ore than 2 million Americans have an opioid use disorder (OUD), and in 2016, more than 42 000 Americans died of opioid overdoses. 1,2 Although in the first years of the opioid crisis, most overdose-associated deaths were caused by misuse of prescription analgesics, heroin and synthetic opioids (fentanyl and its analogues) currently account for most of the fatalities, a scenario that reflects the changing nature of the opioid crisis (Figure 1). We reviewed the pharmacology of opioids because it is relevant to their rewarding and analgesic effects that lead to their misuse, the epidemiology of the crisis and its transformations in the past 2 decades, and the interventions to treat and prevent OUD that must be implemented to overcome the current crisis and prevent it from happening again. Opioid PharmacologyOpioid drugs-prescription analgesics and illicit drugs-exert their pharmacologic effects by engaging the endogenous opioid system, where they act as agonists at the μ-opioid receptor (MOR). The agonist action at the MOR is responsible for the rewarding effects of opioids and analgesia. In the brain, these receptors are highly concentrated in regions that are part of the pain and reward networks. They are also located in regions that regulate emotions, which is why long-term opioid exposure is frequently associated with depression and anxiety. 4 In addition, MORs are located in brainstem regions that regulate breathing; there, IMPORTANCE More than 42 000 Americans died of opioid overdoses in 2016, and the fatalities continue to increase. This review analyzes the factors that triggered the opioid crisis and its further evolution, along with the interventions to manage and prevent opioid use disorder (OUD), which are fundamental for curtailing the opioid crisis.OBSERVATIONS Opioid drugs are among the most powerful analgesics but also among the most addictive. The current opioid crisis, initially triggered by overprescription of opioid analgesics, which facilitated their diversion and misuse, has now expanded to heroin and illicit synthetic opioids (fentanyl and its analogues), the potency of which further increases their addictiveness and lethality. Although there are effective medications to treat OUD (methadone hydrochloride, buprenorphine, and naltrexone hydrochloride), these medications are underused, and the risk of relapse is still high. Strategies to expand medication use and treatment retention include greater involvement of health care professionals (including psychiatrists) and approaches to address comorbidities. In particular, the high prevalence of depression and suicidality among patients with OUD, if untreated, contributes to relapse and increases the risk of overdose fatalities. Prevention interventions include screening and early detection of psychiatric disorders, which increase the risk of substance use disorders, including OUD. CONCLUSIONS AND RELEVANCEAlthough overprescription of opioid medications triggered the opioid crisis, improving opioid prescription practices for pain management, althoug...
Despite the significant reduction in uninsurance levels in Massachusetts that occurred with health care reform, the demand for care at safety-net facilities continues to rise. Most safety-net patients do not view these facilities as providers of last resort; rather, they prefer the types of care that are offered there. It will continue to be important to support safety-net providers, even after health care reform programs are established.
While setting, target populations, level of coordination with supported employment, and financing strategies varied, common SEd components emerged: specialized and dedicated staffing, one-on-one and group skill-building activities, assistance with navigating the academic setting and coordinating different services, and linkages with mental health counseling. The evidence base is growing; however, many published studies to date do not employ rigorous methodology. Conclusions and Implications for Policy and Practice: Continued specification, operationalization, and testing of SEd core components are needed. The components of the evolving SEd model would benefit from rigorous testing to evaluate impact on degree completion and other key impacts such as employment; health, mental health, or recovery; and community participation. In addition to funding streams from special education and Medicaid, new opportunities for increasing the availability of SEd include the Workforce Innovation and Opportunities Act (WIOA) reauthorization, which requires state vocational rehabilitation agencies to fund preemployment services for transition-age individuals. New "set-aside" requirements for the Mental Health Services Block Grant will increase funding for early intervention services for individuals with serious mental illness, potentially including SEd. (PsycINFO Database Record
Purpose This study explores correlates of on‐site availability of substance use disorder treatment services in federally qualified health centers, including buprenorphine treatment that is critical to addressing the opioid epidemic. Methods We employed descriptive and multivariable analyses with weighted 2010 Assessment of Behavioral Health Services survey data and the 2010 Uniform Data System. Findings In 2010, 47.6% of health centers provided on‐site substance use disorder treatment, 12.3% provided buprenorphine treatment for opioids, and 38.8% were interested in expanding buprenorphine availability. Urban health centers, those in the West, and health centers with electronic health records had higher odds of offering on‐site substance use disorder treatment. Compared with on‐site mental health treatment, substance use disorder treatment was available in fewer clinic sites within each organization. Health centers in rural areas had lower odds of providing on‐site buprenorphine treatment (OR = 0.49, 95% CI: 0.26‐0.94), and those in the South had lower odds of providing on‐site buprenorphine treatment compared with health centers in other regions. Rural health centers had lower odds of expressing interest in expanding the availability of buprenorphine treatment (OR = 0.58, 95% CI: 0.35‐0.97). Conclusions Improving access to substance use disorder treatment in primary care is a critical part of the strategy to combat the opioid use disorder epidemic. These findings highlight the important role of health centers as portals of access to substance use disorder treatment services in underserved communities. Recent investments to expand treatment capacity in health centers will expand the availability of substance use disorder services, but urban/rural and regional disparities should be monitored.
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