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Garrison YL, Luo Y, Sahker E. Integration of substance use disorder treatment in traditional mental health facilities: Timeseries and cross-sectional evaluations. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 124:104312. [PMID: 38176176 DOI: 10.1016/j.drugpo.2023.104312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Despite efforts to increase substance use disorder (SUD) treatment provision in the United States (US), the extent to which traditional mental health (MH) facilities offer SUD treatment remains unclear. In the present study, we analyzed the trend in SUD treatment integration among traditional MH facilities in the US from 2014 to 2020 and identified facility-level factors associated with SUD treatment provision. METHODS Data were extracted from the National Mental Health Services Survey (N-MHSS). A timeseries logit trend analysis for the multi-year dataset (2014-2020) was conducted to assess a yearly change in odds of SUD treatment provision. With the 2020 survey data, analyses were conducted to identify the differences between facilities offering SUD treatment and facilities not offering such treatment. Finally, exploratory multivariable logistic regression was conducted to estimate odds of SUD treatment provision by facility variables. RESULTS US MH facility SUD treatment provision went from 51.7 % (2014) to 57.9 % (2020). A mean sample of 12,312 US MH facilities over seven years, demonstrated a significant but small yearly increase in SUD treatment provision (OR = 1.04, 95 % CI = 1.03, 1.04). Important facility characteristics related to SUD treatment provision for facilities without a core SUD focus were MH diagnostics offered (OR = 2.03), dual-diagnosis program offered (OR = 3.65), state drug/alcohol license maintained (OR = 6.66), and VA setting (OR = 7.94). CONCLUSIONS Despite incremental progress in integrating SUD treatment services into US MH facilities, the SUD treatment gap remains large. Training and service development incentives for identified characteristics could help further reduce the treatment gap.
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Affiliation(s)
| | - Yan Luo
- Department of Health Promotion and Human Behavior, Graduate School of Medicine / School of Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan; Population Health and Policy Research Unit, Medical Education Center, Graduate School of Medicine, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Ethan Sahker
- Department of Health Promotion and Human Behavior, Graduate School of Medicine / School of Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan; Population Health and Policy Research Unit, Medical Education Center, Graduate School of Medicine, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.
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Sahker E, Pro G, Poudyal H, Furukawa TA. Evaluating the substance use disorder treatment gap in the United States, 2016-2019: A population health observational study. Am J Addict 2024; 33:36-47. [PMID: 37583093 DOI: 10.1111/ajad.13465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 06/22/2023] [Accepted: 08/05/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Only 10% of Americans with substance use disorders (SUDs) receive treatment with insufficient treatment access and screening practices proposed and potential contributing factors. METHODS This retrospective cross-sectional study used National Survey on Drug Use and Health (NSDUH) data to assess individuals with SUDs receiving treatment between 2016 and 2019 (survey n = 12,111; weighted n = 12,394,214). Demographic, access, and screening characteristics were investigated as predictors of treatment receipt using time-series logistic regression analyses to test trends and assessed treatment receipt odds, controlling for demographic and treatment characteristics. RESULTS For those with past-year SUDs, 13.0% reported receiving past-year SUD treatment (survey n = 1605; weighted n = 1,612,154). The SUD treatment receipt rate remained statistically stable from 2016 to 2019, with a nonsignificant treatment receipt trend declining from 14% to 12%. Treatment changes were notable among Native Americans (+53.80%), Pacific Islanders (+94.10%), multiracial (-59.96%), ages 65+ (-70.18%), and ages 12-17 (-50.70%). In the regression model, race, sex, age, insurance status, and receiving mental health treatment were associated with SUD treatment receipt. DISCUSSION AND CONCLUSIONS The treatment gap remains substantial and stable. Annually, about 87% of Americans with SUDs are not receiving the treatment they need. Asian Americans were less likely and those attending general mental health services were more likely to receive treatment. SCIENTIFIC SIGNIFICANCE We present an updated SUD treatment gap evaluation, and identify access and screening characteristics associated with SUD treatment receipt. Policymakers, clinicians, and researchers must continue improving access and identification of those in need of care.
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Affiliation(s)
- Ethan Sahker
- Graduate School of Medicine, Population Health and Policy Research Unit, Medical Education Center, Kyoto University, Kyoto, Japan
- Department of Health Promotion and Human Behavior, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan
| | - George Pro
- Department of Health Behavior and Health Education, Southern Public Health and Criminal Justice Research Center, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Hemant Poudyal
- Graduate School of Medicine, Population Health and Policy Research Unit, Medical Education Center, Kyoto University, Kyoto, Japan
| | - Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Graduate School of Medicine/School of Public Health, Kyoto University, Kyoto, Japan
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Reilly J, Meurk C, Heffernan E, Sara G. Substance use disorder screening and brief intervention in routine clinical practice in specialist adult mental health services: A systematic review. Aust N Z J Psychiatry 2023; 57:793-810. [PMID: 36632829 DOI: 10.1177/00048674221148394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND OBJECTIVES Substance use disorders co-occurring with other mental health disorders are common and harmful. Clinical guidelines often recommend substance use screening and brief intervention though evidence about screening practice in mental health services is limited. This systematic review of routine clinical practice in adult mental health services aims to identify (a) proportions of screening and brief intervention, (b) how they are practised and (c) their outcomes. METHODS We searched MEDLINE, PsycINFO and Embase and relevant Cochrane databases for articles until 31 July 2021 reporting on adults in English, regardless of geographical location. Backward snowball methods were used to locate additional articles. Screening, brief intervention and mental health services were defined. Data were extracted and variables compared related to setting, period, patient cohort, substances routine substance use disorder care pathways, and study quality was assessed. RESULTS We identified 17 articles reporting routine screening within adult mental health services. Studies in community settings mainly reported on screening for alcohol and other substance use disorders, while studies from inpatient settings reported mainly on tobacco. There was marked variation in methods and screening proportions. Only two studies reported on brief intervention. CONCLUSION This systematic review shows marked variation in mental health services routine screening practices with early focus on alcohol but more recently tobacco screening. We suggest approaches to enhancing implementation of screening and brief intervention in routine care, particularly using electronic health records.
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Affiliation(s)
- John Reilly
- Mental Health Alcohol and Other Drugs Branch, Clinical Excellence Queensland, Queensland Health, Brisbane, QLD, Australia.,School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Carla Meurk
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Forensic Mental Health Group, Queensland Centre for Mental Health Research, Queensland Health, West Moreton Hospital and Health Service, Brisbane, QLD, Australia
| | - Ed Heffernan
- School of Public Health, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Forensic Mental Health Group, Queensland Centre for Mental Health Research, Queensland Health, West Moreton Hospital and Health Service, Brisbane, QLD, Australia.,Queensland Forensic Mental Health Service, Metro North Hospital and Health Service, Brisbane, QLD, Australia
| | - Grant Sara
- NSW Ministry of Health, St Leonards, NSW, Australia
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Carlo AD, Basu A, Unützer J. Associations of Common Depression Treatment Metrics With Patient-centered Outcomes. Med Care 2021; 59:579-587. [PMID: 33827105 PMCID: PMC8187281 DOI: 10.1097/mlr.0000000000001540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Various metrics predicated on Patient Health Questionnaire-9 (PHQ-9) scores denote depression "response" or "remission" over time, but few have been empirically validated. We compare the associations of depression response and remission metrics with concomitant clinical improvement in patient-centered outcomes (PCOs). SUBJECTS Secondary analysis of PHQ-9 and PCO data from the treatment arm (n=906) of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial. RESEARCH DESIGN We conducted univariate correlations between 9 depression treatment metrics and 4 PCOs. For each PCO, we specified a multivariate linear fixed-effects regression model with penalized LASSO (least absolute shrinkage and selection operator) variable selection that included parameters for each incremental absolute PHQ-9 decrease between 0 and 16 points. Model predictive properties were assessed using a split sample analysis. RESULTS There was a notable variation in depression improvement rates across metrics. Each metric was significantly associated with PCOs in univariate analyses. In the multivariate models, the cumulative likelihood of PCO improvement was most improved by absolute PHQ-9 score decreases of 7-9 and 14-16 points. The multivariate models showed greater area under the curve (0.671-0.804) in out-of-sample predictions of PCO changes than the univariate models (0.529-0.649). CONCLUSIONS Choice of depression response metric impacts observed response and remission rates, though PCOs tend to improve with depression improvement regardless of metric choice. Absolute incremental PHQ-9 score decreases are broadly associated with an increased likelihood of favorable PCO scores. Our findings support a novel PHQ-9 metric defined by an absolute score change of 8 points or greater.
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Affiliation(s)
- Andrew D Carlo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine
| | - Anirban Basu
- Departments of Pharmacy
- Health Services
- Economics, University of Washington, Seattle, WA
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine
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McCall MH, Wester KL, Bray JW, Hanchate AD, Veach LJ, Smart BD, Wachter Morris C. SBIRT administered by mental health counselors for hospitalized adults with substance misuse or disordered use: Evaluating hospital utilization and costs. J Subst Abuse Treat 2021; 132:108510. [PMID: 34098211 DOI: 10.1016/j.jsat.2021.108510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/19/2021] [Accepted: 05/21/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE We analyzed the association of Screening, Brief Intervention, and Referral to Treatment (SBIRT) with hospitalizations, emergency department (ED) visits, and related costs, when administered to inpatients with substance misuse or disordered use by professional mental health counselors. METHODS Our study used retrospective program and health records data and a difference-in-differences design with propensity score covariates. The study population consisted of hospital inpatients admitted to integrated care services staffed by physicians, nurses, and mental health counselors. The intervention group consisted of patients selected for intervention based on substance use history and receiving SBIRT (n = 1577). Patients selected for intervention but discharged before SBIRT administration (n = 618) formed the comparison group. The outcome variables were hospitalization and ED visits costs and counts. Costs of hospitalizations and ED visits were combined to allow sufficient data for analysis, with counts treated similarly. Patient-level variables were substance use type and substance use severity. A cluster variable was inpatient clinical service. Zero-censored and two-part logistic and generalized linear models with robust standard errors tested the association of SBIRT interventions with the outcomes. RESULTS For the full study population of patients using alcohol, illicit drugs, or both, SBIRT administered by mental health counselors was not associated with changes in hospitalizations and ED visits. For patients with alcohol misuse or disordered use, SBIRT by mental health counselors was associated an odds ratio of 0.32 (p < .001) of having subsequent hospitalizations or ED visits. For patients with alcohol use who did return as hospital inpatients or to the ED, SBIRT by counselors was associated with a reduction in costs of $2547 per patient (p < .001) and with an incidence rate ratio of 0.57 for counts (p = .003). CONCLUSION Our results suggest that professional mental health counselors on inpatient integrated care teams may provide SBIRT effectively for patients with misuse and disordered use of alcohol, reducing the likelihood of future healthcare utilization and costs.
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Affiliation(s)
- Marcia H McCall
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Kelly L Wester
- School of Education, The University of North Carolina at Greensboro, 1300 Spring Garden Street, Greensboro, NC 27412, United States of America.
| | - Jeremy W Bray
- Bryan School of Business, The University of North Carolina at Greensboro, 516 Stirling Street, Greensboro, NC 27412, United States of America.
| | - Amresh D Hanchate
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Laura J Veach
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Benjamin D Smart
- Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157, United States of America.
| | - Carrie Wachter Morris
- School of Education, The University of North Carolina at Greensboro, 1300 Spring Garden Street, Greensboro, NC 27412, United States of America.
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Ashrafi S, Taylor D, Tang TS. Moving beyond 'don't ask, don't tell': Mental health needs of adults with type 1 diabetes in rural and remote regions of British Columbia. Diabet Med 2021; 38:e14534. [PMID: 33524209 DOI: 10.1111/dme.14534] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 01/20/2021] [Accepted: 01/25/2021] [Indexed: 11/27/2022]
Abstract
AIMS To investigate the mental health needs of adults with type 1 diabetes living in rural and remote regions of Interior, British Columbia (BC) and identify factors associated with accessing support. We also explored perspectives around using peer support and digital health strategies for delivering mental health support. METHODS This study recruited 38 adults with type 1 diabetes to complete a self-report survey and participate in focus groups. We conducted six 90-min focus groups that addressed the following: current and past mental health needs, social media use for type 1 diabetes support, peer supporter recruitment and training, and support delivery features for virtual care platforms. Focus groups were recorded, transcribed, quality checked, coded and analysed to develop themes and subthemes. RESULTS Four core themes emerged: (1) emotional challenges linked to type 1 diabetes management, (2) unique type 1 diabetes-related concerns in rural and remote communities, (3) previous support experiences and future support needs and (4) diabetes-related mental health support interventions involving peer support and digital health strategies. Existing support services are inadequate in meeting the needs of type 1 diabetes adults in Interior BC. Some have turned towards social media as a way to connect with the type 1 diabetes community for support. CONCLUSIONS Though type 1 diabetes adults living in rural and remote settings experience distress associated with the ongoing burdens, frustrations and fears of managing a complex chronic condition, many have not been offered support and do not know how to seek services in the present/future. Peer support and digital health strategies are two potential solutions to address this care gap.
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Affiliation(s)
- Shadan Ashrafi
- Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Deanne Taylor
- Interior Health Authority, Kelowna, BC, Canada
- Faculty of Health and Social Development/Nursing, University of British Columbia Okanagan, Kelowna, BC, Canada
| | - Tricia S Tang
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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Spencer AE, Valentine SE, Sikov J, Yule AM, Hsu H, Hallett E, Xuan Z, Silverstein M, Fortuna L. Principles of Care for Young Adults With Co-Occurring Psychiatric and Substance Use Disorders. Pediatrics 2021; 147:229-239. [PMID: 33386320 PMCID: PMC8276159 DOI: 10.1542/peds.2020-023523f] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/23/2020] [Indexed: 01/22/2023] Open
Abstract
Over 50% of young adults (defined as individuals aged 18-25 years) with substance use disorders (SUDs) have at least 1 co-occurring psychiatric disorder, and the presence of co-occurring disorders worsens SUD outcomes. Treatment of both co-occurring psychiatric disorders and SUDs in young adults is imperative for optimal treatment, yet many barriers exist to achieving this goal. We present a series of evidence-informed principles of care for young adults with co-occurring psychiatric disorders derived by a workgroup of experts convened by Boston Medical Center's Grayken Center for Addiction. The 3 principles are as follows: (1) young adults should receive integrated mental health and addiction care across treatment settings; (2) care should be responsive to the needs of young adults exposed to trauma and other adverse childhood experiences; and (3) treatment programs should regularly assess and respond to the evolving mental health needs, motivations, and treatment goals of young adults with co-occurring disorders. Our guidance for each principle is followed by a review of the evidence supporting that principle, as well as practice considerations for implementation. More research among young adults is critical to identify effective treatments and service systems for those with co-occurring disorders.
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Affiliation(s)
- Andrea E Spencer
- Departments of Psychiatry and
- Boston Medical Center, Boston, Massachusetts; and
| | - Sarah E Valentine
- Departments of Psychiatry and
- Boston Medical Center, Boston, Massachusetts; and
| | - Jennifer Sikov
- Departments of Psychiatry and
- Boston Medical Center, Boston, Massachusetts; and
| | - Amy M Yule
- Departments of Psychiatry and
- Boston Medical Center, Boston, Massachusetts; and
| | - Heather Hsu
- Boston Medical Center, Boston, Massachusetts; and
- Pediatrics, School of Medicine, and
| | | | - Ziming Xuan
- School of Public Health, Boston University, Boston, Massachusetts
| | - Michael Silverstein
- Boston Medical Center, Boston, Massachusetts; and
- Pediatrics, School of Medicine, and
| | - Lisa Fortuna
- Department of Psychiatry, University of California San Francisco, San Francisco, California
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Unützer J, Carlo AC, Arao R, Vredevoogd M, Fortney J, Powers D, Russo J. Variation In The Effectiveness Of Collaborative Care For Depression: Does It Matter Where You Get Your Care? Health Aff (Millwood) 2020; 39:1943-1950. [PMID: 33136506 PMCID: PMC10846930 DOI: 10.1377/hlthaff.2019.01714] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Randomized controlled trials have demonstrated that the collaborative care model for depression in primary care is more effective than usual care, but little is known about the effectiveness of this approach in real-world settings. We used patient-reported outcome data from 11,303 patients receiving collaborative care for depression in 135 primary care clinics to examine variations in depression outcomes. The average treatment response across this large sample of clinics was substantially lower than response rates reported in randomized controlled trials, and substantial outcome variation was observed. Patient factors such as initial depression severity, clinic factors such as the number of years of collaborative care practice, and the degree of implementation support received were associated with depression outcomes at follow-up. Our findings suggest that the level of implementation support could be an important influence on the effectiveness of collaborative care model programs.
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Affiliation(s)
- Jürgen Unützer
- Jürgen Unützer is a professor in the Department of Psychiatry and Behavioral Sciences, University of Washington, in Seattle, Washington
| | - Andrew C Carlo
- Andrew C. Carlo is a senior fellow in the Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Robert Arao
- Robert Arao is a research scientist in the Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Melinda Vredevoogd
- Melinda Vredevoogd is a research program manager in the Department of Psychiatry and Behavioral Sciences, University of Washington
| | - John Fortney
- John Fortney is a professor in the Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Diane Powers
- Diane Powers is a research scientist in the Department of Psychiatry and Behavioral Sciences, University of Washington
| | - Joan Russo
- Joan Russo is an associate professor in the Department of Psychiatry and Behavioral Sciences, University of Washington
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Referral to Treatment After Positive Screens for Unhealthy Drug Use in an Outpatient Veterans Administration Setting. J Addict Med 2019; 14:236-243. [PMID: 31567600 DOI: 10.1097/adm.0000000000000567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To measure the rates and predictors of clinician recommendation for follow-up after a positive screen for unhealthy drug use, in a context of mandatory routine screening. To measure response to clinician recommendations and identification of new drug use diagnoses. METHODS Data are from a Veterans Health Administration (VHA) medical center that introduced mandatory routine screening for unhealthy drug use in outpatient primary care and mental health settings, using a validated single question. This study analyzed VHA electronic health records data for patients who screened positive for unhealthy drug use (n = 570) and estimated logistic regression models to identify the predictors of receiving a recommendation for any follow-up and for specialty substance use disorder (SUD) treatment. Bivariate tests were used for other analyses. RESULTS Among patients who screened positive for unhealthy drug use, 66% received no recommendation to return to primary care or another setting from the screening clinician. Further, among the 23% of patients who received a recommendation to visit specialty SUD treatment, only 25% completed the visit within 60 days. Six percent of all positive screens both received a referral to specialty SUD treatment and acted upon it. CONCLUSIONS In the context of mandatory drug use screening using a single item, rates of clinician action and patient receipt of care appeared low. Improved follow-up will require health systems to provide more supports for clinicians and patients at each of the stages from positive screen to attending the follow-up appointment.
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Huang H, Forstein M, Joseph R. Developing a Collaborative Care Training Program in a Psychiatry Residency. PSYCHOSOMATICS 2017; 58:245-249. [PMID: 28233531 PMCID: PMC5446275 DOI: 10.1016/j.psym.2016.12.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 01/18/2023]
Abstract
BACKGROUND Collaborative care is an evidence-based approach for improving quality mental health access in primary care settings. Although job opportunities will grow over the next decade, few psychiatry residencies have established curricula to train the next generation of psychiatrists to work in this expanding model of care. OBJECTIVE In this article, the authors describe the collaborative care training experience at a safety-net academic institution to provide a template for psychiatry residencies designing curricula to prepare psychiatry residents for collaborative care practices.
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Affiliation(s)
- Hsiang Huang
- Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA.
| | | | - Robert Joseph
- Department of Psychiatry, Cambridge Health Alliance, Cambridge, MA
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Zubkoff L, Shiner B, Watts BV. Staff Perceptions of Substance Use Disorder Treatment in VA Primary Care-Mental Health Integrated Clinics. J Subst Abuse Treat 2016; 70:44-49. [PMID: 27692187 DOI: 10.1016/j.jsat.2016.07.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 07/13/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Guidelines recommend that substance use disorder (SUD) treatment be available in primary care-mental health integrated clinics, which offer mental and behavioral health assessment and treatment in the primary care setting. Despite this recommendation it is unclear what barriers and facilitators exist to SUD treatment being provided in that setting. This work sought to understand current SUD services in such integrated clinics, explore other services may that be appropriate, and identify barriers to such services. METHODS We conducted qualitative interviews with 23 staff members from integrated clinics at 6 Veterans Affairs medical centers. We transcribed interviews and performed thematic analysis to identify emergent themes. RESULTS We identified seven themes affecting staff experience and ability to provide SUD services in the integrated clinic: clinical effectiveness, clinical requirements, regulatory requirements, program goals, proximity of the integrated clinic and SUD services, training on substance use disorder, and role specialization. CONCLUSIONS VA primary care-mental health integrated clinic staff members do not currently view SUD treatment as the focus of their work, but are open to offering SUD treatment including brief psychological interventions or medication. Several barriers to providing SUD treatment were identified, including the need for additional staff training around appropriate interventions for the integrated clinic setting, additional staffing and space, and a structured implementation strategy to promote the use of SUD treatments.
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Affiliation(s)
- Lisa Zubkoff
- White River Junction VAMC, White River Junction, VT; Geisel School of Medicine at Dartmouth, Hanover, NH; VA National Center for Patient Safety, White River Junction, VT.
| | - Brian Shiner
- White River Junction VAMC, White River Junction, VT; Geisel School of Medicine at Dartmouth, Hanover, NH; VA National Center for Patient Safety, White River Junction, VT
| | - Bradley V Watts
- White River Junction VAMC, White River Junction, VT; Geisel School of Medicine at Dartmouth, Hanover, NH; VA National Center for Patient Safety, White River Junction, VT
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Chan YF, Lu SE, Howe B, Tieben H, Hoeft T, Unützer J. Screening and Follow-Up Monitoring for Substance Use in Primary Care: An Exploration of Rural-Urban Variations. J Gen Intern Med 2016; 31:215-222. [PMID: 26269130 PMCID: PMC4720630 DOI: 10.1007/s11606-015-3488-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 06/16/2015] [Accepted: 07/23/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Rates of substance use in rural areas are close to those of urban areas. While recent efforts have emphasized integrated care as a promising model for addressing workforce shortages in providing behavioral health services to those living in medically underserved regions, little is known on how substance use problems are addressed in rural primary care settings. OBJECTIVE To examine rural-urban variations in screening and monitoring primary care- based patients for substance use problems in a state-wide mental health integration program. DESIGN This was an observational study using patient registry. SUBJECTS The study included adult enrollees (n = 15,843) with a mental disorder from 133 participating community health clinics. MAIN OUTCOMES We measured whether a standardized substance use instrument was used to screen patients at treatment entry and to monitor symptoms at follow-up visits. KEY RESULTS While on average 73.6 % of patients were screened for substance use, follow-up on substance use problems after initial screening was low (41.4 %); clinics in small/isolated rural settings appeared to be the lowest (13.6 %). Patients who were treated for a mental disorder or substance abuse in the past and who showed greater psychiatric complexities were more likely to receive a screening, whereas patients of small, isolated rural clinics and those traveling longer distances to the care facility were least likely to receive follow-up monitoring for their substance use problems. CONCLUSIONS Despite the prevalent substance misuse among patients with mental disorders, opportunities to screen this high-risk population for substance use and provide a timely follow-up for those identified as at risk remained overlooked in both rural and urban areas. Rural residents continue to bear a disproportionate burden of substance use problems, with rural-urban disparities found to be most salient in providing the continuum of services for patients with substance use problems in primary care.
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Affiliation(s)
- Ya-Fen Chan
- Department of Psychiatry & Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA.
| | - Shou-En Lu
- Department of Biostatistics, School of Public Health, Rutgers University, Newark, NJ, USA
| | - Bill Howe
- Department of Computer Science & Engineering, University of Washington, Seattle, WA, USA
| | - Hendrik Tieben
- School of Architecture, Chinese University of Hong Kong, Shatin, NT, Hong Kong
| | - Theresa Hoeft
- Department of Psychiatry & Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Jürgen Unützer
- Department of Psychiatry & Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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Abstract
This article uses the behavioral model for vulnerable populations to evaluate the use of substance abuse treatment services among a sample of 926 substance abusers with one or more vulnerable health designations. A two-stage hierarchical logistic regression was completed to determine the influence of vulnerable and traditional need factors on the probability of receiving substance abuse treatment. Among traditional covariates, increased odds of receiving substance abuse treatment are associated with being either non-Hispanic White, Hispanic, having an income > US$5,000, and having a regular source of care. Among vulnerable covariates, injection drug use (odds ratio [OR] = 2.19, confidence interval [CI] = [1.46, 3.27]) and the receipt of public benefits (OR = 1.98, CI = [135, 2.92]) remain independent risk factors for the receipt of substance abuse treatment. Many who experience substance abuse disorders can also experience a multitude of other vulnerable health classifications, suggesting the need for a comprehensive, multidisciplinary approach to the treatment of substance use disorders.
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Roy-Byrne P, Bumgardner K, Krupski A, Dunn C, Ries R, Donovan D, West II, Maynard C, Atkins DC, Graves MC, Joesch JM, Zarkin GA. Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial. JAMA 2014; 312:492-501. [PMID: 25096689 PMCID: PMC4599980 DOI: 10.1001/jama.2014.7860] [Citation(s) in RCA: 154] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance). OBJECTIVE To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points. INTERVENTIONS Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433). MAIN OUTCOMES AND MEASURES The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior. RESULTS Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, β = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, β = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes. CONCLUSIONS AND RELEVANCE A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00877331.
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Affiliation(s)
- Peter Roy-Byrne
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Kristin Bumgardner
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Antoinette Krupski
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Chris Dunn
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Richard Ries
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Dennis Donovan
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Imara I West
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Charles Maynard
- Department of Health Services, School of Public Health, University of Washington, Seattle
| | - David C Atkins
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Meredith C Graves
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Jutta M Joesch
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle3King County Office of Performance, Strategy and Budget, Seattle, Washington
| | - Gary A Zarkin
- RTI International, Research Triangle Park, North Carolina
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