chow ∗ , J.S. Beckmann Psychology, University of Kentucky, Lexington, KY, United States Aims: Drugs of abuse, such as opioids, are a significant public health problem. Research has demonstrated that the presence of a concurrent alternative can reduce the reinforcing effects of a drug of abuse. Herein, we assessed the relative value of remifentanil, a mu-opioid agonist, against a food pellet alternative. Methods: Male Sprague Dawley rats were initially trained to lever press for food pellets. After lever training, rats were placed on a response chain where the onset of the houselight signaled an orienting response into the magazine, which turned off the houselight and extended the response levers. Rats were then catheterized and trained to lever press for remifentanil (10 g/kg). Rats were then placed on a dependent schedule or a free choice procedure. Each procedure consisted of 5 blocks, where drug dose increased by block (0, 0.32, 1.0, 3.2, and 10 g/kg). Each block was accompanied by a distinct tone. Under the free choice procedure, rats could distribute 6 choices across either the drug and food option within 20-minute blocks. Under the dependent schedule drug and food preference was assessed while keeping experience equivalent across each reinforcer (3 drug and 3 food) by randomizing the allocation of reinforcement across options within each block. Finally, the effect of food restriction and drug-associated cues on remifentanil choice was tested. Results: Nonlinear mixed-effects modeling was performed on the percent remifentanil choice made across block. While there were individual differences in the relative preference for drug, the results demonstrate that remifentanil preference increased with dose. Food restriction reduced the relative value of drug, shifting choice right. By removing the drug-associated cues the maximum value of remifentanil decreased, shifting choice down vertically. Finally, removing the orienting response increased the relative value of drug, shifting choice left. Conclusions: Collectively, the results indicate that remifentanil value is relative. Future use of choice procedures will help to isolate the reinforcing effects of drugs of abuse. Financial support: NIH R00 DA033373 and T32 DA016176. http://dx.doi.org/10.1016/j.drugalcdep.2016.08.127 Provider perspectives on care coordination for people living with HIV who use drugs Kasey Claborn 1,2 1
Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, United States 2 Medicine, Rhode Island Hospital, Providence, RI, United States Aims: Drug use is associated with poor linkages to HIV care, reduced retention and adherence to treatment, and increased sexual risk behavior. Many barriers impede the integration of HIV and substance use (SU) care. The aim of this qualitative study was to assess providers’ perspectives on: (1) challenges working with HIVinfected people who use drugs; (2) gaps in existing communication processes; (3) perceived need for coordinated care and limitations; and (4) prior training and perceived need for cross-training. Methods: Individual interviews (IDIs) were conducted with N = 29 providers [n = 16 HIV; n = 13 SU]. Participants were included if they were employed at a local HIV or SU clinic, had a relevant
position title, and had at least one year relevant experience. IDIs were 45–90 min, followed a semi-structured guide, and facilitated by a licensed psychologist. Data is being analyzed using thematic analysis in an iterative process. A review of summaries generated immediately following the IDIs has revealed themes which have been confirmed by a review of n = 12 transcripts. Formal analysis to confirm these preliminary findings are being conducted and will be completed by March 2016. Results: The following themes have emerged: (1) specific patient, provider, and organizational issues are barriers to coordination and consistent across provider type; (2) electronic health record systems have exacerbated stigma for patients and providers; (3) “need a bridge” from HIV care to SU treatment, and SU treatment to both HIV and PrEP services; and (4) all providers noted benefits from cross-training and limitations in prior training. Conclusions: Results highlight concerns and challenges among HIV and SU providers in coordinating care. Both types of providers lack an understanding of treatment modalities, communication processes, and understanding providers’ roles outside of their domain of expertise. Findings demonstrate the need for providerlevel interventions to improve communication and cross-training methods. Financial support: This research was supported by grant number K23 DA039037 from NIDA. http://dx.doi.org/10.1016/j.drugalcdep.2016.08.128 The computer-based drug and alcohol training assessment in Kenya Veronic Clair 1,2,∗ , Victoria Mutiso 3 , Abednego Musau 3 , Erica Frank 1 , David Ndetei 3 1 Univeristy of British Columbia, Vancouver, BC, Canada 2 Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada 3 Africa Mental Health Foundation, Nairobi, Kenya
Aims: NextGenU.org, the Annenberg Physician Training Program in Addiction Medicine (APTPAM), and Africa Mental Health Foundation (AMHF) assessed the impact of online training on urban and rural Kenyan healthcare workers’ (HW) delivery of substance use disorders (SUD) services; using the NextGenU.org model based on expert created competencies, free available learning objects, and mentored activities. Methods: eDATA K includes (1) a pilot study; (2) a pre- and posttraining knowledge, attitudes and skills (KAS) of HW in practice; (3) a RCT comparing alcohol brief interventions (BI) versus screening and information leaflet with 6 months follow-up (f/u); and (4) an implementation science study using a delayed control method to assess the integration of the SUD interventions in on-going practice with or without a quality improvement course. All four studies used quantitative and qualitative methods and data collection tools, administered after obtaining ethical approval and informed consent. Results: The courses improved KAS both in the pilot and in subsequent training of HW in 15 primary care facilities. Both RCT study arms (n = 696) showed a decrease of approximately100 g of alcohol (from about 400 g at baseline) of alcohol consumption in the previous 7 days at 6 months f/u, for those with risky level of alcohol consumption as determined by the ASSIST. Focus groups revealed very significant impact on participants’ health and functioning. HWs were able to integrate the screening and BI in their
Abstracts / Drug and Alcohol Dependence 171 (2017) e2–e226
Remifentanil vs. food choice under a dependent schedule Jonathan J. Chow ∗ , J.S. Beckmann Psychology, University of Kentucky, Lexington, KY, United States Aims: Drugs of abuse, such as opioids, are a significant public health problem. Research has demonstrated that the presence of a concurrent alternative can reduce the reinforcing effects of a drug of abuse. Herein, we assessed the relative value of remifentanil, a mu-opioid agonist, against a food pellet alternative. Methods: Male Sprague Dawley rats were initially trained to lever press for food pellets. After lever training, rats were placed on a response chain where the onset of the houselight signaled an orienting response into the magazine, which turned off the houselight and extended the response levers. Rats were then catheterized and trained to lever press for remifentanil (10 g/kg). Rats were then placed on a dependent schedule or a free choice procedure. Each procedure consisted of 5 blocks, where drug dose increased by block (0, 0.32, 1.0, 3.2, and 10 g/kg). Each block was accompanied by a distinct tone. Under the free choice procedure, rats could distribute 6 choices across either the drug and food option within 20-minute blocks. Under the dependent schedule drug and food preference was assessed while keeping experience equivalent across each reinforcer (3 drug and 3 food) by randomizing the allocation of reinforcement across options within each block. Finally, the effect of food restriction and drug-associated cues on remifentanil choice was tested. Results: Nonlinear mixed-effects modeling was performed on the percent remifentanil choice made across block. While there were individual differences in the relative preference for drug, the results demonstrate that remifentanil preference increased with dose. Food restriction reduced the relative value of drug, shifting choice right. By removing the drug-associated cues the maximum value of remifentanil decreased, shifting choice down vertically. Finally, removing the orienting response increased the relative value of drug, shifting choice left. Conclusions: Collectively, the results indicate that remifentanil value is relative. Future use of choice procedures will help to isolate the reinforcing effects of drugs of abuse. Financial support: NIH R00 DA033373 and T32 DA016176. http://dx.doi.org/10.1016/j.drugalcdep.2016.08.127 Provider perspectives on care coordination for people living with HIV who use drugs Kasey Claborn 1,2 1
Psychiatry & Human Behavior, Warren Alpert Medical School of Brown University, Providence, RI, United States 2 Medicine, Rhode Island Hospital, Providence, RI, United States Aims: Drug use is associated with poor linkages to HIV care, reduced retention and adherence to treatment, and increased sexual risk behavior. Many barriers impede the integration of HIV and substance use (SU) care. The aim of this qualitative study was to assess providers’ perspectives on: (1) challenges working with HIVinfected people who use drugs; (2) gaps in existing communication processes; (3) perceived need for coordinated care and limitations; and (4) prior training and perceived need for cross-training. Methods: Individual interviews (IDIs) were conducted with N = 29 providers [n = 16 HIV; n = 13 SU]. Participants were included if they were employed at a local HIV or SU clinic, had a relevant
position title, and had at least one year relevant experience. IDIs were 45–90 min, followed a semi-structured guide, and facilitated by a licensed psychologist. Data is being analyzed using thematic analysis in an iterative process. A review of summaries generated immediately following the IDIs has revealed themes which have been confirmed by a review of n = 12 transcripts. Formal analysis to confirm these preliminary findings are being conducted and will be completed by March 2016. Results: The following themes have emerged: (1) specific patient, provider, and organizational issues are barriers to coordination and consistent across provider type; (2) electronic health record systems have exacerbated stigma for patients and providers; (3) “need a bridge” from HIV care to SU treatment, and SU treatment to both HIV and PrEP services; and (4) all providers noted benefits from cross-training and limitations in prior training. Conclusions: Results highlight concerns and challenges among HIV and SU providers in coordinating care. Both types of providers lack an understanding of treatment modalities, communication processes, and understanding providers’ roles outside of their domain of expertise. Findings demonstrate the need for providerlevel interventions to improve communication and cross-training methods. Financial support: This research was supported by grant number K23 DA039037 from NIDA. http://dx.doi.org/10.1016/j.drugalcdep.2016.08.128 The computer-based drug and alcohol training assessment in Kenya Veronic Clair 1,2,∗ , Victoria Mutiso 3 , Abednego Musau 3 , Erica Frank 1 , David Ndetei 3 1 Univeristy of British Columbia, Vancouver, BC, Canada 2 Urban Health Research Initiative, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, Canada 3 Africa Mental Health Foundation, Nairobi, Kenya
Aims: NextGenU.org, the Annenberg Physician Training Program in Addiction Medicine (APTPAM), and Africa Mental Health Foundation (AMHF) assessed the impact of online training on urban and rural Kenyan healthcare workers’ (HW) delivery of substance use disorders (SUD) services; using the NextGenU.org model based on expert created competencies, free available learning objects, and mentored activities. Methods: eDATA K includes (1) a pilot study; (2) a pre- and posttraining knowledge, attitudes and skills (KAS) of HW in practice; (3) a RCT comparing alcohol brief interventions (BI) versus screening and information leaflet with 6 months follow-up (f/u); and (4) an implementation science study using a delayed control method to assess the integration of the SUD interventions in on-going practice with or without a quality improvement course. All four studies used quantitative and qualitative methods and data collection tools, administered after obtaining ethical approval and informed consent. Results: The courses improved KAS both in the pilot and in subsequent training of HW in 15 primary care facilities. Both RCT study arms (n = 696) showed a decrease of approximately100 g of alcohol (from about 400 g at baseline) of alcohol consumption in the previous 7 days at 6 months f/u, for those with risky level of alcohol consumption as determined by the ASSIST. Focus groups revealed very significant impact on participants’ health and functioning. HWs were able to integrate the screening and BI in their