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Abstract Objective Opioid overdose survivors present to emergency departments (EDs) and many EDs have developed programs to initiate buprenorphine. The impact of the increasing use of buprenorphine in ED and by other providers is unknown while opioid mortality continues to rise. Public mortality data do not distinguish buprenorphine from other prescription opioids. Our objective was to determine when changes in overdose mortality trends occurred comparing deaths involving buprenorphine to oxycodone, hydrocodone, and methadone. Methods This observational study utilized the drug‐involved mortality database including US death certificates (2010‒2017) in which buprenorphine, oxycodone, hydrocodone, or methadone were contributing causes of death (determined through textual analysis). Population‐ and drug utilization‐adjusted mortality rates were examined using disjointed linear regression. Buprenorphine‐involved deaths were stratified by polysubstance involvement. Results The population‐adjusted mortality rates for buprenorphine‐involved deaths were lowest compared to other opioids; however, the change in rate for buprenorphine increased faster than oxycodone, hydrocodone, and methadone at 8.9% each quarter‐year (95% confidence interval [CI]: 8.0, 9.8) from 2010 to mid‐2016 when it stabilized. After adjusting for changes in dispensing over the study period, buprenorphine‐involved mortality rates were increasing at 5.3% (95% CI: 4.6, 6.1) each quarter‐year. In 2017, 94% buprenorphine‐involved deaths had at least one other drug contributing to the cause of death. Conclusions Given the low mortality, high proportions of polysubstance mortality, and the mixed agonist/antagonist mechanism of action, use of buprenorphine alone likely presents a lower risk for overdose than comparators. Mortality rose faster than dispensing, signaling need to ensure people understand buprenorphine risks, particularly polysubstance use, balanced against importance for treating opioid use disorders.

Background: In 2021, approximately 60 million individuals worldwide and 9 million individuals in the United States (US) reported opioid misuse. In the US, 2.5 million have OUD, of which only about a third receive any substance abuse treatment. OUD is often regarded as a monolithic disorder but different opioid problem subtypes may exist beyond DSM-IV/5 criteria. Understanding the characteristics of these subtypes could be useful for informing treatment and intervention strategies. Methods: Latent class analysis was used to identify OUD symptom subtypes among persons in the US who reported misusing prescription opioids or heroin in the 2015–2018 National Survey on Drug Use and Health (n=10,928). Regression analyses were utilized to determine associations between class membership and treatment receipt, as well as demographic characteristics and other comorbid conditions. Results: Five classes were identified with unique OUD symptom patterns: Class 1: Asymptomatic (71.6%), Class 2: Tolerance/Time (14.5%), Class 3: Loss of Control/Pharmacological (LOC/Pharmacol) (5.7%), Class 4: Social Impairment (2.6%), and Class 5: Pervasive (5.6%). Nearly all persons in the LOC/Pharmacol, Social Impairment, and Pervasive classes met criteria for OUD (98–100%); however, they differed in receipt of past-year treatment for substance use (28%, 28%, 49%, respectively). Age, race, education, insurance status, and criminal activity were also associated with treatment receipt. Conclusions: There were considerable differences in OUD symptom patterns and substance use treatment among individuals who misused opioids. The findings indicate a substantial unmet need for OUD treatment and point to patterns of heterogeneity within OUD that can inform development of treatment programs.

Long coronavirus disease 2019 (COVID-19) is poorly understood, widespread and debilitating. Integrative medical group visits (IMGVs) provide group medical care virtually or in person and are reimbursed by insurance payors. IMGV introduces integrative modalities such as mindfulness, nutrition, and acupressure in a person-centered, supportive, and educational environment. To evaluate a telehealth IMGV program called Nourish to Flourish (N2F) for patients with long COVID, three researchers conducted a qualitative analysis of pre- and post-group individual interviews. Twenty-five patients provided interviews, of which fifteen included pre- and post-group individual interviews. Main themes were unpredictable symptom patterns, a common range of emotions associated with long COVID experience, reconceptualizing self-identity, multiple barriers to care in conventional settings, and connections formed in N2F. Although symptoms varied, N2F participants found commonalities in their experiences of living with long COVID. They empathized with one another regarding changing symptoms, inconsistent social support, shifting identities, and barriers to effective medical care.

BackgroundApproximately 20% of adults in the United States experience chronic pain. Integrative Medical Group Visit (IMGV) offers an innovative approach to chronic pain management through training in mindfulness, nutrition, and other mind-body techniques combined with peer support. To date, there are no studies on IMGV implementation, despite its promise as a feasible non-pharmacological intervention for chronic pain management. In this study, we assessed the feasibility of implementing IMGV and assessing its effectiveness for chronic pain.MethodsImplementation Mapping was used to develop and evaluate implementation strategies for IMGV. Strategies included disseminating educational materials, conducting ongoing training, and conducting educational meetings. IMGV was delivered by three healthcare providers: an allopathic physician, registered yoga teacher, and naturopathic physician. The effectiveness of IMGV on patient health outcomes was assessed through qualitative interviews and a Patient-Reported Outcomes Scale (PROMIS-29). Provider perspectives of acceptability, appropriateness, and feasibility were assessed through periodic reflections (group interviews reflecting on the process of implementation) and field notes. Paired t-tests were used to assess changes between scores at baseline and post intervention. Qualitative data were coded by three experienced qualitative researchers using thematic content analysis.ResultsOf the initial 16 patients enrolled in research, 12 completed at least two sessions of the IMGV. Other than fatigue, there was no statistically significant difference between the pre- and post-scores. Patients reported high satisfaction with IMGV, noting the development of new skills for self-care and the supportive community of peers. Themes from patient interviews and periodic reflections included the feasibility of virtual delivery, patient perspectives on acceptability, provider perspectives of feasibility and acceptability, ease of recruitment, complexity of referral and scheduling process, balancing medical check-in with group engagement, and nursing staff availability.ConclusionsIMGV was feasible, acceptable, and effective from the perspectives of patients and providers. Although statistically significant differences were not observed for most PROMIS measures, qualitative results suggested that participants experienced increased social support and increased pain coping skills. Providers found implementation strategies effective, except for engaging nurses, due to staff being overwhelmed from the pandemic. Lessons learned from this pilot study can inform future research on implementation of IMGV.

Introduction Wide utilization of complementary and integrative health care (CIH) approaches by the American public has warranted an increase in the presence and quality of CIH-focused education.1 Among U.S. medical schools with integrative medicine training programs, passive instruction rather than active involvement in clinical delivery is the norm.2 Future health professionals may benefit from innovative educational models framed around the core competencies for integrative medicine established by the Academic Consortium for Integrative Medicine and Health (ACIMH).3,4 One model that incorporates students into the delivery of CIH services is the integrative group medical visit (IGMV): a program offering peer support, education about nutrition, acupressure, mindfulness, yoga, sleep hygiene, and more.5,6 IGMVs increase access to CIH services, decrease emergency department utilization, and decrease pain medication usage in populations with chronic pain.7,8 Involvement in these programs present students with an opportunity to learn about CIH modalities and their delivery in underserved populations. Prior articles have discussed IGMVs as a component of preventive medicine residency training, but little has been said about how trainee experiences align with ACIMH's core competencies.9 This commentary articulates, from students' perspectives, how the IGMV (1) teaches the ACIMH's integrative medicine core competencies and (2) offers a unique approach to actively involve future providers in CIH delivery. Student Responsibilities and Involvement Viewpoints in this article originate from an undergraduate student (M.K.T.), current medical student (B.M.K.), postdoctoral fellow (A.C.), and two faculty members (J.L.B. and I.J.R.) at an academic program on integrative medicine.10 Students were involved in two virtual IGMVs: one for patients with chronic pain and another adapted to populations experiencing long-COVID. These IGMVs drew from a previously developed curriculum,7 and were embedded in an outpatient integrative medicine clinic with a high burden of patients with chronic pain. Implementation mapping guided efforts to IGMV delivery,11 and the program was found to be feasible and acceptable to patients and providers.12?14 Students interviewed clinical stakeholders, assisted in the development of an implementation protocol, consented participants, conducted pre- and postintervention interviews, and analyzed data. This allowed students to submit abstracts, present at conferences, and assist in article preparation. Students also assisted in adapting the curriculum for telehealth delivery, guided patients through technology issues, constructed a website for IGMV materials, and facilitated discussions on topics of interest. Mapping Student Experiences to Integrative Medicine Core Competencies Conventional clinical training may include ACHIM's integrative medicine core competencies (patient care, medical knowledge, practice-based learning, communication, professionalism, and systems-based practice) at varying degrees; however, clinical practice centered on CIH prioritizes these principles.15 Providers must consider how modalities are presented and received by patients, the context in which this occurs, and the way these services influence patient?provider interactions. Participating in an IGMV is an innovative method of clinical education conducive toward training students in CIH delivery. In this study, students discuss how the model expanded their clinical skills and capacities to provide higher quality care. Core competency 1: Patient care The IGMV taught patient-directed care by prioritizing compassion as an essential component of group-based clinical services. Students witnessed provider responsibilities shift within a group setting as facilitators created a social space where patients could bond over adapting new health behaviors or coping with their symptoms. Facilitators were also observed employing active listening skills to help patients identify their individual goals: a skill that can better align treatment plans with a patient's cultural and health belief systems. Students recognized the challenges patients experience while receiving care and living with chronic conditions as well. For instance, they learned about feelings of frustration and isolation in the context of chronic pain, and how provider uncertainty contributes to feelings of helplessness among those experiencing long-COVID. In addition, students developed capacity to identify which patient personalities are well suited for group-based services: extroverted patients generally embraced group discussions, whereas more reserved individuals may prefer individual meetings with their providers. Core competency 2: Medical knowledge Students learned about the biomedical, health, and social sciences relevant to the field of integrative medicine in the IGMV model by identifying providers as informational liaisons who translate CIH research into practice. Facilitators were ultimately responsible for engaging with literature and clearly communicating its findings, particularly for long-COVID patients where little was known about symptom etiology and treatment. Students were placed within this role when they evaluated literature and drew on prior trainings (i.e., Registered Yoga Teacher training) to develop yoga activities or nutrition discussions under the guidance of a mentor. This exposure to CIH research gave students an opportunity to practice translating scientific findings into clinical settings. In addition, involvement in IGMV discussions led by guest practitioners (i.e., Registered Dietitians) gave students an opportunity to learn about modalities not explicitly included in the IGMV curriculum. Core competency 3: Practice-based learning and improvement The IGMV educated students about the third core competency by exposing them to patient feedback and inspiring involvement in CIH research. Facilitators of the adapted groups for long-COVID symptoms elicited and responded to patient feedback through the use of weekly intake surveys. Witnessing how providers used this information to adjust the curriculum and structure of the IGMV exemplified how patient concerns are prioritized in the delivery of group-based CIH services. Students directly participated in practice-based learning by developing independent research questions or projects related to IGMV. Mentors led students through this process and elicited their assistance in developing grant proposals, leading conference presentations, and drafting articles. This advanced how students engaged with CIH research and taught them valuable clinical research skills. Core competency 4: Interpersonal and communication skills The IGMV taught students how to foster effective respectful relationships with both patients and other practitioners involved in group facilitation. In comparison with conventional shadowing experiences, the patient?provider hierarchy in IGMVs was observed to be flattened, largely due to the ground rules established in partnership with patients during the first group meeting (e.g., not interrupting others, asking others for clarification, and speaking from your own experience). The multidisciplinary team of providers involved within IGMV implementation (doctor of public health, naturopathic doctor, medical doctor) also taught students about how healthy interprofessional collaboration between referring providers and administrators is needed for the successful delivery of CIH. Core competency 5: Professionalism Professionalism was taught within the IGMV as students retained clinical responsibilities, observed how providers established inclusivity, and developed capacity to recognize signs of burnout. Students played a critical role in ensuring successful IGMV delivery as they helped patients navigate technology, sent out weekly emails with meeting information, and made group resources available online. In terms of inclusivity, students learned that safe spaces are not simply assumed: it is a responsibility of the provider to explicitly establish a comfortable environment. Students also developed professionalism by learning the fundamentals of practicing mindfulness and self-care: techniques they could utilize to prevent burnout and enhance the quality of care. Core competency 6: Systems-based practice The last competency is targeted toward understanding CIH's role within the broader health care system. IGMV involvement helped students understand this ideal based on the type of patients referred to the groups as well as some of the administrative barriers to implementation. Students learned about the conversations that needed to happen as part of CIH implementation: meeting with administrators about billing concerns, establishing shared values with clinicians, and engaging stakeholders to establish a robust referral network. Students also grasped how different patients received CIH services: some were entirely invested, whereas others simply attended the groups due to a lack of other options. Either way, students learned about the variety of patients referred to IGMV for chronic pain or long-COVID as well as how CIH approaches can support these populations. Final Remarks Students felt that IGMV programs educated them about the ACIHM's established core competencies, and bolstered their capacity as future providers beyond what would be learned in conventional clinical shadowing experiences. Because the IGMV model is centered around increasing the accessibility and affordability of CIH services to conventionally underserved populations,5 students were challenged to consider how patient diversity and health equity could be incorporated into their future practice. Although the IGMVs discussed target chronic pain and long-COVID, this curriculum has potential to serve populations with diabetes, cancer, mental health needs, and more.6 Involving various future providers in this model at multiple levels of education?undergraduate, graduate, medical, and residency?could teach CIH competencies across specialties and may improve multidisciplinary collaboration as a wide range of professionals (physicians, advanced practice nurses, physician assistants, pharmacists, dentists, and naturopathic doctors) have completed integrative medicine fellowships.16 Student reflections presented within this commentary were shaped by mentors with qualifications and years of experience in CIH. The combination of this professional guidance and interaction with stakeholders who supported IGMV implementation as part of a growing integrative medicine program may not be shared across contexts. Further evaluation is needed to inform how IGMVs meet a variety of patients' needs and support CIH education in diverse clinical settings.

A few bacterial Cas9 nucleases have been repurposed as genome editing tools. Here, the authors use bioinformatic and biochemical analyses to characterize 79 Cas9 proteins, revealing substantial functional diversity and thus expanding the available toolbox of RNA-programmable CRISPR-associated nucleases.

For almost five decades during his professional life, Engle was deeply concerned about the philosophical views that made up social studies education, as well as ways those views were being practiced in the classrooms. In particular, he criticized the philosophical views of two contemporary educators, Edgar Wesley and Jerome Bruner. Wesley believed that social studies was merely a simplified way to organize and teach efficiency in transmitting the body of desired knowledge, concepts and generalizations that make up the various social sciences disciplines presented in elementary and secondary school curricula. Teaching would include primarily teacher-directed use of textbooks, audio-visual aids (e.g., maps, pictures, diagrams, graphs, charts), and well organized lectures. Bruner, on the other hand, posited that the curriculum should imitate real life social science laboratories, allowing students to become miniature social scientists involved in academic inquiry projects as outlined in problem-oriented units found in progressive textbooks, student manuals, and pamphlets. The number of academic units would be limited by the amount of problem-oriented information and the time needed for students to "discover" desired knowledge and inquiry skills. A suggested framework of Engles Curriculum/Instructional Social Studies Project is described in this article.