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Austin EJ, Chen J, Soyer E, Idrisov B, Briggs ES, Moghimi Y, Saxon AJ, Fortney JC, Blanchard BE, Williams EC, Ratzliff AD, Ruiz MS, Koch U. Primary care team perspectives on approaches to engaging patients in treatment for opioid use disorder. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 165:209456. [PMID: 39067765 DOI: 10.1016/j.josat.2024.209456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/28/2024] [Accepted: 07/11/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Engagement is a critical component of successful treatment for opioid use disorder (OUD). However, rates of patient engagement in OUD treatment, especially in outpatient settings, are variable and often low. Little is known about the specific strategies members of primary care teams use to initiate and encourage ongoing participation in OUD treatment. In a national cohort of primary care clinics in the U.S., we explored the perspectives of primary care team members on the meaning of and approaches to OUD treatment engagement. METHODS We conducted semi-structured interviews with 35 providers from multidisciplinary primary care teams in an existing national cohort of 13 clinics across seven states. Teams were delivering OUD treatment via the Collaborative Care Model, a model that combines primary care providers (PCP), behavioral health care managers (BHCM) and consulting psychiatric providers (CPP) in a structured way to provide patient-centered, team-based, and measurement-based care. Interview participants included 14 PCPs, 13 BHCMs, and 8 CPPs. Interviews asked open-ended questions about provider experiences and practices that aided or hindered patient engagement in OUD treatment. Interview transcripts were double-coded by trained qualitative researchers and analyzed using a combination of deductive and inductive approaches to identify themes. RESULTS Two themes emerged that describe provider perspectives on the meaning of engagement: 1) qualifying engagement by the volume of contact with patients, and 2) the need for more multidimensional measures of engagement. Six themes emerged that characterized provider engagement practices: 1) creating an environment of disclosure, 2) normalizing OUD treatment, 3) offering gentle but persistent outreach, 4) providing human connection and encouragement, 5) tailoring treatment to patient needs, and 6) avoiding stigmatizing responses. Analysis identified multiple replicable strategies that providers used to support these engagement practices. CONCLUSIONS Providers consistently apply a range of strategies when trying to engage patients in OUD treatment. Specific engagement strategies used embodied compassion and pragmatism, hallmarks of patient-centered care. Further research is needed to understand the impact of scaling engagement approaches across all care settings.
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Affiliation(s)
- Elizabeth J Austin
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America; Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, D.C., United States of America.
| | - Jessica Chen
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America
| | - Elena Soyer
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America
| | - Bulat Idrisov
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America
| | - Elsa S Briggs
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America
| | - Yavar Moghimi
- Department of Psychiatry and Behavioral Sciences, School of Medicine and Health Sciences, The George Washington University, United States of America
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America; Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, WA, United States of America
| | - John C Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America; Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, United States of America; Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, United States of America
| | - Brittany E Blanchard
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America; Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, United States of America
| | - Emily C Williams
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, United States of America; Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development, VA Puget Sound, Seattle, WA, United States of America
| | - Anna D Ratzliff
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States of America; Advancing Integrated Mental Health Solutions (AIMS) Center, University of Washington, Seattle, WA, United States of America
| | - Monica S Ruiz
- Department of Prevention and Community Health, Milken Institute School of Public Health, The George Washington University, Washington, D.C., United States of America
| | - Ulrich Koch
- Department of Clinical Research and Leadership, School of Medicine and Health Sciences, The George Washington University, Washington, D.C., United States of America
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Tilhou AS, Burns M, Chachlani P, Chen Y, Dague L. How Does Telehealth Expansion Change Access to Healthcare for Patients With Different Types of Substance Use Disorders? SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:473-485. [PMID: 38494728 PMCID: PMC11179974 DOI: 10.1177/29767342241236028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
BACKGROUND Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown. METHODS Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake ("offset"), and the share of visits completed by telemedicine ("share"). RESULTS The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only. CONCLUSIONS Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.
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Affiliation(s)
- Alyssa Shell Tilhou
- Department of Family Medicine, Boston University Medical Center, Boston, MA, USA
| | - Marguerite Burns
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Preeti Chachlani
- Institute for Research on Poverty, University of Wisconsin-Madison, Madison, WI, USA
| | - Ying Chen
- Department of Risk and Insurance, Wisconsin School of Business, University of Wisconsin-Madison, Madison, WI, USA
| | - Laura Dague
- The Bush School of Government and Public Service, Texas A&M University, College Station, TX, USA
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D'Aunno T, Neighbors CJ. Innovation in the Delivery of Behavioral Health Services. Annu Rev Public Health 2024; 45:507-525. [PMID: 37871139 DOI: 10.1146/annurev-publhealth-071521-024027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Several factors motivate the need for innovation to improve the delivery of behavioral health services, including increased rates of mental health and substance use disorders, limited access to services, inconsistent use of evidence-based practices, and persistent racial and ethnic disparities. This narrative review identifies promising innovations that address these challenges, assesses empirical evidence for the effectiveness of these innovations and the extent to which they have been adopted and implemented, and suggests next steps for research. We review five categories of innovations: organizational models, including a range of novel locations for providing services and new ways of organizing services within and across sites; information and communication technologies; workforce; treatment technologies; and policy and regulatory changes. We conclude by discussing the need to strengthen and accelerate the contributions of implementation science to close the gap between the launch of innovative behavioral health services and their widespread use.
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Affiliation(s)
- Thomas D'Aunno
- Wagner Graduate School of Public Service, New York University, New York, NY, USA;
| | - Charles J Neighbors
- Department of Population Health, Grossman School of Medicine, New York University, New York, NY, USA
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Lin CH, Siao SF, Lin PY, Shelley M, Chi YC, Lee YH. Understanding Healthcare Providers' Care for Patients with Medications Treating Opioid Use Disorder in the Emergency Department: A Scoping Review. Subst Use Misuse 2024; 59:622-637. [PMID: 38115559 DOI: 10.1080/10826084.2023.2294964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND There is limited research exploring the changing clinical practices among healthcare providers (HPs) care for patients with Emergency Department (ED)-initiated Medication for Opioid Use Disorder (MOUD). METHODS This scoping review followed the methodological framework of Arksey and O'Malley to map relevant evidence and synthesize the findings. We searched PubMed, EMBASE, CINAHL, Web of Science, and Scopus for related studies from inception through October 12, 2022. Following the application of inclusion and exclusion criteria, 16 studies were included. Subsequently, they were charted and analyzed thematically based on ecological systems theory. RESULTS The main determinants in the four ecological systems were generated as follows: (1) microsystem: willingness and attitude, professional competence, readiness, and preference; (2) mesosystem: ED clinical practices, departmental factors; (3) exosystem: multidisciplinary approaches, discharge planning, and (4) macrosystem: stigma, health insurance, policy. The findings have implications for HPs and researchers, as insufficient adoption, implementation, and retention of MOUD in the ED affect clinical practices. CONCLUSIONS Across the four ecological systems, ED-initiated MOUD is shaped by multifaceted determinants. The microsystem underscores pivotal patient-HP trust dynamics, while the mesosystem emphasizes interdepartmental synergies. Exosystemically, resource allocation and standardized training remain paramount. The macrosystem reveals profound effects of stigma, insurance disparities, and evolving policies on treatment access and efficacy. Addressing these interconnected barriers is crucial for optimizing patient outcomes in the context of MOUD.
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Affiliation(s)
- Chia-Hung Lin
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Shu-Fen Siao
- School of Nursing, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Pei-Ying Lin
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Mack Shelley
- Department of Political Science, Department of Statistics, Iowa State University, Ames, IA, USA
| | - Yu-Chi Chi
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yen-Han Lee
- Department of Health Sciences, College of Health Professions and Sciences, University of Central Florida, Orlando, FL, USA
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Nyaku AN, Zerbo EA, Chen C, Milano N, Johnston B, Chadwick R, Marcello S, Baston K, Haroz R, Crystal S. A survey of barriers and facilitators to the adoption of buprenorphine prescribing after implementation of a New Jersey-wide incentivized DATA-2000 waiver training program. BMC Health Serv Res 2024; 24:179. [PMID: 38331802 PMCID: PMC10851589 DOI: 10.1186/s12913-024-10648-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 01/28/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Opioid-involved overdose deaths continue to rise in the US, despite availability of highly effective treatments for opioid use disorder (OUD), in part due to the insufficient number of treatment providers. Barriers include the need for providers to gain expertise and confidence in providing MOUD to their patients who need these treatments. To mitigate this barrier, New Jersey sponsored a buprenorphine training program with financial incentives for participation, which met the then existing requirement for the DATA-2000 waiver. In a 2019 follow-up survey, participants reported on barriers and facilitators to subsequent buprenorphine prescribing. METHODS Participants in the training program completed a 10-min electronic survey distributed via email. The survey addressed demographics, practice characteristics, current buprenorphine prescribing, and barriers and facilitators to adoption and/or scale up of buprenorphine prescribing. RESULTS Of the 440 attendees with a valid email address, 91 individuals completed the survey for a response rate of 20.6%. Of the 91 respondents, 89 were eligible prescribers and included in the final analysis. Respondents were predominantly female (n = 55, 59.6%) and physicians (n = 55, 61.8%); representing a broad range of specialties and practice sites. 65 (73%) of respondents completed the training and DEA-registration, but only 31 (34.8%) were actively prescribing buprenorphine. The most frequently cited barriers to buprenorphine prescribing were lack of access to support services such as specialists in addiction, behavioral health services, and psychiatry. The most frequently reported potential facilitators were integrated systems with direct access to addiction specialists and psychosocial services, easier referral to behavioral health services, more institutional support, and improved guidance on clinical practice standards for OUD treatment. CONCLUSION More than half (52.3%) of those who completed incentivized training and DEA registration failed to actively prescribe buprenorphine. Results highlight provider perceptions of inadequate availability of support for the complex needs of patients with OUD and suggest that broader adoption of buprenorphine prescribing will require scaling up support to clinicians, including increased availability of specialized addiction and mental health services.
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Affiliation(s)
- Amesika N Nyaku
- Department of Medicine, Division of Infectious Diseases, Rutgers New Jersey Medical School, 185 South Orange Ave, MSB I689, Newark, NJ, 07103, USA.
| | - Erin A Zerbo
- Private Practice, Montclair, NJ, 07042, USA
- Department of Psychiatry, Rutgers New Jersey Medical School, 183 South Orange Ave, BHSB F-Level, Newark, NJ, 07103, USA
| | - Clement Chen
- Department of Psychiatry, Rutgers New Jersey Medical School, 183 South Orange Ave, BHSB F-Level, Newark, NJ, 07103, USA
| | - Nicole Milano
- Mental Health Association in New Jersey, 673 Morris Avenue, Suite 100, Springfield, NJ, 07781, USA
| | - Barbara Johnston
- Mental Health Association in New Jersey, 673 Morris Avenue, Suite 100, Springfield, NJ, 07781, USA
| | - Randall Chadwick
- Rutgers University Behavioral Health Care, 151 Centennial Avenue, Suite 1140, Piscataway, NJ, 08854, USA
| | - Stephanie Marcello
- Rutgers University Behavioral Health Care, 151 Centennial Avenue, Suite 1140, Piscataway, NJ, 08854, USA
| | - Kaitlan Baston
- Department of Internal Medicine, Cooper Medical School of Rowan University, Three Cooper Plaza, Camden, NJ, 08103, USA
| | - Rachel Haroz
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St, 3rd Floor, New Brunswick, NJ, 08901, USA
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Krupp J, Hung F, LaChapelle T, Yarrington ME, Link K, Choi Y, Chen H, Marais AD, Sachdeva N, Chakraborty H, McKellar MS. Impact of Policy Change on Access to Medication for Opioid Use Disorder in Primary Care. South Med J 2023; 116:333-340. [PMID: 37011580 PMCID: PMC10045971 DOI: 10.14423/smj.0000000000001544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 04/05/2023]
Abstract
OBJECTIVES The opioid overdose epidemic is escalating. Increasing access to medications for opioid use disorder in primary care is crucial. The impact of the US Department of Health and Human Services' policy change removing the buprenorphine waiver training requirement on primary care buprenorphine prescribing remains unclear. We aimed to investigate the impact of the policy change on primary care providers' likelihood of applying for a waiver and the current attitudes, practices, and barriers to buprenorphine prescribing in primary care. METHODS We used a cross-sectional survey with embedded educational resources disseminated to primary care providers in a southern US academic health system. We used descriptive statistics to aggregate survey data, logistic regression models to evaluate whether buprenorphine interest and familiarity correlate with clinical characteristics, and a χ2 test to evaluate the effect of the educational intervention on screening. RESULTS Of the 54 respondents, 70.4% reported seeing patients with opioid use disorder, but only 11.1% had a waiver to prescribe buprenorphine. Few nonwaivered providers were interested in prescribing, but perceiving buprenorphine to be beneficial to the patient population was associated with interest (adjusted odds ratio 34.7, P < 0.001). Two-thirds of nonwaivered respondents reported the policy change having no impact on their decision to obtain a waiver; however, among interested providers, it increased their likelihood of obtaining a waiver. Barriers to buprenorphine prescribing included lack of clinical experience, clinical capacity, and referral resources. Screening for opioid use disorder did not increase significantly after the survey. CONCLUSIONS Although most primary care providers reported seeing patients with opioid use disorder, interest in prescribing buprenorphine was low and structural barriers remained the dominant obstacles. Providers with a preexisting interest in buprenorphine prescribing reported that removing the training requirement was helpful.
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Affiliation(s)
| | - Frances Hung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine
| | | | - Michael E. Yarrington
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine
| | - Katherine Link
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine
| | - Yujung Choi
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Hillary Chen
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Andrea Des Marais
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Nidhi Sachdeva
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Mehri S. McKellar
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine
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Murray-Krezan C, Dopp A, Tarhuni L, Carmody MD, Becker K, Anderson J, Komaromy M, Meredith LS, Watkins KE, Wagner K, Page K. Screening for opioid use disorder and co-occurring depression and post-traumatic stress disorder in primary care in New Mexico. Addict Sci Clin Pract 2023; 18:6. [PMID: 36707910 PMCID: PMC9881516 DOI: 10.1186/s13722-023-00362-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/18/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Identifying patients in primary care services with opioid use disorder and co-occurring mental health disorders is critical to providing treatment. Objectives of this study were to (1) assess the feasibility of recruiting people to screen in-person for opioid use disorder and co-occurring mental health disorders (depression and/or post-traumatic stress disorder) in primary care clinic waiting rooms in preparation for a randomized controlled trial, and (2) compare results of detecting these disorders by universal in-person screening compared to electronic health record (EHR) diagnoses. METHODS This cross-sectional feasibility and pilot study recruited participants from four primary care clinics, two rural and two urban, from three health care organizations in New Mexico. Inclusion criteria were adults (≥ 18 years), attending one of the four clinics as a patient, and who spoke English or Spanish. Exclusion criteria were people attending the clinic for a non-primary care visit (e.g., dental, prescription pick up, social support). The main outcomes and measures were (1) recruitment feasibility which was assessed by frequencies and proportions of people approached and consented for in-person screening, and (2) relative differences of detecting opioid use disorder and co-occurring mental health disorders in waiting rooms relative to aggregate EHR data from each clinic, measured by prevalence and prevalence ratios. RESULTS Over two-weeks, 1478 potential participants were approached and 1145 were consented and screened (77.5% of patients approached). Probable opioid use disorder and co-occurring mental health disorders were identified in 2.4% of those screened compared to 0.8% in EHR. Similarly, universal screening relative to EHR identified higher proportions of probable opioid use disorder (4.5% vs. 3.4%), depression (17.5% vs. 12.7%) and post-traumatic stress disorder (19.0% vs. 3.6%). CONCLUSIONS Universal screening for opioid use disorder, depression, and post-traumatic stress disorder was feasible, and identified three times as many patients with these co-occurring disorders compared to EHR. Higher proportions of each condition were also identified, especially post-traumatic stress disorder. Results support that there are likely gaps in identification of these disorders in primary care services and demonstrate the need to better address the persistent public health problem of these co-occurring disorders.
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Affiliation(s)
- Cristina Murray-Krezan
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA.
- Department of Medicine, Division of General Internal Medicine, School of Medicine, University of Pittsburgh, 200 Meyran Ave, Suite 300, Pittsburgh, PA, 15213, USA.
| | - Alex Dopp
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | - Lina Tarhuni
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Mary D Carmody
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Kirsten Becker
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | - Jessica Anderson
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Miriam Komaromy
- Grayken Center for Addiction, Boston Medical Center, Boston University, Boston, MA, 02118, USA
| | - Lisa S Meredith
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | | | - Katherine Wagner
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Kimberly Page
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
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Abstract
INTRODUCTION The opioid epidemic has evolved into a combined stimulant epidemic, with escalating stimulant and fentanyl-related overdose deaths. Primary care providers are on the frontlines grappling with patients' methamphetamine use. Although effective models exist for treating opioid use disorder in primary care, little is known about current clinical practices for methamphetamine use. METHODS Six semistructured group interviews were conducted with 38 primary care providers. Interviews focused on provider perceptions of patients with methamphetamine use problems and their care. Data were analyzed using inductive and thematic analysis and summarized along the following dimensions: (1) problem identification, (2) clinical management, (3) barriers and facilitators to care, and (4) perceived needs to improve services. RESULTS Primary care providers varied in their approach to identifying and treating patient methamphetamine use. Unlike opioid use disorders, providers reported lacking standardized screening measures and evidence-based treatments, particularly medications, to address methamphetamine use. They seek more standardized screening tools, Food and Drug Administration-approved medications, reliable connections to addiction medicine specialists, and more training. Interest in novel behavioral health interventions suitable for primary care settings was also noteworthy. CONCLUSIONS The findings from this qualitative analysis revealed that primary care providers are using a wide range of tools to screen and treat methamphetamine use, but with little perceived effectiveness. Primary care faces multiple challenges in effectively addressing methamphetamine use among patients singularly or comorbid with opioid use disorders, including the lack of Food and Drug Administration-approved medications, limited patient retention, referral opportunities, funding, and training for methamphetamine use. Focusing on patients' medical issues using a harm reduction, motivational interviewing approach, and linkage with addiction medicine specialists may be the most reasonable options to support primary care in compassionately and effectively managing patients who use methamphetamines.
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McGovern MP, Dunn J, Bonnell LN, Leibowitz G, Waddell E, Rose G, Littenberg B. The Association Between Depression and Substance Use Among Primary Care Patients With Comorbid Medical and Behavioral Health Conditions. J Prim Care Community Health 2023; 14:21501319231200302. [PMID: 37728047 PMCID: PMC10515515 DOI: 10.1177/21501319231200302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/16/2023] [Accepted: 08/23/2023] [Indexed: 09/21/2023] Open
Abstract
INTRODUCTION The scope of primary care increasingly encompasses patient behavioral health problems, manifest typically through depression screening and treatment. Although substance use is highly comorbid with depression, it is not commonly identified and addressed in the primary care context. This study aimed to examine the association between the likelihood of substance use disorder and increased depression severity, both cross-sectionally and longitudinally, among a sample of 2409 patients from 41 geographically dispersed and diverse primary care clinics across the US. METHODS This is secondary analysis of data obtained from a multi-site parent study of integrated behavioral health in primary care, among patients with both chronic medical and behavioral health conditions. Patient reported outcome surveys were gathered from patients at 3 time points. The primary care practices were blind to which of their patients completed surveys. Included were standardized measures of depression severity (Patient Health Questionnaire-9) [PHQ-9] and substance use disorder likelihood (Global Appraisal of Individual Needs-Short Screener [GSS]). RESULTS Four percent of the study population screened positive for substance use disorder. PHQ-9 scores indicated depression among 43% of all patients. There was a significant association between the likelihood of substance use disorder and depression initially, at a 9-month follow-up, and over time. These associations remained significant after adjusting for age, gender, race, ethnicity, education, income, and other patient and contextual characteristics. CONCLUSIONS The findings suggest that substance use disorder is associated with depression severity cross-sectionally and over time. Primary care clinics and health systems might consider implementing substance use screening in addition to the more common screening strategies for depression. Especially for patients with severe depression or those who do not respond to frontline depression treatments, the undermining presence of a substance use disorder should be explored.
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Affiliation(s)
| | - Julia Dunn
- Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | | | - Gail Rose
- University of Vermont, Burlington, VT, USA
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Jones AL, Kelley AT, Suo Y, Baylis JD, Codell NK, West NA, Gordon AJ. Trends in Health Service Utilization After Enrollment in an Interdisciplinary Primary Care Clinic for Veterans with Addiction, Social Determinants of Health, or Other Vulnerabilities. J Gen Intern Med 2023; 38:12-20. [PMID: 35194740 PMCID: PMC8862702 DOI: 10.1007/s11606-022-07456-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/03/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Models of interdisciplinary primary care (IPC) may improve upon traditional primary care approaches in addressing addiction and social determinants of health. OBJECTIVE To compare the trends in health care utilization in the year before and after enrollment in an IPC clinic model, and explore the variations in temporal patterns for patients with histories of high emergency department (ED) use, homelessness, and/or substance use disorders (SUDs). DESIGN AND PARTICIPANTS Interrupted time series study of utilization among IPC patients. MAIN MEASURES Quarterly ED, inpatient, primary care, and behavioral health visits were abstracted from administrative data before and after IPC enrollment. Negative binomial segmented regressions estimated changes in health care utilization over time. We used interactions to test for statistical differences in temporal patterns for IPC subgroups. RESULTS Among IPC patients (n=994), enrollment was associated with overall reductions in ED, inpatient, and behavioral health visits (p's<0.001) and increases in primary care (p's<0.001). Temporal patterns of ED visits, hospitalizations, and behavioral health differed across IPC subgroups (interaction p's<0.001). For those with histories of high ED use (n=265), ED, inpatient, and behavioral health visits decreased after enrollment (level change incidence rate ratios [IRRs]=0.57-0.69) and continued to decline over time (post-enrollment IRRs=0.80-0.88). Among other patients with homeless experiences (n=123), there were initial declines in hospitalizations (IRR=0.33) and overall declines in behavioral health visits (level change and post-enrollment IRRs=0.46-0.94). Other patients with SUDs had initial declines in hospitalizations (IRR=0.46), and post-enrollment declines in rates of specialty SUD visits (IRR=0.92). For all patients, primary care visits initially increased (level change IIRs=2.47-1.34) then gradually declined (post-enrollment IRRs=0.92-0.92). CONCLUSIONS An IPC model of care reduces acute care and behavioral health service use, particularly for patients with historically high ED use. IPC models may improve patient and system outcomes of vulnerable patient populations with social, clinical, and addiction morbidities.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - A Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ying Suo
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jacob D Baylis
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nodira K Codell
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Nancy A West
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Greater Intermountain Node (GIN) of the NIDA Clinical Trials Network, University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
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Reist C, Petiwala I, Latimer J, Raffaelli SB, Chiang M, Eisenberg D, Campbell S. Collaborative mental health care: A narrative review. Medicine (Baltimore) 2022; 101:e32554. [PMID: 36595989 PMCID: PMC9803502 DOI: 10.1097/md.0000000000032554] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The Collaborative Care model is a systematic strategy for treating behavioral health conditions in primary care through the integration of care managers and psychiatric consultants. Several randomized controlled trials have demonstrated that Collaborative Care increases access to mental health care and is more effective and cost efficient than the current standard of care for treating common mental illnesses. Large healthcare systems and organizations have begun to adopt Collaborative Care initiatives and are seeing improved treatment outcomes and provider and patient satisfaction. This review discusses current research on the effectiveness and cost-efficiency of Collaborative Care. In addition, this paper discusses its ability to adapt to specific patient populations, such as geriatrics, students, substance use, and women with perinatal depression, as well as the significance of measurement-based care and mental health screening in achieving improved clinical outcomes. Current data suggests that Collaborative Care may significantly improve patient outcomes and time-to-treatment in all reviewed settings, and successfully adapts to special patient populations. Despite the high upfront implementation burden of launching a Collaborative Care model program, these costs are generally offset by long term healthcare savings.
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Affiliation(s)
- Christopher Reist
- University of California, Irvine, Irvine, CA
- Veterans Affairs Long Beach Healthcare System, Long Beach, CA
| | | | | | | | - Maurice Chiang
- Carbon Health Technologies, Inc, Oakland, CA
- * Correspondence: Maurice Chiang, Carbon Health Technologies, Inc. 2100 Franklin Street, Suite 355, Oakland CA 94612 (e-mail: )
| | | | - Scott Campbell
- Department of Psychiatry & Behavioral Neurosciences, Cedars-Sinai Medical Care Foundation, Los Angeles, CA
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12
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Lowe E, Kogan AC, Feldman CT, Ma SB, Lie DA. Preceptors' preparedness to teach about substance and opioid use disorder: a qualitative study. BMC MEDICAL EDUCATION 2022; 22:867. [PMID: 36517790 PMCID: PMC9749622 DOI: 10.1186/s12909-022-03922-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 11/25/2022] [Indexed: 06/17/2023]
Abstract
STUDY AIM Little is known about preceptors' comfort and readiness to teach clinical students about the care of patients with substance and opioid use disorder (SUD/OUD). This study explores preceptors' views about caring for such patients, and their preparedness to teach about SUD/OUD management, to improve graduate competencies. METHODS Participants were recruited by convenience and snowball sampling. Semi-structured interviews were conducted with physician, physician assistant, and nurse practitioner preceptors who taught medical and physician assistant students. Interviews were conducted via Zoom® videoconferencing. Transcripts were generated and independently analyzed for themes by 4 experienced coders using constant comparison and a grounded theory approach. RESULTS Fifteen interviews were conducted to theme saturation. We identified 3 major themes and 10 subthemes supported by exemplar quotes. The major themes were: education about SUD/OUD in primary care (subthemes include need for longitudinal curriculum, redefining 'success' in treatment, and precepting challenges), treatment of SUD/OUD in primary care (need for systemic support and care continuity), and medication-assisted therapy (MAT) training as a tool for teaching (preceptors' own training, and need for clinical students to be trained). CONCLUSIONS Preceptors agreed that treatment of SUD/OUD belongs in primary care and students should learn about SUD/OUD from the start of their medical education. Data analysis enabled the construction of an emerging conceptual framework reflecting a diversity of experiences and opinions of preceptor comfort and preparedness to teach about SUD/OUD, associated with various barriers and motivators. This framework can guide future strategies to address facilitators and obstacles to advance and promote preceptor preparedness to teach students about the care and management of patients with SUD/OUD.
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Affiliation(s)
- Enya Lowe
- Division of Physician Assistant Studies, Primary Care Physician Assistant Program, Department of Family Medicine, Keck School of Medicine of USC, University of Southern California, 1000 S. Fremont Avenue Bldg #635, Alhambra, CA 91803 USA
| | - Alexis Coulourides Kogan
- Family Medicine and Gerontology, Department of Family Medicine and Geriatrics, Keck School of Medicine of USC, University of Southern California, Alhambra, USA
| | - Corinne T. Feldman
- Division of Physician Assistant Studies, Primary Care Physician Assistant Program, Department of Family Medicine, Keck School of Medicine of USC, University of Southern California, 1000 S. Fremont Avenue Bldg #635, Alhambra, CA 91803 USA
| | - Sae Byul Ma
- Division of Physician Assistant Studies, Primary Care Physician Assistant Program, Department of Family Medicine, Keck School of Medicine of USC, University of Southern California, 1000 S. Fremont Avenue Bldg #635, Alhambra, CA 91803 USA
| | - Désirée A. Lie
- Division of Physician Assistant Studies, Primary Care Physician Assistant Program, Department of Family Medicine, Keck School of Medicine of USC, University of Southern California, 1000 S. Fremont Avenue Bldg #635, Alhambra, CA 91803 USA
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13
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Leyrer-Jackson JM, Acuña AM, Olive MF. Current and emerging pharmacotherapies for opioid dependence treatments in adults: a comprehensive update. Expert Opin Pharmacother 2022; 23:1819-1830. [PMID: 36278879 PMCID: PMC9764962 DOI: 10.1080/14656566.2022.2140039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/21/2022] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Opioid use disorder (OUD) is characterized by compulsive opioid seeking and taking, intense drug craving, and intake of opioids despite negative consequences. The prevalence of OUDs has now reached an all-time high, in parallel with peak rates of fatal opioid-related overdoses, where 15 million individuals worldwide meet the criteria for OUD. Further, in 2020, 120,000 opioid-related deaths were reported worldwide with over 75,000 of those deaths occurring within the United States. AREAS COVERED In this review, we highlight pharmacotherapies utilized in patients with OUDs, including opioid replacement therapies, and opioid antagonists utilized for opioid overdoses and deterrent of opioid use. We also highlight newer treatments, such as those targeting the neuroimmune system, which are potential new directions for research given the recently established role of opioids in activating neuroinflammatory pathways, as well as over the counter remedies, including kratom, that may mitigate withdrawal. EXPERT OPINION To effectively treat OUDs, a deeper understanding of the current therapeutics being utilized, their additive effects, and the added involvement of the neuroimmune system are essential. Additionally, a complete understanding of opioid-induced neuronal alterations and therapeutics that target these abnormalities - including the neuroimmune system - is required to develop effective treatments for OUDs.
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Affiliation(s)
- Jonna M. Leyrer-Jackson
- Department of Medical Education, School of Medicine, Creighton University, Phoenix, AZ, 85012, USA
| | - Amanda M. Acuña
- Department of Psychology, Arizona State University, Tempe, AZ, 85257, USA
- Interdepartmental Graduate Program in Neuroscience, Arizona State University, Tempe, AZ, 85257, USA
| | - M. Foster Olive
- Department of Psychology, Arizona State University, Tempe, AZ, 85257, USA
- Interdepartmental Graduate Program in Neuroscience, Arizona State University, Tempe, AZ, 85257, USA
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14
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Collaboration Leading to Addiction Treatment and Recovery from Other Stresses (CLARO): process of adapting collaborative care for co-occurring opioid use and mental disorders. Addict Sci Clin Pract 2022; 17:25. [PMID: 35395811 PMCID: PMC8991671 DOI: 10.1186/s13722-022-00302-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 03/16/2022] [Indexed: 12/15/2022] Open
Abstract
Background Opioid use disorders (OUD), co-occurring with either depression and/or PTSD, are prevalent, burdensome, and often receive little or low-quality care. Collaborative care is a service delivery intervention that uses a team-based model to improve treatment access, quality, and outcomes in primary care patients, but has not been evaluated for co-occurring OUD and mental health disorders. To address this treatment and quality gap, we adapted collaborative care for co-occurring OUD and mental health disorders. Methods Our adapted model is called Collaboration Leading to Addiction Treatment and Recovery from Other Stresses (CLARO). We used the five-step Map of Adaptation Process (McKleroy in AIDS Educ Prev 18:59–73, 2006) to develop the model. For each step, our stakeholder team of research and clinical experts, primary care partners, and patients provided input into adaptation processes (e.g., adaptation team meetings, clinic partner feedback, patient interviews and beta-testing). To document each adaptation and our decision-making process, we used the Framework for Reporting Adaptations and Modifications-Enhanced (Wiltsey Stirman in Implement Sci 14:1–10, 2019). Results We documented 12 planned fidelity-consistent adaptations to collaborative care, including a mix of content, context, and training/evaluation modifications intended to improve fit with the patient population (co-occurring disorders) or the New Mexico setting (low-resource clinics in health professional shortage areas). Examples of documented adaptations include use of community health workers as care coordinators; an expanded consultant team to support task-shifting to community health workers; modified training protocols for Problem-Solving Therapy and Written Exposure Therapy to incorporate examples of treating patients for depression or PTSD with co-occurring OUD; and having care coordinators screen for patients’ social needs. Conclusions We completed the first three steps of the Map of Adaptation Process, resulting in a variety of adaptations that we believe will make collaborative care more acceptable and feasible in treating co-occurring OUD and mental health disorders. Future steps include evaluating the effectiveness of CLARO and documenting reactive and/or planned adaptations to the model that occur during its implementation and delivery. Trial registration NCT04559893, NCT04634279. Registered 08 September 2020, https://clinicaltrials.gov/ct2/show/NCT04559893
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15
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Nwabueze C, Elom H, Liu S, Walter SM, Sha Z, Acevedo P, Liu Y, Su BB, Xu C, Piamjariyakul U, Wang K. Gender differences in the associations of multiple psychiatric and chronic conditions with major depressive disorder among patients with opioid use disorder. J Addict Dis 2021; 40:168-178. [PMID: 34328394 DOI: 10.1080/10550887.2021.1957639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE The study examined the associations of multiple psychiatric and chronic conditions with the self-reported history of major depressive disorder (MDD) among patients with opioid use disorder (OUD) and tested whether the associations differed by gender. METHODS We conducted a secondary data analysis of baseline data from a clinical trial including 1,646 participants with OUD, of which 465 had MDD. A variable cluster analysis was used to classify chronic medical and psychiatric conditions. Multivariable logistic regression analyses were used to estimate their associations with MDD in subjects with OUD. RESULTS Nine variables were divided into three clusters: cluster 1 included heart condition, hypertension, and liver problems; cluster 2 included gastrointestinal (GI) problems and head injury, and cluster 3 included anxiety disorder, bipolar disorder, and schizophrenia. The overall prevalence of MDD in participants with OUD was 28.3% (22.8% for males and 39.5% for females). Gender, anxiety disorder, schizophrenia, liver problems, heart condition, GI problems, and head injury were significantly associated with MDD. Gender-stratified analyses showed that bipolar disorder, liver problems and individuals with one chronic condition were associated with MDD only in males, whereas heart condition, hypertension, and GI problems were associated with MDD only in females. In addition, anxiety disorder, head injury, individuals with one or more than two psychiatric conditions, and individuals with more than two chronic conditions were associated with MDD regardless of gender. CONCLUSIONS Treatment plans in patients with OUD should not only address MDD but also co-morbid psychiatric and chronic medical conditions that occur with MDD.
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Affiliation(s)
- Christian Nwabueze
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Hilary Elom
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Sophia Liu
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Suzy Mascaro Walter
- Department of Family and Community Health, School of Nursing, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Zhanxin Sha
- School of Kinesiology and Nutrition, College of Education and Human Sciences, University of Southern Mississippi, Hattiesburg, MS, USA
| | - Priscila Acevedo
- Department of Health and Biomedical Sciences, College of Health Affairs, University of Texas Rio Grande Valley, Brownsville, TX, USA
| | - Ying Liu
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN, USA
| | - Brenda Bin Su
- Department of Health and Biomedical Sciences, College of Health Affairs, University of Texas Rio Grande Valley, Brownsville, TX, USA
| | - Chun Xu
- Department of Health and Biomedical Sciences, College of Health Affairs, University of Texas Rio Grande Valley, Brownsville, TX, USA
| | - Ubolrat Piamjariyakul
- School of Nursing, Health Sciences Center, West Virginia University, Morgantown, WV, USA
| | - Kesheng Wang
- Department of Family and Community Health, School of Nursing, Health Sciences Center, West Virginia University, Morgantown, WV, USA
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