Nora Jacobson

Embedded within a larger randomized controlled trial assessing implementation strategies for delivering medications for opioid use disorder (MOUD) in jails and during transition to community treatment, this article focuses on barriers to MOUD. Twenty-three qualitative interviews representing 19 organizations were conducted to understand these barriers. The three that surfaced as most pertinent are: policy, organizational structure, and stigma related to addiction and incarceration. This study also found a double stigma for those incarcerated and struggling with addiction, amplifying barriers to MOUD. Improving MOUD implementation is essential to reducing fatal overdoses, enhancing care postrelease, and expanding treatment access in the community.

Background: Strategies to implement evidence-based practices often require modifications. A systematic approach to documenting these changes was not widely adopted until the Framework for Reporting Adaptations and Modifications to Evidence-Based Implementation Strategies (FRAME-IS) emerged in 2021, enabling researchers to characterize both proactive and reactive implementation changes. While publications demonstrating the FRAME-IS's application are emerging, few have reflected on the use of the tool itself. The National Institutes of Health-funded Deidentified Opioid Initiative R01 trial, testing strategies to implement the Centers for Disease Control and Prevention guidelines on opioid prescribing, offered a timely chance to assess the FRAME-IS's utility in a multisite, hybrid type-3 trial. Method: An interdisciplinary team of researchers, clinicians, and implementers documented modifications using the FRAME-IS across four implementation strategies that comprise an implementation package called systems consultation: (1) audit and feedback, (2) educational meetings, (3) practice facilitation, and (4) prescriber peer consulting. Modifications were needed due to COVID-19, the rise in telemedicine, changes in opioid prescribing, and healthcare system variations. Results: The Deidentified Opioid Initiative was implemented in 32 clinics within two Midwestern healthcare systems using a sequential, multiple-assignment randomized trial. The implementation team completed the FRAME-IS's seven modules for each strategy's modifications and reflected on the process of using the tool, strengths, and limitations. Conclusions: The team found the FRAME-IS is practical, comprehensive, and user-friendly. It effectively documents modifications and fosters reflection, raising critical questions about implementation. Challenges included role blurring (i.e., researcher/implementer/coordinator), capturing the complexity of cascading modifications (i.e., how one modification leads to another), and a lack of reporting options to capture modifications in a clustered, multisite trial (i.e., clinical staff nested in clinics nested in healthcare systems). Considerations and recommendations from this case study can enhance the FRAME-IS, guide other scholars in its use, and improve the research community's ability to measure the dynamic evolution of implementation strategies systematically. Future research should explore how documented modifications impact implementation outcomes.

One-size-fits-all opioid treatment for chronic pain may undermine treatment effectiveness and cause adverse effects. We explore personalized nonpharmacological and noninvasive chronic pain treatment as a promising approach to minimize these risks and optimize outcomes for each patient. Our paper introduces the definition of personalized treatment, emphasizes the significance of intervention personalization, and outlines strategies for inter-and intra-patient personalization in chronic pain management. We also discuss empirical studies on personalized chronic pain treatment. Research has shown a variety of strategies for personalizing nonpharmacological and noninvasive chronic pain treatment. These strategies have demonstrated the potential to improve effectiveness. However, many critical scientific questions remain unanswered. To fully harness the potential of personalized nonpharmacological and noninvasive chronic pain treatment, future research should conduct robust clinical trials and meta-analyses comparing personalized and non-personalized chronic pain interventions, examine diverse personalization approaches, incorporate ecological momentary assessment into outcomes assessment, leverage digital technologies, engage patients in treatment design, and assess factors influencing the implementation of personalized chronic pain treatment.

Journal of Medical Internet Research - International Scientific Journal for Medical Research, Information and Communication on the Internet #Preprint #PeerReviewMe: Warning: This is a unreviewed preprint. Readers are warned that the document has not been peer-reviewed by expert/patient reviewers or an academic editor, may contain misleading claims, and is likely to undergo changes before final publication, if accepted, or may have been rejected/withdrawn. Readers with interest and expertise are encouraged to sign up as peer-reviewer, if the paper is within an open peer-review period. Please cite this preprint only for review purposes or for grant applications and CVs (if you are the author). Background: Implementation frameworks like the EPIS model emphasize the importance of the “fit” between an intervention and its context, which includes the needs of its target population, as well as the culture, resources, and capabilities of the implementing organization. Even though lack of fit is a major barrier to implementation, fit has not often been a focus of implementation research. Objective: This paper uses fit as a lens to examine the implementation of Tula, an mHealth app aimed at reducing risky drinking days among individuals meeting the criteria for mild to moderate alcohol use disorder, in a 3-arm (app alone; app plus peer mentoring; app plus health coaching) RCT. Methods: Semi-structured interviews with 18 trial participants and 7 Tula implementers were conducted. Trial participants were pulled equally from each arm of the trial, and represented participants who demonstrated both high and low engagement with the application. Implementers consisted of a project manager, 4 peer mentors, and 2 health coaches. Interviews with participants focused on their motivations, opinions, and experiences of the intervention and their perception of their drinking behavior following the intervention, including how their use of the app worked to change that behavior. Interviews with implementers were centered on their roles, theories of change, perceptions of intervention, and areas for improvement. All interviews were analyzed using rapid qualitative analysis with both deductive and inductive components. Results: We identified areas of both fit and misfit. For example, there was a good fit between implementers’ theories of change and participants’ description of how change occurred. Fit was improved by the versatility of the app, which allowed participants to customize their experiences. Conversely, misfit was noted in the app’s inability to cultivate connection for many participants and a disjunction between the role of peer mentors in the intervention and their broader professional ethos. Conclusions: Focusing on fit provides a useful guide to enhance future iterations of the Tula app that lead to better sustainment of the intervention. Clinical Trial: NCT04011644 (ClinicalTrials.gov). Registered 08 July 2019. Available at: https://clinicaltrials.gov/study/NCT04011644

BACKGROUND Implementation frameworks like the EPIS model emphasize the importance of the “fit” between an intervention and its context, which includes the needs of its target population, as well as the culture, resources, and capabilities of the implementing organization. Even though lack of fit is a major barrier to implementation, fit has not often been a focus of implementation research. OBJECTIVE This paper uses fit as a lens to examine the implementation of Tula, an mHealth app aimed at reducing risky drinking days among individuals meeting the criteria for mild to moderate alcohol use disorder, in a 3-arm (app alone; app plus peer mentoring; app plus health coaching) RCT. METHODS Semi-structured interviews with 18 trial participants and 7 Tula implementers were conducted. Trial participants were pulled equally from each arm of the trial, and represented participants who demonstrated both high and low engagement with the application. Implementers consisted of a project manager, 4 peer mentors, and 2 health coaches. Interviews with participants focused on their motivations, opinions, and experiences of the intervention and their perception of their drinking behavior following the intervention, including how their use of the app worked to change that behavior. Interviews with implementers were centered on their roles, theories of change, perceptions of intervention, and areas for improvement. All interviews were analyzed using rapid qualitative analysis with both deductive and inductive components. RESULTS We identified areas of both fit and misfit. For example, there was a good fit between implementers’ theories of change and participants’ description of how change occurred. Fit was improved by the versatility of the app, which allowed participants to customize their experiences. Conversely, misfit was noted in the app’s inability to cultivate connection for many participants and a disjunction between the role of peer mentors in the intervention and their broader professional ethos. CONCLUSIONS Focusing on fit provides a useful guide to enhance future iterations of the Tula app that lead to better sustainment of the intervention. CLINICALTRIAL NCT04011644 (ClinicalTrials.gov). Registered 08 July 2019. Available at: https://clinicaltrials.gov/study/NCT04011644 INTERNATIONAL REGISTERED REPORT RR2-10.2196/31109

Background: Researchers have conducted numerous studies seeking to understand how to improve the implementation of changes in health care organizations, but less focus has been given to applying lessons already learned from implementation science. Finding innovative ways to apply these findings efficiently and consistently will improve current research on implementation strategies and allow organizations utilizing these techniques to make changes more effectively. Objective: This research aims to compare a practical implementation approach that uses principles from prior implementation studies to more traditional ways of implementing change. Methods: A total of 43 addiction treatment sites in Iowa were randomly assigned to 2 different implementation strategies in a randomized comparative effectiveness trial studying the implementation of an eHealth substance use disorder treatment technology. One strategy used an adaptation of the Network for the Improvement of Addiction Treatment (NIATx) improvement approach, while the other used a traditional product training model. This paper discusses lessons learned about implementation. Results: This midterm report indicates that use of the NIATx approach appears to be leading to improved outcomes on several measures, including initial and sustained use of new technology by both counselors and patients. Additionally, this research indicates that seamlessly integrating organizational changes into existing workflows and using coaching to overcome hurdles and assess progress are important to improve implementation projects. Conclusions: At this interim point in the study, it appears that the use of the NIATx improvement process leads to better outcomes in implementation of changes within health care organizations. Moreover, some strategies used in this improvement process are particularly useful and should be drawn on more heavily in future implementation efforts. Trial Registration: ClinicalTrials.gov NCT03954184; https://clinicaltrials.gov/ct2/show/NCT03954184

Background: Due to the COVID-19 pandemic, healthcare providers were forced to shift many services quickly from in-person to virtual, including substance use disorder (SUD) and mental health (MH) treatment services. This led to a sharp increase in telehealth services, with health systems seeing patients virtually at hundreds of times the rate as before the onset of the COVID-19 pandemic. By analyzing qualitative data about SUD and MH care organizations’ experiences using telehealth, this study aims to elucidate emergent themes related to telehealth use by the front-line behavioral health workforce. Methods: This study uses qualitative data from large-scale web surveys distributed to SUD and MH organizations between May and August 2020. At the end of these surveys, the following question was posed in free-response form: “Is there anything else you would like to say about use of telehealth during or after the COVID-19 pandemic?” Respondents were asked to answer on behalf of their organizations. The 391 responses to this question were analyzed for emergent themes using a conventional approach to content analysis. Results: Three major themes emerged: COVID-specific experiences with telehealth, general experiences with telehealth, and recommendations to continue telehealth delivery. Convenience, access to new populations, and lack of commute were frequently cited advantages of telehealth, while perceived ineffectiveness of and limited access to technology were frequently cited disadvantages. Also commonly mentioned was the relaxation of reimbursement regulations. Respondents supported continuation of relaxed regulations, increased institutional support, and using a combination of telehealth and in-person care in their practices. Conclusions: This study advanced our knowledge of how the behavioral health workforce experiences telehealth delivery. Further longitudinal research comparing treatment outcomes of those receiving in-person and virtual services will be necessary to undergird organizations’ financial support, and perhaps also legislative support, for virtual SUD and MH services.

Objective As part of an effort to design an implementation strategy tailoring tool, our research group sought to understand what is known about how contextual factors and prescriber characteristics affect the adoption of guideline-concordant opioid-prescribing practices in primary care settings. Design We conducted a realist synthesis of 71 articles. Results We found that adoption is related to contextual factors at the individual, clinic, health system and environmental levels, which operate via intrapersonal, interpersonal, organisational and structural mechanisms. Conclusion A single static model cannot capture the complexity of the relationships between contexts, mechanisms and outcomes. Instead, a deeper understanding requires a dynamic model that conceptualises clusters of contextual factors and mechanisms that tend towards guideline concordance and clusters that tend toward non-concordance. Trail registration number ClinicalTrial.gov registration number NCT04044521.

BACKGROUND Researchers have conducted numerous studies seeking to understand how to improve the implementation of changes in health care organizations, but less focus has been given to applying lessons already learned from implementation science. Finding innovative ways to apply these findings efficiently and consistently will improve current research on implementation strategies and allow organizations utilizing these techniques to make changes more effectively. OBJECTIVE This research aims to compare a practical implementation approach that uses principles from prior implementation studies to more traditional ways of implementing change. METHODS A total of 43 addiction treatment sites in Iowa were randomly assigned to 2 different implementation strategies in a randomized comparative effectiveness trial studying the implementation of an eHealth substance use disorder treatment technology. One strategy used an adaptation of the Network for the Improvement of Addiction Treatment (NIATx) improvement approach, while the other used a traditional product training model. This paper discusses lessons learned about implementation. RESULTS This midterm report indicates that use of the NIATx approach appears to be leading to improved outcomes on several measures, including initial and sustained use of new technology by both counselors and patients. Additionally, this research indicates that seamlessly integrating organizational changes into existing workflows and using coaching to overcome hurdles and assess progress are important to improve implementation projects. CONCLUSIONS At this interim point in the study, it appears that the use of the NIATx improvement process leads to better outcomes in implementation of changes within health care organizations. Moreover, some strategies used in this improvement process are particularly useful and should be drawn on more heavily in future implementation efforts. CLINICALTRIAL ClinicalTrials.gov NCT03954184; https://clinicaltrials.gov/ct2/show/NCT03954184