Curtis Bone

Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review

Purpose The authors conducted a systematic review of the medical literature to determine the factors most strongly associated with localizing primary care physicians (PCPs) in underserved urban or rural areas of the United States. Method In November 2015, the authors searched databases (MEDLINE, ERIC, SCOPUS) and Google Scholar to identify published peer-reviewed studies that focused on PCPs and reported practice location outcomes that included U.S. underserved urban or rural areas. Studies focusing on practice intentions, nonphysicians, patient panel composition, or retention/turnover were excluded. They screened 4,130 titles and reviewed 284 full-text articles. Results Seventy-two observational or case–control studies met inclusion criteria. These were categorized into four broad themes aligned with prior literature: 19 studies focused on physician characteristics, 13 on financial factors, 20 on medical school curricula/programs, and 20 on graduate medical education (GME) programs. Studies found significant relationships between physician race/ethnicity and language and practice in underserved areas. Multiple studies demonstrated significant associations between financial factors (e.g., debt or incentives) and underserved or rural practice, independent of preexisting trainee characteristics. There was also evidence that medical school and GME programs were effective in training PCPs who locate in underserved areas. Conclusions Both financial incentives and special training programs could be used to support trainees with the personal characteristics associated with practicing in underserved or rural areas. Expanding and replicating medical school curricula and programs proven to produce clinicians who practice in underserved urban or rural areas should be a strategic investment for medical education and future research.

Training addiction counselors to deliver a brief psychoeducational intervention for chronic pain among patients in opioid agonist treatment: A pilot investigation

ABSTRACT Background: Despite high rates of chronic pain among their patients, opioid agonist treatment (OAT) counselors report an absence of training to manage chronic pain. Methods: A multidisciplinary team developed a tailored training for counselors to screen and address chronic pain via a brief psychosocial intervention, and implemented it with 52 addiction counselors. Data on knowledge (9 true-false items) as well as attitudes, interest, and perceived ability (scored on 5-point Likert-type scales) were collected from counselors before (pre-test), after (post-test) training, and after 6 months (follow-up). Results: Pre-test knowledge scores varied considerably. Compared to pre-test, mean counselor knowledge scores increased significantly post-training and at follow-up (ps.<05). The training was associated with increases in positive attitudes toward the role of counselors in managing chronic pain, interest in assessing chronic pain, and counselor ability to assess as well as suggest appropriate interventions for pain (all ps <.05). Perceived ability to assess chronic pain and suggest appropriate treatment interventions were higher at follow-up than at pre-test (ps <.05). Conclusions: Findings related to the initial evaluation of this training were promising, and future research is warranted to further examine the efficacy of training drug counselors on psychosocial interventions to manage chronic pain among OAT patients.

Prisoners as Patients: The Opioid Epidemic, Medication-Assisted Treatment, and the Eighth Amendment:

This article argues that correctional institutions violate the Eighth Amendment when they refuse to establish MAT programs and prevent doctors from exercising medical judgment to properly treat incarcerated people with OUD.

Multimodal Treatment Options, Including Rotating to Buprenorphine, Within a Multidisciplinary Pain Clinic for Patients on Risky Opioid Regimens: A Quality Improvement Study.

Objectives We aimed to evaluate a novel clinical program designed to address unsafe use of opioids prescribed for pain-the Opioid Reassessment Clinic (ORC)-to inform practice and health system improvement. Design Controlled, retrospective cohort study. Setting The ORC is a multidisciplinary clinic in a primary care setting in a Veterans Health Administration hospital designed to perform longitudinal treatment of patients with unsafe use of opioids prescribed for pain, including tapering or rotating to the partial opioid agonist buprenorphine. Subjects We included patients referred to the ORC from March 1, 2016, to March 1, 2017, who had an intake appointment (intervention group) and who did not (control group). Methods We compared a priori-defined metrics at the patient, clinic process, and health system levels and compared metrics between groups. Results During the study period, 114 veterans were referred to the ORC, and 71 (62%) of these had an intake appointment. Those in the intervention group were more likely to trial buprenorphine (N = 41, 62% vs N = 1, 2%, P < 0.01) and had greater reductions in their full agonist morphine equivalent daily dose than those in the control group (30 mg [interquartile range {IQR} = 0-120] vs 0 mg [IQR = 0-20] decrease, P < 0.01). Of those engaging in the ORC, 20 (30%) had not transitioned chronic pain management back to their primary care providers (PCPs) by the end of follow-up. Only one patient transitioned the management of buprenorphine to the PCP. Conclusions Results suggest the ORC was effective in reducing total prescribed opioid doses and in transitioning patients to partial-agonist therapy, but PCP adoption strategies are needed.

Our Ethical Obligation to Treat Opioid Use Disorder in Prisons: A Patient and Physician's Perspective

The opioid epidemic has claimed the lives of more than 183,000 individuals since 1999 and is now the leading cause of accidental death in the United States. Meanwhile, rates of incarceration have quadrupled in recent decades, and drug use is the leading cause of incarceration. Medication-assisted treatment or MAT (i.e. methadone, buprenorphine) is the gold standard for treatment of opioid use disorder. Incarcerated individuals with opioid use disorder treated with methadone or buprenorphine have a lower risk of overdose, lower rates of hepatitis C transmission, and lower rates of re-incarceration. Despite evidence of improved outcomes, many jails and prisons do not offer MAT to individuals with opioid use disorder. This seems partly due to a scientifically unjustified preference for an abstinence-only treatment approach. The absence of MAT in prisons and jails results in poor outcomes for individuals and poses a public health threat to communities. Furthermore, it disproportionately harms poor communities and communities of color. Health care providers in prisons and jails have an ethical obligation to offer MAT to individuals with opioid use disorder to mitigate risk of infectious diseases, opioid overdose and health disparities associated with incarceration.

They Didn’t Believe Her Pain: My Education in Interpersonal Violence

In my first year of medical school, I began to care for patients who were survivors of interpersonal violence. As I transitioned from didactics to clinical experiences, I was struck by how common the hidden threads of physical and sexual violence were in my patients’ stories of chronic pain, depression, and poor health outcomes. Their symptoms often seemed intangible and challenging to treat, unable to fit neatly into typical diagnostic and therapeutic algorithms. In response, I saw clinicians become frustrated and dissatisfied with their ability to treat these patients. Better care for survivors may begin simply with believing our patients’ pain.

Under-reporting of risky drug use among primary care patients in federally qualified health centers

Objective:The Affordable Care Act encourages integration of behavioral health into primary care. We aim to estimate the level of under-reporting of drug use in federally qualified health centers (FQHCs) among self-reported risky drug users. Methods:Adult patients in the waiting rooms of 4 FQHCs who self-reported risky drug use on the screening instrument World Health Organizations Alcohol, Smoking and Substance Involvement Screening Test (score 4–26), who participated in the “Quit Using Drugs Intervention Trial,” submitted urine samples for drug testing. Under-reporters were defined as patients who denied use of a specific drug via questionnaire, but whose urine drug test was positive for that drug. Descriptive statistics, Pearson chi-square test, and logistic regression were used for analysis. Results:Of the 192 eligible participants, 189 (96%) provided urine samples. Fifty-four samples were negative or indeterminate, yielding 135 participants with positive urine drug tests for this analysis: 6 tested positive for amphetamines, 18 opiates, 21 cocaine, 97 marijuana. Thirty patients (22%) under-reported drug use and 105 (78%) reported drug use accurately. Under-reporting by specific substances was: amphetamines 66%, opiates 45%, cocaine 14%, and marijuana 7%. Logistic regression revealed that under-reporting of any drug was associated with history of incarceration and older age (odds ratios 2.6 and 3.3, respectively; P < 0.05). Conclusions:Under-reporting of drug use is prevalent even among self-reported drug users in primary care patients of FQHCs (22%), but varied considerably based on the substance used. Further research is indicated to assess the extent of under-reporting among all primary care patients, regardless of their self-reported drug use status.