Common data elements for substance use disorders in electronic health records: the NIDA Clinical Trials Network experience

An International, Multidisciplinary Consensus Set of Patient-Centered Outcome Measures for Substance-Related and Addictive Disorders

Background: In 1990, the United States' Institute of Medicine promoted the principles of outcomes monitoring in the alcohol and other drugs treatment field to improve the evidence synthesis and quality of research. While various national outcome measures have been developed and employed, no global consensus on standard measurement has been agreed for addiction. It is thus timely to build an international consensus. Convened by the International Consortium for Health Outcomes Measurement (ICHOM), an international, multi-disciplinary working group reviewed the existing literature and reached consensus for a globally applicable minimum set of outcome measures for people who seek treatment for addiction. Methods: To this end, 26 addiction experts from 11 countries and 5 continents, including people with lived experience (n = 5; 19%), convened over 16 months (December 2018-March 2020) to develop recommendations for a minimum set of outcome measures. A structured, consensus-building, modified Delphi process was employed. Evidence-based proposals for the minimum set of measures were generated and discussed across eight videoconferences and in a subsequent structured online consultation. The resulting set was reviewed by 123 professionals and 34 people with lived experience internationally. Results: The final consensus-based recommendation includes alcohol, substance, and tobacco use disorders, as well as gambling and gaming disorders in people aged 12 years and older. Recommended outcome domains are frequency and quantity of addictive disorders, symptom burden, health-related quality of life, global functioning, psychosocial functioning, and overall physical and mental health and wellbeing. Standard case-mix (moderator) variables and measurement time points are also recommended. Conclusions: Use of consistent and meaningful outcome measurement facilitates carer-patient relations, shared decision-making, service improvement, benchmarking, and evidence synthesis for the evaluation of addiction treatment services and the dissemination of best practices. The consensus set of recommended outcomes is freely available for adoption in healthcare settings globally.

Adoption of Electronic Health Record Among Substance Use Disorder Treatment Programs: Nationwide Cross-Sectional Survey Study

BACKGROUND

Electronic health record (EHR) systems have been shown to be associated with improvements in care processes, quality of care, and patient outcomes. EHR also has a crucial role in the delivery of substance use disorder (SUD) treatment and is considered important for addressing SUD crises, including the opioid epidemic. However, little is known about the adoption of EHR in SUD treatment programs or the organizational-level factors associated with the adoption of EHR in SUD treatment.

OBJECTIVE

We examined the adoption of EHR in SUD programs, with a focus on changes in adoption from 2014 to 2017, and identified organizational-level factors associated with EHR adoption.

METHODS

We used data from the 2014 and 2017 National Drug Abuse Treatment System Surveys. Our analysis included 1027 SUD programs (531 in 2014 and 496 in 2017). We used chi-square and Mann-Whitney U tests for categorical and continuous variables, respectively, to assess changes in EHR adoption, technology use, program, and client characteristics. We also investigated differences in characteristics and barriers to adoption by EHR adoption status (adopted EHR vs had not adopted or were planning to adopt EHR). We then conducted multivariate logistic regressions to examine internal and external factors associated with EHR adoption.

RESULTS

The adoption of EHR increased significantly from 57.6% (306/531) in 2014 to 69.2% (343/496) in 2017 (P<.001), showing that nearly one-third (153/496, 30.8%) of SUD programs had not yet adopted an EHR system by 2017. We identified a significant increase in technology use and ownership by a parent company (P=.01 and P<.001) and a decrease in the percentage of uninsured patients in 2017 (P<.001), compared to 2014. Our analysis further showed significant differences by adoption status for three major barriers to adoption: (1) start-up costs, (2) ongoing financial costs, and (3) privacy or security concerns (P<.001). Programs that used computerized scheduling (adjusted odds ratio [AOR] 3.02, 95% CI 2.23-4.09) and billing systems (AOR 2.29, 95% CI 1.62-3.25) were more likely to adopt EHR. Similarly, ownership type, such as private nonprofit (AOR 1.86, 95% CI 1.31-2.65) and public (AOR 2.14, 95% CI 1.27-3.67), or interest in participating in a patient-centered medical home (AOR 1.93, 95% CI 1.29-2.92), were associated with an increased likelihood to adopt EHR. Overall, SUD programs were more likely to adopt an EHR system in 2017 compared to 2014 (AOR 1.44, 95% CI 1.07-1.94).

CONCLUSIONS

Our findings highlighted that SUD programs may be on track to achieve widespread EHR adoption. However, there is a need for focused strategies, resources, and policies explicitly designed to systematically address barriers and tackle obstacles to expanding the adoption of EHR systems. These efforts must be holistic and address factors at multiple organizational levels.

Patterns of substance use among adolescents in and out of foster care: An analysis of linked health and child welfare administrative data

BACKGROUND

Young adults with a history of foster care have higher risk for substance use disorders. Social systems can deliver substance use prevention to youth; however, the timing of intervention delivery and how needs differ for youth in foster care are unclear.

OBJECTIVE

To compare initiation and rates of substance use among adolescents in foster care to demographically similar adolescents never in foster care as identified by the healthcare system, and identify factors associated with increased substance use.

PARTICIPANTS AND SETTING

Youth in foster care (n = 2787, ages 10-20, inclusive) and demographically matched youth never in foster care (n = 2787) were identified using linked child welfare and electronic health records from a single pediatric children's hospital and county over a five-year period (2012-2017).

METHODS

All healthcare encounters were reviewed and coded for substance use by type (alcohol, tobacco, cannabis, other). Age of first reported or documented substance use was also captured. Demographic and child welfare information was extracted from administrative records. Survival and logistic regression models were estimated.

RESULTS

In adjusted models, youth in foster care initiated substance use at earlier ages (HR = 2.50, p < .01) and had higher odds of engaging in use (AOR = 1.54; p < .01) than youth never in care. By age 12, substance use initiation was more likely while youth were in foster care than when they were not in foster care (HR = 1.42, p < .01). Placement stability and family care settings reduced odds of lifetime substance use.

CONCLUSIONS

Foster care placement is associated with substance use. Screening may be important for prevention.

Pilot Testing of an mHealth App for Tobacco Cessation in People Living With HIV: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

An estimated 40% of people living with HIV smoke cigarettes. Although smoking rates in the United States have been declining in recent years, people living with HIV continue to smoke cigarettes at twice the rate of the general population. Mobile health (mHealth) technology is an effective tool for people living with a chronic illness, such as HIV, as currently 84% of households in the United States report that they have a smartphone. Although many studies have used mHealth interventions for smoking cessation, few studies have recruited people living with HIV who smoke.

OBJECTIVE

The objective of the pilot randomized controlled trial (RCT) is to examine the feasibility, acceptability, and preliminary efficacy of the Sense2Quit App as a tool for people living with HIV who are motivated to quit smoking.

METHODS

The Sense2Quit study is a 2-arm RCT for people living with HIV who smoke cigarettes (n=60). Participants are randomized to either the active intervention condition, which consists of an 8-week supply of nicotine replacement therapy, standard smoking cessation counseling, and access to the Sense2Quit mobile app and smartwatch, or the control condition, which consists of standard smoking cessation counseling and a referral to the New York State Smokers' Quitline. The Sense2Quit app is a mobile app connected through Bluetooth to a smartwatch that tracks smoking gestures and distinguishes them from other everyday hand movements. In the Sense2Quit app, participants can view their smoking trends, which are recorded through their use of the smartwatch, including how often or how much they smoke and the amount of money that they are spending on cigarettes, watch videos with quitting tips, information, and distractions, play games, set reminders, and communicate with a study team member.

RESULTS

Enrollment of study participants began in March 2023 and is expected to end in October 2023. All data collection is expected to be completed by the end of January 2024. This RCT will test the difference in outcomes between the control and intervention arms. The primary outcome will be the percentage of participants with biochemically verified 7-day point prevalence smoking or tobacco abstinence at their 12-week follow-up. Results from this pilot study will be disseminated to the research community following the completion of all data collection.

CONCLUSIONS

The Sense2Quit study leverages mHealth so that it can help smokers improve their efforts at smoking cessation. Our research has the potential to not only increase quitting rates among people living with HIV who may need a prolonged, tailored intervention but also inform further development of mHealth for people living with HIV. This mHealth study will contribute significant findings to the greater mHealth research community, providing evidence as to how mHealth should be developed and tested among the target population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05609032; https://clinicaltrials.gov/study/NCT05609032.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49558.

Development and testing of data infrastructure in the American College of Emergency Physicians' Clinical Emergency Data Registry for opioid-related research

Objective

Prior research has identified gaps in the capacity of electronic health records (EHRs) to capture the intricacies of opioid-related conditions. We sought to enhance the opioid data infrastructure within the American College of Emergency Physicians' Clinical Emergency Data Registry (CEDR), the largest national emergency medicine registry, through data mapping, validity testing, and feasibility assessment.

Methods

We compared the CEDR data dictionary to opioid common data elements identified through prior environmental scans of publicly available data systems and dictionaries used in national informatics and quality measurement of policy initiatives. Validity and feasibility assessments of CEDR opioid-related data were conducted through the following steps: (1) electronic extraction of CEDR data meeting criteria for an opioid-related emergency care visit, (2) manual chart review assessing the quality of the extracted data, (3) completion of feasibility scorecards, and (4) qualitative interviews with physician reviewers and informatics personnel.

Results

We identified several data gaps in the CEDR data dictionary when compared with prior environmental scans including urine drug testing, opioid medication, and social history data elements. Validity testing demonstrated correct or partially correct data for >90% of most extracted CEDR data elements. Factors affecting validity included lack of standardization, data incorrectness, and poor delimitation between emergency department (ED) versus hospital care. Feasibility testing highlighted low-to-moderate feasibility of date and social history data elements, significant EHR platform variation, and inconsistency in the extraction of common national data standards (eg, Logical Observation Identifiers Names and Codes, International Classification of Diseases, Tenth Revision codes).

Conclusions

We found that high-priority data elements needed for opioid-related research and clinical quality measurement, such as demographics, medications, and diagnoses, are both valid and can be feasibly captured in a national clinical quality registry. Future work should focus on implementing structured data collection tools, such as standardized documentation templates and adhering to data standards within the EHR that would better characterize ED-specific care for opioid use disorder and related research.

The opioid use disorder core outcomes set (OUD-COS) for treatment research: findings from a Delphi consensus study

BACKGROUND AND AIM

There is no gold-standard and considerable heterogeneity in outcome measures used to evaluate treatments for opioid use disorder (OUD) along the opioid treatment cascade. The aim of this study was to develop the US National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network (CTN) opioid use disorder core outcomes set (OUD-COS).

DESIGN

Four-round, e-Delphi expert panel consensus study and plenary research group discussion and targeted consultation.

SETTING

United States.

PARTICIPANTS

A panel of 25 members including clinical practitioners, clinical researchers and administrative staff from the CTN, the network's affiliated clinical and community sites and the NIDA Centre for the CTN.

MEASUREMENTS

From a pool of 24 candidate items in four domains (biomedical/disease status; behaviors, symptoms and functioning; opioid treatment cascade; and morbidity and mortality), the panel completed an on-line questionnaire to rank items with defined specification on a 9-point scale for importance, with a standard 70% consensus criterion.

FINDINGS

After the fourth round of the questionnaire and subsequent discussion, consensus was reached for five outcomes: two patient-reported (global impression of improvement and incident non-fatal overdose); one clinician-reported (illicit/non-medical drug toxicology); and two from administrative records (duration of treatment and fatal opioid poisoning).

CONCLUSIONS

An e-Delphi consensus study has produced the US National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network opioid use disorder core outcomes set (version 1) for opioid use disorder treatment efficacy and effectiveness research.

Automated detection of substance use information from electronic health records for a pediatric population

OBJECTIVE

Substance use screening in adolescence is unstandardized and often documented in clinical notes, rather than in structured electronic health records (EHRs). The objective of this study was to integrate logic rules with state-of-the-art natural language processing (NLP) and machine learning technologies to detect substance use information from both structured and unstructured EHR data.

MATERIALS AND METHODS

Pediatric patients (10-20 years of age) with any encounter between July 1, 2012, and October 31, 2017, were included (n = 3890 patients; 19 478 encounters). EHR data were extracted at each encounter, manually reviewed for substance use (alcohol, tobacco, marijuana, opiate, any use), and coded as lifetime use, current use, or family use. Logic rules mapped structured EHR indicators to screening results. A knowledge-based NLP system and a deep learning model detected substance use information from unstructured clinical narratives. System performance was evaluated using positive predictive value, sensitivity, negative predictive value, specificity, and area under the receiver-operating characteristic curve (AUC).

RESULTS

The dataset included 17 235 structured indicators and 27 141 clinical narratives. Manual review of clinical narratives captured 94.0% of positive screening results, while structured EHR data captured 22.0%. Logic rules detected screening results from structured data with 1.0 and 0.99 for sensitivity and specificity, respectively. The knowledge-based system detected substance use information from clinical narratives with 0.86, 0.79, and 0.88 for AUC, sensitivity, and specificity, respectively. The deep learning model further improved detection capacity, achieving 0.88, 0.81, and 0.85 for AUC, sensitivity, and specificity, respectively. Finally, integrating predictions from structured and unstructured data achieved high detection capacity across all cases (0.96, 0.85, and 0.87 for AUC, sensitivity, and specificity, respectively).

CONCLUSIONS

It is feasible to detect substance use screening and results among pediatric patients using logic rules, NLP, and machine learning technologies.

Using a health information technology survey to explore the availability of addiction treatment data in the electronic health records: A National Drug Abuse Treatment Clinical Trials Network study

BACKGROUND

Healthcare data from electronic health records (EHRs) and related health information technology (IT) tools are critical data sources for pragmatic clinical trials and observational studies aimed at producing real-world evidence. To unlock the full potential of such data to advance science, the data must be complete and in structured formats to facilitate research use.

METHODS

A Health IT survey was conducted within the National Drug Abuse Treatment Clinical Trials Network (CTN) to explore information related to data completeness and presence of unstructured data (e.g., clinical notes, free text) for conducting the EHR-based research for substance use disorders (SUDs). The analysis was based on 36 participants from 36 facilities located in 14 states and affiliated with the CTN.

RESULTS

The mean age of the participants (n = 34) was 48.0 years (SD = 9.8). Of the participants enrolled, 50.0% were female and 82.4% were white. Participants' facilities were from four census-defined regions (South 35.3%, Northeast 29.4%, West 20.6%, Midwest 11.8%, Missing 2.9%) and represented diverse settings. The EHR was used by all surveyed facilities including 17 different kinds of EHR platforms or vendors, and 17.6% (n = 6) of surveyed facilities also used a separate EHR for behavioral health care (e.g., SUD care). Paper records were also used by 76.5% of surveyed facilities for clinical care (e.g., for health risk appraisal questionnaires, substance use screening or assessment, check-in screening, substance use specific intervention/treatment or referral, or labs/testing). The prevalence of using a patient portal, practice management system, and mHealth for patient care was 76.5%, 50.0%, and 29.4%, respectively.

CONCLUSION

While results are descriptive in nature, they reveal the heterogeneity in the existing EHRs and frequent use of paper records to document patient care tasks, especially for SUD care. The use of a separate EHR for behavioral healthcare also suggests the challenge of obtaining complete EHR data to support research for SUDs. Much EHR development, integration, and standardization needs to be done especially in regard to SUD treatment to facilitate research across disparate healthcare systems.

Electronic health record adoption among US substance use disorder and other mental health treatment facilities

OBJECTIVE

This study examined Electronic Health Record (EHR) utilization among US substance use disorder (SUD) versus mental health (MH) treatment facilities.

METHODS

Data from the National Survey of Substance Abuse Treatment Services and the National Mental Health Services Survey were used to examine differences in clinical and administrative utilization of EHR.

RESULTS

EHR use was significantly less common among SUD facilities compared to MH facilities for both non-exclusive (mixed computer and paper) and exclusive (paper-free) use. Fewer than 25 % of facilities of either type reported exclusive EHR use for core clinical activities (progress notes, laboratory monitoring, and prescriptions) with wide variability among states. Being an inpatient facility, having Joint Commission accreditation, being a private-for-profit, or a public facility were significantly positively associated with exclusive EHR use for core clinical activities; these associations were stronger among SUD facilities than MH facilities. Accepting Medicare was associated with exclusive EHR use for core clinical activities in both facility types, while accepting private insurance was associated with such use only among SUD treatment facilities.

CONCLUSIONS

EHR adoption among SUD facilities lags behind MH facilities. However, exclusive EHR use for clinical purposes remains elusive for both types of facilities with no more than a quarter of facilities in any state reporting such use. Some of the factors associated with exclusive EHR use for clinical purposes among SUD treatment facilities-such as Joint Commission accreditation-may be policy leverage points to expedite EHR adoption in these facilities.

Core outcomes set for research on the treatment of opioid use disorder (COS-OUD): the National Institute on Drug Abuse Clinical Trials Network protocol for an e-Delphi consensus study

BACKGROUND

A lack of consensus on the optimal outcome measures to assess the efficacy and effectiveness of interventions for the treatment of opioid use disorder (OUD) has hampered the pooling of research data for evidence synthesis and clinical guidelines. A core outcome set (COS) is a minimum set of outcome measures that are recommended for all studies of a particular condition. The National Drug Abuse Treatment Clinical Trials Network (CTN) Core Outcome Set for OUD (COS-OUD) is a development study to identify core constructs, meaningful outcomes, and their optimal measurement for all efficacy and effectiveness studies of OUD treatment and service delivery.

METHODS/DESIGN

Overseen by an expert workgroup, a modified, stepwise, e-Delphi methodology will be used to gain consensus among a panel of clinical practitioners and researchers involved in the treatment of OUD, who are members of the CTN. Sequential rounds of anonymous, online questionnaires will be used to identify, rate the importance of, and refine a core outcome set. A consensus threshold will be achieved if at least 70% of the panel rate the measure as critical for inclusion in the COS-OUD. Where consensus is not reached or there are suggestions for new measures, these will be brought forward to a further round of review prior to a consensus meeting. Products from this study will be communicated via peer-reviewed scientific journals and conferences.

DISCUSSION

This initiative will develop a COS for OUD intervention trials, treatment studies, and service delivery and will support the pooling of research and clinical practice data and efforts to develop measurement-based care within the OUD treatment cascade.

TRIAL REGISTRATION

http://www.comet-initiative.org/Studies/Details/1579.

Chronic High Risk Prescription Opioid Use Among Persons With HIV

Persons with HIV (PWH) are a population at risk for adverse sequelae of opioid use. Yet, few studies have examined correlates of chronic high risk opioid use and its impact on HIV outcomes. Trends in prescribing patterns and identification of factors that impact the use of opioid prescriptions among PWH are crucial to determine prevention and treatment interventions. This study examined electronic medical records (EMR) of patients receiving HIV care to characterize prescribing patterns and identify risk factors for chronic high risk prescription opioid use and the impact on HIV outcomes among PWH in primary care from July 1, 2016-December 31, 2017. EMR were analyzed from 8,882 patients who were predominantly male and ethnically and racially diverse with half being 50 years of age or older. The majority of the 8,744 prescriptions (98% oral and 2% transdermal preparations) given to 1,040 (12%) patients were oxycodone (71%), 8% were morphine, 7% tramadol, 4% hydrocodone, 4% codeine, 2% fentanyl, and 4% were other opioids. The number of monthly prescriptions decreased about 14% during the study period. Bivariate analyses indicated that most demographic and clinical variables were associated with receipt of any opioid prescription. After controlling for patient socio-demographic characteristics and clinical factors, the odds of receipt of any prescription were higher among patients with pain diagnoses and opioid use and mental health disorders. In addition, the odds of receipt of high average daily morphine equivalent dose (MED) prescriptions were higher for patients with pain diagnoses. Lastly, patients with substance use disorders (SUD) had an increased likelihood of detectable viral load compared to patients with no SUD, after adjusting for known covariates. Our findings show that despite opioid prescribing guidelines and monitoring systems, additional efforts are needed to prevent chronic high risk prescriptions in patients with comorbid conditions, including pain-related, mental health and substance use disorders. Evidence about the risk for chronic high risk use based on prescribing patterns could better inform pain management and opioid prescribing practices for patients receiving HIV care.

Modeling cancer clinical trials using HL7 FHIR to support downstream applications: A case study with colorectal cancer data

BACKGROUND AND OBJECTIVE

Identification and Standardization of data elements used in clinical trials may control and reduce the cost and errors during the operational process, and enable seamless data exchange between the electronic data capture (EDC) systems and Electronic Health Record (EHR) systems. This study presents a methodology to comprehensively capture the clinical trial data element needs.

MATERIALS AND METHODS

Case report forms (CRF) for clinical trial data collection were used to approximate the clinical information need, whereby these information needs were then mapped to a semantically equivalent field within an existing FHIR cancer profile. For items without a semantically equivalent field, we considered these items to be information needs that cannot be represented in current standards and proposed extensions to support these needs.

RESULTS

We successfully identified 62 discrete items from a preliminary survey of 43 base questions in four CRFs used in colorectal cancer clinical trials, in which 28 items are modeled with FHIR extensions and their associated responses for colorectal cancer. We achieved promising results in the data population of the CRFs with average Precision 98.5 %, Recall 96.2 %, and F-measure 96.8 % for all base questions. We also demonstrated the auto-filled answers in CRFs can be used to discover patient subgroups using a topic modeling approach.

CONCLUSION

CRFs can be considered as a proxy for representing information needs for their respective cancer types. Mining the information needs can serve as a valuable resource for expanding existing standards to ensure they can comprehensively represent relevant clinical data without loss of granularity.

Routine Assessment of Symptoms of Substance Use Disorders in Primary Care: Prevalence and Severity of Reported Symptoms

BACKGROUND

Most patients with substance use disorders (SUDs) never receive treatment and SUDs are under-recognized in primary care (PC) where patients can be treated or linked to treatment. Asking PC patients to directly report SUD symptoms on questionnaires might help identify SUDs but to our knowledge, this approach is previously untested.

OBJECTIVE

To describe the prevalence and severity of DSM-5 SUD symptoms reported by PC patients as part of routine care.

DESIGN

Cross-sectional study using secondary data.

PARTICIPANTS

A total of 241,265 adult patients who visited one of 25 PC sites in an integrated health system in Washington state and had alcohol, cannabis, or other drug use screening documented in their EHRs (March 2015-July 2018) were included in main analyses if they had a positive screen for high-risk substance use defined as AUDIT-C score 7-12 points, or report of past-year daily cannabis use or any other drug use.

MAIN MEASURES

The main outcome was number of SUD symptoms based on Diagnostic and Statistical Manual, 5th edition (DSM-5), reported on Symptom Checklists (0-11) for alcohol or other drugs: 2-3 mild; 4-5 moderate; 6-11 severe.

RESULTS

Of screened patients, 16,776 (5.7%) reported high-risk use of alcohol (2.4%), cannabis (3.9%), and/or other drugs (1.7%), and 65.0-69.9% of those completed Symptom Checklists. Of those with high-risk alcohol use, 52.5% (95% CI 50.9-54.0%) reported ≥ 2 symptoms consistent with mild-severe alcohol use disorders. Of those reporting daily cannabis use, 29.8% (28.6-30.9%) reported ≥ 2 symptoms consistent with mild-severe SUDs. Of those reporting any other drug use, 37.5% (35.7-39.3%) reported ≥ 2 symptoms consistent with mild-severe SUDs.

CONCLUSIONS AND RELEVANCE

Many PC patients who screened positive for high-risk substance use reported symptoms consistent with DSM-5 SUDs on self-report Symptom Checklists. Use of SUD Symptom Checklists could support PC providers in making SUD diagnoses and initiating discussions of substance use.

Assessment of Co-Occurring Substance Use During Opiate Treatment Programs in the United States

The effectiveness of opiate treatment programs (OTPs) can be significantly influenced by co-occurring substance use, yet there are no standardized guidelines for assessing the influence of co-occurring substance use on treatment outcomes. In this review, we aim to provide an overview on the status of the assessment of co-occurring substance use during participation in OTPs in the United States. We searched 4 databases-MEDLINE/PubMed, EMBASE, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)-from database inception to November 2018 to select relevant publications on OTPs that assessed participants' co-occurring substance use. We used a standardized protocol to extract study, intervention, and co-occurring substance use characteristics. Methodological quality was assessed using the Quality in Prognosis Studies tool. Of the 3,219 titles screened, 614 abstracts and 191 full-text original publications were assessed, leaving 85 eligible articles. Co-occurring substance use was most often assessed during opioid treatments using combined (pharmacological and behavioral) (n = 57 studies) and pharmacological (n = 25 studies) interventions. Cocaine, alcohol, marijuana, and benzodiazepines were frequently measured, while amphetamines and tobacco were rarely assessed. Great variation existed between studies in the timing and measurement of co-occurring substance use, as well as definitions for substances and polysubstance/polydrug use. Inconsistencies in the investigation of co-occurring substance use make comparison of results across studies challenging. Standardized measures and consensus on research on co-occurring substance use is needed to produce the evidence required to develop personalized treatment programs for persons using multiple substances and to inform best-practice guidelines for addressing polydrug use during participation in OTPs.

Commentary on Winhusen et al. (2019): Substance use disorders, chronic diseases, and electronic health records-a paradigm for screening and intervention

The use of the electronic health record to study the relationship between substance use disorders, diabetes and hypertension has identified high-severity, high-cost conditions. Improving data quality and validation will enhance our ability to perform medical record-based screening of substance use disorders and treatment of their complications among patients with multiple chronic illnesses.

Barriers and facilitators affecting the implementation of substance use screening in primary care clinics: a qualitative study of patients, providers, and staff

Background

Alcohol and drug use are leading causes of morbidity and mortality that frequently go unidentified in medical settings. As part of a multi-phase study to implement electronic health record-integrated substance use screening in primary care clinics, we interviewed key clinical stakeholders to identify current substance use screening practices, barriers to screening, and recommendations for its implementation.

Methods

Focus groups and individual interviews were conducted with 67 stakeholders, including patients, primary care providers (faculty and resident physicians), nurses, and medical assistants, in two urban academic health systems. Themes were identified using an inductive approach, revised through an iterative process, and mapped to the Knowledge to Action (KTA) framework, which guides the implementation of new clinical practices (Graham et al. in J Contin Educ Health Prof 26(1):13–24, 2006).

Results

Factors affecting implementation based on KTA elements were identified from participant narratives. Identifying the problem: Participants consistently agreed that having knowledge of a patient’s substance use is important because of its impacts on health and medical care, that substance use is not properly identified in medical settings currently, and that universal screening is the best approach. Assessing barriers: Patients expressed concerns about consequences of disclosing substance use, confidentiality, and the individual’s own reluctance to acknowledge a substance use problem. Barriers identified by providers included individual-level factors such as lack of clinical knowledge and training, as well as systems-level factors including time pressure, resources, lack of space, and difficulty accessing addiction treatment. Adapting to the local context: Most patients and providers stated that the primary care provider should play a key role in substance use screening and interventions. Opinions diverged regarding the optimal approach to delivering screening, although most preferred a patient self-administered approach. Many providers reported that taking effective action once unhealthy substance use is identified is crucial.

Conclusions

Participants expressed support for substance use screening as a valuable part of medical care, and identified individual-level as well as systems-level barriers to its implementation. These findings suggest that screening programs should clearly communicate the goals of screening to patients and proactively counteract stigma, address staff concerns regarding time and workflow, and provide education as well as treatment resources to primary care providers.

Electronic supplementary material

The online version of this article (10.1186/s13722-018-0110-8) contains supplementary material, which is available to authorized users.

Advancing Analytic Approaches to Address Key Questions in Mechanisms of Behavior Change Research

OBJECTIVE

Interest in studying mechanisms of behavior change (MOBCs) in substance use disorder (SUD) treatments has grown considerably in the past two decades. Much of this work has focused on identifying which variables statistically mediate the effect of SUD treatments on clinical outcomes. However, a fuller conceptualization of MOBCs will require greater understanding of questions that extend beyond traditional mediation analysis, including better understanding of when MOBCs change during treatment, when they are most critical to aiding the initiation or maintenance of change, and how MOBCs themselves arise as a function of treatment processes.

METHOD

In the present study, we review why these MOBC-related questions are often minimally addressed in empirical research and provide examples of data analytic methods that may address these issues. We highlight several recent studies that have used such methods and discuss how these methods can provide unique theoretical insights and actionable clinical information.

RESULTS

Several statistical approaches can enhance the field's understanding of the timing and development of MOBCs, including growth-curve modeling, time-varying effect modeling, moderated mediation analysis, dynamic systems modeling, and simulation methods.

CONCLUSIONS

Adopting greater diversity in methods for modeling MOBCs will help researchers better understand the timing and development of key change variables and will expand the theoretical precision and clinical impact of MOBC research. Advances in research design, measurement, and technology are key to supporting these advances.

Using electronic health record data for substance use Screening, Brief Intervention, and Referral to Treatment among adults with type 2 diabetes: Design of a National Drug Abuse Treatment Clinical Trials Network study

BACKGROUND

The Affordable Care Act encourages healthcare systems to integrate behavioral and medical healthcare, as well as to employ electronic health records (EHRs) for health information exchange and quality improvement. Pragmatic research paradigms that employ EHRs in research are needed to produce clinical evidence in real-world medical settings for informing learning healthcare systems. Adults with comorbid diabetes and substance use disorders (SUDs) tend to use costly inpatient treatments; however, there is a lack of empirical data on implementing behavioral healthcare to reduce health risk in adults with high-risk diabetes. Given the complexity of high-risk patients' medical problems and the cost of conducting randomized trials, a feasibility project is warranted to guide practical study designs.

METHODS

We describe the study design, which explores the feasibility of implementing substance use Screening, Brief Intervention, and Referral to Treatment (SBIRT) among adults with high-risk type 2 diabetes mellitus (T2DM) within a home-based primary care setting. Our study includes the development of an integrated EHR datamart to identify eligible patients and collect diabetes healthcare data, and the use of a geographic health information system to understand the social context in patients' communities. Analysis will examine recruitment, proportion of patients receiving brief intervention and/or referrals, substance use, SUD treatment use, diabetes outcomes, and retention.

DISCUSSION

By capitalizing on an existing T2DM project that uses home-based primary care, our study results will provide timely clinical information to inform the designs and implementation of future SBIRT studies among adults with multiple medical conditions.

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.

A Framework for Usable and Effective Clinical Decision Support: Experience from the iCPR Randomized Clinical Trial

INTRODUCTION

The promise of Clinical Decision Support (CDS) has always been to transform patient care and improve patient outcomes through the delivery of timely and appropriate recommendations that are patient specific and, more often than not, are appropriately actionable. However, the users of CDS-providers-are frequently bombarded with inappropriate and inapplicable CDS that often are not informational, not integrated into the workflow, not patient specific, and that may present out of date and irrelevant recommendations.

METHODS

The integrated clinical prediction rule (iCPR) project was a randomized clinical trial (RCT) conducted to determine if a novel form of CDS, i.e., clinical prediction rules (CPRs), could be efficiently integrated into workflow and result in changes in outcomes (e.g., antibiotic ordering) when embedded within a commercial electronic health record (EHR). We use the lessons learned from the iCPR project to illustrate a framework for constructing usable, useful, and effective actionable CDS while employing off-the-shelf functionality in a production system. Innovations that make up the framework combine the following: (1) active and actionable decision support, (2) multiple rounds of usability testing with iterative development for user acceptance, (3) numerous context sensitive triggers, (4) dedicated training and support for users of the CDS tool for user adoption, and (5) support from clinical and administrative leadership. We define "context sensitive triggers" as being workflow events (i.e., context) that result in a CDS intervention.

DISCUSSION

Success of the framework can be measured by CDS adoption (i.e., intervention is being used), acceptance (compliance with recommendations), and clinical outcomes (where appropriate). This framework may have broader implications for the deployment of Health Information Technology (HIT).

RESULTS AND CONCLUSION

iCPR was well adopted(57.4% of users) and accepted (42.7% of users). Usability testing identified and fixed many issues before the iCPR RCT. The level of leadership support and clinical guidance for iCPR was key in establishing a culture of acceptance for both the tool and its recommendations contributing to adoption and acceptance. The dedicated training and support lead to the majority of the residents reporting a high level of comfort with both iCPR tools strep pharyngitis (64.4 percent) and pneumonia (62.7 percent) as well as a high likelihood of using the tools in the future. A surprising framework addition resulted from usability testing: context sensitive triggers.

Validation of the Drug Abuse Screening Test (DAST-10): A study on illicit drug use among Chinese pregnant women

We assessed the Chinese version of the Drug Abuse Screening Test (DAST-10) for identifying illicit drug use during pregnancy among Chinese population. Chinese pregnant women attending their first antenatal visit or their first unbooked visit to the maternity ward were recruited during a 4-month study period in 2011. The participants completed self-administered questionnaires on demographic information, a single question on illicit drug use during pregnancy and the DAST-10. Urine samples screened positive by the urine Point-of-Care Test were confirmed by gas chromatography-mass spectrometry. DAST-10 performance was compared with three different gold standards: urinalysis, self-reported drug use, and evidence of drug use by urinalysis or self-report. 1214 Chinese pregnant women participated in the study and 1085 complete DAST-10 forms were collected. Women who had used illicit drugs had significantly different DAST-10 scores than those who had not. The sensitivity of DAST-10 for identify illicit drug use in pregnant women ranged from 79.2% to 33.3% and specificity ranged from 67.7% to 99.7% using cut-off scores from ≥ 1 to ≥ 3. The ~ 80% sensitivity of DAST-10 using a cut-off score of ≥ 1 should be sufficient for screening of illicit drug use in Chinese pregnant women, but validation tests for drug use are needed.

A spectrum of sharing: maximization of information content for brain imaging data

Efforts to expand sharing of neuroimaging data have been growing exponentially in recent years. There are several different types of data sharing which can be considered to fall along a spectrum, ranging from simpler and less informative to more complex and more informative. In this paper we consider this spectrum for three domains: data capture, data density, and data analysis. Here the focus is on the right end of the spectrum, that is, how to maximize the information content while addressing the challenges. A summary of associated challenges of and possible solutions is presented in this review and includes: 1) a discussion of tools to monitor quality of data as it is collected and encourage adoption of data mapping standards; 2) sharing of time-series data (not just summary maps or regions); and 3) the use of analytic approaches which maximize sharing potential as much as possible. Examples of existing solutions for each of these points, which we developed in our lab, are also discussed including the use of a comprehensive beginning-to-end neuroinformatics platform and the use of flexible analytic approaches, such as independent component analysis and multivariate classification approaches, such as deep learning.

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.

Expanding the National Drug Abuse Treatment Clinical Trials Network to address the management of substance use disorders in general medical settings

The Patient Protection and Affordable Care Act (2010) and the Mental Health Parity and Addiction Equity Act (2008) expand substance use disorder (SUD) care services in the USA into general medical settings. Care offered in these settings will engage substance-using patients in an integrated and patient-centered environment that addresses physical and mental health comorbidities and follows a chronic care model. This expansion of SUD services presents a great need for evidence-based practices useful in general medical settings, and reveals several research gaps to be addressed. The National Drug Abuse Treatment Clinical Trials Network of the National Institute on Drug Abuse can serve an important role in this endeavor. High-priority research gaps are highlighted in this commentary. A discussion follows on how the National Drug Abuse Treatment Clinical Trials Network can transform to address changing patterns in SUD care to efficiently generate evidence to guide SUD treatment practice within the context of recent US health care legislation.

Italy's electronic health record system for opioid agonist treatment

Electronic health record systems (EHRs) play an increasingly important role in opioid agonist treatment. In Italy, an EHR called the Multi Functional Platform (MFP) is in use in 150 opioid-agonist treatment facilities in 8 of Italy's 23 regions. This report describes MFP and presents 2010 data from 65 sites that treated 8145 patients, of whom 72.3% were treated with methadone and 27.7% with buprenorphine. Patients treated with buprenorphine compared to methadone were more likely to be male (p < .01) and younger (p < .001). Methadone compared to buprenorphine patients had a higher percentage of opioid-positive urine tests (p < .001) and longer mean length of stay (p = .004). MFP has been implemented widely in Italy and has been able to track patient outcomes across treatment facilities. In the future, this EHR system can be used for performance improvement initiatives.

Blending research and practice: an evolving dissemination strategy in substance abuse

Substance abuse is a leading cause of death and disability throughout the world. The mission of the National Institute on Drug Abuse (NIDA) is to lead the United States in bringing the power of science to bear on drug abuse and addiction. This charge has two critical components: (a) strategic support of research across a broad range of disciplines and (b) rapid, effective dissemination of research results that can improve prevention and treatment efforts, with potential to inform policy. The NIDA Clinical Trials Network and the Blending Initiative are critical elements of this strategy, and the social work field is poised to use these resources to expand its role in the dissemination and implementation of NIDA's mission.

Integrating substance abuse care with community diabetes care: implications for research and clinical practice

Cigarette smoking and alcohol use are prevalent among individuals with diabetes in the US, but little is known about screening and treatment for substance use disorders in the diabetic population. This commentary discusses the scope and clinical implications of the public health problem of coexisting substance use and diabetes, including suggestions for future research. Diabetes is the seventh leading cause of death in the US, and is associated with many severe health complications like cardiovascular disease, stroke, kidney damage, and limb amputations. There are an estimated 24 million adults in the US with type 2 diabetes. Approximately 20% of adults aged 18 years or older with diabetes report current cigarette smoking. The prevalence of current alcohol use in the diabetic population is estimated to be around 50%-60% in epidemiological surveys and treatment-seeking populations. Cigarette smoking is associated with an increased risk of type 2 diabetes in a dose-dependent manner and is an independent modifiable risk factor for development of type 2 diabetes. Diabetic patients with an alcohol or other drug use disorder show a higher rate of adverse health outcomes. For example, these patients experience more frequent and severe health complications as well as an increased risk of hospitalization, and require longer hospital stays. They are also less likely to seek routine care for diabetes or adhere to diabetes treatment than those without an alcohol or other drug use disorder. The Affordable Care Act of 2010 and the Mental Health Parity Act and Addiction Equity Act of 2008 provide opportunities for facilitating integration of preventive services and evidence-based treatments for substance use disorders with diabetes care in community-based medical settings. These laws also offer emerging areas for research.

Developing data elements for research information system in health; a starting point for systems integration

BACKGROUND

This study defines necessary data elements required for the research information system in the domain of health, and its level of accountability to national health research indicators from the experts' perspective is being explored.

METHODS

This qualitative study was conducted based on comparative approach using the focus group method. Data were collected through 6 semi-structured group discussions held at the Undersecretary for Research and Technology, Ministry of Health and Medical Education, Tehran, Iran. For this study, 48 researchers were selected for the group discussions. All interviews and group discussions were recorded and transcribed. The Data analysis was performed simultaneously using Strauss and Corbin method.

RESULTS

BASED ON CONTENT ANALYSIS, THE NECESSARY DATA ELEMENTS IDENTIFIED FOR THE NATIONAL HEALTH RESEARCH INFORMATION SYSTEM DESIGNED FOR ALL DATABASES WERE THE FOLLOWING: organizations, researchers, journals, articles, research projects and dissertations. Also, extracted from the focus group discussion were three main themes regarding data elements of these databases for the National Health Research Information System: 1) essential elements for each database 2) the system's data elements accountability to the national indicators in the domain of health research and 3) recommendations in the direction of optimizing the data.

CONCLUSIONS

The results obtained from this study can serve as a valuable source in designing research information system in the domain of health within the country and in the region as well.