“You Have to Want It”: A Pervasive Mental Model of Addiction Recovery and Its Implications for Sustaining Change

Background: Addiction to illicit drugs is a complex phenomenon characterized by cyclical patterns of relapse, remission, and, for some, a full recovery. People who use drugs (PWUD) and their loved ones form ‘mental models’ of recovery that develop over time through experience and observation. The role of these mental models and how they interact to undermine or support recovery is poorly understood. Therefore, this study asks: 1) What do people who use drugs and their loved ones believe it takes to successfully recover from addiction? and 2) Given these beliefs about recovery and the available evidence on remission, relapse, and recovery, what places to intervene and leverage points would support recovery and prevent relapse? Methods: Data were collected from in-depth qualitative interviews with 14 people who use drugs (PWUD) and 10 loved ones of PWUD (“loved ones”) in a rural county in Missouri to elicit their mental models of addiction recovery. A grounded theory was developed and translated into mathematical equations to build a system dynamics model. System dynamics is a method to understand systems in terms of their interacting reinforcing and balancing feedback loops. The model was calibrated to replicate a prototypical pattern of addiction relapse, remission, and recovery. The grounded theory and model experiments were used to identify leverage points for sustaining positive change (i.e., recovery). Results: Participants believed that “you have to want it” to recover from addiction, where “wanting it” means improved social role functioning, seeking support, and abstinence. Insufficient proof of “wanting it” leads some loved ones to withdraw their support, which reinforces the addiction cycle. Model simulations show that expectations for social role functioning are a key driver of addiction and recovery. Changing the model structure so that support is not contingent on proof of “wanting it” has negligible immediate impact on drug use but creates the strongest eventual recovery. Support that is no longer contingent increases expectations for social role functioning, the benefits of which accumulate over time. When these benefits combine with strong balancing feedback loops, the recovery is stronger. Discussion: Increasing expectations for social role functioning is a key leverage point for recovery from addiction (i.e., for sustaining change). Support can be a critical factor that increases expectations. However, “wanting it” is, in effect, to no longer be addicted, meaning that many PWUD do not get support when they need it most because they have not yet proven to others that they can respond rationally to negative consequences. Thus, expectations must also be increased through means other than support from loved ones, including connecting with others who have similar lived experiences, and sustainable, meaningful changes in social role functioning. This requires social welfare, health, and criminal justice policies and programs that reverse, not merely slow down or even strengthen, the reinforcing loops that drive addiction

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Reducing Opioid use Disorder and Overdose Deaths in the United States: A Dynamic Modeling Analysis

Opioid overdose deaths remain a major public health crisis. We used a system dynamics simulation model of the U.S. opioid-using population age 12 and older to explore the impacts of 11 strategies on the prevalence of opioid use disorder (OUD) and fatal opioid overdoses from 2022 to 2032. These strategies spanned opioid misuse and OUD prevention, buprenorphine capacity, recovery support, and overdose harm reduction. By 2032, three strategies saved the most lives: (i) reducing the risk of opioid overdose involving fentanyl use, which may be achieved through fentanyl-focused harm reduction services; (ii) increasing naloxone distribution to people who use opioids; and (iii) recovery support for people in remission, which reduced deaths by reducing OUD. Increasing buprenorphine providers’ capacity to treat more people decreased fatal overdose, but only in the short term. Our analysis provides insight into the kinds of multifaceted approaches needed to save lives

Exploring Quality of Primary Care for Patients Who Experience Homelessness and the Clinicians Who Serve Them: What Are Their Aspirations?

To develop and evaluate an effective model of patient-centered, high-quality, homeless-focused primary care, our team explored key domains of primary care that may be important to patients. We anchored our conceptual framework in two reports from the Institute of Medicine (IOM) that defined components of primary care and quality of care. Using questions developed from this framework, we conducted semistructured interviews with 36 homeless-experienced individuals with past-year primary care engagement and 24 health care professionals (clinicians and researchers) who serve homeless-experienced patients in the primary care setting. Template analysis revealed factors important to this population. These included stigma, respect, and perspectives on patient control of medical decision-making in regard to both pain and addiction. For patients experiencing homelessness, the results suggest that quality primary care may have different meanings for patients and professionals, and that services should be tailored to meet homeless-specific needs

Experience of primary care among homeless individuals with mental health conditions.

The delivery of primary care to homeless individuals with mental health conditions presents unique challenges. To inform healthcare improvement, we studied predictors of favorable primary care experience among homeless persons with mental health conditions treated at sites that varied in degree of homeless-specific service tailoring. This was a multi-site, survey-based comparison of primary care experiences at three mainstream primary care clinics of the Veterans Administration (VA), one homeless-tailored VA clinic, and one tailored non-VA healthcare program. Persons who accessed primary care service two or more times from July 2008 through June 2010 (N = 366) were randomly sampled. Predictor variables included patient and organization characteristics suggested by the patient perception model developed by Sofaer and Firminger (2005), with an emphasis on mental health. The primary care experience was assessed with the Primary Care Quality-Homeless (PCQ-H) questionnaire, a validated survey instrument. Multiple regression identified predictors of positive experiences (i.e. higher PCQ-H total score). Significant predictors of a positive experience included a site offering tailored service design, perceived choice among providers, and currently domiciled status. There was an interaction effect between site and severe psychiatric symptoms. For persons with severe psychiatric symptoms, a homeless-tailored service design was significantly associated with a more favorable primary care experience. For persons without severe psychiatric symptoms, this difference was not significant. This study supports the importance of tailored healthcare delivery designed for homeless persons' needs, with such services potentially holding special relevance for persons with mental health conditions. To improve patient experience among the homeless, organizations may want to deliver services that are tailored to homelessness and offer a choice of providers