Applied Evidence

Medication-assisted recovery (MAR)—the preferred terminology for the service formerly known as medication-assisted treatment—entails a comprehensive set of interventions for managing opioid use disorder (OUD), including medications for opioid use disorder (MOUD). Despite the benefits of MAR—reducing opioid use, opioid-related mortality, and health care costs^1-3—only 11% of patients with a diagnosis of OUD received MOUD in 2020.³

When medication-assisted recovery services are rendered in primary care, treatment retention improves by 25%—highlighting a role for family medicine clinicians in treating OUD.

Primary care physicians, including family physicians, are well positioned to provide MAR across the patient’s lifespan. However, many family medicine clinicians do not possess the logistical knowledge or resources to implement this service.⁴ In this article, we describe options for, and barriers to, MAR and societal issues that have an impact on the care of these patients.

Pathophysiology of OUD

Opioids relieve pain by stimulating μ-opioid receptors and activating the brain’s reward system. These pleasurable effects motivate repeated use.⁵ Frequent opioid exposure causes neuroadaptation, tolerance, and dependence. For patients with OUD who are misusing illicit or prescription opioids, periods of abstinence following neuroadaptation lead to withdrawal symptoms that vary in intensity, depending on the drug, dose, and duration of use. Upregulated noradrenergic tone and dopamine deficiency manifest as numerous signs and symptoms of withdrawal, including⁵:

Physiologic: secretory (diaphoresis, rhinorrhea, lacrimation, vomiting, diarrhea) and stimulatory (mydriasis, piloerection, hypertension, tachycardia, insomnia)
Psychological: pain, cravings, dysphoria, anxiety.

A single episode of opioid withdrawal is not directly life-threatening, but untreated episodes can progressively amplify negative feedback and reinforce continued opioid use.⁶ Left untreated, withdrawal can be terminal.

Image: Copyright Joe Gorman

Medication-assisted recovery: Effective intervention

MAR services that integrate medical, behavioral, and psychosocial programs can reduce mortality from OUD 2-fold.^7,8 A meta-analysis found that, when MAR services are rendered in primary care, treatment retention improves by 25% (number needed to treat [NNT] = 6) and ongoing illicit opioid use is reduced by 50% (NNT = 6), relative to care at a specialty clinic⁹—highlighting a role for family medicine clinicians in treating OUD.

All 3 US Food and Drug Administration (FDA)–approved MOUD (methadone, buprenorphine, and naltrexone) reduce cravings; 2 (methadone and buprenorphine) mitigate withdrawal symptoms by activating the μ-opioid receptor; and naltrexone diminishes the reinforcing effects of use (TABLE^10-12). It is crucial to recognize the pharmacologic distinctions among MOUD because untreated withdrawal syndromes increase dropout from treatment programs and subsequent relapse.¹³

The Hx of medication-assisted recovery

To understand the landscape of MAR, it is important to understand the history of opioid treatment in the United States. In 1966, Congress passed the Narcotic Addiction Rehabilitation Act (NARA), which secured federal assistance by which state and local governments could develop drug treatment programs.¹⁴ NARA permitted legal offenders with OUD to be civilly committed to treatment programs, rather than prosecuted. However, limited resources and a burgeoning population led, instead, to low-cost outpatient programs saddled by strict requirements that lacked a basis for improving clinical outcomes.

Continue to: At the time NARA...

At the time NARA was passed by Congress, OUD was viewed—inaccurately—as a criminal problem, not a medical one. Subsequent legislation was crafted through that lens, which has placed a heavy burden on patients until today.¹⁴ Although medical understanding of OUD has advanced tremendously over the past 50 years, treatment remains siloed from mainstream medicine, even in primary care.

There is no one-size-fits-all approach to MAR, and relapse is common. Patient-specific factors and the availability of resources should be considered when designing the most individualized, advantageous plan for MAR.

Methadone

Background. Methadone has the most extensive history for treating OUD and consistently has demonstrated efficacy.¹³ A meta-analysis of randomized controlled trials comparing methadone to nonpharmacotherapy alone found that methadone improved treatment retention by an absolute 57% (NNT = 2).¹⁰

Methadone was approved by the FDA for detoxification and maintenance treatment in the early 1970s, although the Narcotic Addict Treatment Act (NATA) of 1974 restricted dispensing of maintenance treatment to highly regulated clinics known as opioid treatment programs (OTPs).¹⁴ NATA required the treating physician to register with the US Drug Enforcement Agency (DEA) and to comply with conservative dosing regimens and observed dosing.

Over time, regulations evolved to give the physician greater flexibility in developing a care plan, allowing “take-home” doses, and improving patients’ access to care. Although access to methadone for the treatment of OUD remains limited to federally certified OTPs, regulations facilitate incorporation of a whole-person approach to care, including counseling, individual and group therapy, and toxicology testing.⁷

Continue to: Clinical considerations

Clinical considerations. Methadone requires slow titration. For patients starting methadone as an outpatient, federal law¹⁵ limits the initial dose to 30 mg and requires physician documentation when the first-day total dosage exceeds 40 mg. This dosing constraint makes it challenging to provide care because a daily dosage ≥ 60 mg has been found to produce, first, higher program retention (relative risk = 1.36; 95% CI, 1.13-1.63) and, second, greater reduction in illicit opioid use (relative risk = 1.59; 95% CI, 1.16-2.18) than is seen in patients who receive a lower daily dosage.¹⁶

Due to a prolonged elimination half-life, methadone reaches steady-state in 3 to 5 days. Patients and their families should be educated that withdrawal symptoms might not feel fully managed in the first few days of therapy and that time is required to experience safely the regimen’s full effects.

Aggressive dose-titration during methadone induction can result in drug accumulation and respiratory depression. The risk for methadone-related mortality is highest in the first 2 weeks of therapy, mostly related to overdose potential if the drug is combined with other opioids.¹⁷

Buprenorphine

Background. The prescribing rate for buprenorphine, particularly in primary care, is accelerating.¹⁸ A meta-analysis of randomized controlled trials found that¹¹:

compared to placebo, buprenorphine, at any dosage, improves treatment retention by an absolute 21% to 28% (NNT = 4-5)
patients receiving high-dose buprenorphine (≥ 16 mg/d) had fewer evident cases of illicit opioid use.

Unlike methadone, buprenorphine exerts partial agonism at the μ-opioid receptor, resulting in a so-called ceiling effect that significantly reduces the adverse effect profile, including respiratory depression and euphoria, relative to a full-agonist opioid, such as methadone.¹⁹

Continue to: Whereas accessing methadone...

Whereas accessing methadone is limited to OTPs, buprenorphine is available for office-based treatment. By hosting OUD treatment and primary care in the same place, primary care physicians can provide comprehensive medical care including and beyond OUD, thereby improving retention and managing comorbidity.²⁰

Integrated models involving support staff—eg, nurses, behavioral health providers, and pharmacists—have produced the greatest success with office-based treatment models.²¹ Office-based treatment normalizes OUD as a chronic disease managed by the primary care physician, enabling concurrent harm-reduction strategies; medication reconciliation; and convenient, regular prescribing intervals (eg, every 30 days).²² Nevertheless, access to buprenorphine is limited. Because buprenorphine is a controlled substance, the Ryan Haight Online Pharmacy Consumer Protection Act of 2008 prevents initial prescribing of buprenorphine without in-person evaluation. Telehealth consultations increased access to buprenorphine through temporary exceptions during the COVID-19 pandemic. However, revised rules and regulations for telehealth visits for these controlled substances are forthcoming from the DEA as temporary exceptions for telehealth consultations come to an end. Additionally, prescribing buprenorphine for OUD requires that the treating physician undergo specific training and obtain qualifications, which have evolved over time through federal legislation.

The Drug Addiction Treatment Act of 2000 (DATA 2000) authorized what is known as an X-waiver, which allows physicians to prescribe controlled substances for office-based treatment of OUD, provided that:

they are registered to do so with the Substance Abuse and Mental Health Services Administration and the DEA
they have had subspecialty training in addiction or completed an 8-hour training course
they are able to refer patients to appropriate counseling and ancillary services.

DATA 2000 restricted patient panel sizes to 30 patients in the first year, expanding thereafter upon appropriate certification.

Although medical understanding of OUD has advanced tremendously over the past 50 years, treatment remains siloed from mainstream medicine, even in primary care.

The Comprehensive Addiction and Recovery Act of 2016 (CARA) and the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act of 2018 (the SUPPORT Act) collectively extended prescribing authority for MOUD to other qualifying practitioners (eg, advanced practice clinicians). Despite these attempts to expand access to services, the overdose death rate has continued to increase.

Continue to: To further expand access to MAR...

To further expand access to MAR, the US Department of Health and Human Services updated its practice guidelines in April 2021, allowing clinicians to bypass X-waiver training requirements by applying for a notification-of-intent (NOI) buprenorphine waiver.^a However, clinicians are still limited to prescribing buprenorphine for 30 patients at a time. Clinicians who undergo complete X-waiver training may prescribe for 100 patients in the first year and, if eligible, 275 patients thereafter.

In addition, as a component of the Consolidation Appropriations Act of 2023, Congress passed the Mainstreaming Addiction Treatment Act of 2021, or MAT 2021, and Medication Access and Training Expansion Act of 2021, or MATE 2021. MAT eliminated the X-waiver, NOI, and restrictions on the number of patients for whom a provider could prescribe buprenorphine, under federal authority; however, restrictions within one’s state might limit the ability to prescribe buprenorphine. MATE 2021 is an educational requirement for licensing by the DEA (at application and renewal) that will require prescribers to complete 8 hours of training in substance use disorders starting in June 2023.

Patients and their families should be educated that withdrawal symptoms might not feel fully managed in the first few days of methadone therapy.

Use of the monthly injectable extended-release buprenorphine product^b is limited by an FDA Risk Evaluation and Mitigation Strategy (REMS) program, which requires specialized training and certification by the prescriber, distributor, and administering clinician. REMS reduces buprenorphine accessibility due to time, cost, and regulatory barriers; although such restrictions have been instituted with the patient’s safety in mind, any limitation to buprenorphine prescribing, apart from controlled substance licensure, serves only to limit access to a primary component of MAR.

Clinical considerations. Due to the competitive nature of buprenorphine and its high affinity for the μ-opioid receptor, the drug can displace other opioid agonists and precipitate acute withdrawal. The withdrawal experience can thereby condition fear and disfavor toward buprenorphine among patients.

It is vital, therefore, that (1) patients’ expectations for treatment be managed appropriately and (2) the treating physician be prepared to provide additional buprenorphine for adequate maintenance doses and utilize adjunct comfort agents (clonidine, nonsteroidal anti-inflammatory drugs, ondansetron) to manage acute withdrawal symptoms. Newer buprenorphine dosing strategies, such as micro-induction and macro-induction, have emerged to curtail these risks.^23,24 This is an evolving area of MAR; newer low-threshold initiation strategies²⁵ (see “Low-threshold MOUD prescribing models,” in the text that follows) and evidence that supports micro-induction²⁶ might eliminate the practice of requiring active withdrawal for treatment.

Continue to: Regardless of the strategy...

Regardless of the strategy for dosing buprenorphine, it’s critical that patients be educated on how to initiate treatment outside a clinical setting, such as at home, where they occupy a familiar haven during a potentially uncomfortable time and can be as effective at initiation as they would be in a clinical setting, with no difference in precipitation of adverse effects.

At-home induction might be more appropriate for patients who are not yet in significant enough withdrawal while in the physician's office.²⁷ Guidance should be provided on dosing instructions, self-assessment of withdrawal symptoms, and, if applicable, patience with the slow-dissolving sublingual tablet or film formulation.

Naltrexone

Background. Naltrexone is available as an oral tablet and an extended-release, once-monthly intramuscular injection; the latter has demonstrated superiority in MAR.²⁸ Oral naltrexone has limited supporting evidence, is inferior to other MOUD options, and should not be used to treat OUD.⁷ Altogether, approval of naltrexone for OUD is controversial, due to potentially unethical trials and approval processes,²⁹ although a multicenter randomized controlled trial demonstrated the drug’s noninferiority with respect to treatment retention relative to buprenorphine.³⁰ Used over time, naltrexone does not relieve withdrawal symptoms but can reduce cravings.

Clinical considerations. There are numerous clinical barriers that limit the use of naltrexone.

First, patients should be abstinent from opioids for 7 to 14 days prior to starting therapy; usually, this means undergoing medically supervised withdrawal in a controlled environment. This is an obvious limitation for patients who are constrained financially—those who lack, or have inadequate, health insurance or are unable to be away from their job for an extended time.

Continue to: Second, because naltrexone...

Second, because naltrexone does not address withdrawal symptoms, supportive therapies should be incorporated into the treatment plan, including:

clonidine for hyperadrenergic symptoms (anxiety, diaphoresis, hypertension)
nonopioid analgesics for pain
antiemetics, such as ondansetron and metoclopramide, for nausea or vomiting
loperamide for diarrhea
diphenhydramine for insomnia.

Third, patients taking naltrexone have a diminished response to opioids. This complicates pain management in the event of an emergent surgical procedure.

Last, when naltrexone wears off, patients are effectively opioid-naïve, which increases the risk for overdose in those who stop therapy abruptly.²⁹ The increased risk for overdose should be communicated to all patients with OUD who are being treated with naltrexone.

This nonopioid option is appealing to policymakers and is often prioritized in the criminal justice system; however, the decreased efficacy of naltrexone (compared to methadone and buprenorphine), potential for overdose, and challenges in initiating treatment are concerning and limit the drug’s use in many real-world settings.

Because naltrexone is not a controlled substance, regulations regarding maintaining inventory and distribution are more flexible.

Continue to: Overall, the cost-effectiveness...

Overall, the cost-effectiveness of intramuscular naltrexone is unclear. State-administered insurance programs vary in their requirements for coverage of naltrexone treatment.³¹

Comprehensive medication reconciliation is vital

Overall fragmentation of care within OTPs places patients at risk for adverse events, such as drug interactions.³² Under Title 42 of the US Code,³³ patients must provide written consent for an OTP provider to disclose their history of a substance use disorder. Allowing the patient to decide which medical providers can access their treatment records for an OUD benefits patient confidentiality but poses numerous issues worth exploring.

All prescribed controlled substances are recorded in the prescription drug monitoring program, or PDMP, a state-level electronic database accessible to health care professionals to inform prescribing decisions and identify drug interactions. The PDMP has substantially reduced opioid overprescribing and improved identification of patients at risk for overdose or misuse of opioids.

Buprenorphine, available for office-based treatment, has a so-called ceiling effect that reduces the adverse effect profile, including respiratory depression and euphoria.

Unlike all other controlled substances, however, prescriptions ordered by an OTP are not recorded in the PDMP (although there are recent exceptions to this scenario). Without such information, a physician might not have important information about the patient when making medical decisions—placing the patient at risk for harmful outcomes, such as drug–drug and drug–disease interactions.

For example: Methadone is associated with a prolonged QT interval,³⁴ increasing the risk for a fatal arrhythmia. Concurrent QT-prolonging medications, such as azithromycin and citalopram, further increase this risk.³⁵ Because methadone dispensing is isolated from the patient’s medical record, the clinician who prescribes MOUD has an incomplete patient history and could make a potentially fatal treatment decision.

Continue to: Diversion is unlikely

Diversion is unlikely

Health care providers often express concern about diversion in MOUD. However, misuse and diversion rates of methadone and buprenorphine have declined steadily since 2011, and, in fact, are actually lower than the diversion rate of prescription antibiotics.³⁶

Regardless, diversion of buprenorphine should not be a concern for physicians prescribing MOUD. Although a prescriber might worry about manipulation of the formulation of buprenorphine for intravenous administration, addition of naloxone to buprenorphine in tablet form diminishes the potential for overdose. Additionally, the ceiling effect of buprenorphine limits the likelihood of significant respiratory depression and euphoria.

Should buprenorphine reach a patient for whom it was not prescribed, it is highly unlikely that an overdose would result. Rather, the medication would protect against the effects of illicit opioids and relieve withdrawal symptoms. Most people with OUD who have misused buprenorphine have done so to relieve withdrawal symptoms,³⁷ not to experience intoxication.

Health care deserts

So-called health care deserts in parts of the United States are an ongoing problem that disproportionately affects lower-income and segregated Black and Hispanic communities³⁸—communities that shoulder the highest burden of OUD and OUD-related mortality³⁹ and whose populace is in greatest need of MAR. Even when health care is accessible in such a desert, some clinicians and pharmacies refuse to prescribe or dispense MOUD because of the accompanying stigma of OUD.

Prescribing buprenorphine for OUD requires that the treating physician undergo specific training, including subspecialty training in addiction or an 8-hour training course.

A MAR desert, like a pharmacy desert, is a geographic region—one without access to a MAR or an OTP provider, thereby preventing patients from reaching appropriate care; for some patients, having to travel to the nearest provider can render treatment inaccessible.⁴⁰

Continue to: Efforts are in place to identify...

Efforts are in place to identify areas at greatest need of OUD-related medical services, such as heat maps that identify areas of increased utilization of emergency medical services for opioid overdose. State-run programs have been implemented to increase access, such as the Illinois Helpline (https://helplineil.org) that provides support and resources for patients, friends, family, and providers.

Novel solutions

Key strategies to increase access to care and slow the opioid epidemic include low-threshold prescribing of MOUD and mobile OTPs.⁴¹

Low-threshold MOUD prescribing models. Adoption of one of these models in a medical practice that provides MAR might increase absolute enrollment. A low-threshold prescribing model involves⁴²:

same-day treatment
leniency with respect to abstinence periods and a concomitant substance use disorder
enhanced accessibility to MOUD through nontraditional medical settings.

Do not use oral naltrexone to treat OUD; this route of administration has limited supporting evidence.

Low-threshold prescribing is flexible in regard to patients’ needs and bypasses many of the barriers discussed in this article. Impressive multicenter success has been achieved by the CA Bridge program in California (https://cabridge.org), including an increase in recognition of OUD, treatment initiations, and outpatient engagement.²⁵

The cost-effectiveness of low-threshold MOUD prescribing programs remains to be determined.

Mobile OTPs. In July 2021, the DEA authorized a mobile component to existing OTP registrants that is permitted to dispense methadone and buprenorphine. Mobile units are physically separate from the OTP but have similar functions, depending on available space. Services that cannot be provided on the mobile unit of an OTP must be available at its brick-and-mortar location.⁷ Logistically, OTP registrants no longer need a separate registration to implement a mobile unit, thus expanding care to patients in underserved or remote areas who often encounter barriers to access.⁴³

Conclusion

Understanding the distinct clinical and accessibility benefits and limitations among available MOUD is essential for prescribing clinicians. Accessing treatment is limited by federal regulation, stigma, and the existence of health care deserts that limit access to necessary care for patients with OUD. Newer harm-reduction models, such as low-threshold prescribing and mobile OTPs, represent progress, but many patients remain untreated.

a At buprenorphine.samhsa.gov/forms/select-practitioner-type.php

b Sold under the brand name Sublocade.

CORRESPONDENCE
Jennie B. Jarrett, PharmD, MMedEd, Department of Pharmacy Practice, University of Illinois Chicago College of Pharmacy, 833 South Wood Street (MC 886), Chicago, IL 60612; [email protected]

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Article PDF

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Author and Disclosure Information

Department of Pharmacy Practice, College of Pharmacy (Drs. Posen, Keller, Elmes, and Jarrett) and Department of Academic Internal Medicine (Dr. Messmer) and Department of Family and Community Medicine (Drs. Gastala and Neeb), College of Medicine, University of Illinois Chicago
[email protected]

Drs. Posen, Keller, Elmes, Messmer, Gastala, and Neeb reported no potential conflict of interest relevant to this article. Dr. Jarrett is a consultant to Trevena, developer of an investigative agent, TRV734, for medication-assisted treatment of opioid use disorder. She receives research funding from the US Health Resources and Services Administration; the Illinois Department of Human Services; the Substance Abuse and Mental Health Services Administration of the US Department of Health and Human Services; the Gordon and Betty Moore Foundation; and the Coleman Foundation.

Issue

The Journal of Family Practice - 72(4)

Publications

MDedge Family Medicine

The Journal of Family Practice

Federal Practitioner

Topics

Addiction Medicine

Pain

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Read more about Medication-assisted recovery for opioid use disorder: A guide

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Andrew Posen, PharmD

Eden Keller, PharmD

Abigail T. Elmes, PharmD

Sarah Messmer, MD

Nicole Gastala, MD

Christine Neeb, MD

Jennie B. Jarrett, PharmD, MMedEd

Author(s)

Andrew Posen, PharmD

Eden Keller, PharmD

Abigail T. Elmes, PharmD

Sarah Messmer, MD

Nicole Gastala, MD

Christine Neeb, MD

Jennie B. Jarrett, PharmD, MMedEd

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When medication-assisted recovery services are rendered in primary care, treatment retention improves by 25%—highlighting a role for family medicine clinicians in treating OUD.

Pathophysiology of OUD

Physiologic: secretory (diaphoresis, rhinorrhea, lacrimation, vomiting, diarrhea) and stimulatory (mydriasis, piloerection, hypertension, tachycardia, insomnia)
Psychological: pain, cravings, dysphoria, anxiety.

Image: Copyright Joe Gorman

Medication-assisted recovery: Effective intervention

The Hx of medication-assisted recovery

Continue to: At the time NARA...

Methadone

Continue to: Clinical considerations

Buprenorphine

Background. The prescribing rate for buprenorphine, particularly in primary care, is accelerating.¹⁸ A meta-analysis of randomized controlled trials found that¹¹:

compared to placebo, buprenorphine, at any dosage, improves treatment retention by an absolute 21% to 28% (NNT = 4-5)
patients receiving high-dose buprenorphine (≥ 16 mg/d) had fewer evident cases of illicit opioid use.

Continue to: Whereas accessing methadone...

they are registered to do so with the Substance Abuse and Mental Health Services Administration and the DEA
they have had subspecialty training in addiction or completed an 8-hour training course
they are able to refer patients to appropriate counseling and ancillary services.

DATA 2000 restricted patient panel sizes to 30 patients in the first year, expanding thereafter upon appropriate certification.

Although medical understanding of OUD has advanced tremendously over the past 50 years, treatment remains siloed from mainstream medicine, even in primary care.

Continue to: To further expand access to MAR...

Patients and their families should be educated that withdrawal symptoms might not feel fully managed in the first few days of methadone therapy.

Continue to: Regardless of the strategy...

Naltrexone

Clinical considerations. There are numerous clinical barriers that limit the use of naltrexone.

Continue to: Second, because naltrexone...

Second, because naltrexone does not address withdrawal symptoms, supportive therapies should be incorporated into the treatment plan, including:

clonidine for hyperadrenergic symptoms (anxiety, diaphoresis, hypertension)
nonopioid analgesics for pain
antiemetics, such as ondansetron and metoclopramide, for nausea or vomiting
loperamide for diarrhea
diphenhydramine for insomnia.

Third, patients taking naltrexone have a diminished response to opioids. This complicates pain management in the event of an emergent surgical procedure.

Because naltrexone is not a controlled substance, regulations regarding maintaining inventory and distribution are more flexible.

Continue to: Overall, the cost-effectiveness...

Overall, the cost-effectiveness of intramuscular naltrexone is unclear. State-administered insurance programs vary in their requirements for coverage of naltrexone treatment.³¹

Comprehensive medication reconciliation is vital

Buprenorphine, available for office-based treatment, has a so-called ceiling effect that reduces the adverse effect profile, including respiratory depression and euphoria.

Continue to: Diversion is unlikely

Diversion is unlikely

Health care deserts

Prescribing buprenorphine for OUD requires that the treating physician undergo specific training, including subspecialty training in addiction or an 8-hour training course.

Continue to: Efforts are in place to identify...

Novel solutions

Key strategies to increase access to care and slow the opioid epidemic include low-threshold prescribing of MOUD and mobile OTPs.⁴¹

Low-threshold MOUD prescribing models. Adoption of one of these models in a medical practice that provides MAR might increase absolute enrollment. A low-threshold prescribing model involves⁴²:

same-day treatment
leniency with respect to abstinence periods and a concomitant substance use disorder
enhanced accessibility to MOUD through nontraditional medical settings.

Do not use oral naltrexone to treat OUD; this route of administration has limited supporting evidence.

The cost-effectiveness of low-threshold MOUD prescribing programs remains to be determined.

Conclusion

a At buprenorphine.samhsa.gov/forms/select-practitioner-type.php

b Sold under the brand name Sublocade.

When medication-assisted recovery services are rendered in primary care, treatment retention improves by 25%—highlighting a role for family medicine clinicians in treating OUD.

Pathophysiology of OUD

Physiologic: secretory (diaphoresis, rhinorrhea, lacrimation, vomiting, diarrhea) and stimulatory (mydriasis, piloerection, hypertension, tachycardia, insomnia)
Psychological: pain, cravings, dysphoria, anxiety.

Image: Copyright Joe Gorman

Medication-assisted recovery: Effective intervention

The Hx of medication-assisted recovery

Continue to: At the time NARA...

Methadone

Continue to: Clinical considerations

Buprenorphine

Background. The prescribing rate for buprenorphine, particularly in primary care, is accelerating.¹⁸ A meta-analysis of randomized controlled trials found that¹¹:

compared to placebo, buprenorphine, at any dosage, improves treatment retention by an absolute 21% to 28% (NNT = 4-5)
patients receiving high-dose buprenorphine (≥ 16 mg/d) had fewer evident cases of illicit opioid use.

Continue to: Whereas accessing methadone...

they are registered to do so with the Substance Abuse and Mental Health Services Administration and the DEA
they have had subspecialty training in addiction or completed an 8-hour training course
they are able to refer patients to appropriate counseling and ancillary services.

DATA 2000 restricted patient panel sizes to 30 patients in the first year, expanding thereafter upon appropriate certification.

Although medical understanding of OUD has advanced tremendously over the past 50 years, treatment remains siloed from mainstream medicine, even in primary care.

Continue to: To further expand access to MAR...

Patients and their families should be educated that withdrawal symptoms might not feel fully managed in the first few days of methadone therapy.

Continue to: Regardless of the strategy...

Naltrexone

Clinical considerations. There are numerous clinical barriers that limit the use of naltrexone.

Continue to: Second, because naltrexone...

Second, because naltrexone does not address withdrawal symptoms, supportive therapies should be incorporated into the treatment plan, including:

clonidine for hyperadrenergic symptoms (anxiety, diaphoresis, hypertension)
nonopioid analgesics for pain
antiemetics, such as ondansetron and metoclopramide, for nausea or vomiting
loperamide for diarrhea
diphenhydramine for insomnia.

Third, patients taking naltrexone have a diminished response to opioids. This complicates pain management in the event of an emergent surgical procedure.

Because naltrexone is not a controlled substance, regulations regarding maintaining inventory and distribution are more flexible.

Continue to: Overall, the cost-effectiveness...

Overall, the cost-effectiveness of intramuscular naltrexone is unclear. State-administered insurance programs vary in their requirements for coverage of naltrexone treatment.³¹

Comprehensive medication reconciliation is vital

Buprenorphine, available for office-based treatment, has a so-called ceiling effect that reduces the adverse effect profile, including respiratory depression and euphoria.

Continue to: Diversion is unlikely

Diversion is unlikely

Health care deserts

Prescribing buprenorphine for OUD requires that the treating physician undergo specific training, including subspecialty training in addiction or an 8-hour training course.

Continue to: Efforts are in place to identify...

Novel solutions

Key strategies to increase access to care and slow the opioid epidemic include low-threshold prescribing of MOUD and mobile OTPs.⁴¹

Low-threshold MOUD prescribing models. Adoption of one of these models in a medical practice that provides MAR might increase absolute enrollment. A low-threshold prescribing model involves⁴²:

same-day treatment
leniency with respect to abstinence periods and a concomitant substance use disorder
enhanced accessibility to MOUD through nontraditional medical settings.

Do not use oral naltrexone to treat OUD; this route of administration has limited supporting evidence.

The cost-effectiveness of low-threshold MOUD prescribing programs remains to be determined.

Conclusion

a At buprenorphine.samhsa.gov/forms/select-practitioner-type.php

b Sold under the brand name Sublocade.

References

1. Baser O, Chalk M, Fiellin DA, et al. Cost and utilization outcomes of opioid-dependence treatments. Am J Manag Care. 2011;17(suppl 8):S235-S248.

2. Gibson A, Degenhardt L, Mattick RP, et al. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction. 2008;103:462-468. doi: 10.1111/j.1360-0443.2007.02090.x

5. Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002;1:13-20. doi: 10.1151/spp021113

6. Koob GF. Neurobiology of opioid addiction: opponent process, hyperkatifeia, and negative reinforcement. Biol Psychiatry. 2020;87:44-53. doi: 10.1016/j.biopsych.2019.05.023

9. Korownyk C, Perry D, Ton J, et al. Opioid use disorder in primary care: PEER umbrella systematic review of systematic reviews. Can Fam Physician. 2019;65:e194-e206.

14. Institute of Medicine Committee on Federal Regulation of Methadone Treatment; Rettig R, Yarmolinsky A, eds. Federal Regulation of Methadone Treatment. National Academies Press; 1995.

15. 42 eCFR §8. Medication assisted treatment for opioid use disorders. Revised March 15, 2023. Accessed March 23, 2023. www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-8?toc=1

16. Faggiano F, Vigna-Taglianti F, Versino E, et al. Methadone maintenance at different dosages for opioid dependence. Cochrane Database Syst Rev. 2003;(3):CD002208. doi: 10.1002/14651858.CD002208

17. Baxter LE Sr, Campbell A, Deshields M, et al. Safe methadone induction and stabilization: report of an expert panel. J Addict Med. 2013;7:377-386. doi: 10.1097/01.ADM.0000435321.39251.d7

18. Olfson M, Zhang VS, Schoenbaum M, et al. Trends in buprenorphine treatment in the United States, 2009-2018. JAMA. 2020;323:276-277. doi: 10.1001/jama.2019.18913

19. Walsh SL, Preston KL, Stitzer ML, et al. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clin Pharmacol Ther. 1994;55:569-580. doi: 10.1038/clpt.1994.71

27. Lee JD, Vocci F, Fiellin DA. Unobserved “home” induction onto buprenorphine. J Addict Med. 2014;8:299-308. doi: 10.1097/ADM.0000000000000059

29. Wolfe D, Carrieri MP, Dasgupta N, et al. Concerns about injectable naltrexone for opioid dependence. Lancet. 2011;377:1468-1470. doi: 10.1016/S0140-6736(10)62056-9

32. Ferrari A, Coccia CPR, Bertolini A, et al. Methadone—metabolism, pharmacokinetics and interactions. Pharmacol Res. 2004;50:551-559. doi: 10.1016/j.phrs.2004.05.002

33. 42 eCFR Part 2. Confidentiality of substance use disorder patient records. January 18, 2017. Accessed March 23, 2023. www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2

34. Kao DP, Haigney MCP, Mehler PS, et al. Arrhythmia associated with buprenorphine and methadone reported to the Food and Drug Administration. Addiction. 2015;110:1468-1475. doi: 10.1111/add.13013

36. Leshner AI, Mancher M, eds. Barriers to broader use of medications to treat opioid use disorder. In: Medications for Opioid Use Disorder Save Lives. National Academies Press; 2019:109-136.

37. Chilcoat HD, Amick HR, Sherwood MR, et al. Buprenorphine in the United States: Motives for abuse, misuse, and diversion. J Subst Abuse Treat. 2019;104:148-157. doi: 10.1016/j.jsat. 2019.07.005

42. Jakubowski A, Fox A. Defining low-threshold buprenorphine treatment. J Addict Med. 2020;14:95-98. doi: 10.1097/ADM.0000000000000555

References

1. Baser O, Chalk M, Fiellin DA, et al. Cost and utilization outcomes of opioid-dependence treatments. Am J Manag Care. 2011;17(suppl 8):S235-S248.

2. Gibson A, Degenhardt L, Mattick RP, et al. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction. 2008;103:462-468. doi: 10.1111/j.1360-0443.2007.02090.x

5. Kosten TR, George TP. The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 2002;1:13-20. doi: 10.1151/spp021113

6. Koob GF. Neurobiology of opioid addiction: opponent process, hyperkatifeia, and negative reinforcement. Biol Psychiatry. 2020;87:44-53. doi: 10.1016/j.biopsych.2019.05.023

9. Korownyk C, Perry D, Ton J, et al. Opioid use disorder in primary care: PEER umbrella systematic review of systematic reviews. Can Fam Physician. 2019;65:e194-e206.

14. Institute of Medicine Committee on Federal Regulation of Methadone Treatment; Rettig R, Yarmolinsky A, eds. Federal Regulation of Methadone Treatment. National Academies Press; 1995.

15. 42 eCFR §8. Medication assisted treatment for opioid use disorders. Revised March 15, 2023. Accessed March 23, 2023. www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-8?toc=1

16. Faggiano F, Vigna-Taglianti F, Versino E, et al. Methadone maintenance at different dosages for opioid dependence. Cochrane Database Syst Rev. 2003;(3):CD002208. doi: 10.1002/14651858.CD002208

17. Baxter LE Sr, Campbell A, Deshields M, et al. Safe methadone induction and stabilization: report of an expert panel. J Addict Med. 2013;7:377-386. doi: 10.1097/01.ADM.0000435321.39251.d7

18. Olfson M, Zhang VS, Schoenbaum M, et al. Trends in buprenorphine treatment in the United States, 2009-2018. JAMA. 2020;323:276-277. doi: 10.1001/jama.2019.18913

19. Walsh SL, Preston KL, Stitzer ML, et al. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clin Pharmacol Ther. 1994;55:569-580. doi: 10.1038/clpt.1994.71

27. Lee JD, Vocci F, Fiellin DA. Unobserved “home” induction onto buprenorphine. J Addict Med. 2014;8:299-308. doi: 10.1097/ADM.0000000000000059

29. Wolfe D, Carrieri MP, Dasgupta N, et al. Concerns about injectable naltrexone for opioid dependence. Lancet. 2011;377:1468-1470. doi: 10.1016/S0140-6736(10)62056-9

32. Ferrari A, Coccia CPR, Bertolini A, et al. Methadone—metabolism, pharmacokinetics and interactions. Pharmacol Res. 2004;50:551-559. doi: 10.1016/j.phrs.2004.05.002

33. 42 eCFR Part 2. Confidentiality of substance use disorder patient records. January 18, 2017. Accessed March 23, 2023. www.ecfr.gov/current/title-42/chapter-I/subchapter-A/part-2

34. Kao DP, Haigney MCP, Mehler PS, et al. Arrhythmia associated with buprenorphine and methadone reported to the Food and Drug Administration. Addiction. 2015;110:1468-1475. doi: 10.1111/add.13013

36. Leshner AI, Mancher M, eds. Barriers to broader use of medications to treat opioid use disorder. In: Medications for Opioid Use Disorder Save Lives. National Academies Press; 2019:109-136.

37. Chilcoat HD, Amick HR, Sherwood MR, et al. Buprenorphine in the United States: Motives for abuse, misuse, and diversion. J Subst Abuse Treat. 2019;104:148-157. doi: 10.1016/j.jsat. 2019.07.005

42. Jakubowski A, Fox A. Defining low-threshold buprenorphine treatment. J Addict Med. 2020;14:95-98. doi: 10.1097/ADM.0000000000000555

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PRACTICE RECOMMENDATIONS

› Consider resource availability (eg, treatment programs and regulatory barriers), in addition to patient- and medicationspecific factors, when designing the most individualized, advantageous medication-assisted recovery plan, to reduce the risk for mortality. B

› Schedule early (< 2 weeks) and frequent follow-up with patients who are starting medications for opioid use disorder (particularly methadone), to manage risk when mortality is highest and to support recovery. C

› Set and manage patient expectations for control of withdrawal symptoms when initiating medications for opioid use disorder (particularly buprenorphine). B

Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

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Sports: An underutilized tool for patients with disabilities

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Sports: An underutilized tool for patients with disabilities

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Elizabeth Perkins, PhD, RNLD

Approximately 6.5 million people in the United States have an intellectual disability, the most common type of developmental disability.¹ People with disabilities are 3 times more likely to have heart disease, stroke, or diabetes than adults without disabilities.²

Sports as a treatment modality are not used to full advantage to combat these conditions in people with intellectual/developmental disabilities (IDDs). Participation in sport activities can lead to weight loss, reduce risk for cardiovascular disease, and optimize physical health. Sports also can help enhance social and communication skills and improve quality of life for this patient population (TABLE).^3-6

Physical and social benefits of exercise

However, a 2014 report found that while inactive adults with disabilities (hearing, vision, cognition, mobility) were 50% more likely to report 1 or more chronic diseases than those who were physically active, only 44% of adults with disabilities who visited a health professional in the previous 12 months received a physical activity recommendation.⁷In addition, more than 50% of adults with disabilities are not meeting US recommended exercise guidelines.^7-9

Family physicians may not feel they have adequate training to counsel patients with IDDs. Additional limiting factors include dependence on caregivers for exercise participation, expense, transportation difficulties, a lack of choice in sporting activities, and the patient’s level of motivation.¹⁰The guidance reviewed here details how to modify the pre-participation sports physical exam specifically for patients with IDDs. It also provides sport and exercise recommendations for patients with 3 disabilities: Down syndrome, cerebral palsy, and autism spectrum disorder.

Worth noting: As is true for adults without disabilities, those with IDDs should participate in at least 150 minutes of moderate-intensity, or 75 minutes of vigorous intensity, aerobic physical activity each week.⁹Recommend muscle-strengthening activities be performed at least 2 days each week.⁹

Exercise recommendations for patients with Down syndrome

One in every 700 babies receives a diagnosis of Down syndrome.¹¹Among its many possible manifestations—which include intellectual disability, heart disease, and diabetes—Down syndrome is associated with an increased risk for obesity, which makes exercise an extremely important lifestyle modification for these patients. Obesity can lead to obstructive sleep apnea causing cor pulmonale and even premature death. Continuous positive airway pressure intervention can be difficult in terms of patient compliance. However, weight loss through exercise and sports is an effective intervention to mitigate these obesity-related health comorbidities.

Pre-participation exam. A focused history and physical exam are often conducted before a patient engages in organized competitive or recreational sports. The pre-participation sports physical exam typically focuses on cardiac, neurologic, hereditary, and musculoskeletal disorders. While we recommend including these baseline elements as part of the exam for patients with disabilities, we also recommend modifying the exam to include disability-specific screening for associated comorbidities.

Continue to: For patients with Down syndrome...

For patients with Down syndrome, a complete pre-participation sports physical exam is warranted. Inquire specifically about neck pain or dislocations, heart murmur, cardiac surgery, seizures, sleep issues, history of congenital abdominal defect, hematologic malignancy, and bone pain as part of the focused physical exam.

Look for evidence of patellofemoral instability, pes planus, scoliosis, hallux deformities, decreased muscle tone, and muscular weakness. Check for cataracts and perform a thorough cardiovascular exam to assess for murmur or signs of chronic hypoxia, such as cyanosis. If a heart murmur is detected, refer the patient to a cardiologist.

Patients with Down syndrome are also at increased risk for atlantoaxial instability. A thorough neurologic evaluation to screen for this condition is indicated; however, routine radiologic screening is not needed.¹²

An annual complete blood cell count and thyroid-stimulating hormone test are recommended for all children with Down syndrome.¹³ For patients with Down syndrome who are 13 to 21 years of age, an echocardiogram also is recommended for concerning symptoms.¹³ Ferritin levels also should be assessed annually for patients who are younger than 13 years of age to check for iron-deficiency anemia.¹³Consider high-risk screening strategies for patients with diabetes and metabolic syndrome.

Special considerations. Patients with Down syndrome were found to be injured more frequently than individuals with other disabilities during the Special Olympics.¹⁴ These patients may be hypersensitive to pain with prolonged pain responses, or unable to verbally communicate their pain or injury.¹⁵

Continue to: The complexity of pain assessment...

The complexity of pain assessment in patients with Down syndrome may increase the difficulty of accurately diagnosing an injury, leading to underdiagnosis or overdiagnosis. To increase accuracy of pain assessment in this setting, we recommend using the Wong-Baker FACES Pain Rating Scale or a numeric pain rating scale in verbal patients.¹⁵ In nonverbal patients, facial expressions are reliable indicators of pain.

Which exercise? Healthy patients with Down syndrome can participate in any sport. Aerobic exercise can help lower body fat, reduce oxidative stress, and improve blood flow.⁶ Muscle-strengthening exercises can lead to improved daily functioning and balance. Strength training and aerobic exercise benefit aging patients with Down syndrome who are struggling with obesity. Such exercise also helps increase bone mineral density and improve cardiovascular fitness, especially when initiated at a young age. Consistent exercise promotes positive health outcomes throughout the lifespan.¹⁶

Exercise recommendations for patients with cerebral palsy

Cerebral palsy, the most common motor disability in children, is associated with intellectual disability, seizures, respiratory insufficiency, scoliosis, osteoporosis, mood disorders, dysphagia, and speech and hearing impairment.¹⁷ The increasing survival of premature babies born with cerebral palsy and the growing prevalence of adults with the condition point to the importance of expanding one’s knowledge of how best to care for this population.¹⁸

Pre-participation exam. In addition to a complete sport physical exam, it’s important to further evaluate patients with cerebral palsy for epilepsy, joint contractures, muscle weakness, spinal deformities, and respiratory insufficiency. The Gross Motor Function Classification system, commonly used for patients with cerebral palsy, scores functional ability in 5 levels.¹⁸ Patients at Level I are the most mobile; patients at Level V need wheelchair transport in all settings.

Consider sports and exercise a vital therapeutic modality— something beyond a form of recreation.

Further evaluation of spinal deformities can be initiated with x-ray screening. Consider ordering dual x-ray absorptiometry scans to evaluate bone mass.¹⁷

Continue to: Special considerations

Special considerations. Patients with cerebral palsy have a heightened risk for depression and anxiety.¹⁹Mental health can be assessed via the General Anxiety Disorder-7, the Patient Health Questionnaire-9, and the Ask Suicide-Screening Questions tools, among others. Mental health screening may need to be adjusted depending on the patient’s level of cognition and ability to communicate. The patient’s caregiver also can provide supplemental information.

Consider screening vitamin D levels in patients with cerebral palsy. Approximately 50% of adults with cerebral palsy are vitamin D–deficient secondary to sedentary behavior and lack of sun exposure.^20-22

Optimal medical management has been shown to decrease muscle spasticity and may be beneficial before initiating an exercise program. For patients with moderate-to-severe symptoms, referral for physical therapy to further improve gross motor function and spasticity may be required before initiating an exercise program.

Which exercise? Individuals with cerebral palsy spend 76% to 99% of their waking hours being sedentary.⁵Consequently, they typically have decreased cardiorespiratory endurance and decreased muscle strength. Strength training may improve muscle spasticity, gross motor function, joint health, and respiratory insufficiency.⁵ Even in those who function at Level IV-V of the Gross Motor Function Classification system, exercise reduces vertebral fractures and improves time spent standing.²³ By improving endurance, spasticity, and strength with exercise, deconditioning can be mitigated.

Involvement in sports promotes peer interactions, personal interests, and positive self-identity. It can give a newfound passion for life. Additionally, families of children with disabilities who engage in leisure activities together have less caregiver burden.^24,25 Sporting activities offer a way to optimize psychosocial well-being for the patient and the entire family.

Continue to: Dance promotes functionality...

Dance promotes functionality and psychosocial adjustment.²⁶ Hippotherapy, defined as therapy and rehabilitation during which the patient interacts with horses, can diminish muscle spasticity.²⁷ Aquatic therapy also may increase muscle strength.²⁸

Sports for patients with autism spectrum disorder

Autism spectrum disorder is defined as persistent deficits in social communication and social interaction that are usually evident in the first 3 years of life.²⁹Autism can manifest with or without intellectual or language impairment. Patients with autism commonly have difficulty processing sensory stimuli and can experience “sensory overload.” More than half have a coexisting mental health disorder, such as attention-deficit/hyperactivity disorder, anxiety, depression, schizophrenia, or bipolar disorder.³⁰

Vigorous exercise is associated with a reduction in stereotypic behaviors, hyperactivity, aggression, and self-injury in patients with autism spectrum disorder.

Aversions to foods and food selectivity, as well as adverse effects from medical treatment of autism-related agitation, result in a higher incidence of obesity in patients with autism.^31,32

Pre-participation exam. In addition to a comprehensive pre-participation exam, the Autism Spectrum Syndrome Questionnaire (ASSQ) and Modified Checklist for Autism in Toddlers are tools to screen school-age children with normal cognition to mild intellectual disability.³³ These questionnaires have limitations, however. For example, ASSQ has limited ability to identify the female autistic phenotype.³⁴ As such, these are solely screening tools. Final diagnosis is based on clinical judgment.

Special considerations. Include screening for constipation or diarrhea, fiber intake, food aversions, and common mental health comorbidities using Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition criteria.²⁹ Psychiatric referral may be necessary if certain previously undiagnosed condition(s) become apparent. The patient’s caregiver can provide supplemental information

Continue to: During the physical exam...

During the physical exam, limit sensory stimuli as much as possible, including lights and sounds. Verbalize components of the exam before touching a patient with autism who is sensitive to physical touch.

Which exercise? Participation in sports is an effective therapy for autism and can help patients develop communication skills and promote socialization. Vigorous exercise is associated with a reduction in stereotypic behaviors, hyperactivity, aggression, and self-injury.³ Sports also can offer an alternative channel for social interaction. Children with autism may have impaired or delayed motor skills, and exercise can improve motor skill proficiency.⁴

The prevalence of feeding problems in children with autism spectrum disorder is estimated to be as high as 90%, and close to 70% are selective eaters.^31,35,36 For those with gastrointestinal disorders, exercise can exert positive effects on the microbiome-gut-brain axis.³⁷ Additionally, patients with autism are much more likely to be overweight or obese.³² Physical activity offers those with autism health benefits similar to those for the general population.³²

Children with autism spectrum disorder have similar odds of injury, including serious injury, relative to population controls.³⁸ Karate and swimming are among the most researched sports therapy options for patients with autism.^38-40 Both are shown to improve motor ability and reduce communication deficits.

Summing up

The literature, although limited, demonstrates that exercise and sports improve the health and well-being of people with IDDs throughout the lifespan, especially if childhood exercise/sports involvement is maintained.

Exercise participation increases based on the individual’s desire to be fit and active, skills practice, peer involvement, family support, accessible facilities, and skilled staff.

Encourage your patients to participate in sports, but be aware of factors that can limit (or facilitate) participation.⁴¹ Exercise participation increases based on, among other things, the individual’s desire to be fit and active, skills practice, peer involvement, family support, accessible facilities, and skilled staff.¹⁰

Additional resources that can help people with IDDs access sports and recreational activities include the Special Olympics; Paralympics; YMCA; after-school programs; The American College of Sports Medicine; The National Center on Health, Physical Activity, and Disability; and disability-certified inclusive fitness trainers.

CORRESPONDENCE
Kristina Jones, BS, 12901 Bruce B. Downs Boulevard, Tampa, FL 33612; [email protected]

References

1. CDC. Addressing gaps in healthcare for individuals with intellectual disabilities. Updated October 15, 2019. Accessed January 21, 2023. www.cdc.gov/grand-rounds/pp/2019/20191015-intellectual-disabilities.html

2. CDC. Vital signs: adults with disabilities. Physical activity is for everybody. Updated November 16, 2018. Accessed January 21, 2023. www.cdc.gov/vitalsigns/disabilities/index.html

3. Di Palma D, Molisso V. Sport for autism. J Humanities Soc Pol. 2017;3:42-49.

4. Pan CY, Chu CH, Tsai CL, et al. The impacts of physical activity intervention on physical and cognitive outcomes in children with autism spectrum disorder. Autism. 2017;21:190-202. doi: 10.1177/1362361316633562

5. Verschuren O, Peterson MD, Balemans AC, et al. Exercise and physical activity recommendations for people with cerebral palsy. Dev Med Child Neurol. 2016;58:798-808. doi: 10.1111/dmcn.13053

6. Paul Y, Ellapen TJ, Barnard M, et al. The health benefits of exercise therapy for patients with Down syndrome: a systematic review. Afr J Disabil. 2019;8:576. doi: 10.4102/ajod.v8i0.576

7. Carroll DD, Courtney-Long EA, Stevens AC, et al. Vital signs: disability and physical activity—United States, 2009-2012. MMWR Morb Mortal Wkly Rep. 2014;63:407-413.

8. Rimmer JH. Physical activity for people with disabilities: how do we reach those with the greatest need? NAM Perspectives. Published April 6, 2015. Accessed March 23, 2023. https://nam.edu/perspectives-2015-physical-activity-for-people-with-disabilities-how-do-we-reach-those-with-the-greatest-need/

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Article PDF

JFP07204102.pdf

Author and Disclosure Information

Morsani College of Medicine (Ms. Jones, Ms. Rivera, and Drs. Bindas and Woodward) and College of Behavioral and Community Sciences (Dr. Perkins), University of South Florida, Tampa
[email protected]

The authors reported no potential conflict of interest relevant to this article.

*Kristina Jones and Cianna Rivera contributed equally as first authors of this work.

Issue

The Journal of Family Practice - 72(3)

Publications

MDedge Family Medicine

The Journal of Family Practice

Topics

Mixed Topics

Page Number

102-106

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