Raina Croff

Extended-Release Naltrexone: A Qualitative Analysis of Barriers to Routine Use.

The Medication Research Partnership (a national health plan and nine addiction treatment centers contracted with the health plan) sought to facilitate the adoption of pharmacotherapy for alcohol and opioid use disorders. Qualitative analysis of interviews with treatment center change leaders, individuals working for the manufacturer and its technical assistance contractor, and health plan managers extracted details on the processes used to order, store, bill for, and administer extended-release naltrexone. Qualitative themes were categorized using domains from the Consolidated Framework for Implementation Research (intervention characteristics, outer setting, inner setting, and provider characteristics). Characteristics of XR-NTX that inhibited use included the complexity of ordering and using the medication; cost was also a barrier. Outer setting barriers reflected patient needs and external health plan policies on formulary coverage, benefit management, and reimbursement. Program structures, the lack of physician linkages, a culture resistant to the use of medication, and unease with change were inner setting elements that limited use of XR-NTX. Patient stereotypes and a lack of knowledge about XR-NTX affected practitioner willingness to treat patients and prescribe XR-NTX. The Consolidated Framework for Implementation Research provided a useful lens to understand and interpret the processes affecting access to XR-NTX.

Alcohol screening among opioid agonist patients in a primary care clinic and an opioid treatment program

Abstract Problem alcohol use is associated with adverse health and economic outcomes, especially among people in opioid agonist treatment. Screening, brief intervention, and referral to treatment (SBIRT) are effective in reducing alcohol use; however, issues involved in SBIRT implementation among opioid agonist patients are unknown. To assess identification and treatment of alcohol use disorders, we reviewed clinical records of opioid agonist patients screened for an alcohol use disorder in a primary care clinic (n = 208) and in an opioid treatment program (n = 204) over a two-year period. In the primary care clinic, 193 (93%) buprenorphine patients completed an annual alcohol screening and six (3%) had elevated AUDIT scores. In the opioid treatment program, an alcohol abuse or dependence diagnosis was recorded for 54 (27%) methadone patients. Practitioner focus groups were completed in the primary care (n = 4 physicians) and the opioid treatment program (n = 11 counselors) to assess experience with and attitudes towards screening opioid agonist patients for alcohol use disorders. Focus groups suggested that organizational, structural, provider, patient, and community variables hindered or fostered alcohol screening. Alcohol screening is feasible among opioid agonist patients. Effective implementation, however, requires physician training and systematic changes in workflow.

Provider and State Perspectives on Implementing Cultural-Based Models of Care for American Indian and Alaska Native Patients with Substance Use Disorders

American Indians/Alaska Natives (AI/ANs) suffer disproportionate rates of substance use disorders compared to Americans overall. Providers serving AI/AN communities are drawing from a diverse toolkit of treatment strategies that incorporate Native worldviews and community-shared values in order to improve outcomes. This paper describes findings from interviews with 22 program directors and 18 representatives from Single State Authorities on substance abuse. Interviews assessed provider and state efforts to increase AI/AN client engagement and to improve the quality of care through culturally relevant interventions. Results suggested that providers employed flexibility and originality to cultural-based programs by broadening established practices, adopting outside traditions, and creating new ones to fit client needs. However, gaps in state–tribal collaborations and inter-group complexities such as staff-based tensions, a widening generational divide, and blurred consensus of “tradition” affect service delivery. Overall, respondents underlined the critical role culturally relevant care plays in individual and community healing.

Considerations for Research and Development of Culturally Relevant Mindfulness Interventions in American Minority Communities

As many health disparities in American minority communities (AMCs) are stress related, there has been an increased interest in the development of mindfulness programs as potential stress-reduction measures in these communities. However, the bulk of the extant literature on mindfulness research and mindfulness interventions is based upon experiences with the larger White community. The intent of this commentary is to share a framework that includes key cultural considerations for conducting research and developing culturally salient mindfulness programs with AMCs. We build on our experiences and the experiences of other researchers who have explored mindfulness in African- and Native American communities; in particular, we examine issues around community outreach with an emphatic gesture toward emphasizing protection of AMCs and their participants. Discussed are considerations with respect to attitudinal foundations in mindfulness-based research and program development with these communities. However, the overall message of this paper is not to provide a “to-do” list of research steps, but to rather, encourage researchers to turn inward and consider the development of skillful characteristics that will increase the likelihood of a successful research venture while also protecting the cultural traditions of the AMC of interest.

Strategies to implement and sustain medication use for alcohol and opioid disorders

Background Medication for treatment of alcohol and opioid use disorders decreases relapse rates and increases long-term recovery. Inclusion of medications in treatment plans, however, may be a complex process for addiction treatment centers. Sustaining use of medications requires additional wellorganized and concerted efforts. Qualitative interviews explore implementation and sustainability strategies and barriers encountered by participating providers to promote adoption of medication for opioidand alcoholdependent patients.

Overcoming Barriers to Adopting and Implementing Pharmacotherapy: the Medication Research Partnership

Pharmacotherapy includes a growing number of clinically effective medications for substance use disorder, yet there are significant barriers to its adoption and implementation in routine clinical practice. The Medication Research Partnership (MRP) was a successful effort to promote adoption of pharmacotherapy for opioid and alcohol use disorders in nine substance abuse treatment centers and a commercial health plan. This qualitative analysis of interviews (n = 39) conducted with change leaders at baseline and at the end/beginning of 6-month change cycles explains how treatment centers overcame obstacles to the adoption, implementation, and sustainability of pharmacotherapy. Results show that barriers to adopting, implementing, and sustaining pharmacotherapy can be overcome through incremental testing of organizational change strategies, accompanied by expert coaching and a learning community of like-minded professionals. The greatest challenges lie in overcoming abstinence-only philosophies, establishing a business case for pharmacotherapy, and working with payers and pharmaceutical representatives.

Things Are Changing so Fast: Integrative Technology for Preserving Cognitive Health and Community History

Background and Objectives Multimodal interventions are increasingly targeting multiple cognitive decline risk factors. However, technology remains mostly adjunctive, largely prioritizes age relevancy over cultural relevancy, and often targets individual health without lasting, community-wide deliverables. Meanwhile, African Americans remain overburdened by cognitive risk factors yet underrepresented in cognitive health and technology studies. The Sharing History through Active Reminiscence and Photo-imagery (SHARP) program increases physical, social, and cognitive activity within a culturally meaningful context that produces community deliverables-an oral history archive and cognitive health education. Design and Methods The SHARP application was tested with 19 African Americans ≥55 years, aiming for an easy, integrative, and culturally meaningful experience. The application guided triads in walks 3 times weekly for 6 months in Portland, Oregons historically Black neighborhoods; local historical images prompted recorded conversational reminiscence. Focus groups evaluated factors influencing technology acceptance-attitudes about technology, usefulness, usability, and relevance to integrating program goals. Thematic analysis guided qualitative interpretation. Results Technology acceptance was influenced by group learning, paper-copy replicas for reluctant users, ease of navigation, usefulness for integrating and engaging in health behaviors, relevance to integrating individual benefit and the community priority of preserving history amidst gentrification, and flexibility in how the community uses deliverables. Perceived community benefits sustained acceptance despite intermittent technology failure. Discussion and Implications We offer applicable considerations for brain health technology design, implementation, and deliverables that integrate modalities, age, and cultural relevance, and individual and community benefit for more meaningful, and thus more motivated community engagement.

FEELS LIKE IT'S FOR US, BY US: IMPACT ON MINORITY RETENTION IN THE SHARP STUDY

Background: African Americans are underrepresented in research as participants and researchers (National Science Foundation, 2015).Many factors contribute to this, including a history of exploitation such as the Syphilis trials (Centers for Disease Control, 2017) and radiation experiments on African American children, (The Hole in the Head, 2009) and the lower likelihood of African American researchers to get funded compared to their white counterparts (National Institutes of Health, 2015). Racial concordance between researchers and participants establishes trust and is valuable in minority research engagement, (Fryer et. Al, 2015) and could potentially play a role in reducing cognitive health disparities among African Americans. The Sharing History through Active-Reminiscence and Photo-Imagery (SHARP) Study aims to improve older African Americans’ cognitive health, and serves as a platform to mentor new African American Alzheimer’s disease researchers. Methods: In a 2016 and a 2017 cohort, a total of 31 older African Americans (7 with mild cognitive impairment) walked in triads for 6 months using tablet devices that prompted conversational reminiscence through historic images and questions about African American culture. In focus groups, participants evaluated the study’s motivational factors. Discussions were transcribed and coded for thematic analysis. During this period, African American undergraduate and graduate students from the Portland metropolitan region were integrated into research activities of the SHARP study in a mentored research environment. Results:Over the study’s two years, seven African American students, have beenmentored in brain health research through the SHARP study. The 2016 and 2017 participant cohorts had a 71% and 90% retention rate, respectively. Participants attributed their sustained engagement in part to the study’s African American leadership and its strong commitment to mentoring African American researchers. Participants found value, pride, and an increased sense of purpose in being part of a study that invested in their own health, in the preservation of their community’s history, and in the next generation of African American brain health researchers. Conclusions:An increased presence of African Americans as researchers and participants can increase retention and yield better outcomes in minority based research.

‘YOU DON'T NEED TO DO THINGS FACE-TO-FACE ANYMORE...’: STAR-C-TELEMEDICINE

(MCI) or mild dementia, even though it is used in this population. Methods: We enrolled 28 older adults ( 50 years) to a randomized parallel-group trial of center-based versus home-based exercise. Participants were diagnosed with MCI or mild dementia (MoCA 17 or MMSE 22), were safe to exercise, and were currently exercising 2x/wk. At baseline, participants reported physical activity levels using the PASE and had physical activity assessed using an accelerometer (Actigraph GT3x+) over 7 days. Physical function was assessed using the 6-min walk, 5x sit-stand, and gait speed. Spearman’s rank correlation coefficient (rs) was calculated between PASE scores and accelerometer (% time in moderate-vigorous physical activity [MVPA], step count) and physical function scores. Results: Participants’ average age (SD) was 75.5 (8.2) years and education was 15.0 (3.5) years; they were 18% (n1⁄45) female. There were no significant relationships between the PASE score and either accelerometer scores (% time in moderate-vigorous physical activity, step count) or physical function (sit-stand, 6min walk, gait speed) (p>0.07). However, rs were in the expected direction. Non-significant, positive rs occurred between PASE score and % MVPA (rs1⁄40.31, p1⁄40.13), step count (rs1⁄40.30, p1⁄40.14), and 6-min walk time (rs1⁄40.23, p1⁄40.16). Negative rs occurred between PASE score and gait speed (rs1⁄4-0.34, p1⁄40.06). Conclusions: Our results are insufficient to support the validation of the PASE of among individuals with MCI or mild dementia. Further work is needed to support use of the PASE in this group. With additional participants enrolled to the trial through late 2018, it is possible that the expanded sample will clarify the validity of the PASE in this population.