BACKGROUND:Rehabilitation for hip joint-related pain (HRP) is challenging to navigate and often leads to suboptimal clinical outcomes and frustration for both clinicians and patients. OBJECTIVE:To determine physical therapist (PT)-identified facilitators and barriers to rehabilitation for patients with HRP to inform strategies for improving rehabilitation. DESIGN:Qualitative; focus groups. SETTING:Academic and clinical. PARTICIPANTS:Licensed PTs who treat patients with HRP (N = 20; 12 female/8 male) participated in virtual focus groups (N = 4 groups; 4-6 PTs per group). MAIN OUTCOME MEASURE(S):PTs reported demographics (age, gender, race, ethnicity), number of years practicing, practice setting, and additional certifications. We used a hybrid deductive-inductive thematic analysis to determine PT-identified facilitators and barriers to rehabilitation for HRP. RESULTS:PTs reported treating an average of 15 patients with HRP per month. Thematic analyses revealed five main facilitators to rehabilitation: (1) patient education, (2) patient empowerment, (3) traditional biomedical rehabilitation interventions, (4) collaborative model, and (5) therapeutic alliance and patient-centered care. Barriers to rehabilitation included (1) patients' mood, (2) treatment expectations, (3) structural or logistical challenges, (4) lack of physician support, and (5) pain perception. CONCLUSIONS:Improving interprofessional communication, setting realistic treatment expectations, and considering biopsychosocial contributors to hip pain may be opportunities to improve rehabilitation engagement and outcomes for patients with HRP. Future work examining the efficacy and dose-response of movement retraining and postural correction is warranted, as physical therapists reported relying heavily on these rehabilitation interventions.

Drug use is a highly stigmatized behavior, and drug-related stigma is a key driver of behavioral risk, lower health care utilization, and associated adverse health outcomes among people who inject drugs (PWID). While instruments exist for measuring drug-related stigma, their applicability to community-based PWID across multiple stigma types (enacted, anticipated, internalized) and settings (health care, society, family) is limited, as most were developed using treatment-based samples and all were developed in urban populations. This study sought to develop a Drug Use Stigma Scale (DUSS) that addresses these limitations. We developed an initial list of 39 items based on literature review and qualitative interviews (N = 27) and three focus groups (N = 28) with PWID recruited from syringe services programs and via peer referral in two predominantly rural West Virginia counties. The scale items were administered in a survey to 336 PWID recruited from the same two counties divided into development and validation samples. Responses to the 39-item scale went through a multidimensional refinement process, including examination of internal consistency, Confirmatory Factor Analysis (CFA), and a three-factor CFA based on stigma setting. Next, a set of final measurement CFAs were conducted. Finally, the resulting scale was examined for criterion-related concurrent validation. The final DUSS consisted of 16 items with excellent fit statistics for the development sample: SRMR: 0.03, RMSEA: 0.09, GFI: 0.92, CFI: 0.96, NFI: 0.94. Fit attenuated but remained satisfactory for the validation sample. DUSS scores were significantly associated with increased odds of not seeking healthcare when needed (OR: 1.47, p = 0.001; OR: 1.61, p < 0.0001) after controlling for gender and age. Thus, the resulting scale, the DUSS, demonstrates strong validity and internal reliability across multiple stigma mechanisms and settings in a rural population, making it a valuable tool for broadly assessing drug-related stigma and related intervention effectiveness among PWID.

BACKGROUND:The introduction of fentanyl into the unregulated drug supply has drastically altered drug landscapes across the United States and increasingly contributed to overdose. As part of a larger study about opioid overdose, we assessed how the emergence of fentanyl has shaped health outcomes and social relations in an underserved region of California. METHODS:From 2022-2024, we engaged in ethnographic fieldwork, surveys, and qualitative interviews with people 18+ years old and reporting opioid or stimulant use in the prior three months. We generated descriptive statistics and examined un/intentional fentanyl use among people using opioids (regardless of stimulant use) compared to those exclusively using stimulants. Qualitative interviews were thematically coded to lend insight into the social contexts of fentanyl use. RESULTS:Of 195 survey participants, 31 % were women, and 60 % identified as racialized groups, with an average age of 43; the qualitative sub-sample (n = 53 interviews) was similar. People using opioids were often initially unintentionally exposed to fentanyl through the heroin supply or prescription pills, but shifted to intentional use. People using stimulants attributed unintentional fentanyl use to adulterated methamphetamine, mistaking fentanyl for other drugs, and sharing smoking tools. Socially, fentanyl heightened overdose risk and fueled community stigma, while paradoxically instantiating forms of community care (i.e., overdose response, warning those experimenting with fentanyl). CONCLUSION:Our research calls for evidence-based education about fentanyl, expanded access to harm reduction services, including community drug checking and safer smoking supplies, and low-barrier drug treatment as part of broader efforts to promote community care.

OBJECTIVE:To identify barriers and facilitators to amputation prevention in a rural state using a mixed methods approach integrating spatial epidemiology, regression analysis, and qualitative methods. METHODS:We conducted a sequential explanatory mixed methods study in West Virginia, the only state entirely within Appalachia and among the most rural in the U.S. Quantitative analysis of 2011-2016 hospital discharge data from the State Inpatient Database (Healthcare Cost and Utilization Project) identified geographic disparities in diabetes/peripheral artery disease-related amputation using Bayesian spatial hierarchical modeling and multivariable regression. Qualitative interviews and focus groups were conducted with patients, caregivers, and providers from high-risk zip codes to explore the barriers and facilitators to limb preservation. Thematic analysis was used to identify emergent themes. RESULTS:Amputation rates in West Virginia were geographically clustered, with major amputations occurring at 5 per 1000 and minor amputations at 7 per 1000 patients. Regression models showed increased risk for those with peripheral artery disease complicating diabetes, Medicaid insurance, and rural residence. Sixty-six people participated in interviews and focus groups. Four major themes emerged: (1) lack of patient and provider education, (2) barriers to access and care coordination, (3) geographic and cultural challenges tied to rurality, and (4) treatment nonadherence linked to communication breakdowns and hopelessness. CONCLUSIONS:Disparities in amputation risk are driven by complex, inter-related factors in rural settings. Findings support the need for targeted interventions focused on provider and patient education, care coordination, mental health support, and culturally grounded community engagement. This framework may guide future efforts to decrease amputation rates in other underserved populations.

Adolescent violence is understudied as a public health challenge for rural adolescents. Anger expression, also referred to as externalized anger, is a risk factor for adolescent violent behavior. Survey data from 1649 early adolescents in the Young Mountaineer Health Study (YMHS) cohort were used to identify correlates of externalized anger drawing on an adapted socioecological model. Correlates examined included: Relative family income; family affluence; neighborhood characteristics (safety, ties, collective efficacy); family living arrangements; social support from adults at home and school; and harsh parenting. Gender was utilized as an effect modifier. We employed two Poisson regression models for main effects and gender interaction effects. Parameter estimates were exponentiated and interpreted as Rate Ratios (RR). Significant main effects included perceived neighborhood safety (RR = 0.98, 95 % CI = 0.97-0.99), support from adults at home (RR = 0.98, 95 % CI = 0.97-0.99) and school (RR = 0.99, 95 % CI = 0.98-0.99), and harsh parenting (RR = 1.06, 95 % CI = 1.05-1.07). Several gender differences emerged in the interaction model. Boys reported significantly lower anger compared to girls (RR = 0.90, 95 % CI = 0.86-0.94). In the gender-based interaction model harsh parenting was more strongly associated with externalized anger among boys (RR = 1.03, 95 % CI = 1.01-1.06). Implications are discussed for future research on the relationship between externalized anger and violence prevention among rural adolescents.

ImportanceDespite the proliferation of pharmacy standing-order naloxone dispensing across many US states before the change to over-the-counter status, few policy analyses have evaluated the implementation of pharmacy naloxone standing orders in addressing opioid overdose fatality among communities.ObjectiveTo determine whether the implementation of pharmacy standing-order naloxone was associated with lower opioid fatality rates compared with communities without pharmacies with standing-order naloxone.Design, Setting, and ParticipantsThis retrospective multisite study was conducted with an interrupted time series analysis across 351 municipalities in Massachusetts over 24 quarters (from January 1, 2013, through December 31, 2018). Standing-order naloxone dispensing data were collected from 2 sources for all major chain pharmacies and many independent pharmacies, covering 70% of retail pharmacies in Massachusetts. Municipalities had various standing-order naloxone implementation inceptions during the study period. Data were analyzed from December 2021 to November 2023.ExposureThe main exposure was measured by the first quarter with standing-order naloxone dispensation as the actual implementation inception.Main Outcomes and MeasuresThe primary study outcome was municipal opioid fatality rate per 100 000 population obtained from the Massachusetts Registry of Vital Records and Statistics.ResultsThe median (IQR) population size across 351 municipalities was 10 314 (3635 to 21 781) people, with mean (SD) proportion of female individuals was 51.1% (2.8 percentage points). Pharmacies from 214 municipalities (60.9%) reported dispensing standing-order naloxone over the study period. At the baseline of the first quarter of 2013, municipalities that eventually had standing-order naloxone had greater quarterly opioid fatality rates compared with those that never implemented standing-order naloxone (3.51 vs 1.03 deaths per 100 000 population; P < .001). After adjusting for municipal-level sociodemographic and opioid prevention factors, there was significant slope decrease of opioid fatality rates (annualized rate ratio, 0.84; 95% CI, 0.78-0.91; P < .001) following standing-order naloxone dispensing, compared with the municipalities that did not implement standing-order naloxone. There were no significant level changes of opioid fatality rates in the adjusted models. Sensitivity analyses yielded similar and significant findings.Conclusions and RelevanceThese findings suggest that community pharmacy dispensing of naloxone with standing orders was associated with a relative, gradual, and significant decrease in opioid fatality rates compared with communities that did not implement the standing-order naloxone program. These findings support the expansion of naloxone access, including over-the-counter naloxone as part of a multifaceted approach to address opioid overdose.

Importance:Despite their widespread adoption across the US, policies imposing one-size-fits-all limits on the duration of prescriptions for opioids have shown modest and mixed implications for prescribing. Objective:To assess whether a prescription duration limit policy tailored to different clinical settings was associated with shorter opioid prescription lengths. Design, Setting, and Participants:This cross-sectional study examined changes in opioid prescribing patterns for opioid-naive Medicaid enrollees aged 12 to 64 years before and after implementation of a statewide prescription duration limit policy in West Virginia in June 2018. Patients with cancer or Medicare coverage were excluded. The policy assigned a 7-day duration limit to opioid prescriptions for adults treated in outpatient hospital- or office-based practices, a 4-day limit for adults treated in emergency departments, and a 3-day limit for pediatric patients younger than 18 years regardless of clinical setting. Data were examined from January 1, 2017, through September 30, 2019, and data were analyzed from June 12 to October 30, 2023. Main Outcomes and Measures:Whether a patient's initial opioid prescription was longer in days than the June 2018 policy limit for a given care setting before and after policy implementation. Interrupted time series models were used to calculate the association between the policy's implementation and outcomes. Results:The analytic sample included 44 703 Medicaid enrollees (27 957 patients [62.5%] before policy implementation and 16 746 patients [37.5%] after policy implementation; mean [SD] age, 33.9 [13.4] years; 27 461 females [61.4%]). Among adults treated in outpatient hospital- or office-based settings, the duration limit policy was associated with a decrease of 8.83 (95% CI, -10.43 to -7.23) percentage points (P < .001), or a 56.8% relative reduction, in the proportion of prescriptions exceeding the 7-day limit. In the emergency department setting, the policy was associated with a decrease of 7.03 (95% CI, -10.38 to -3.68) percentage points (P < .001), a 37.5% relative reduction, in the proportion of prescriptions exceeding the 4-day limit. The proportion of pediatric opioid prescriptions longer than the 3-day limit decreased by 12.80 (95% CI, -17.31 to -8.37) percentage points (P < .001), a 26.5% relative reduction, after the policy's implementation. Conclusions and Relevance:Results of this cross-sectional study suggest that opioid prescription duration limits tailored to different clinical settings are associated with reduced length of prescriptions for opioid-naive patients. Additional research is needed to evaluate whether these limits are associated with reductions in the incidence of opioid use disorder or with unintended consequences, such as shifts to illicit opioids.

Amputation is a devastating complication of diabetes (DM) and peripheral artery disease (PAD) and a marker for health inequity. Yet, few amputation interventions are tailored for marginalized communities, use implementation science (IS), or community- engaged research (CEnR). Amputation interventions described in the literature include standardized diabetic foot exams (DFEs), multidisciplinary limb preservation teams, and "hot-foot" hotlines. We used IS and CEnR to adapt and implement these evidence-based interventions in a rural high-risk community and assessed 1-year feasibility and acceptability outcomes. The interventions were implemented in two rural clinics. IS models and frameworks (COM-B and CFIR) were used. CEnR methods included the creation of a Community Advisory Board (CAB) with stakeholders and a Project Advisory Board (PAB) with local health care providers. The CAB/PAB collaborated on needs assessments, mobilizing resources, intervention adaptation, and reviewing findings. A mixed methods design was used for data collection and analysis (Fig 1). DFE training was conducted in clinics focusing on needs identified pre-implementation. Prospective chart reviews were performed with virtual clinic check-ins every 6 weeks. Focus groups were held pre- implementation and at 6 months post-implementation. Concurrently, the multidisciplinary limb preservation team model was adapted into a monthly case-based learning teleconference, and a "hot-foot" phone line with standardized triage connected primary providers directly to vascular nurses. At baseline, 107 of 220 (48.6%) patients received an annual DFE, 33.6% had all four exam components, 37.4% had identified foot abnormalities, and 6.5% were referred to a specialist. At 12 months, 290 of 392 (74%) of patients received a DFE, 85.5% had all four components, 73.8% had identified abnormalities, and 26.6% were referred (Table I). All increases were statistically significant and exceeded benchmarks. Qualitative analysis identified clinic-level process changes as important facilitators, and rurality/lack of specialists and patient refusals as barriers. Mixed methods data integration found divergence between the quantitative finding of a 306% increase in referrals to specialists and the qualitative finding that providers did not believe that patients had access to specialty care. The virtual teleconference completed six sessions with 118 total attendees. The "hot-foot" hotline was used once with clinicians reporting they did not need it. We demonstrate successful, sustained implementation of an amputation prevention intervention in a high-risk rural community using IS and CEnR. This approach was crucial for overcoming barriers to intervention implementation in a resource-poor environment. Additional research to assess patient-level experience, better understand key components of the intervention, and study scalability and clinical effectiveness is planned.TableJoint display of amputation prevention intervention implementation metricsImplementation metricsBaseline (n = 220)12 months (n = 392)% Increase(P < .000)Qualitative themesInterview quotesMeta-inferencesIncrease foot exams (anticipated increase 20%)48.6%74%52%aClinic-level process changes'lust the flow is really easy, we'vemade it easy...the team effort is reallygood...1514)"It's in the water now."(56)ConvergentEncountering andaddressing patient refusals"I don't think (the patients are (as shynow.' (58)"They don't fight back as muchwhenever we started laying out wipes...for people to wipe their feet off.-(511)Increase identification of foot abnormalities (anticipated increase 50%)37.4%73.8%97.4%.Clinic-level processchanges"Prior I hadn't really... framed any of mythinking around...the ADA scale....) likehaving that structure and that littlereference card—I think we all keep itaround." (56)ConvergentIncrease referrals to specialists (anticipated increase 50%)6.5%26.6%306%Rurality/isolation/lack of specialists"We have a real problem with travel and people havin' money and cars...(to) get to specialty appointments' (Si)DivergentEncountering and addressing patient refusals"I've been a little bit surprised by...the nervousness of people literally to justcross the mountain" (56)This table shows both quantitative and qualitative data and integrates the methodologies to display meta-inferences. Open table in a new tab

Background: Pain and dysfunction persist for most patients following hip-related pain treatment. Additionally, individuals with hip-related pain are typically less physically active than individuals without hip pain, despite evidence that regular physical activity reduces chronic musculoskeletal pain. Poor psychological health is common in patients with hip-related pain and further reinforces low physical activity. Mind–body interventions can improve psychological health and activity levels but have yet to be integrated to provide comprehensive, psychologically informed care for patients with hip-related pain. Thus, we are using the NCCIH intervention development framework to develop Helping Improve PSychological Health (HIPS), a novel, multimodal mind–body intervention to improve physical activity for individuals with hip-related pain and poor psychological health. Methods: We will recruit physical therapists (N = 20) and patients with hip-related pain (N = 20) to participate in 60 min qualitative interviews (focus groups with therapists; one-on-one interviews with patients). Using these data, we will develop the initial HIPS intervention and provider training materials. One physical therapist will be trained to deliver the HIPS intervention to five participants in an open pilot trial. Participants will attend six 30 min HIPS intervention sessions. We will collect quantitative data on satisfaction, improvement, and physical activity, alongside qualitative exit interviews with participants and the physical therapist in order to refine the HIPS intervention and provider training materials. Results: This study has been approved by the MGB IRB. We aim to develop and test the initial feasibility of the HIPS intervention in an open pilot trial. The findings from this project will inform a subsequent feasibility RCT.

Families of people with opioid use disorder (OUD) often provide informal care, serving an integral supportive role in the healthcare system. Yet these family members are often overlooked as a population under strain and in need of support themselves. In this study, we examine the stress faced by family members of persons with OUD in Massachusetts, USA, through semi-structured qualitative interviews (N = 22, April-July 2018). Data revealed that family members experience shame around OUD and live in a state of overwhelming worry about opioid overdose and that this fear permeates all aspects of their lives, impacting their health, relationships, employment, and finances. Effective coping and social support mitigated some of these challenges. This study fills a gap in the research by examining the challenges distinct to supporting a loved one with OUD - largely stress and trauma related to opioid overdose.

Historically, back pain has been an inciting complaint for the initiation of opioids. Aggressive marketing of opioids to treat back pain coupled with the initiation of pain being treated as "the fifth vital sign" contributed to the emerging opioid crisis in the USA. West Virginia (WV) has long been considered the epicenter of the crisis. In 2018, the WV legislature passed a bill that placed prescribing limits on opioids. Our group set out to investigate the impacts of opioid prescribing restrictions through a sequential, mixed methods study evaluating prescription trends and stakeholder experiences. These stakeholder experiences generated emergent themes regarding the evolution of the opioid crisis up to and beyond the implementation of the bill, which is of relevance to neurosurgeons and back pain treatment. This study explores those findings for a neurosurgical audience. This study consisted of open-ended, semi-structured interviews with a purposive sample of 50 physicians, pharmacists, and patients in WV. Interviews were recorded and transcribed verbatim. Content analysis was utilized as the methodological orientation. Five theoretical domains relevant to the treatment of back pain emerged, describing the prevalence of opioid use, barriers to access care, the importance of opioids for function in resource-poor rural areas, disconnected and siloed care, and patient views on the impacts of pain care gaps and solutions. Spinal pain care in rural WV is complex due to identified challenges. Care siloing factors in suboptimal spinal pain care. Future work should define, implement, and assess the real-world effectiveness of treatment paradigms for the full spectrum of surgical and non-surgical back pain complaints. Neurosurgeons should be present in this arena.

Background: Adolescent violence in the United States is a prevalent public health problem and is understudied in rural settings. Anger is a significant risk factor for adolescent violence. To better craft adolescent violence interventions, it is important to examine anger and identify its most significant associated factors. Aims: This study examined (1) self-reported anger changes over time for rural American adolescents; and (2) structural, community, interpersonal, and individual level factors that may contribute to anger. Methods: We analyzed self-reported survey data from West Virginian middle schoolers (N = 2861) with anger as the outcome. Data was collected twice yearly from October 2020 through April 2023. Independent variables included perceptions of inequality, individual socioeconomic status (SES), neighborhood characteristics, family structure, support from adults at home and school, and harsh parenting. Analysis: Generalized estimating equation Poisson regression models for main effects and gender interaction were used. Parameter estimates were exponentiated and interpreted as Rate Ratios (RR). Self-reported gender was an effect modifier. Results: Significant main effects included perceived inequality (RR = 0.98, 95 % CI = 0.97-0.99), SES (RR = 0.99, 95 % CI = 0.98-0.99), supportive adults at school (RR = 0.99, 95 % CI = 0.98-0.99), primary caregiver support (RR = 0.99, 95 % CI = 0.98-0.99), and harsh parenting (RR = 1.10, 95 % CI = 1.05-1.05). Significant gender interaction terms included perceived harsh parenting (RR = 0.98, 95 % CI = 0.97-0.99) and supportive adults at school (RR = 1.01, 95 % CI = 1.00-1.02) for 'other' genders (i.e., participants identifying as neither boy nor girl) compared to boys. Conclusions: Findings underline the importance of examining rural adolescent anger development and associated risk factors for designing prevention approaches to curb downstream violent behavior.

Background: Civil commitment statutes allow qualified individuals to petition for court-mandated commitment for someone with a substance use disorder (SUD). Despite a lack of empirical evidence showing efficacy of involuntary commitment, these statutes are prevalent worldwide. We examined perspectives on civil commitment among family members and close friends of people who use illicit opioids in Massachusetts, U.S.A. Methods: Eligible individuals were Massachusetts residents, >= 18 years of age, did not use illicit opioids but had a close relationship with someone who did. We used a sequential mixed methods approach in which semistructured interviews (N = 22) were followed by a quantitative survey (N = 260). Thematic analysis was used to analyze qualitative data and survey data were analyzed using descriptive statistics. Results: While some family members were influenced by SUD professionals to petition for civil commitment, influence from social networks based on personal experience was more common. Motivations for civil commitment included initiating recovery and believing that commitment would reduce overdose risk. Some reported that it afforded them respite from caring for, and worrying about, their loved one. A minority discussed increases in overdose risk following a period of forced abstinence. Participants expressed concerns about the variable quality of care during commitment, largely based on the use of corrections facilities for civil commitment in Massachusetts. A minority endorsed the use of these facilities for civil commitment. Conclusions: Despite participants' uncertainty and the harms stemming from civil commitment, including increased risk of overdose after forced abstinence and the use of corrections facilities, family members resorted to this mechanism to reduce immediate overdose risk. Our findings indicate that peer support groups are an appropriate forum to disseminate information about evidenced-based treatment and that family members and others close to those with SUD often lack adequate support for, and respite from, the stress of caring for them.

Medications for opioid use disorder (OUD) such as buprenorphine reduce overdose mortality and other opioid related acute health events but have historically been highly regulated. The recent Mainstreaming Addiction Treatment (MAT) Act ended the requirement clinicians complete a specified training and apply for a DATA 2000 (“X”) waiver on their Drug Enforcement Administration (DEA) number, to prescribe buprenorphine. With the MAT Act, any practitioner with Schedule III prescribing authority (a regular DEA number) can now prescribe buprenorphine for OUD. While this has potential to improve OUD treatment access, the impact will depend on implementation. Though the MAT Act may facilitate increased buprenorphine prescribing, ensuring adequate buprenorphine dispensing is also critical to improving Medications for opioid use disorder. Recognized buprenorphine bottlenecks arise from a complex convergence of factors in community pharmacies, threatening to undercut the benefits of the MAT Act. If prescribing increases but is not matched by increased dispensing, bottlenecks may worsen. Any worsening of buprenorphine bottlenecks could have a disproportionate impact in rural areas where residents may rely on fewer pharmacies to fill prescriptions for people in larger geographic area and where larger prescribing-dispensing gaps already exist such as in Southern states. Rigorous research will be needed to document the overall impact of the MAT Act on community pharmacists and their patients. At the federal level, pharmacists and their professional organizations should lobby the DEA to de-schedule or re-schedule buprenorphine. The DEA should announce a moratorium on enforcement actions against wholesalers and pharmacies related to buprenorphine distribution and dispensing. More supports should be offered to community pharmacies by state pharmacy boards and associations including continuing pharmacy education and technical assistance for advocating with wholesalers to increase buprenorphine order sizes, and to more effectively communicate with prescribers. Pharmacies should not have to face these challenges alone. Regulators, wholesalers, and researchers must join together with community pharmacies to further reduce regulatory barriers to dispensing, provide evidence-based interventions where needed to support pharmacy dispensing efforts, conduct rigorous implementation research, and be constantly vigilant in identifying and addressing multi-level buprenorphine bottlenecks in the wake of the MAT Act.

Introduction: Increasing evidence-based treatment for opioid use disorder (OUD) is key to reducing opioid-related morbidity and mortality. Family and close friends of people with OUD can play an important role in motivating and facilitating their loved ones' treatment. We examined evolving knowledge about OUD and its treatment among family and close friends of people who use illicit opioids and their experiences navigating the treatment system. Methods: Eligible individuals were Massachusetts residents, >= 18 years of age, did not use illicit opioids in the past 30 days, and had a close relationship with someone who currently uses illicit opioids. Recruitment leveraged a nonprofit support network for family members of persons with a substance use disorder (SUD). We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N = 22, April-July 2018) informed the development of a quantitative survey (N = 260, February-July 2020). Attitudes and experiences related to OUD treatment constituted an emergent theme in qualitative interviews, which informed a section of the subsequent survey.Results: Both qualitative and quantitative data indicated support groups were instrumental in increasing OUD knowledge and influencing attitudes toward treatment options. Regarding how best to motivate drug treatment engagement, some participants favored what they referred to as a "tough love" approach that typically included a preference for abstinence-based treatment, while others favored a positive reinforcement approach focused on enhancing treatment motivation. Loved ones' treatment preferences and scientific evidence played a minor role in determining preferred treatment modalities, and only 38 % of survey participants believed that using medications for OUD is more effective than treatment without medications. A majority (57 %) agreed that finding a drug treatment slot or bed was either somewhat or very difficult, and that once in the system treatment was costly and involved multiple returns to treatment after relapse.Conclusions: Support groups appear to be important forums for gaining knowledge about OUD, negotiating strategies to motivate their loved ones' entry into treatment, and forming preferences for treatment modalities. Participants emphasized the influence of other group members more so than their loved ones' preferences or empirical evidence of effectiveness with regard to choosing treatment programs and approaches.

Background: West Virginia (WV) has been at the forefront of the opioid crisis in the United States, with the highest rate of opioid overdose mortality involving prescription opioids in the country. To curb the crisis, the state government implemented a restrictive opioid prescribing law in March 2018, Senate Bill 273 (SB273), to decrease opioid prescribing. However, sweeping changes in opioid policy can have downstream effects on stakeholders such as pharmacists. This study is part of a sequential mixed methods investigation of the impact of SB273 in WV in which we interviewed various stakeholders-including pharmacists-about the impact of the law. Objectives: This paper aims to explore how pharmacy practice during the opioid crisis impacted the need for restrictive legislation and how SB273 impacted subsequent pharmacy practice in WV. Methods: Semi-structured interviews were conducted with 10 pharmacists who were practicing in counties that had been designated as high-prescribing counties based upon countylevel prescribing/dispensing data from state records. Analysis of the interviews was informed by the methodological orientation of content analysis to identify emerging themes. Results: Participants described confronting questionable opioid prescriptions, treatment costs, and insurance coverage driving opioids as a first-line choice for pain management, as well as the influence of corporate policies and the immense responsibility of being the "last line of defense" in the opioid crisis. A central impediment to the care of patients was the inability of the pharmacists to effectively communicate their concerns to prescribers, making improved prescriber-dispenser communication an essential next step in minimizing opioid care gaps. Conclusion: This is one of few qualitative studies that have explored pharmacists' experiences, perceptions, and role in the opioid crisis leading up to and during the enactment of a restrictive opioid prescribing law. In light of the difficulties they faced, a restrictive opioid prescribing law was viewed positively by pharmacists. (c) 2023 American Pharmacists Association (R). Published by Elsevier Inc. All rights reserved.

Abstract Background Expanding access to the opioid antagonist naloxone to reduce overdose mortality is a public health priority in the United States. Naloxone standing orders (NSOs) have been established in many states to increase naloxone dispensing at pharmacies, but increased pharmacy access does not ensure optimal uptake among those likely to witness an overdose. In a prior statewide purchase trial, we documented high levels of naloxone access at Massachusetts pharmacies under a statewide NSO. In this study, we characterize barriers to pharmacy-based naloxone uptake among potential opioid overdose “bystanders” (friends or family of people who use opioids) that may be amenable to intervention. Methods Eligible bystanders were Massachusetts residents ≥ 18 years of age, did not use illicit opioids in the past 30 days, and knew someone who currently uses illicit opioids. We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N = 22) were conducted April-July 2018, to inform the development of a subsequent quantitative survey (N = 260), conducted February-July 2020. Results Most survey participants (77%) reported ever obtaining naloxone but few (21%) attempted to purchase it at a pharmacy. Qualitative participants revealed that barriers to utilizing the NSO included low perceived risk of overdose, which was rooted in misconceptions regarding the risks of prescription opioid misuse, denial about their loved one’s drug use, and drug use stereotypes; inaccurate beliefs about the impact of naloxone on riskier opioid use; and concerns regarding anticipated stigma and confidentiality. Many participants had engaged in mutual support groups, which served as a source of free naloxone for half (50%) of those who had ever obtained naloxone. Conclusions Despite high levels of pharmacy naloxone access in Massachusetts, few bystanders in our study had attempted to obtain naloxone under the NSO. Low perceived risk of overdose, misinformation, stigma, and confidentiality were important barriers to pharmacy naloxone uptake, all of which are amenable to intervention. Support groups provided a setting for addressing stigma and misinformation and provided a discreet and comfortable setting for naloxone access. Where these groups do not exist and for bystanders who do not participate in such groups, pharmacies are well-positioned to fill gaps in naloxone availability.

PURPOSE:Opioid use disorder has caused significant morbidity and mortality resulting in opioid prescribing limiting laws, such as State Bill 273 in West Virginia. The purpose of this study is to explore the impacts of a restrictive opioid prescription law on physicians in medical practice in West Virginia.METHODS:A qualitative study with open-ended semistructured interviews with a purposive sample of physicians in West Virginia. Interviews were recorded and transcribed verbatim. A preliminary code book was developed by 3 coinvestigators. Interview transcriptions were analyzed with a code-based text search query. Content analysis was utilized as the methodological orientation underpinning for the current work.RESULTS:Interviews were conducted with 20 physicians (10 primary care physicians and 10 specialty physicians) in practice in West Virginia. Physicians identified 5 theoretical domains related to SB273: changing opioid prescribing and documentation requirements; rural socioeconomic disparities; a continuum between chronic pain and substance use disorder; difficulty in balancing patient needs and the concern for diversion; lack of available alternatives to opioids for chronic.CONCLUSION:Prescribing opioids in rural West Virginia is complex due to identified challenges. Recommendations for opioids prescribing legislation include clear messaging of guidelines and recommendations, efforts to address socioeconomic disparities of health and pain, and improved accessibility for treatment of both pain and dependence in rural communities are important areas of growth in the rural health care environment.

Objectives: In a prior statewide naloxone purchase trial conducted in Massachusetts, we documented a high rate of naloxone dispensing under the state's standing order program. The purpose of this study was to understand the factors that facilitate naloxone access under the Massachusetts naloxone standing order (NSO) program and identify any remaining barriers amenable to intervention. Design: Mixed methods design involving a pharmacist survey and 3 pharmacist focus groups. Setting and participants: Focus groups were conducted at 3 separate professional conferences for pharmacists (n = 27). The survey was conducted among Massachusetts pharmacists (n 339) working at a stratified random sample chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019. Outcome measures: Facilitators and barriers to NSO implementation and naloxone dispensing and pharmacists' attitudes and beliefs regarding naloxone and opioid use. Results: Most pharmacists described NSO implementation as being straightforward, although differences were reported by pharmacy type in both the survey and focus groups. Facilitators included centralized implementation at chain pharmacies, access to Web-based resources, regularly stocking naloxone, and use of naloxone-specific intake forms. Barriers included patient confidentiality concerns and payment/cost issues. Only 31% of surveyed pharmacists reported always providing naloxone counseling; the most commonly cited barriers were perceived patient discomfort (21%) and time limitations (14%). Confidential space was also more of a concern for independent (vs. chain) pharmacists (18% vs. 6%, P = 0.008). A majority of pharmacists held supportive attitudes toward naloxone, although some reported having moral/ethical concerns about naloxone provision. Conclusion: We documented several facilitators to NSO implementation and naloxone dispensing. Areas for improvement include addressing stigma and misconceptions around opioids and naloxone use. These remain important targets for improving pharmacy-based naloxone dispensing, although our overall positive results suggest Massachusetts' experience with NSO implementation can inform other states' efforts to expand pharmacy-based naloxone access. (C) 2022 American Pharmacists Association (R). Published by Elsevier Inc. All rights reserved.