Treatment for substance use disorder: opportunities and challenges under the affordable care act

How Social Workers Can Be Deployed to Assist with the Ongoing Opioid Crisis

The opioid epidemic has claimed more than 1 million lives in the United States over the past two decades. The persistent increase in deaths indicates that current strategies intended to decrease the negative consequences of opioid use are inadequate. Harm reduction strategies are designed to promote safer substance usage and reduce overdose mortality rates, yet the implementation of harm reduction programs is inhibited by community- and provider-level stigma against people who use opioids, coupled with limited understanding and insufficient education about harm reduction approaches. Despite ongoing research, engagement in opioid treatment programs remains a challenge, and the opioid crisis continues to disproportionately harm marginalized populations. This article describes how social workers are prepared to play a larger role in opioid use treatment because they are trained with the skill set and values necessary to facilitate access to harm reduction programs, promote engagement in substance use treatment, and create and advocate for interventions to address problematic substance use, especially in high-need communities.

Predictors of Receiving Mental Health Services in Trauma Patients With Positive Drug Screen

INTRODUCTION

Initial interaction with health care system presents an important opportunity to provide substance use disorder (SUD) rehabilitation in the form of mental health services (MHSs). This study aims to identify predictors of receipt of MHSs among adult trauma patients with SUD and positive drug screen.

METHODS

In this analysis of 2017-2021 American College of Surgeons-Trauma Quality Improvement Program (ACS TQIP), adult(≥18 y) patients with SUD and positive drug screen who survived the hospital admission were included. Outcomes measure was the receipt of MHS. Poisson regression analysis with clustering by facility was performed to identify independent predictors of receipt of MHS.

RESULTS

128,831 patients were identified of which 3.4% received MHS. Mean age was 41 y, 76% were male, 63% were White, 25% were Black, 12% were Hispanic, and 82% were insured. Median injury severity score was 9, and 54% were managed at an ACS level I trauma center. On regression analysis, female gender (aOR = 1.17, 95% CI = 1.09-1.25), age ≥65 y (aOR = 0.98, 95% CI = 0.97-0.99), White race (aOR = 1.37, 95% CI = 1.28-1.47), Hispanic ethnicity (aOR = 0.84, 95% CI = 0.76-0.93), insured status (aOR = 1.22, 95% CI = 1.13-1.33), and management at ACS level I trauma centers (aOR = 1.47, 95% CI = 1.38-1.57) were independent predictors of receipt of MHS.

CONCLUSIONS

Race, ethnicity, and socioeconomic factors predict the receipt of MHS in trauma patients with SUD and positive drug screens. It is unknown if these disparities affect the long-term outcomes of these vulnerable patients. Further research is warranted to expand on the contributing factors leading to these disparities and possible strategies to address them.

Association of copayments with healthcare utilization and expenditures among Medicaid enrollees with a substance use disorder

BACKGROUND

The purpose of this study was to examine the association between copayments and healthcare utilization and expenditures among Medicaid enrollees with substance use disorders.

METHODS

This study used claims data (2020-2021) from a private insurer participating in Arkansas's Medicaid expansion. We compared service utilization and expenditures for enrollees in different Medicaid program structures with varying copayments. Enrollees with incomes above 100 % FPL (N = 10,240) had copayments for substance use treatment services while enrollees below 100 % FPL (N = 2478) did not. Demographic, diagnostic, utilization, and cost information came from claims and enrollment information. The study identified substance use and clinical comorbidities using claims from July through December 2020 and evaluated utilization and costs in 2021. Generalized linear models (GLM) estimated outcomes using single equation and two-part modeling. A gamma distribution and log link were used to model expenditures, and negative binomial models were used to model utilization. A falsification test comparing behavioral health telemedicine utilization, which had no cost sharing in either group, assessed whether differences in the groups may be responsible for observed findings.

RESULTS

Substance use enrollees with copayments were less likely to have a substance use or behavioral health outpatient (-0.04 PP adjusted; p = 0.001) or inpatient visit (-0.04 PP; p = 0.001) relative to their counterparts without copayments, equal to a 17 % reduction in substance use or behavioral health outpatient services and a nearly 50 % reduction in inpatient visits. The reduced utilization among enrollees with a copayment was associated with a significant reduction in total expenses ($954; p = 0.001) and expenses related to substance use or behavioral health services ($532; p = 0.001). For enrollees with at least one behavioral health visit, there were no differences in outpatient or inpatient utilization or expenditures between enrollees with and without copayments. Copayments had no association with non-behavioral health or telemedicine services where neither group had cost sharing.

CONCLUSION

Copayments serve as an initial barrier to substance use treatment, but are not associated with the amount of healthcare utilization conditional on using services. Policy makers and insurers should consider the role of copayments for treatment services among enrollees with substance use disorders in Medicaid programs.

Barriers and facilitators to the implementation of the Flinders Chronic Condition Management Program in outpatient drug and alcohol settings in Australia

INTRODUCTION

There has been a growing call for drug and/or alcohol dependence to be managed as a chronic condition. The Flinders Chronic Condition Management Program (Flinders Program) was implemented in a drug and alcohol service in Australia in 2019-2022 to explore the feasibility of chronic condition management in outpatient clinics. Implementation involved: adaptation of the Flinders Program; adaptation of clinical procedures; training clinicians and managers; training Flinders Program Accredited Trainers; and system integration. This study aims to explore barriers and enablers to implementation.

METHODS

A qualitative formative evaluation was undertaken. Data included implementation documents (n = 7), responses to open-ended questions in post-training surveys (n = 27), and focus groups and interviews with implementation staff, clinicians, managers and a trainer (n = 16). Data were analysed using the Consolidated Framework for Implementation Research in a 'coding reliability' approach to thematic analysis.

RESULTS

Participants responded positively to the Flinders Program's philosophy, processes, tools and training. However, barriers were identified across three Consolidated Framework for Implementation Research domains: (i) outer setting (client suitability and incompatibility with external policies and incentives); (ii) characteristics of individuals (low self-efficacy); and (iii) inner setting (lack of system and workflow integration).

DISCUSSION AND CONCLUSIONS

Executive support and systems integration are important for the implementation of the Flinders Program in drug and alcohol services. This needs to be achieved within externally mandated key performance indicators for outpatient services. Further research is needed to fully evaluate the potential of a chronic condition management framework in Australian outpatient drug and alcohol services.

Imagining the future can shape the present: A systematic review of the impact of episodic future thinking on substance use outcomes

OBJECTIVE

The combination of the high prevalence of problematic substance use and substance use disorders (SUD) with the low rates of spontaneous remission continues to generate interest in the development of novel and efficacious interventions. Theoretically, episodic future thinking (EFT) is capable of targeting various underlying psychological and neurobiological substrates of SUD by traversing various research domain criteria systems.

METHOD

The systematic review examines EFT as a potentially efficacious intervention for problematic substance use and SUD. The review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We examined 46 full-text studies (from 1,238 total records obtained from APA PsycInfo and Pubmed databases and reference list search), which yielded a final sample of 16 studies.

RESULTS

The studies showed heterogeneity in their risk of bias, EFT protocols, and control conditions. Overall, EFT showed benefits in reducing self-reported or task-based substance use-related outcomes.

CONCLUSIONS

Future research directions include establishing the feasibility of EFT, examining the generalizability in decreasing real-world substance use, identifying mediators and moderators of EFT outcomes, and determining the sustainability of EFT effects over time. EFT has high potential for dissemination. Limitations and potential for future research are discussed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Untreated substance use disorder affects glycemic control: Results in patients with type 2 diabetes served within a network of community-based healthcare centers in Florida

Introduction

Patients with diabetes and comorbid substance use disorders (SUD) experience poor diabetes management, increased medical complications and mortality. However, research has documented that patients engaged in substance abuse treatment have better management of their comorbid conditions. The current study examines diabetes management among patients with type 2 diabetes, with and without comorbid SUD, receiving care at Florida-based Federally Qualified Health Centers (FQHC) of Health Choice Network (HCN).

Methods

A retrospective analysis was conducted using deidentified electronic health records of 37,452 patients with type 2 diabetes who received care at a HCN site in Florida between 2016 and 2019. A longitudinal logistic regression analysis examined the impact of SUD diagnosis on achievement of diabetes management [HbA1c < 7.0% (53 mmol/mol)] over time. A secondary analysis evaluated, within those with an SUD diagnosis, the likelihood of HbA1c control between those with and without SUD treatment.

Results

The longitudinal assessment of the relationship between SUD status and HbA1c control revealed that those with SUD (N = 6,878, 18.4%) were less likely to control HbA1c over time (OR = 0.56; 95% CI = 0.49-0.63). Among those with SUD, patients engaged in SUD treatment were more likely to control HbA1c (OR = 5.91; 95% CI = 5.05-6.91).

Discussion

Findings highlight that untreated SUD could adversely affect diabetes control and sheds light on the opportunity to enhance care delivery for patients with diabetes and co-occurring SUD.

Predicting and responding to change: Perceived environmental uncertainty among substance use disorder treatment programs

INTRODUCTION

Substance use disorder (SUD) treatment programs offering addiction health services (AHS) must be prepared to adapt to change in their operating environment. These environmental uncertainties may have implications for service delivery, and ultimately patient outcomes. To adapt to a multitude of environmental uncertainties, treatment programs must be prepared to predict and respond to change. Yet, research on treatment programs preparedness for change is sparse. We examined reported difficulties in predicting and responding to changes in the AHS system, and factors associated with these outcomes.

METHODS

Cross-sectional surveys of SUD treatment programs in the United States in 2014 and 2017. We used linear and ordered logistic regression to examine associations between key independent variables (e.g., program, staff, and client characteristics) and four outcomes, (1) reported difficulties in predicting change, (2) predicting effect of change on organization, (3) responding to change, and (4) predicting changes to make to respond to environmental uncertainties. Data were collected through telephone surveys.

RESULTS

The proportion of SUD treatment programs reporting difficulty predicting and responding to changes in the AHS system decreased from 2014 to 2017. However, a considerable proportion still reported difficulty in 2017. We identified that different organizational characteristics are associated with their reported ability to predict or respond to environmental uncertainty. Findings show that predicting change is significantly associated with program characteristics only, while predicting effect of change on organizations is associated with program and staff characteristics. Deciding how to respond to change is associated with program, staff, and client characteristics, while predicting changes to make to respond is associated with staff characteristics only.

CONCLUSIONS

Although treatment programs reported decreased difficulty predicting and responding to changes, our findings identify program characteristics and attributes that could better position programs with the foresight to more effectively predict and respond to uncertainties. Given resource constraints at multiple levels in treatment programs, this knowledge might help identify and optimize aspects of programs to intervene upon to enhance their adaptability to change. These efforts may positively influences processes or care delivery, and ultimately translate into improvements in patient outcomes.

Comparison of the acute effects of Tai chi versus high-intensity interval training on inhibitory control in individuals with substance use disorder

Objective

The purpose of this study is to investigate the effects of a single session of Tai chi (TC) exercise and high-intensity interval training (HIIT) on inhibitory control in individuals with substance use disorder (SUD).

Methods

A total 47 males with methamphetamine dependence were recruited from a compulsory drug rehabilitation center; participation in this study was voluntary. The participants were randomly assigned to the TC group or the HIIT group, and computer-based Go/No-go and Stroop tasks were used to assess inhibitory control in an indoor setting prior to and following exercise. Independent sample t-test was applied for baseline comparison of continuous variables, while analysis of variance was applied to test differences in the effect of each intervention before and after a single session of exercise.

Results

In Go/No-go test, the reaction time of the TC and HIIT groups in the post-test was shorter than that at the baseline, and the response accuracy of the post-test were higher than that of the baseline. In the Stroop task, the reaction time of two groups in the post-test was shorter than that at the baseline; while, greater improvement in response accuracy was observed in HIIT group in the post-test than that of the baseline.

Conclusion

Both TC and HIIT can promote inhibitory control in individuals with SUD. Compared with the TC group, the HIIT group showed greater improvements in response accuracy. These findings demonstrate the potential of TC and HIIT in improving cognition in SUD.

Clinical trial registration

[http://www.chictr.org.cn/], identifier [ChiCTR1900022158].

Thirty Years of TheASAMCriteria: A Report Card

The American Society of Addiction Medicine Criteria (ASAM) Criteria has profoundly influenced addiction treatment and reimbursement, with its growing toolkit of ASAM CONTINUUM software, ASAM-CARF Level of Care Certification Program, educational programs, and publications. A retrospective accounting shows that the field has made considerable strides, but has far to go. Providers and payers still need to (1) improve consistency in their use of standardized, multidimensional patient assessment; (2) improve flexibility in providing and reimbursing person-centered, individualized services; (3) improve measurement in treatment planning for determination of progress; and (4) focus on outcomes and value in the care they deliver.

Motherhood, pregnancy and gateways to intervene in substance use disorder

Motherhood increases women's use of health and social services, presenting opportunities to identify and refer women with substance use disorder (SUD) to treatment. We pooled 4 years (2015-2018) of cross-sectional data from National Survey on Drug Use and Health on women of child-bearing age (18-44) in the United States (n = 64,346). (1) We compared the use of services (health, social and criminal justice involvement) by SUD and 'motherhood' (pregnant or has one or more children under 18). We used multivariable logistic regression models to estimate the association between motherhood, SUD and their interaction with the use of services. (2) We estimated the association between the use of different services and SUD treatment use among women with SUD. Among women of child-bearing age, 9.7% had SUD. Mothers who had SUD were more likely to use social services (AOR = 1.48 [95% CI: 1.22, 1.79]) and mental health services compared with non-mothers who did not have SUD (AOR = 1.40 [95% CI: 1.19, 1.65]). The following factors were associated with increased odds of receiving SUD treatment among mothers: mental health treatment utilisation (AOR = 1.94 [95% CI: 1.29, 2.93]); Medicaid coverage (AOR = 2.48 [95% CI: 1.64, 3.76]); and criminal justice involvement (AOR = 3.38 [95% CI: 1.97, 5.80]). To increase treatment access, it is important to address women's different stages in life, including how to best engage women in SUD care across different settings.

Treatment providers' perspectives on a gender-responsive approach in alcohol and drug treatment for women in Belgium

BACKGROUND

Gender inequity is a pervasive challenge to health equity on a global scale, and research shows the impact of sex and gender on substance use regarding for example epidemiology, treatment needs, treatment admission and treatment outcomes. The gender-transformative approach to action and health indicates that health interventions may maintain, exacerbate or reduce gender-related health inequalities, depending on the degree and quality of gender-responsiveness within the programme or policy. However, research shows a lack of gender-responsive initiatives in the alcohol and drug addiction field.

AIMS

The purpose of this study is to explore in depth how alcohol and drug treatment can be made more sensitive to female users' treatment needs from the perspective of service providers. Consequently, study findings can inform the development of gender-responsive treatment options and aid to a deeper understanding of how these trends are designated on the continuum of approaches to action and health in the alcohol and drug field.

METHODS

Four focus groups were organized across different regions in Belgium with a total of 43 participants, including service providers, policy makers and women who use(d) drugs.

RESULTS

The perspective of the participants on substance use prevention and treatment for female users incorporates some crucial gender-specific and gender-transformative features. Next to implementing mother-child options, a holistic approach, experts by experience and empowering women in treatment, professionals report the relevance of awareness raising campaigns targeting all levels and sectors in society. Also, recurring attention was given to the role of men in the narratives of female users.

CONCLUSION

Study findings show that the field of alcohol and drug prevention and treatment is being looked at through the lens of gender-responsiveness. However, to achieve improvement in the lives of both women and men, and hence creating more equal chances and opportunities in substance abuse treatment, the gender-transformative approach in addiction care needs to be further explored, criticized and established in practice and future research.

Effectiveness of Mindfulness-Based Relapse Prevention in Individuals with Substance Use Disorders: A Systematic Review

OBJECTIVES

This systematic review aimed to understand the current state of the art about the effectiveness of mindfulness-based relapse prevention (MBRP) on individuals with substance use disorders (SUD), taking into account not only SUD variables (e.g., cravings, frequency of use) but also other relevant clinical variables (e.g., anxiety and depressive symptoms, quality of life).

METHODS

A comprehensive search of electronic databases was conducted to identify studies that investigate MBRP interventions on individuals with SUD. Studies that met the inclusion criteria were synthesized and assessed using systematic review methods.

RESULTS

Thirteen studies were included in the present review. The methodological quality of the included studies was moderately strong. Nine studies (69.2%) used the traditional 16 h MBRP program. Six studies (46.1%) chose to use a co-intervention treatment ranging from the treatment as usual (TAU) to cognitive behavioral therapy. All but one study indicated that their interventions produced positive effects on at least one addiction outcome measure. None of the interventions were evaluated across different settings or populations.

CONCLUSIONS

Despite some heterogeneity regarding the type of MBRP program used, results support the effectiveness of these interventions in the SUD population, especially in reducing cravings, decreasing the frequency of use, and improving depressive symptoms.

Medication assisted therapy and recovery homes

There is a need to better understand improved recovery supportive services for those on Medication Assisted Treatment (MAT) for opioid use disorder (OUD) and, at the same time, enhance the available treatment interventions and positive long-term outcomes for this vulnerable population. A growing empirical literature supports the assertion that improved access to housing and recovery support is a low-cost, high-potential opportunity that could help former substance users who are utilizing MAT to sustain their recovery. Recovery home support could serve the populations that need them most, namely servicing a significant number of the enrolled in MAT programs. The two largest networks of recovery homes are staff run Traditional Recovery Homes (TRH) and self-run Oxford House Recovery Homes (OH). There is a need to better understand how substance users on MAT respond to recovery homes, as well as how those in recovery homes feel toward those on MAT and how any barriers to those utilizing MAT may be reduced. Recovery may be an outcome of the transactional process between the recovering individual and his/her social environment. In particular, how recovery houses can help people on MAT attain long-term recovery.

Harmonizing healthcare and other resource measures for evaluating economic costs in substance use disorder research

BACKGROUND

Standardization and harmonization of healthcare resource utilization data can improve evaluations of the economic impact of treating people with substance use disorder (SUD), including reductions in use of expensive hospital and emergency department (ED) services, and can ensure consistency with current cost-effectiveness and cost-benefit analysis guidelines.

METHODS

We examined self-reported healthcare and other resource utilization data collected at baseline from three National Institute on Drug Abuse (NIDA)-funded Seek, Test, Treat, and Retain intervention studies of individuals living with/at risk for HIV with SUD. Costs were calculated by multiplying mean healthcare resource utilization measures by monetary conversion factors reflecting cost per unit of care. We normalized baseline recall timeframes to past 30 days and evaluated for missing data.

RESULTS

We identified measures that are feasible and appropriate for estimating healthcare sector costs including ED visits, inpatient hospital and residential facility stays, and outpatient encounters. We also identified two self-reported measures to inform societal costs (days experiencing SUD problems, participant spending on substances). Missingness was 8% or less for all study measures and was lower for single questions measuring utilization in a recall period.

CONCLUSIONS

We recommend including measures representing units of service with specific recall periods (e.g., 6 months vs. lifetime), and collecting healthcare resource utilization data using single-question measures to reduce missingness.

Cannabis use, other drug use, and risk of subsequent acute care in primary care patients

BACKGROUND

Cannabis and other drug use is associated with adverse health events, but little is known about the association of routine clinical screening for cannabis or other drug use and acute care utilization. This study evaluated whether self-reported frequency of cannabis or other drug use was associated with subsequent acute care.

METHOD

This retrospective cohort study used EHR and claims data from 8 sites in Washington State that implemented annual substance use screening. Eligible adult primary care patients (N = 47,447) completed screens for cannabis (N = 45,647) and/or other drug use, including illegal drug use and prescription medication misuse, (N = 45,255) from 3/3/15-10/1/2016. Separate single-item screens assessed frequency of past-year cannabis and other drug use: never, less than monthly, monthly, weekly, daily/almost daily. An indicator of acute care utilization measured any urgent care, emergency department visits, or hospitalizations ≤19 months after screening. Adjusted Cox proportional hazards models estimated risk of acute care.

RESULTS

Patients were predominantly non-Hispanic White. Those reporting cannabis use less than monthly (Hazard Ratio [HR] = 1.12, 95 % CI = 1.03-1.21) or daily (HR = 1.24; 1.10-1.39) had greater risk of acute care during follow-up than those reporting no use. Patients reporting other drug use less than monthly (HR = 1.34; 1.13-1.59), weekly (HR = 2.21; 1.46-3.35), or daily (HR = 2.53; 1.86-3.45) had greater risk of acute care than those reporting no other drug use.

CONCLUSION

Population-based screening for cannabis and other drug use in primary care may have utility for understanding risk of subsequent acute care. It is unclear whether findings will generalize to U.S. states with broader racial/ethnic diversity.

Current reporting of usability and impact of mHealth interventions for substance use disorder: A systematic review

BACKGROUND

Connected interventions use data collected through mobile/wearable devices to trigger real-time interventions and have great potential to improve treatment for substance use disorder (SUD). This review aims to describe the current landscape, effectiveness and usability of connected interventions for SUD.

METHODS

A systematic review was conducted to identify articles evaluating connected health interventions for SUD in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (PubMed, IEEE, and Scopus) were searched over a five-year period. Included articles described a connected health intervention targeting SUD and provided outcomes data. Data were extracted using a standardized reporting tool.

RESULTS

A total of 1676 unique articles were identified during the initial search, with 32 articles included in the final analysis. Seven articles of the 32 were derived from two large studies. The most commonly studied SUD was alcohol use disorder. Sixteen articles reported at least one statistically significant result with respect to reduced craving and/or substance use. The majority of articles used ecological momentary assessment to trigger interventions, while four used biologic/physiologic data. Two articles used a wearable device. Common intervention types included craving management, coping assistance, and tailored feedback. Twenty-three articles measured usability factors, and acceptability was generally reported as high.

CONCLUSION

Identified themes included a focus on AUD, use of smart phones, use of EMA for intervention delivery, positive effects on SUD related outcomes, and overall high acceptability. Wearables that directly monitor biologic data and predictive analytics using integrated data streams represent understudied opportunities for new research.

Healthcare utilization of individuals with substance use disorders following Affordable Care Act implementation in a California healthcare system

BACKGROUND

Practitioners expected the Affordable Care Act (ACA) to increase availability of health services and access to treatment for Americans with substance use disorders (SUDs). Yet research has not examined the associations among ACA enrollment mechanisms, deductibles, and the use of SUD treatment and other healthcare services. Understanding these relationships can inform future healthcare policy.

METHODS

We conducted a longitudinal analysis of patients with SUDs newly enrolled in the Kaiser Permanente Northern California health system in 2014 (N = 6957). Analyses examined the likelihood of service utilization (primary care, specialty SUD treatment, psychiatry, inpatient, and emergency department [ED]) over three years after SUD diagnosis, and associations with enrollment mechanisms (ACA Exchange vs. other), deductibles (none, $1-$999 [low] and ≥$1000 [high]), membership duration, psychiatric comorbidity, and demographic characteristics. We also evaluated whether the enrollment mechanism moderated the associations between deductible limits and utilization likelihood.

RESULTS

Service utilization was highest in the 6 months after SUD diagnosis, decreased in the following 6 months, and remained stable in years 2-3. Relative to patients with no deductible, those with a high deductible had lower odds of using all health services except SUD treatment; associations with primary care and psychiatry were strongly negative among Exchange enrollees. Among non-Exchange enrollees, patients with deductibles were more likely than those without deductibles to receive SUD treatment. Exchange enrollment compared to other mechanisms was associated with less ED use. Psychiatric comorbidity was associated with greater use of all services. Nonwhite patients were less likely to initiate SUD and psychiatry treatment.

CONCLUSIONS

Higher deductibles generally were associated with use of fewer health services, especially in combination with enrollment through the Exchange. The role of insurance factors, psychiatric comorbidity and race/ethnicity in health services for people with SUDs are important to consider as health policy evolves.

Factors influencing social work students' motivation to work in drug treatment settings: the role of knowledge and attitudes

Given the continuing problem of drug use in the United States and the high risk of burnout among substance use treatment staff, this study focuses on examining the relationship between social work students' knowledge and attitudes toward individuals who use drugs and their motivation to work in drug treatment settings. A Multiple linear regression analysis was conducted, using a convenience sample of 229 social work students (age = 21 to 60, female = 82.5%, White = 79.9%, African American = 13.5%, Asian = 2.6%, Hispanic = 3.9%) at a large public university in an eastern state. Results revealed that knowledge and positive attitudes were key factors stimulating social work students' motivation to work with individuals who use drugs, and knowledge was the most influential factor. Social work students are more likely to want to work with individuals who use drugs if they have positive attitudes toward their clients and increased knowledge of drugs and drug-related problems. Interestingly, there is no significant difference in motivation between those who have negative attitudes and other people. Implications for social work education on substance abuse are discussed.

Outpatient care for opioid use disorder among the commercially insured: Use of medication and psychosocial treatment

BACKGROUND

Evidence-based outpatient treatment for opioid use disorder (OUD) consists of medications that treat OUD (MOUD) and psychosocial treatments (e.g., psychotherapy or counseling, case management). Prior studies have not examined the use of these components of care in a commercially insured population.

METHODS

We analyzed claims data from a large national commercial insurer of enrollees age 17-64 identified with OUD (2008-2016, N = 87,877 persons and 122,708 person-years). Multinomial logistic regression models identified factors associated with receiving in a given year: 1) both MOUD and psychosocial visits, 2) MOUD without psychosocial visits, 3) psychosocial visits without MOUD, or 4) neither. We estimated predicted probabilities for key variables of interest.

RESULTS

Identification of OUD nearly tripled during the observation period (0.17% in 2008, 0.45% in 2016). Among person-years identified as having OUD, 36.3% included MOUD (8.1% both MOUD and psychosocial visits and 28.2% MOUD without psychosocial visits). In adjusted analyses, women had a lower probability of receiving either treatment alone or in combination (e.g.,MOUD plus psychosocial visits: women = 6.7% [6.5%-6.9%] vs. men = 9.2% [9.0%-9.4%]). Moderate/severe vs. mild OUD was associated with a higher probability of receiving MOUD (e.g., MOUD plus psychosocial visits: 8.7% [8.6%-8.9%] vs. 0.9% [0.7%-1.0%]). In contrast, an OUD overdose was associated with a greater probability of receiving neither treatment (78.2% [77.4%-79.0%] vs. 55.5% [55.2%-55.8%]). Over time, the probability of receiving each MOUD and psychosocial treatment category increased relative to 2008, but reached a peak and then plateaued or declined, by the end of the study period.

CONCLUSIONS

A significant treatment gap exists among individuals identified with OUD in this commercially insured population, with greater risks of receiving no treatment for women and for individuals with mild versus moderate or severe OUD. Overdose is associated with receiving neither MOUD nor psychosocial treatment. While treated prevalence initially increased relative to 2008, rates of treatment subsequently plateaued. Additional study and monitoring to elucidate barriers to OUD treatment in commercially insured populations are warranted.

Longitudinal properties of the PARADISE24fin questionnaire in treatment of substance use disorders

AIM

Improvement of overall functioning is an important goal in the treatment of substance use disorders, and thus tools for monitoring change are needed. The current study aimed to evaluate the longitudinal metric invariance and sensitivity to change for the PARADISE24fin questionnaire.

METHODS

A total of 1153 patients with substance use disorders completed the PARADISE24fin in two measurement occasions along their treatment. Patients were categorized into three groups according to their treatment status at the second occasion (end of the treatment, on-treatment follow-up, and re-start treatment). The latent structure of the PARADISE24fin questionnaire was analyzed in the two measurement occasions with confirmatory factor analyses. Evidence of the PARADISE24fin sensitivity to change was studied comparing mean change scores for the three treatment status groups.

RESULTS

The PARADISE24fin showed a strong longitudinal metric invariance across the two occasions in the three treatment status groups. The PARADISE24fin scores decreased during treatment, especially among the group of patients that had completed their treatment.

CONCLUSIONS

The PARADISE24fin is a reliable questionnaire to measure changes in psychosocial difficulties in substance use disorders overtime.

Consideration of opioid agonist treatment in a pregnant adolescent: A case report and literature review

Background: Opioid use greatly increases the risk of overdose death, as well as contracting human immunodeficiency virus (HIV) and hepatitis. Opioid agonist treatment is recommended for pregnant women who are dependent on opioids. However, there is a dearth of studies on the use of opioid agonist treatment in pregnant teenagers. Case: Ms. A, a 15 year-old G1PO in foster care, presented to our tertiary women's hospital requesting opioid agonist treatment for use of pill opioids. She reported nasal inhalation of 5-6 opioid tablets daily, with recent attempts to self-taper using nonprescribed buprenorphine since learning of her pregnancy. Last reported opioid use was >24 hours prior to admission. Urine drug testing was positive only for opioids (negative for buprenorphine and methadone). She did not exhibit significant withdrawal symptoms while hospitalized. The psychiatric treatment team recommended deferring opioid agonist treatment and pursuing outpatient substance use treatment. Unfortunately, Ms. A did not attend outpatient treatment and was lost to follow up. Discussion: Based upon our experience and review of the studies regarding opioid use disorder (OUD) and perinatal and adolescent opioid use, we recommend that pregnant adolescents with OUD be referred to opioid agonist treatment with buprenorphine or methadone. Studies specifically addressing opioid agonist treatment in pregnant teenagers are needed.

An Empirically-based Theory of the Relationships Among Social Embeddedness, Economic Viability, Learned Recovery Skills and Perceived Quality of Life in Recovery Homes

Key characteristics of recovery homes include governance style (which can play a central role in structuring recovery mechanisms), social embeddedness (e.g., social relationships within the home), economic viability (e.g., the individual's ability to be self-supporting), and learned recovery skills (such as coping with stress, avoiding putting one's self in risky situations, etc.). These domains can have important associations with perceived quality of life (measured across physical, psychological, social relationships, and environmental domains). The current study investigated relationships among these key "active ingredients" (Moos, 2007) of recovery homes. In addition, we present dynamic model consistent with these observed relationships, to illustrate how relevant mechanisms interact over time to and affect system evolution. Data were collected from recovery home residents in three states. Findings supported our overall hypotheses indicating that social embeddedness, stress, and self-efficacy were related to quality of life, and policy and treatment-design implications are further examined by simulating system dynamics.

Development of a Cascade of Care for responding to the opioid epidemic

Amid worsening opioid overdose death rates, the nation continues to face a persistent addiction treatment gap limiting access to quality care for opioid use disorder (OUD). Three FDA-approved medications (methadone, buprenorphine, and extended-release naltrexone) have high quality evidence demonstrating reductions in drug use and overdose events, but most individuals with OUD do not receive them. The development of a unified public health framework, such as a Cascade of Care, could improve system level practice and treatment outcomes. In response to feedback from many stakeholders over the past year, we have expanded upon the OUD treatment cascade, first published in 2017, with additional attention to prevention stages and both individual-level and population-based services to better inform efforts at the state and federal level. The proposed cascade framework has attracted considerable interest from federal agencies including the Centers for Disease Control and Prevention (CDC) and National Institute on Drug Abuse (NIDA) along with policy-makers nationwide. We have reviewed recent literature and evidence-based interventions related to prevention, identification, and treatment of individuals with OUD and modeled updated figures from the 2016 National Survey on Drug Use and Health. Many currently employed interventions (prescriber guidelines, prescription monitoring programs, naloxone rescue) address prevention of OUD or downstream complications but not treatment of the underlying disorder itself. An OUD Cascade of Care framework could help structure local and national efforts to combat the opioid epidemic by identifying key targets, interventions, and quality indicators across populations and settings to achieve these ends. Improved data collection and reporting methodology will be imperative.

Patient predictors of substance use disorder treatment initiation in primary care

INTRODUCTION

Primary care clinics are opportune settings in which to deliver substance use disorder (SUD) treatment, but little is known about which patients initiate treatment in these settings.

METHODS

Using secondary data from a RCT that aimed to integrate SUD treatment into a federally qualified health center (FQHC) using an organizational readiness and collaborative care (CC) intervention, we examined patient-level predictors of initiation of evidence-based practices for opioid and/or alcohol use disorders (OAUDs): a brief behavioral treatment (BT) based on motivational interviewing and cognitive behavioral therapy and medication-assisted treatment (MAT) (extended-release injectable naltrexone (XR-NTX) for patients with an alcohol use disorder or opioid use disorder and buprenorphine/naloxone (BUP/NX) for patients with an opioid use disorder). Using the Andersen model of health care access, we tested bivariate and multivariate logistic regression models to assess associations between patient factors and initiation of BT and MAT.

RESULTS

Twenty-three percent of all participants (N = 392) received BT and 13% received MAT. In the multivariate model examining factors associated with initiation of BT, being of "other" or "multiple" races compared with being White (OR = 0.45, CI = 0.22, 0.92), being homeless (OR = 0.45, CI = 0.21, 0.97) and having been arrested within 90 days of baseline (OR = 0.21 CI = 0.63, 0.69) were associated with significantly lower odds of initiating BT. Greater self-stigma (OR = 1.60, CI = 1.06, 2.42), receiving MAT (OR = 5.52, CI = 2.34, 12.98), and having received the CC study intervention (OR = 12.95, CI = 5.91, 28.37) were associated with higher odds of initiating BT. In the multivariate model examining patient factors associated with initiating MAT, older age (OR = 1.07, CI = 1.03, 1.11), female gender (OR = 3.05, CI = 1.25, 7.46), having a diagnosis of heroin abuse or dependence (with or without alcohol abuse or dependence compared with have a diagnosis of alcohol dependence only (OR = 3.03, CI = 1.17, 7.86), and having received at least one session of BT (OR = 6.42, CI = 2.59, 15.94), were associated with higher odds of initiating MAT.

CONCLUSIONS

Individuals who initiate BT for OAUDs in a FQHC are less likely to be homeless and more likely to have greater self-stigma. Those who receive MAT are more likely to be of older age, female, and to have a diagnosis of heroin abuse or dependence, with or without concomitant alcohol abuse or dependence, rather than alcohol abuse or dependence alone. Receiving collaborative care (e.g., a warm handoff, and follow-up by a care coordinator) may be critical to initiating BT. Receiving at least one session of BT is associated with higher odds of receiving MAT, and receiving MAT is associated with higher odds of receiving BT. The Andersen model of health care access provides some insight into who initiates BT and MAT for OAUD treatment in FQHC-based primary care; further research is needed to explore system-level factors that may also influence treatment initiation.

Feasibility of a Mobile Phone App to Support Recovery From Addiction in China: Secondary Analysis of a Pilot Study

Background

Mobile health technologies have been found to improve the self-management of chronic diseases. However, there is limited research regarding their feasibility in supporting recovery from substance use disorders (SUDs) in China.

Objective

The objective of this study was to examine the feasibility of a mobile phone-based ecological momentary assessment (EMA) app by testing the concordance of drug use assessed by the EMA, urine testing, and a life experience timeline (LET) assessment.

Methods

A total of 75 participants dependent on heroin or amphetamine-type stimulant (ATS) in Shanghai were recruited to participate in a 4-week pilot study. Of the participants, 50 (67% [50/75]) were randomly assigned to the experimental group and 25 (33% [25/75]) were assigned to the control group. The experimental group used mobile health (mHealth) based EMA technology to assess their daily drug use in natural environments and received 2 short health messages each day, whereas the control group only received 2 short health messages each day from the app. Urine tests and LET assessments were conducted each week and a post-intervention survey was administered to both groups. The correlations among the EMA, the LET assessment, and the urine test were investigated.

Results

The mean age of the participants was 41.6 (SD 8.0) years, and 71% (53/75) were male. During the 4 weeks of observation, 690 daily EMA survey data were recorded, with a response rate of 49.29% (690/1400). With respect to drug use, the percent of agreement between the EMA and the LET was 66.7%, 79.2%, 72.4%, and 85.8%, respectively, for each of the 4 weeks, whereas the percent of agreement between the EMA and the urine test was 51.2%, 65.1%, 61.9%, and 71.5%, respectively. The post-intervention survey indicated that 46% (32/70) of the participants preferred face-to-face interviews rather than the mHealth app.

Conclusions

This study demonstrated poor agreement between the EMA data and the LET and found that the acceptance of mHealth among individuals with SUDs in China was not positive. Hence, greater efforts are needed to improve the feasibility of mHealth in China.

Using Choice Architecture to Integrate Substance Use Services with Primary Care: Commentary on Donohue et al

: At a time when death and disability linked to problematic substance use have reached crisis levels, integration of substance use disorder (SUD) services into primary care settings is a clear national priority. Incentive-based interventions can catalyze such adoption, but have thus far demonstrated limited efficaciousness. Behavioral Economics can inform efforts to incentivize healthcare providers to adopt SUD interventions. Choice architecture principles dictate pegging rewards to defined quality metrics, improving provider information about effective and cost-effective practices, and reducing barriers to SUD service provision through technological tools, tackling stigma, and addressing real and perceived regulatory burdens and risks. Additional research is needed to inform these and other key elements in the choice environment designed to facilitate the integration of SUD care into primary care. Success in the deployment of the "cascade of care" model in primary care settings during the HIV/AIDS epidemic provides room for optimism, but also underscores the urgency of rapid scale-up in diagnostic and treatment services for SUD to address the burgeoning opioid crisis.

Medication-assisted treatment for substance use disorders within a national community health center research network

BACKGROUND

The Affordable Care Act increases access to treatment services for people who suffer from substance use disorders (SUDs), including alcohol use disorders (AUDs) and opioid use disorders (OUDs). This increased access to treatment has broad implications for delivering health services and creates a dramatic need for transformation in clinical care, service lines, and collaborative care models. Medication-assisted treatments (MAT) are effective for helping SUD patients reach better outcomes. This article uses electronic health record (EHR) data to examine the prevalence of EHR-documented SUDs, patient characteristics, and patterns of MAT prescribing and screening for patients within the Community Health Applied Research Network (CHARN), a national network of 17 community health centers that facilitates patient-centered outcomes research among underserved populations.

METHODS

Hierarchical generalized linear models examined patient characteristics, SUD occurrence rates, MAT prescription, and human immunodeficiency virus (HIV) and hepatitis virus C screening for patients with AUDs or OUDs. Results: Among 572,582 CHARN adult patients, 16,947 (3.0%) had a documented AUD diagnosis and 6,080 (1.1%) an OUD diagnosis. Alcohol MAT prescriptions were documented for 547 AUD patients (3.2%) and opioid MAT for 1,764 OUD patients (29.0%). Among OUD patients, opioid MAT was significantly associated with HIV screening (odds ratio [OR] = 1.31, P < .001) in OUD patients, as was alcohol MAT among AUD patients (OR = 1.30, P = .013).

CONCLUSIONS

These findings suggest that effective opioid and alcohol MAT may be substantially underprescribed among safety-net patients identified as having OUDs or AUDs.

Internalized stigma as an independent risk factor for substance use problems among primary care patients: Rationale and preliminary support

BACKGROUND

Little is known about internalized stigma among primary care patients, and whether the presence of internalized stigma is related to the severity of substance use problems independent of substance use-related variables. We sought to examine the relationship between internalized stigma and substance use problems among primary care patients with opioid or alcohol use disorders (OAUDs).

METHODS

We present baseline data from 393 primary care patients who were enrolled in a study of collaborative care for OAUDs. Regression analyses examined the relationship between internalized stigma and substance use problems, controlling for demographics, psychiatric comorbidity, and quantity/frequency of use.

RESULTS

The majority of participants reported thinking, at least sometimes, that they "have permanently screwed up" their lives (60%), and felt "ashamed" (60%), and "out of place in the world" (51%) as a result of their opioid or alcohol use. Higher internalized stigma was significantly related to more substance use problems (β=2.68, p<0.01), even after the effects of covariates were accounted for. Stigma added 22%, out of 51% total variance explained, leading to a significant improvement in prediction of substance use problems.

CONCLUSIONS

Among this group of primary care patients with OAUDs, rates of internalized stigma were comparable to those reported in specialty substance use treatment settings. Consistent with extant specialty care literature, our results suggest that internalized stigma may be a unique contributor that is associated with treatment outcomes, such as substance use problems, among primary care patients with OAUDs.

Depression care among adults with co-occurring major depressive episodes and substance use disorders in the United States

OBJECTIVE

We examined 12-month prevalence and correlates of receiving depression care and perceiving helpfulness of depression care among U.S. adults with major depressive episodes (MDE) and substance use disorders (SUD).

METHOD

Data were from 325,800 adults who participated in the 2008-2014 National Surveys on Drug Use and Health (NSDUH). Descriptive analyses and bivariable and multivariable logistic regression models were applied.

RESULTS

In the U.S., 3.3 million adults (1.4% of the adult population) had co-occurring MDE and SUD in the past year. Among adults with both disorders, 55.4% reported receiving past-year depression care. Among those with past-year depression care, 36.1% perceived it as helpful. Compared with adults who did not receive substance use treatment in the past year, those who received substance use treatment were significantly more likely to receive depression care, and those who received treatment of both disorders were more likely to perceive their depression care as helpful (adjusted risk ratios (ARRs) = 1.5-1.6). Compared with adults who received depression care only from general medical providers, those who received depression care from specialty mental health providers were more likely to report that their care was helpful (ARRs = 1.4-1.6). Receipt of prescription medication for MDE was associated with perceived helpfulness of depression care (ARR = 1.3, 95% CI = 1.05-1.73).

CONCLUSIONS

Almost half of adults with co-occurring MDE and SUD did not receive past-year depression care. Among those who received depression care, most did not perceive it as helpful. Substance use treatment, specialty mental health treatment, and antidepressant medications were perceived as helpful aspects of depression care.

Gender differences in the effects of childhood adversity on alcohol, drug, and polysubstance-related disorders

PURPOSE

To examine gender differences in the associations between childhood adversity and different types of substance use disorders and whether gender moderates these relationships.

METHODS

We analyzed data from 19,209 women and 13,898 men as provided by Wave 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to examine whether gender moderates the associations between childhood adversity and DSM-IV defined lifetime occurrence of alcohol, drug, and polysubstance-related disorders. We used multinomial logistic regression, weighted to be representative of the US adult civilian, noninstitutionalized population, and we calculated predicted probabilities by gender, controlling for covariates. To test which specific moderation contrasts were statistically significant, we conducted pair-wise comparisons corrected for multiple comparisons using Bonferroni's method.

RESULTS

For each type of substance use disorder, risk was increased by more exposure to childhood adversity, and women had a lower risk than men. However, moderation effects revealed that with more experiences of childhood adversity, the gender gap in predicted probability for a disorder narrowed in relation to alcohol, it converged in relation to drugs such that risk among women surpassed that among men, and it widened in relation to polysubstances.

CONCLUSIONS

Knowledge regarding substance-specific gender differences associated with childhood adversity exposure can inform evidence-based treatments. It may also be useful for shaping other types of gender-sensitive public health initiatives to ameliorate or prevent different types of substance use disorders.

Access to healthcare insurance and healthcare services among syringe exchange program clients in Massachusetts: qualitative findings from health navigators with the iDU ("I do") Care Collaborative

BACKGROUND

Little is known about access to health insurance among people who inject drugs (PWID) who attend syringe exchange programs (SEPs). The goal of the current study was to assess perceptions of SEP staff, including health navigators and program managers, on access to health insurance and healthcare access among SEP clients following implementation of state and federal policies to enhance universal healthcare access in Massachusetts.

METHODS

Between December 2014 and January 2015, we conducted in-depth interviews (n = 14) with SEP staff, including both program managers and health navigators, to assess knowledge, attitudes, and beliefs related to health insurance enrollment and access to enhanced referrals among SEP clients. We developed a preliminary coding scheme from the interview guide and used a grounded theory approach to guide inclusion of subsequent thematic codes that emanated from the data. We analyzed the coded data thematically in an iterative fashion using a consensus-based approach.

RESULTS

We identified five primary themes that emerged from the qualitative interviews, including high levels of health insurance enrollment among SEP clients; barriers to enrolling in health insurance; highly needed referrals to services, including improved access to substance use disorder treatment and hepatitis C virus treatment; barriers to referring clients to these highly needed services; and recommendations for policy change.

CONCLUSIONS

While barriers to enrollment and highly needed referrals remain, access to and enrollment in healthcare insurance plans among PWID at SEPs in Massachusetts are high. With the uncertain stability of the Affordable Care Act following the US presidential election of 2016, our findings summarize the opportunities and challenges that are connected to health insurance and healthcare access in Massachusetts. SEPs can play an important role in facilitating access to health insurance and enhancing access to preventive health and primary care.

Massachusetts Substance Use Disorder Treatment Organizations' Perspectives on the Affordable Care Act: Changes in Payment, Services, and System Design

The Affordable Care Act (ACA) expanded insurance benefits and coverage for substance use disorder (SUD) treatment and encouraged delivery and payment reforms. Massachusetts passed a similar reform in 2006. This study aims to assess Massachusetts SUD treatment organizations' responses to the ACA. Organizational interviews addressing challenges of and responses to the ACA were conducted in person June-December 2014 with 31 leaders at 12 treatment organizations across Massachusetts. Many organizations were affiliated with medical or social services and offered a range of SUD services. Sampling was based on services offered (detoxification only, detoxification and outpatient, outpatient only). Framework analysis was used. Challenges identified were considered similar to ongoing challenges, not unique to the ACA. Organizations experienced insurance expansions in 2006 and faced new challenges, including insurance coverage, payment arrangements, expansion of services, and system design. System design efforts included care coordination/integration, workforce development, and health information technology. Differences in responses related to connections with medical and social service organizations. Many organizations engaged in efforts to respond to changing policies by expanding capacity and services. Offering a range of SUD treatment (e.g., detoxification and outpatient) and affiliating with a medical organization could enable organizations to respond to new insurance, delivery, and payment reforms.

Psychoactive medications and disengagement from office based opioid treatment (obot) with buprenorphine

BACKGROUND

The prevalence of psychoactive medications (PAMs) use in patients enrolled in Office Based Opioid Treatment (OBOT) and its association with engagement in this care is largely unknown.

OBJECTIVE

To describe the use of PAMs, including those medications with emerging evidence of misuse ("emerging PAMs" - gabapentin, clonidine and promethazine) among patients on buprenorphine, and its association with disengagement from OBOT.

METHODS

This is a retrospective cohort study of adults on buprenorphine from January 2002 to February 2014. The association between use of PAMs and 6-month disengagement from OBOT was examined using multivariable logistic regression models. A secondary analysis exploring time-to-disengagement was conducted using Cox regression models.

RESULTS

At OBOT entry, 43% of patients (562/1308) were prescribed any PAM; including 17% (223/1308) on an emerging PAM. In separate adjusted analyses, neither the presence of any PAM (adjusted odds ratio [AOR] 1.07, 95% CI [0.78, 1.46]) nor an emerging PAM (AOR 1.28 [0.95, 1.74]) was significantly associated with 6-month disengagement. The results were similar for the Cox model (any PAM (adjusted hazard ratio [AHR] 1.16, 95% CI [1.00, 1.36]), emerging PAM (AHR 1.18 [0.98, 1.41])). Exploratory analyses suggested gabapentin (AHR 1.30 [1.05-1.62]) and clonidine (AHR 1.33 [1.01-1.73]) specifically, may be associated with an overall shorter time to disengagement.

CONCLUSIONS

Psychoactive medication use is common among patients in buprenorphine treatment. No significant association was found between the presence of any psychoactive medications, including medications with emerging evidence of misuse, and 6-month disengagement from buprenorphine treatment.

Opportunities for social work under the Affordable Care Act: A call for action

The Affordable Care Act (ACA) has profoundly restructured American health care. Numerous social work authors have commented on the importance of the ACA's reforms to social work practice, education, and research. This article summarizes the literature, adds relevant information, and makes recommendations for future actions. The policy, opinion, and peer-reviewed literatures were systematically reviewed. Sixty-three publications appeared between 2010 and 2015 are included. Five themes emerged, as follows: 1) the crucial provisions of the ACA, 2) the natural affinity of social work and the ACA reforms, 3) curricular adaptations needed to address changing workforce needs, 4) areas for continued social work advocacy, and 5) opportunities for high-impact social work research. This article provides a comprehensive introduction to the ACA, its reforms, and opportunities for social work to assume a high visibility leadership role in implementing the reforms, with particular emphasis on needed curricular changes and opportunities for research.

Motivational Interviewing: Creating a Leadership Role for Social Work in the Era of Healthcare Reform

To better address the needs of individuals with a range of complex health conditions, the Affordable Care Act has shifted the focus from acute care to prevention through behavior change and promoted the integration of physical and behavioral healthcare systems. Central to healthcare reform is delivering person-centered care, which means actively engaging people in their treatment decisions and managing their wellness. Motivational Interviewing (MI) is perhaps the most widely used intervention to promote behavior change. Although MI is utilized across most health disciplines, social workers are uniquely positioned to lead dissemination and on-going training efforts in this area.

The Affordable Care Act, Substance Use Disorders, and Low-Income Clients: Implications for Social Work

Social workers are leaders in the substance abuse services field and may often work in substance use disorder (SUD) education, prevention, assessment, treatment, or resource coordination and case management roles. As the Patient Protection and Affordable Care Act (ACA) (2010) drives changes in the fields of health and behavioral health, social workers have an opportunity to lead structural changes at the micro and macro levels that will have a positive impact on low-income clients with SUDs. In this article, authors examine the current state of SUDs and health care access, the impact of the ACA on the field, and implications for social work practice and education. Social workers should seek specialized education and credentialing in SUD services, know how to help clients apply for health care coverage, and advocate for integrated substance abuse treatment and health care programs and an expansion of Medicaid in their local communities. Social workers are well positioned to be a voice for clients to ensure that the current structural changes result in a better, integrated system of care that is able to respond to the needs of low-income clients with SUDs.

SBIRT-A: Adapting SBIRT to Maximize Developmental Fit for Adolescents in Primary Care

The Screening, Brief Intervention and Referral to Treatment (SBIRT) model is widely recommended as part of routine visits in pediatric primary care despite a dearth of evidence on its effectiveness, feasibility, and developmental appropriateness for adolescents in this setting. The purpose of this article is to explicate ways that SBIRT may be tailored to better serve adolescents in primary care under a set of recommended adaptations that we refer to collectively as SBIRT-A or Screening, Brief Intervention, and Referral to Treatment for Adolescents. Each component of the SBIRT-A framework incorporates recommendations to optimize developmental fit with adolescents based on extant empirical research, developmental theory, and well-documented barriers to service delivery in primary care. Commonalities across proposed adaptations include reliance upon proactive methods to identify and engage youth; innovation in service delivery aimed at improving the consistency and reach of interventions; and a family-focused approach to engagement, assessment, and intervention. Specific recommendations include taking advantage of every clinical encounter with the family to screen, involving caregivers in assessments and brief interventions, leveraging technology to administer brief interventions and booster sessions, and patient- and family-centered procedures for treatment referral and engagement. The adaptations proposed in this article have the potential to enhance the detection of adolescents with SU problems in primary care, the consistency of intervention provision, and engagement of this typically recalcitrant population into appropriate treatment.

The Diffusion of Acamprosate for the Treatment of Alcohol Use Disorder: Results From a National Longitudinal Study

To consider how the Affordable Care Act may impact the diffusion of acamprosate, an evidence-based treatment for alcohol use disorder (AUD), the present study estimated the associations between acamprosate availability, Medicaid revenues, and private insurance revenues. Data were collected from organizational leaders of national samples of 307 specialty treatment centers in 2009-2012 and 372 treatment centers in 2011-2013. Notably, there was not a significant change in the percentage of organizations offering acamprosate over the study period. However, greater reliance on Medicaid and private insurance as sources of revenue was positively associated with the availability of acamprosate. In addition, acamprosate availability was positively associated with access to physicians and the presence of on-site primary medical care, while centers that placed greater emphasis on confrontational group therapy were significantly less likely to offer acamprosate for AUD treatment. To the extent that the ACA is expanding the number of insured individuals enrolled in Medicaid and commercial insurance sold through health insurance exchanges, this study suggests that the ACA may hold promise for expanding the availability of this EBP for AUD treatment. Future research is needed to measure whether this potential impact actually occurs within the specialty treatment system over time.

Substance use and mental diagnoses among adults with and without type 2 diabetes: Results from electronic health records data

BACKGROUND

Comorbid diabetes and substance use diagnoses (SUD) represent a hazardous combination, both in terms of healthcare cost and morbidity. To date, there is limited information about the association of SUD and related mental disorders with type 2 diabetes mellitus (T2DM).

METHODS

We examined the associations between T2DM and multiple psychiatric diagnosis categories, with a focus on SUD and related psychiatric comorbidities among adults with T2DM. We analyzed electronic health record (EHR) data on 170,853 unique adults aged ≥18 years from the EHR warehouse of a large academic healthcare system. Logistic regression analyses were conducted to estimate the strength of an association for comorbidities.

RESULTS

Overall, 9% of adults (n=16,243) had T2DM. Blacks, Hispanics, Asians, and Native Americans had greater odds of having T2DM than whites. All 10 psychiatric diagnosis categories were more prevalent among adults with T2DM than among those without T2DM. Prevalent diagnoses among adults with T2MD were mood (21.22%), SUD (17.02%: tobacco 13.25%, alcohol 4.00%, drugs 4.22%), and anxiety diagnoses (13.98%). Among adults with T2DM, SUD was positively associated with mood, anxiety, personality, somatic, and schizophrenia diagnoses.

CONCLUSIONS

We examined a large diverse sample of individuals and found clinical evidence of SUD and psychiatric comorbidities among adults with T2DM. These results highlight the need to identify feasible collaborative care models for adults with T2DM and SUD related psychiatric comorbidities, particularly in primary care settings, that will improve behavioral health and reduce health risk.

Successful Organizational Strategies to Sustain Use of A-CHESS: A Mobile Intervention for Individuals With Alcohol Use Disorders

Background

Mobile health (mHealth) services are growing in importance in health care research with the advancement of wireless networks, tablets, and mobile phone technologies. These technologies offer a wide range of applications that cover the spectrum of health care delivery. Although preliminary experiments in mHealth demonstrate promising results, more robust real-world evidence is needed for widespread adoption and sustainment of these technologies.

Objective

Our aim was to identify the problems/challenges associated with sustained use of an mHealth addiction recovery support app and to determine strategies used by agencies that successfully sustained client use of A-CHESS.

Methods

Qualitative inquiry assessed staff perceptions about organizational attributes and strategies associated with sustained use of the mobile app, A-CHESS. A total of 73 interviews of clinicians and administrators were conducted. The initial interviews (n=36) occurred at the implementation of A-CHESS. Follow-up interviews (n=37) occurred approximately 12 and 24 months later. A coding scheme was developed and Multiuser NVivo was used to manage and analyze the blinded interview data.

Results

Successful strategies used by treatment providers to sustain A-CHESS included (1) strong leadership support, (2) use of client feedback reports to follow up on non-engaged clients, (3) identify passionate staff and incorporate A-CHESS discussions in weekly meetings, (4) develop A-CHESS guidelines related to client use, (5) establish internal work groups to engage clients, and (6) establish a financial strategy to sustain A-CHESS use. The study also identified attributes of A-CHESS that enhanced as well as inhibited its sustainability.

Conclusions

Mobile apps can play an important role in health care delivery. However, providers will need to develop strategies for engaging both staff and patients in ongoing use of the apps. They will also need to rework business processes to accommodate the changes in communication frequency and style, learn to use app data for decision making, and identify financing mechanisms for supporting these changes.

Challenges and opportunities for integrating preventive substance-use-care services in primary care through the Affordable Care Act

Undertreated or untreated substance use disorders (SUD) remain a pervasive, medically-harmful public health problem in the United States, particularly in medically underserved and low-income populations lacking access to appropriate treatment. The need for greater access to SUD treatment was expressed as policy in the Final Rule on standards related to essential health benefits, required to be covered through the 2010 Affordable Care Act (ACA) health insurance exchanges. SUD treatment services have been included as an essential health benefit, in a manner that complies with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. Consequently, with the ACA, a vast expansion of SUD-care services in primary care is looming. This commentary discusses challenges and opportunities under the ACA for equipping health care professionals with appropriate workforce training, infrastructure, and resources to support and guide science-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) for SUD in primary care.

Barriers and Facilitators to Substance Use Treatment in the Rural South: A Qualitative Study

PURPOSE

Little qualitative research has examined factors associated with care in substance abuse treatment agencies in Southeastern rural communities. This study explored client- and agency stakeholder-perceived barriers and facilitators to substance use treatment delivery in southeastern rural communities.

METHODS

Group and individual interviews were conducted with 40 key stakeholders and 40 clients at 9 substance abuse agencies serving rural communities in a southeastern state. Qualitative thematic analysis was used to identify perceived barriers and facilitators to substance abuse services in rural communities.

FINDINGS

Four primary themes emerged from the client and stakeholder interviews as both barriers and facilitators: availability of services for individuals with substance use disorders; access to the current technology for client services and agency functioning; cost of services; and stigma.

CONCLUSIONS

This study identifies novel barriers and facilitators to substance use care in the rural South and highlights essential areas for consideration when developing and implementing substance use care in this geographic region. These findings can be used as guidelines to provide better care to individuals with substance use disorders living in rural communities.

Examining attrition rates at one specialty addiction treatment provider in the United States: a case study using a retrospective chart review

Background

Engaging individuals who have a substance use disorder (SUD) in treatment continues to be a challenge for the specialty addiction treatment field. Research has consistently revealed high rates of missed appointments at each step of the enrollment process: 1. between calling for services and assessment, 2. between assessment and enrollment, and 3. between enrollment and completion of treatment. Extensive research has examined each step of the process; however, there is limited research examining the overall attrition rate across all steps.

Methods

A single case study of a specialty addiction treatment agency was used to examine the attrition rates across the first three steps of the enrollment process. Attrition rates were tracked between August 1, 2011 and July 31, 2012. The cohort included 1822 unique individuals who made an initial request for addiction treatment services. Monthly retrospective reviews of medical records, phone logs, and billing data were used to calculate attrition rates. Attrition rates reported in the literature were collected and compared to the rates found at the target agency.

Results

Median time between request for treatment and assessment was 6 days (mean 7.5) and between assessment and treatment enrollment was 8 days (mean 12.5). An overall attrition rate of 80% was observed, including 45% between call and assessment, 32% between assessment and treatment enrollment (another 17% could not be determined), and 37% left or were removed from treatment before 30 days. Women were less likely to complete 30 days of treatment compared to men. No other demographics were related to attrition rates.

Discussion

One out of every five people who requested treatment completed a minimum of 30 days of a treatment. The attrition rate was high, yet similar to rates noted in the literature. Limitations of the single case study are noted.

Conclusion

Attrition rates in the U.S. are high with approximately 75% to 80% of treatment seekers disengaging at one of the multiple stages of the enrollment and treatment process. Significant changes in the system are needed to improve engagement rates.

Medications development for substance-use disorders: contextual influences (dis)incentivizing pharmaceutical-industry positioning

INTRODUCTION

The significant contribution of substance-use disorders (SUDs) to the global-disease burden and associated unmet medical needs has not engendered a commensurate level of pharma-industry research and development (R&D) for novel SUD therapeutics invention. Analysis of contextual factors shaping this position suggests potential routes toward incentivizing R&D commitment for that purpose.

AREAS COVERED

This article considers multiple primary factors that have consorted to disincentivize pharma industry's operating in the SUD space: ill-understood pathology; variegated treatments and patient profiles; involved clinical trials; and - with particular reference to SUDs-negative cultural/business stigmas and shallow commercial precedent. Industry incentivization for SUD drug innovation requires progress on several fronts, including: translational experimental data and systems; personalized, holistic SUD treatment approaches; interactions among pharma, nonindustry constituencies, and the medical profession with vested interests in countering negative stereotypes and expanding SUD treatment options; and public-private alliances focused on improving SUD pharmacotherapy.

EXPERT OPINION

Given the well-entrenched business stance whereby the prospect of future profits in major markets largely determines drug-company R&D investment trajectory, strategic initiatives offering substantial reductions in the risks and opportunity (i.e., time and money) costs associated with SUD drug discovery are likely to be the most potent drivers for encouraging mainstream industry positioning in this therapeutic area. Such initiatives could originate from front-loaded R&D operational and back-loaded patent, regulatory, marketing and health-care policy reforms. These may be too involved and protracted for the turbulent pharmaceutical industry to entertain amid its recent retrenchment from psychiatric/CNS diseases and intense pressures to increase productivity and shareholder value.

Patient registries for substance use disorders

This commentary discusses the need for developing patient registries of substance use disorders (SUD) in general medical settings. A patient registry is a tool that documents the natural history of target diseases. Clinicians and researchers use registries to monitor patient comorbidities, care procedures and processes, and treatment effectiveness for the purpose of improving care quality. Enactments of the Affordable Care Act 2010 and the Mental Health Parity and Addiction Equity Act 2008 open opportunities for many substance users to receive treatment services in general medical settings. An increased number of patients with a wide spectrum of SUD will initially receive services with a chronic disease management approach in primary care. The establishment of computer-based SUD patient registries can be assisted by wide adoption of electronic health record systems. The linkage of SUD patient registries with electronic health record systems can facilitate the advancement of SUD treatment research efforts and improve patient care.