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Kramer J, Wilens TE, Rao V, Villa R, Yule AM. Feasibility of a 2-Part Substance Use Screener Self-Administered by Patients on Paper: Observational Study. JMIR Form Res 2024; 8:e52801. [PMID: 38916950 PMCID: PMC11234052 DOI: 10.2196/52801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 03/26/2024] [Accepted: 05/08/2024] [Indexed: 06/26/2024] Open
Abstract
BACKGROUND Measurement-based care in behavioral health uses patient-reported outcome measures (PROMs) to screen for mental health symptoms and substance use and to assess symptom change over time. While PROMs are increasingly being integrated into electronic health record systems and administered electronically, paper-based PROMs continue to be used. It is unclear if it is feasible to administer a PROM on paper when the PROM was initially developed for electronic administration. OBJECTIVE This study aimed to examine the feasibility of patient self-administration of a 2-part substance use screener-the Tobacco, Alcohol, Prescription medications, and other Substances (TAPS)-on paper. This screener was originally developed for electronic administration. It begins with a limited number of questions and branches to either skip or reflex to additional questions based on an individual's responses. In this study, the TAPS was adapted for paper use due to barriers to electronic administration within an urgent care behavioral health clinic at an urban health safety net hospital. METHODS From August 2021 to March 2022, research staff collected deidentified paper TAPS responses and tracked TAPS completion rates and adherence to questionnaire instructions. A retrospective chart review was subsequently conducted to obtain demographic information for the patients who presented to the clinic between August 2021 and March 2022. Since the initial information collected from TAPS responses was deidentified, demographic information was not linked to the individual TAPS screeners that were tracked by research staff. RESULTS A total of 507 new patients were seen in the clinic with a mean age of 38.7 (SD 16.6) years. In all, 258 (50.9%) patients were male. They were predominantly Black (n=212, 41.8%), White (n=152, 30%), and non-Hispanic or non-Latino (n=403, 79.5%). Most of the patients were publicly insured (n=411, 81.1%). Among these 507 patients, 313 (61.7%) completed the TAPS screener. Of these 313 patients, 76 (24.3%) adhered to the instructions and 237 (75.7%) did not follow the instructions correctly. Of the 237 respondents who did not follow the instructions correctly, 166 (70%) answered more questions and 71 (30%) answered fewer questions than required in TAPS part 2. Among the 237 patients who did not adhere to questionnaire instructions, 44 (18.6%) responded in a way that contradicted their response in part 1 of the screener and ultimately affected their overall TAPS score. CONCLUSIONS It was challenging for patients to adhere to questionnaire instructions when completing a substance use screener on paper that was originally developed for electronic use. When selecting PROMs for measurement-based care, it is important to consider the structure of the questionnaire and how the PROM will be administered to determine if additional support for PROM self-administration needs to be implemented.
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Affiliation(s)
- Joanna Kramer
- Department of Psychiatry, Boston Medical Center, Boston, MA, United States
| | - Timothy E Wilens
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Vinod Rao
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Richard Villa
- Department of Psychiatry, Boston Medical Center, Boston, MA, United States
| | - Amy M Yule
- Department of Psychiatry, Boston Medical Center, Boston, MA, United States
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De Biasio MJ, Furman M, Clarke A, Hui W, Elia Y, Baranger J, Villemain O, Mertens L, Mahmud FH. Abnormal vascular thickness and stiffness in young adults with type 1 diabetes: new insights from cutting-edge ultrasound modalities. Cardiovasc Diabetol 2024; 23:178. [PMID: 38789969 PMCID: PMC11127355 DOI: 10.1186/s12933-024-02280-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/18/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in patients with Type 1 Diabetes (T1D). Early markers of CVD include increased carotid intima-media thickness (CIMT) and pulse wave velocity (PWV), but these existing ultrasound technologies show limited spatial and temporal resolution in young adults. The purpose of this study is to evaluate the utility of high-resolution ultrasound modalities, including high frequency ultrasound CIMT (hfCIMT) and ultrafast ultrasound PWV (ufPWV), in young adults with Type 1 Diabetes. METHODS This is a prospective single-center observational cohort study including 39 participants with T1D and 25 age and sex matched controls. All participants underwent hfCIMT and ufPWV measurements. hfCIMT and ufPWV measures of T1D were compared with controls and associations with age, sex, BMI, A1c, blood pressure, and lipids were studied. RESULTS Mean age was 24.1 years old in both groups. T1D had a greater body mass index (27.7 [5.7] vs 23.1 [3.2] kg/m2), LDL Cholesterol, and estimated GFR, and had a mean A1c of 7.4 [1.0] % (57 mmol/mol) and diabetes duration of 16.1 [3.7] years with 56% using insulin pumps. In T1D, hfCIMT was significantly increased as compared to controls (0.435 ± 0.06 mm vs 0.379 ± 0.06 mm respectively, p < 0.01). ufPWV measures were significantly increased in T1D (systolic foot PWV: 5.29 ± 0.23 m/s vs 5.50 ± 0.37 m/s, p < 0.01; dicrotic notch PWV = 7.54 ± 0.46 m/s vs 7.92 ± 0.41 m/s, p < 0.01). Further, there was an impact of A1c-measured glycemia on hfCIMT, but this relationship was not seen with ufPWV. No significant statistical correlations between hfCIMT and ufPWV measures in either T1D or healthy controls were observed. CONCLUSION Young adults with T1D present with differences in arterial thickness and stiffness when compared with controls. Use of novel high-resolution ultrasound measures describe important relationships between early structural and vascular pathophysiologic changes and are promising tools to evaluate pre-clinical CVD risk in youth with T1D. TRIAL REGISTRATION ISRCTN91419926.
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Affiliation(s)
- Michael J De Biasio
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Michelle Furman
- Department of Pediatrics, Division of Endocrinology and Metabolism, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Antoine Clarke
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Wei Hui
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Yesmino Elia
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jerome Baranger
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Olivier Villemain
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Luc Mertens
- Division of Cardiology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Farid H Mahmud
- Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Pediatrics, Division of Endocrinology and Metabolism, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Pautrat M, Barbier E, Lebeau JP. Identifying available substance use disorder screening tests feasible for use in primary care: A systematic review. Prev Med Rep 2024; 38:102610. [PMID: 38375183 PMCID: PMC10874871 DOI: 10.1016/j.pmedr.2024.102610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 11/22/2023] [Accepted: 01/11/2024] [Indexed: 02/21/2024] Open
Abstract
Substance use disorders substantially contribute to the global burden of disease. Early detection in primary care is recommended, and numerous screening tests are available. However, barriers to addictive disorder screening exist and the feasibility of using these tests in primary care is unclear. This study aims to identify available addictive disorder screening tests whose feasibility has been evaluated in primary care. This systematic literature review was performed using Pubmed, PsycINFO, and the Cochrane Library databases. The search strategy included four research topics: addictive disorders, screening, primary care, and feasibility. Selection criteria included published studies evaluating the feasibility of an addictive disorder screening test in primary care. Data were extracted for each included article, and each analyzed screening test. Of the 4911 articles selected, 20 were included and 16 screening tests were studied. Physician feasibility was evaluated with satisfaction questionnaires or qualitative studies, mainly measuring test administration time. Patient feasibility was measured using criteria including "ease of use", comprehension, or format preference. Self-administered formats were preferred, especially electronic versions. Overall, the TAPS (Tobacco, Alcohol, Prescription medication, and other Substance use) tool provides a good balance between ease of use, brevity of administration and more extensive screening for substance use disorders. Feasibility appears to be a set of heterogeneous criteria relating to users, including comprehension or satisfaction, and practical aspects, including administration time or format preference. The criteria synthesized in this review could serve as a basis for screening test feasibility studies in primary care given the absence of feasibility study guidelines.
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Affiliation(s)
- Maxime Pautrat
- Department of General Practice, University of Tours, France
- University of Tours, EA7505 Education Ethique Santé, France
| | | | - Jean Pierre Lebeau
- Department of General Practice, University of Tours, France
- University of Tours, EA7505 Education Ethique Santé, France
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Campbell AG, Naz S, Gharbi S, Chambers J, Denne S, Litzelman DK, Wiehe SE. The Concordance of Electronic Health Record Diagnoses and Substance use Self-Reports Among Reproductive Aged Women Enrolled in a Community-Based Addiction Reduction Program. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2024; 61:469580241237051. [PMID: 38528783 DOI: 10.1177/00469580241237051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Substance use disorders among reproductive aged women are a major public health issue. There is little work investigating the validity and reliability of electronic health record (EHR) data for measuring substance use in this population. This study examined the concordance of self-reported substance use with clinical diagnoses of substance use, substance abuse and substance use disorder in EHR data. Reproductive age women enrolled in the Community-Based Addiction Reduction (CARE) program were interviewed by peer recovery coaches (PRC) at enrollment. That survey data was linked with EHR data (n = 102). Concordance between self-reported substance use and clinical diagnoses in the EHR was examined for opioids, cannabis/THC, and cocaine. Cohen's kappa, sensitivity, and specificity were calculated. The survey captured a higher number of women who use substances compared to the EHR. The concordance of self-report with EHR diagnosis varied by substance and was higher for opioids (17.6%) relative to cannabis/THC (8.8%), and cocaine (3.0%). Additionally, opioids had higher sensitivity (46.2%) and lower specificity (76.2%) relative to cannabis/THC and cocaine. Survey data collected by PRCs captured more substance use than EHRs, suggesting that EHRs underestimate substance use prevalence. The higher sensitivity and lower specificity of opioids was due to a larger number of women who had a diagnosis of opioid use in the EHR who did not self-report opioid use in the self-report survey relative to cannabis/THC and cocaine. Opioid self-report and diagnosis may be influenced by research setting, question wording, or receipt of medication for opioid use disorder.
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Affiliation(s)
| | - Saman Naz
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sami Gharbi
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Joanna Chambers
- Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana Clinical Translational Sciences Institute, Indianapolis, IN, USA
| | - Scott Denne
- Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana Clinical Translational Sciences Institute, Indianapolis, IN, USA
| | - Debra K Litzelman
- Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana Clinical Translational Sciences Institute, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
| | - Sarah E Wiehe
- Indiana University School of Medicine, Indianapolis, IN, USA
- Indiana Clinical Translational Sciences Institute, Indianapolis, IN, USA
- Regenstrief Institute, Inc., Indianapolis, IN, USA
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López CM, Goodrum NM, Brown TP, O'Brien A, Davies F, Moreland A. The REACH (Resiliency, Engagement, and Accessibility for Comorbid HIV/PTSD/SUD populations) Protocol: Using a Universal Screener to Improve Mental Health and Enhance HIV Care Outcomes. J Behav Health Serv Res 2023; 50:452-467. [PMID: 37524892 DOI: 10.1007/s11414-023-09850-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 08/02/2023]
Abstract
Among people living with HIV (PLWH), 50% report substance use disorders (SUDs), and 30-61% report posttraumatic stress disorder (PTSD). Comorbid PTSD/SUD/HIV has been linked to faster HIV progression and twice the rate of death, lower medical adherence and retention, and increased viral load compared to PLWH without co-occurring PTSD or SUD. A critical first step in establishing comprehensive mental health services for PLWH is the implementation of an evidence-based screening protocol for PTSD and SUDs to facilitate referrals to specialty mental health providers. Guided by the Consolidated Framework for Implementation Research, this mixed-methods study aimed to examine the feasibility of delivering the REACH (Resiliency, Engagement, and Accessibility for Comorbid HIV/PTSD/SUD populations) Screening protocol. Three case managers were instructed to provide the REACH screening electronically to all patients that they saw for enrollment or re-enrollment appointments over 3 months (n=102). Of the 70 patients who completed the screener, 27% had clinically significant PTSD symptoms and 48.6% had SUD concerns. Qualitative feedback revealed themes related to beliefs about SU and PTSD, attitudes toward screening, comfort in the discussion of SU and PTSD, and referral and treatment considerations. Discussion includes lessons learned for implementation of this assessment of PTSD/SUD in PLWH as a novel approach to increase mental health engagement and promote health equity, with the potential long-term impact of improving HIV care outcomes via ameliorating mental health/SUD, and implications for prevention of HIV transmission. Implementation science can be leveraged to understand the gap in the utilization of existing evidence-based screening tools in HIV care settings.
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Affiliation(s)
- Cristina M López
- Medical University of South Carolina, 67 President Street, MSC 861, Charleston, SC, 29425, USA.
| | | | | | - Aaron O'Brien
- Roper St. Francis Ryan White Wellness Center, Charleston, SC, USA
| | - Faraday Davies
- Medical University of South Carolina, 67 President Street, MSC 861, Charleston, SC, 29425, USA
| | - Angela Moreland
- Medical University of South Carolina, 67 President Street, MSC 861, Charleston, SC, 29425, USA
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Fernandez AC, Waljee JF, Gunaseelan V, Brummett CM, Englesbe MJ, Bicket MC. Prevalence of Unhealthy Substance Use and Associated Characteristics Among Patients Presenting for Surgery. Ann Surg 2023; 278:e740-e744. [PMID: 36538617 PMCID: PMC10205913 DOI: 10.1097/sla.0000000000005767] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To assess the prevalence of and identify characteristics associated with unhealthy use before surgery. BACKGROUND Although the escalation in US drug overdose deaths is apparent, the unhealthy use of substances among patients presenting for surgery is unclear. METHODS We conducted a retrospective study of patients presenting for elective surgical procedures between December 2018 and July 2021 and prospectively recruited to 1 of 2 clinical research studies (Michigan Genomics Initiative, Prevention of Iatrogenic Opioid Dependence after Surgery Study). The primary outcome was unhealthy substance use in the past 12 months as determined using the Tobacco, Alcohol, Prescription medication, and other Substance use tool. RESULTS Among 1912 patients, unhealthy substance use was reported in 768 (40.2%). The most common substances with unhealthy use were illicit drugs [385 (20.1%)], followed by alcohol 358 (18.7%)], tobacco [262 (13.7%)], and prescription medications [86 (4.5%)]. Patients reporting unhealthy substance use were significantly more likely to be younger, male [aOR: 1.95 (95% CI, 1.58-2.42)], and have higher scores for pain [aOR: 1.07 (95% CI, 1.02-1.13)], and anxiety [aOR: 1.03 (95% CI, 1.01-1.04)]. Unhealthy substance use was more common among surgical procedures of the forearm, wrist, and hand [aOR: 2.58 (95% CI, 1.01-6.55)]. CONCLUSIONS As many as 2 in 5 patients in the preoperative period may present with unhealthy substance use before elective surgery. Given the potential impact of substance use on surgical outcomes, increased recognition of the problem by screening patients is a critical next step for surgeons and perioperative care teams.
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Affiliation(s)
- Anne C Fernandez
- Department of Psychiatry, Addiction Center, University of Michigan, Ann Arbor, MI
| | - Jennifer F Waljee
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI
| | - Vidhya Gunaseelan
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI
| | - Chad M Brummett
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
| | - Michael J Englesbe
- Department of Surgery, University of Michigan, Ann Arbor, MI
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI
| | - Mark C Bicket
- Opioid Prescribing Engagement Network, Institute for Healthcare Policy and Innovation, University of Michigan School of Public Health, University of Michigan, Ann Arbor, MI
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI
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McNeely J, McLeman B, Gardner T, Nesin N, Amarendran V, Farkas S, Wahle A, Pitts S, Kline M, King J, Rosa C, Marsch L, Rotrosen J, Hamilton L. Implementation of substance use screening in rural federally-qualified health center clinics identified high rates of unhealthy alcohol and cannabis use among adult primary care patients. Addict Sci Clin Pract 2023; 18:56. [PMID: 37726839 PMCID: PMC10510292 DOI: 10.1186/s13722-023-00404-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 07/31/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Screening for substance use in rural primary care clinics faces unique challenges due to limited resources, high patient volumes, and multiple demands on providers. To explore the potential for electronic health record (EHR)-integrated screening in this context, we conducted an implementation feasibility study with a rural federally-qualified health center (FQHC) in Maine. This was an ancillary study to a NIDA Clinical Trials Network study of screening in urban primary care clinics (CTN-0062). METHODS Researchers worked with stakeholders from three FQHC clinics to define and implement their optimal screening approach. Clinics used the Tobacco, Alcohol, Prescription Medication, and Other Substance (TAPS) Tool, completed on tablet computers in the waiting room, and results were immediately recorded in the EHR. Adult patients presenting for annual preventive care visits, but not those with other visit types, were eligible for screening. Data were analyzed for the first 12 months following implementation at each clinic to assess screening rates and prevalence of reported unhealthy substance use, and documentation of counseling using an EHR-integrated clinical decision support tool, for patients screening positive for moderate-high risk alcohol or drug use. RESULTS Screening was completed by 3749 patients, representing 93.4% of those with screening-eligible annual preventive care visits, and 18.5% of adult patients presenting for any type of primary care visit. Screening was self-administered in 92.9% of cases. The prevalence of moderate-high risk substance use detected on screening was 14.6% for tobacco, 30.4% for alcohol, 10.8% for cannabis, 0.3% for illicit drugs, and 0.6% for non-medical use of prescription drugs. Brief substance use counseling was documented for 17.4% of patients with any moderate-high risk alcohol or drug use. CONCLUSIONS Self-administered EHR-integrated screening was feasible to implement, and detected substantial alcohol, cannabis, and tobacco use in rural FQHC clinics. Counseling was documented for a minority of patients with moderate-high risk use, possibly indicating a need for better support of primary care providers in addressing substance use. There is potential to broaden the reach of screening by offering it at routine medical visits rather than restricting to annual preventive care visits, within these and other rural primary care clinics.
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Affiliation(s)
- Jennifer McNeely
- Department of Population Health, Section on Tobacco, Alcohol and Drug Use, New York University Grossman School of Medicine, 180 Madison Ave., 17th Floor, New York, NY, 10016, USA.
| | - Bethany McLeman
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Evergreen Center, Suite 315, Lebanon, NH, 03766, USA
| | - Trip Gardner
- Penobscot Community Health Care (PCHC), 103 Maine Avenue, Bangor, ME, 04401, USA
| | - Noah Nesin
- Penobscot Community Health Care (PCHC), 103 Maine Avenue, Bangor, ME, 04401, USA
| | - Vijay Amarendran
- Penobscot Community Health Care (PCHC), 103 Maine Avenue, Bangor, ME, 04401, USA
| | - Sarah Farkas
- Department of Psychiatry, New York University Grossman School of Medicine, 1 Park Ave, New York, NY, 10016, USA
| | - Aimee Wahle
- The Emmes Company, 401 N. Washington St., Rockville, MD, 20850, USA
| | - Seth Pitts
- The Emmes Company, 401 N. Washington St., Rockville, MD, 20850, USA
| | - Margaret Kline
- The Emmes Company, 401 N. Washington St., Rockville, MD, 20850, USA
| | - Jacquie King
- The Emmes Company, 401 N. Washington St., Rockville, MD, 20850, USA
| | - Carmen Rosa
- National Institute on Drug Abuse, c/o NIH Mail Center, NIDA 3@FN MSC 6022, 16071 Industrial Drive-Dock 11, Gaithersburg, MD, 20892, USA
| | - Lisa Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Parkway, Evergreen Center, Suite 315, Lebanon, NH, 03766, USA
| | - John Rotrosen
- Department of Psychiatry, New York University Grossman School of Medicine, 1 Park Ave, New York, NY, 10016, USA
| | - Leah Hamilton
- Department of Population Health, Section on Tobacco, Alcohol and Drug Use, New York University Grossman School of Medicine, 180 Madison Ave., 17th Floor, New York, NY, 10016, USA
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA, 98101, USA
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Woodward D, Wilens TE, Glantz M, Rao V, Burke C, Yule AM. A systematic review of substance use screening in outpatient behavioral health settings. Addict Sci Clin Pract 2023; 18:18. [PMID: 36967381 PMCID: PMC10041696 DOI: 10.1186/s13722-023-00376-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE Despite the frequent comorbidity of substance use disorders (SUDs) and psychiatric disorders, it remains unclear if screening for substance use in behavioral health clinics is a common practice. The aim of this review is to examine what is known about systematic screening for substance use in outpatient behavioral health clinics. METHODS We conducted a PRISMA-based systematic literature search assessing substance use screening in outpatient adult and pediatric behavioral health settings in PubMed, Embase, and PsycINFO. Quantitative studies published in English before May 22, 2020 that reported the percentage of patients who completed screening were included. RESULTS Only eight articles met our inclusion and exclusion criteria. Reported prevalence of screening ranged from 48 to 100%, with half of the studies successfully screening more than 75% of their patient population. There were limited data on patient demographics for individuals who were and were not screened (e.g., gender, race) and screening practices (e.g., electronic versus paper/pencil administration). CONCLUSIONS The results of this systematic review suggest that successful screening for substance use in behavioral health settings is possible, yet it remains unclear how frequently screening occurs. Given the high rates of comorbid SUD and psychopathology, future research is necessary regarding patient and clinic-level variables that may impact the successful implementation of substance use screening. Trial registry A methodological protocol was registered with the PROSPERO systematic review protocol registry (ID: CRD42020188645).
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Affiliation(s)
- Diana Woodward
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Timothy E Wilens
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | | | - Vinod Rao
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Colin Burke
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Amy M Yule
- Department of Psychiatry, Boston Medical Center, 850 Harrison Avenue, Boston, MA, 02118, USA.
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Murray-Krezan C, Dopp A, Tarhuni L, Carmody MD, Becker K, Anderson J, Komaromy M, Meredith LS, Watkins KE, Wagner K, Page K. Screening for opioid use disorder and co-occurring depression and post-traumatic stress disorder in primary care in New Mexico. Addict Sci Clin Pract 2023; 18:6. [PMID: 36707910 PMCID: PMC9881516 DOI: 10.1186/s13722-023-00362-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 01/18/2023] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Identifying patients in primary care services with opioid use disorder and co-occurring mental health disorders is critical to providing treatment. Objectives of this study were to (1) assess the feasibility of recruiting people to screen in-person for opioid use disorder and co-occurring mental health disorders (depression and/or post-traumatic stress disorder) in primary care clinic waiting rooms in preparation for a randomized controlled trial, and (2) compare results of detecting these disorders by universal in-person screening compared to electronic health record (EHR) diagnoses. METHODS This cross-sectional feasibility and pilot study recruited participants from four primary care clinics, two rural and two urban, from three health care organizations in New Mexico. Inclusion criteria were adults (≥ 18 years), attending one of the four clinics as a patient, and who spoke English or Spanish. Exclusion criteria were people attending the clinic for a non-primary care visit (e.g., dental, prescription pick up, social support). The main outcomes and measures were (1) recruitment feasibility which was assessed by frequencies and proportions of people approached and consented for in-person screening, and (2) relative differences of detecting opioid use disorder and co-occurring mental health disorders in waiting rooms relative to aggregate EHR data from each clinic, measured by prevalence and prevalence ratios. RESULTS Over two-weeks, 1478 potential participants were approached and 1145 were consented and screened (77.5% of patients approached). Probable opioid use disorder and co-occurring mental health disorders were identified in 2.4% of those screened compared to 0.8% in EHR. Similarly, universal screening relative to EHR identified higher proportions of probable opioid use disorder (4.5% vs. 3.4%), depression (17.5% vs. 12.7%) and post-traumatic stress disorder (19.0% vs. 3.6%). CONCLUSIONS Universal screening for opioid use disorder, depression, and post-traumatic stress disorder was feasible, and identified three times as many patients with these co-occurring disorders compared to EHR. Higher proportions of each condition were also identified, especially post-traumatic stress disorder. Results support that there are likely gaps in identification of these disorders in primary care services and demonstrate the need to better address the persistent public health problem of these co-occurring disorders.
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Affiliation(s)
- Cristina Murray-Krezan
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA.
- Department of Medicine, Division of General Internal Medicine, School of Medicine, University of Pittsburgh, 200 Meyran Ave, Suite 300, Pittsburgh, PA, 15213, USA.
| | - Alex Dopp
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | - Lina Tarhuni
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Mary D Carmody
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Kirsten Becker
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | - Jessica Anderson
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Miriam Komaromy
- Grayken Center for Addiction, Boston Medical Center, Boston University, Boston, MA, 02118, USA
| | - Lisa S Meredith
- Health Care Division, RAND Corporation, Santa Monica, CA, 90417-2038, USA
| | | | - Katherine Wagner
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
| | - Kimberly Page
- Department of Internal Medicine, Division of Epidemiology, Biostatistics and Preventive Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, 87131, USA
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Lemp JM, Pengpid S, Buntup D, Bärnighausen TW, Geldsetzer P, Peltzer K, Rehm J, Sornpaisarn B, Probst C. Addressing alcohol use among blood pressure patients in Thai primary care: Lessons from a survey-based stakeholder consultation. Prev Med Rep 2022; 29:101954. [PMID: 36161118 PMCID: PMC9502666 DOI: 10.1016/j.pmedr.2022.101954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 08/12/2022] [Accepted: 08/14/2022] [Indexed: 11/20/2022] Open
Abstract
Alcohol use is a major risk factor for noncommunicable diseases in Thailand, and one of its pathways is high blood pressure. Given that brief intervention can effectively reduce hazardous alcohol consumption, this study aimed to investigate how hypertensive patients with concomitant alcohol use are identified and treated in Thai primary care settings and what this may mean for screening and lifestyle intervention strategies. In a cross-sectional, mixed-method design, we surveyed 91 participants from three different groups of Thai stakeholders: policy- and decisionmakers; healthcare practitioners; and patients diagnosed with hypertension. Data was collected between December 2020 and May 2021. Responses were analyzed descriptively and using open coding tools to identify current practices, barriers, facilitators, and implications for interventions. All stakeholder groups regarded alcohol use as an important driver of hypertension. While lifestyle interventions among hypertensive patients were perceived as beneficial, current lifestyle support was limited. Barriers included limited resources in primary healthcare facilities, lack of continuous monitoring or follow-up, missing tools or procedures for risk assessment and lifestyle intervention, and stigmatization of alcohol use. Our results suggest that although screening for lifestyle risk factors (including alcohol use) and lifestyle interventions are not yet sufficiently established, a wide range of stakeholders still recognize the potential of interventions targeted at hazardous alcohol use among hypertensive patients. Future interventions may establish standardized assessment tools, be tailored to high-risk groups, and include electronic or remote elements.
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Affiliation(s)
- Julia M. Lemp
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Supa Pengpid
- ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand
- Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa
| | - Doungjai Buntup
- ASEAN Institute for Health Development, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand
| | - Till W. Bärnighausen
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Harvard Center for Population and Development Studies, Cambridge, MA, USA
- Africa Health Research Institute (AHRI), KwaZulu-Natal, South Africa
| | - Pascal Geldsetzer
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Karl Peltzer
- Department of Research Administration and Development, University of Limpopo, Turfloop, South Africa
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Jürgen Rehm
- Institute of Clinical Psychology and Psychotherapy, TU Dresden, Dresden, Germany
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- I.M. Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Bundit Sornpaisarn
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Faculty of Public Health, Mahidol University, Ratchathewi, Bangkok, Thailand
| | - Charlotte Probst
- Heidelberg Institute of Global Health, Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
- Corresponding author at: Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.
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Abstract
Unhealthy alcohol use-the consumption of alcohol at a level that has caused or has the potential to cause adverse physical, psychological, or social consequences-is common, underrecognized, and undertreated. For example, data from the 2020 National Survey on Drug Use and Health indicate that 7.0% of adults reported heavy alcohol use in the previous month, and only 4.2% of adults with alcohol use disorder received treatment. Primary care is an important setting for optimizing screening and treatment of unhealthy alcohol use to promote individual and public health.
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Affiliation(s)
- Joseph H Donroe
- Yale Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut (J.H.D.)
| | - E Jennifer Edelman
- Yale Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, and Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut (E.J.E.)
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Emenyonu N, Kekibiina A, Woolf-King S, Kyampire C, Fatch R, Dawson-Rose C, Muyindike W, Hahn J. Digital Health Screening in People With HIV in Uganda to Increase Alcohol Use Reporting: Qualitative Study on the Development and Testing of the Self-administered Digital Screener for Health. JMIR Form Res 2022; 6:e35015. [PMID: 36048519 PMCID: PMC9478818 DOI: 10.2196/35015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 06/10/2022] [Accepted: 07/21/2022] [Indexed: 11/16/2022] Open
Abstract
Background Alcohol consumption is a critical driver of the HIV epidemic worldwide, particularly in sub-Saharan Africa, where unhealthy alcohol use and HIV are prevalent. Brief alcohol interventions are effective in reducing alcohol use; however, they depend on effective screening for unhealthy alcohol use, which is often underreported. Thus, there is a need to develop methods to improve reporting of unhealthy alcohol use as an essential step toward referral to brief alcohol interventions. Self-administered digital health screeners may improve reporting. Objective This study aimed to develop and test a digital, easy-to-use self-administered health screener. The health screener was designed to be implemented in a busy, underresourced HIV treatment setting and used by patients with varying levels of literacy. Methods We conducted a qualitative study at the Immune Suppression Syndrome (ISS) Clinic of Mbarara Regional Referral Hospital in Uganda to develop and test a digital self-administered health screener. The health screener included a training module and assessed behaviors regarding general health, HIV care, and mental health as well as sensitive topics such as alcohol use and sexual health. We conducted focus group discussions with clinicians and patients with HIV of the Mbarara ISS Clinic who consumed alcohol to obtain input on the need for and content, format, and feasibility of the proposed screener. We iteratively revised a tablet-based screener with a subset of these participants, piloted the revised screener, and conducted individual semistructured in-depth interviews with 20 participants who had taken part in our previous studies on alcohol and HIV, including those who had previously underreported alcohol use and with low literacy. Results A total of 45 people (n=5, 11% clinicians and n=40, 89% Mbarara ISS Clinic patients) participated in the study. Of the patient participants, 65% (26/40) were male, 43% (17/40) had low literacy, and all (40/40, 100%) had self-reported alcohol use in previous studies. Clinicians and patients cited benefits such as time savings, easing of staff burden, mitigation of patient-provider tension around sensitive issues, and information communication, but also identified areas of training required, issues of security of the device, and confidentiality concerns. Patients also stated fear of forgetting how to use the tablet, making mistakes, and losing information as barriers to uptake. In pilot tests of the prototype, patients liked the feature of a recorded voice in the local language and found the screener easy to use, although many required additional help and training from the study staff to complete the screener. Conclusions We found a self-administered digital health screener to be appealing to patients and clinicians and usable in a busy HIV clinic setting, albeit with concerns about confidentiality and training. Such a screener may be useful in improving reporting of unhealthy alcohol use for referral to interventions.
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Affiliation(s)
- Nneka Emenyonu
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Allen Kekibiina
- MUST Grants Office, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Sarah Woolf-King
- Department of Psychology, Syracuse University, Syracuse, NY, United States
| | - Catherine Kyampire
- MUST Grants Office, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Robin Fatch
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Carol Dawson-Rose
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Winnie Muyindike
- MUST Grants Office, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Judith Hahn
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
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13
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Pautrat M, Pierre Lebeau J, Laporte C. Identifying available addictive disorder screening tests validated in primary care: A systematic review. Addict Behav 2022; 126:107180. [PMID: 34864478 DOI: 10.1016/j.addbeh.2021.107180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 11/08/2021] [Accepted: 11/10/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Substance use disorders and non-substance addictive behaviors are major, growing health concerns. Efficient screening primary care settings encouraged but its widespread implementation is restricted without an appropriate screening approach for clinical practice or guidance for practitioners choose an appropriate screening test. This study aims to identify addictive disorder screening tests which are validated in primary care and suggest steps to help practitioners select the appropriate test. METHOD A systematic review of the literature through Pubmed, PsycINFO and The Cochrane Library was performed from database inception to December 21, 2020. The search strategy included three research topics: screening, addictive disorders, and primary care. Selection criteria included published studies evaluating the validity of an addictive disorder screening test in primary care settings. RESULTS 8638 papers were selected, and 50 studies were included. Seventeen questionnaires validated in primary care covered the main substance use disorders, but none screened for non-substance addictive behaviors. Tests such as ASSIST, S2BI, SUBS and TAPS screen for a variety of substance use disorders while others such as TICS and CAGE-AID only have a few questions to improve feasibility. However, some shorter tests had weaker psychometric properties. CONCLUSIONS Seventeen addictive disorder screening tests validated in primary care are available. The feasibility and acceptability in primary care of the shorter tests needs to be assessed. A transversal screening test, adapted to the constraints of primary care, that enables clinicians to detect substance use disorders and non-substance addictive behaviors is needed.
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Affiliation(s)
- Maxime Pautrat
- Department of General Practice, University of Tours, France; University of Tours, EA7505 Education Ethique Santé, France.
| | - Jean Pierre Lebeau
- Department of General Practice, University of Tours, France; University of Tours, EA7505 Education Ethique Santé, France
| | - Catherine Laporte
- University of Clermont Auvergne, Clermont Auvergne INP, CHU Clermont-Ferrand, CNRS, Institut Pascal, F-63000 Clermont-Ferrand, France
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14
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Lea AN, Altschuler A, Leibowitz AS, Levine-Hall T, McNeely J, Silverberg MJ, Satre DD. Patient and provider perspectives on self-administered electronic substance use and mental health screening in HIV primary care. Addict Sci Clin Pract 2022; 17:10. [PMID: 35139911 PMCID: PMC8827178 DOI: 10.1186/s13722-022-00293-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 01/26/2022] [Indexed: 11/26/2022] Open
Abstract
Background Substance use disorders, depression and anxiety disproportionately affect people with HIV (PWH) and lead to increased morbidity and mortality. Routine screening can help address these problems but is underutilized. This study sought to describe patient and provider perspectives on the acceptability and usefulness of systematic electronic, self-administered screening for tobacco, alcohol, other substance use, and mental health symptoms among patients in HIV primary care. Methods Screening used validated instruments delivered pre-appointment by both secure messaging and clinic-based tablets, with results integrated into the electronic health record (EHR). Qualitative analysis of semi-structured interviews with 9 HIV primary care providers and 12 patients in the 3 largest HIV primary care clinics in the Kaiser Permanente Northern California health system who participated in a clinical trial evaluating computerized screening and behavioral interventions was conducted. Interviews were audio-recorded and transcribed. A thematic approach was utilized for coding and analysis of interview data using a combination of deductive and inductive methods. Results Four key themes were identified: (1) perceived clinical benefit of systematic, electronic screening and EHR integration for providers and patients; (2) usefulness of having multiple methods of questionnaire completion; (3) importance of the patient–provider relationship to facilitate completion and accurate reporting; and (4) barriers, include privacy and confidentiality concerns about reporting sensitive information, particularly about substance use, and potential burden from repeated screenings. Conclusions Findings suggest that electronic, self-administered substance use and mental health screening is acceptable to patients and may have clinical utility to providers. While offering different methods of screening completion can capture a wider range of patients, a strong patient–provider relationship is a key factor in overcoming barriers and ensuring accurate patient responses. Further investigation into facilitators, barriers, and utility of electronic screening for PWH and other high-priority patient populations is indicated. Trial registration ClinicalTrials.gov, NCT03217058. Registered 13 July 2017, https://clinicaltrials.gov/ct2/show/NCT03217058 Supplementary Information The online version contains supplementary material available at 10.1186/s13722-022-00293-7.
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Affiliation(s)
- Alexandra N Lea
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Amy S Leibowitz
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Tory Levine-Hall
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Jennifer McNeely
- Department of Population Health, Section on Tobacco, Alcohol, and Drug Use, New York University Grossman School of Medicine, 180 Madison Ave., New York, NY, 10016, USA
| | - Michael J Silverberg
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612, USA.,Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA, 94143, USA
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15
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The Substance Use Treatment and Recovery Team (START) study: protocol for a multi-site randomized controlled trial evaluating an intervention to improve initiation of medication and linkage to post-discharge care for hospitalized patients with opioid use disorder. Addict Sci Clin Pract 2022; 17:39. [PMID: 35902888 PMCID: PMC9331017 DOI: 10.1186/s13722-022-00320-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND People with opioid use disorder experience high burden of disease from medical comorbidities and are increasingly hospitalized with medical complications. Medications for opioid use disorder are an effective, life-saving treatment, but patients with an opioid use disorder admitted to the hospital seldom initiate medication for their disorder while in the hospital, nor are they linked with outpatient treatment after discharge. The inpatient stay, when patients may be more receptive to improving their health and reducing substance use, offers an opportunity to discuss opioid use disorder and facilitate medication initiation and linkage to treatment after discharge. An addiction-focus consultative team that uses evidence-based tools and resources could address barriers, such as the need for the primary medical team to focus on the primary health problem and lack of time and expertise, that prevent primary medical teams from addressing substance use. METHODS This study is a pragmatic randomized controlled trial that will evaluate whether a consultative team, called the Substance Use Treatment and Recovery Team (START), increases initiation of any US Food and Drug Administration approved medication for opioid use disorder (buprenorphine, methadone, naltrexone) during the hospital stay and increases linkage to treatment after discharge compared to patients receiving usual care. The study is being conducted at three geographically distinct academic hospitals. Patients are randomly assigned within each hospital to receive the START intervention or usual care. Primary study outcomes are initiation of medication for opioid use disorder in the hospital and linkage to medication or other opioid use disorder treatment after discharge. Outcomes are assessed through participant interviews at baseline and 1 month after discharge and data from hospital and outpatient medical records. DISCUSSION The START intervention offers a compelling model to improve care for hospitalized patients with opioid use disorder. The study could also advance translational science by identifying an effective and generalizable approach to treating not only opioid use disorder, but also other substance use disorders and behavioral health conditions. TRIAL REGISTRATION Clinicaltrials.gov: NCT05086796, Registered on 10/21/2021. https://www. CLINICALTRIALS gov/ct2/results?recrs=ab&cond=&term=NCT05086796&cntry=&state=&city=&dist = .
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16
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Abstract
Unhealthy alcohol and drug use are among the top 10 causes of preventable death in the United States, but they are infrequently identified and addressed in medical settings. Guidelines recommend screening adult primary care patients for alcohol and drug use, and routine screening should be a component of high-quality clinical care. Brief, validated screening tools accurately detect unhealthy alcohol and drug use, and their thoughtful implementation can facilitate adoption and optimize the quality of screening results. Recommendations for implementation include patient self-administered screening tools, integration with electronic health records, and screening during routine primary care visits.
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Affiliation(s)
- Jennifer McNeely
- Section on Alcohol, Tobacco, and Drug Use, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 17th Floor, New York, NY 10016, USA; Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU Grossman School of Medicine, New York, NY 10016, USA.
| | - Leah Hamilton
- Section on Alcohol, Tobacco, and Drug Use, Department of Population Health, NYU Grossman School of Medicine, 180 Madison Avenue, 17th Floor, New York, NY 10016, USA; Kaiser Permanente Washington Health Research Institute, 1730 Minor Avenue, Seattle, WA 98101, USA
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17
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Lindson N, Pritchard G, Hong B, Fanshawe TR, Pipe A, Papadakis S. Strategies to improve smoking cessation rates in primary care. Cochrane Database Syst Rev 2021; 9:CD011556. [PMID: 34693994 PMCID: PMC8543670 DOI: 10.1002/14651858.cd011556.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Primary care is an important setting in which to treat tobacco addiction. However, the rates at which providers address smoking cessation and the success of that support vary. Strategies can be implemented to improve and increase the delivery of smoking cessation support (e.g. through provider training), and to increase the amount and breadth of support given to people who smoke (e.g. through additional counseling or tailored printed materials). OBJECTIVES To assess the effectiveness of strategies intended to increase the success of smoking cessation interventions in primary care settings. To assess whether any effect that these interventions have on smoking cessation may be due to increased implementation by healthcare providers. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group's Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and trial registries to 10 September 2020. SELECTION CRITERIA We included randomized controlled trials (RCTs) and cluster-RCTs (cRCTs) carried out in primary care, including non-pregnant adults. Studies investigated a strategy or strategies to improve the implementation or success of smoking cessation treatment in primary care. These strategies could include interventions designed to increase or enhance the quality of existing support, or smoking cessation interventions offered in addition to standard care (adjunctive interventions). Intervention strategies had to be tested in addition to and in comparison with standard care, or in addition to other active intervention strategies if the effect of an individual strategy could be isolated. Standard care typically incorporates physician-delivered brief behavioral support, and an offer of smoking cessation medication, but differs across studies. Studies had to measure smoking abstinence at six months' follow-up or longer. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methods. Our primary outcome - smoking abstinence - was measured using the most rigorous intention-to-treat definition available. We also extracted outcome data for quit attempts, and the following markers of healthcare provider performance: asking about smoking status; advising on cessation; assessment of participant readiness to quit; assisting with cessation; arranging follow-up for smoking participants. Where more than one study investigated the same strategy or set of strategies, and measured the same outcome, we conducted meta-analyses using Mantel-Haenszel random-effects methods to generate pooled risk ratios (RRs) and 95% confidence intervals (CIs). MAIN RESULTS We included 81 RCTs and cRCTs, involving 112,159 participants. Fourteen were rated at low risk of bias, 44 at high risk, and the remainder at unclear risk. We identified moderate-certainty evidence, limited by inconsistency, that the provision of adjunctive counseling by a health professional other than the physician (RR 1.31, 95% CI 1.10 to 1.55; I2 = 44%; 22 studies, 18,150 participants), and provision of cost-free medications (RR 1.36, 95% CI 1.05 to 1.76; I2 = 63%; 10 studies,7560 participants) increased smoking quit rates in primary care. There was also moderate-certainty evidence, limited by risk of bias, that the addition of tailored print materials to standard smoking cessation treatment increased the number of people who had successfully stopped smoking at six months' follow-up or more (RR 1.29, 95% CI 1.04 to 1.59; I2 = 37%; 6 studies, 15,978 participants). There was no clear evidence that providing participants who smoked with biomedical risk feedback increased their likelihood of quitting (RR 1.07, 95% CI 0.81 to 1.41; I2 = 40%; 7 studies, 3491 participants), or that provider smoking cessation training (RR 1.10, 95% CI 0.85 to 1.41; I2 = 66%; 7 studies, 13,685 participants) or provider incentives (RR 1.14, 95% CI 0.97 to 1.34; I2 = 0%; 2 studies, 2454 participants) increased smoking abstinence rates. However, in assessing the former two strategies we judged the evidence to be of low certainty and in assessing the latter strategies it was of very low certainty. We downgraded the evidence due to imprecision, inconsistency and risk of bias across these comparisons. There was some indication that provider training increased the delivery of smoking cessation support, along with the provision of adjunctive counseling and cost-free medications. However, our secondary outcomes were not measured consistently, and in many cases analyses were subject to substantial statistical heterogeneity, imprecision, or both, making it difficult to draw conclusions. Thirty-four studies investigated multicomponent interventions to improve smoking cessation rates. There was substantial variation in the combinations of strategies tested, and the resulting individual study effect estimates, precluding meta-analyses in most cases. Meta-analyses provided some evidence that adjunctive counseling combined with either cost-free medications or provider training enhanced quit rates when compared with standard care alone. However, analyses were limited by small numbers of events, high statistical heterogeneity, and studies at high risk of bias. Analyses looking at the effects of combining provider training with flow sheets to aid physician decision-making, and with outreach facilitation, found no clear evidence that these combinations increased quit rates; however, analyses were limited by imprecision, and there was some indication that these approaches did improve some forms of provider implementation. AUTHORS' CONCLUSIONS There is moderate-certainty evidence that providing adjunctive counseling by an allied health professional, cost-free smoking cessation medications, and tailored printed materials as part of smoking cessation support in primary care can increase the number of people who achieve smoking cessation. There is no clear evidence that providing participants with biomedical risk feedback, or primary care providers with training or incentives to provide smoking cessation support enhance quit rates. However, we rated this evidence as of low or very low certainty, and so conclusions are likely to change as further evidence becomes available. Most of the studies in this review evaluated smoking cessation interventions that had already been extensively tested in the general population. Further studies should assess strategies designed to optimize the delivery of those interventions already known to be effective within the primary care setting. Such studies should be cluster-randomized to account for the implications of implementation in this particular setting. Due to substantial variation between studies in this review, identifying optimal characteristics of multicomponent interventions to improve the delivery of smoking cessation treatment was challenging. Future research could use component network meta-analysis to investigate this further.
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Affiliation(s)
- Nicola Lindson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Gillian Pritchard
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
- Canadian Public Health Association, Ottawa, Canada
| | - Bosun Hong
- Oral Surgery Department, Birmingham Dental Hospital, Birmingham, UK
| | - Thomas R Fanshawe
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andrew Pipe
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
| | - Sophia Papadakis
- Division of Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Canada
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McNeely J, Adam A, Rotrosen J, Wakeman SE, Wilens TE, Kannry J, Rosenthal RN, Wahle A, Pitts S, Farkas S, Rosa C, Peccoralo L, Waite E, Vega A, Kent J, Craven CK, Kaminski TA, Firmin E, Isenberg B, Harris M, Kushniruk A, Hamilton L. Comparison of Methods for Alcohol and Drug Screening in Primary Care Clinics. JAMA Netw Open 2021; 4:e2110721. [PMID: 34014326 PMCID: PMC8138691 DOI: 10.1001/jamanetworkopen.2021.10721] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
IMPORTANCE Guidelines recommend that adult patients receive screening for alcohol and drug use during primary care visits, but the adoption of screening in routine practice remains low. Clinics frequently struggle to choose a screening approach that is best suited to their resources, workflows, and patient populations. OBJECTIVE To evaluate how to best implement electronic health record (EHR)-integrated screening for substance use by comparing commonly used screening methods and examining their association with implementation outcomes. DESIGN, SETTING, AND PARTICIPANTS This article presents the outcomes of phases 3 and 4 of a 4-phase quality improvement, implementation feasibility study in which researchers worked with stakeholders at 6 primary care clinics in 2 large urban academic health care systems to define and implement their optimal screening approach. Site A was located in New York City and comprised 2 clinics, and site B was located in Boston, Massachusetts, and comprised 4 clinics. Clinics initiated screening between January 2017 and October 2018, and 93 114 patients were eligible for screening for alcohol and drug use. Data used in the analysis were collected between January 2017 and October 2019, and analysis was performed from July 13, 2018, to March 23, 2021. INTERVENTIONS Clinics integrated validated screening questions and a brief counseling script into the EHR, with implementation supported by the use of clinical champions (ie, clinicians who advocate for change, motivate others, and use their expertise to facilitate the adoption of an intervention) and the training of clinic staff. Clinics varied in their screening approaches, including the type of visit targeted for screening (any visit vs annual examinations only), the mode of administration (staff-administered vs self-administered by the patient), and the extent to which they used practice facilitation and EHR usability testing. MAIN OUTCOMES AND MEASURES Data from the EHRs were extracted quarterly for 12 months to measure implementation outcomes. The primary outcome was screening rate for alcohol and drug use. Secondary outcomes were the prevalence of unhealthy alcohol and drug use detected via screening, and clinician adoption of a brief counseling script. RESULTS Patients of the 6 clinics had a mean (SD) age ranging from 48.9 (17.3) years at clinic B2 to 59.1 (16.7) years at clinic B3, were predominantly female (52.4% at clinic A1 to 64.6% at clinic A2), and were English speaking. Racial diversity varied by location. Of the 93,114 patients with primary care visits, 71.8% received screening for alcohol use, and 70.5% received screening for drug use. Screening at any visit (implemented at site A) in comparison with screening at annual examinations only (implemented at site B) was associated with higher screening rates for alcohol use (90.3%-94.7% vs 24.2%-72.0%, respectively) and drug use (89.6%-93.9% vs 24.6%-69.8%). The 5 clinics that used a self-administered screening approach had a higher detection rate for moderate- to high-risk alcohol use (14.7%-36.6%) compared with the 1 clinic that used a staff-administered screening approach (1.6%). The detection of moderate- to high-risk drug use was low across all clinics (0.5%-1.0%). Clinics with more robust practice facilitation and EHR usability testing had somewhat greater adoption of the counseling script for patients with moderate-high risk alcohol or drug use (1.4%-12.5% vs 0.1%-1.1%). CONCLUSIONS AND RELEVANCE In this quality improvement study, EHR-integrated screening was feasible to implement in all clinics and unhealthy alcohol use was detected more frequently when self-administered screening was used at any primary care visit. The detection of drug use was low at all clinics, as was clinician adoption of counseling. These findings can be used to inform the decision-making of health care systems that are seeking to implement screening for substance use. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02963948.
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Affiliation(s)
- Jennifer McNeely
- Department of Population Health, New York University Grossman School of Medicine, New York
- Department of Medicine, Division of General Internal Medicine, New York University Grossman School of Medicine, New York
| | - Angéline Adam
- Department of Psychiatry, University Hospital Lausanne, Lausanne, Switzerland
| | - John Rotrosen
- Department of Psychiatry, New York University Grossman School of Medicine, New York
| | - Sarah E. Wakeman
- Department of Medicine, Harvard Medical School, Massachusetts General Hospital, Boston
| | | | - Joseph Kannry
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | - Sarah Farkas
- Department of Psychiatry, New York University Grossman School of Medicine, New York
| | - Carmen Rosa
- National Institute on Drug Abuse, Bethesda, Maryland
| | - Lauren Peccoralo
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Eva Waite
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Aida Vega
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jennifer Kent
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Catherine K. Craven
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | - Elizabeth Firmin
- Department of Psychiatry, Massachusetts General Hospital, Boston
| | | | - Melanie Harris
- Department of Population Health, New York University Grossman School of Medicine, New York
| | - Andre Kushniruk
- School of Health Information Science, University of Victoria, Victoria, British Columbia, Canada
| | - Leah Hamilton
- Department of Population Health, New York University Grossman School of Medicine, New York
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Meredith LS, Komaromy MS, Cefalu M, Murray-Krezan C, Page K, Osilla KC, Dopp AR, Leamon I, Tarhuni L, Hindmarch G, Jacobsohn V, Watkins KE. Design of CLARO (Collaboration Leading to Addiction Treatment and Recovery from other Stresses): A randomized trial of collaborative care for opioid use disorder and co-occurring depression and/or posttraumatic stress disorder. Contemp Clin Trials 2021; 104:106354. [PMID: 33713840 DOI: 10.1016/j.cct.2021.106354] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 03/04/2021] [Accepted: 03/05/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Opioid use disorder (OUD) co-occurring with depression and/or posttraumatic stress disorder (PTSD) is common and, if untreated, may lead to devastating consequences. Despite the availability of evidence-based treatments for these disorders, receipt of treatment is low. Even when treatment is provided, quality is variable. Primary care is an important and underutilized setting for treating co-occurring disorders (COD) because OUD, depression and PTSD are frequently co-morbid with medical conditions and most people visit a primary care provider at least once a year. With rising rates of OUD and opioid-related fatalities, this is a critical treatment and quality gap in a vulnerable and stigmatized population. METHODS CLARO (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses) is a multi-site, randomized pragmatic trial of collaborative care (CC) for co-occurring disorders in 13 rural and urban primary care clinics in New Mexico to improve care for patients with OUD and co-occurring depression and/or PTSD. CC, a service delivery approach that uses multi-faceted interventions, has not been tested with COD. We will enroll and randomize 900 patients to either CC adapted for COD (CC-COD) or enhanced usual care (EUC) and will collect patient data at baseline, 3-, and 6-month follow-up. Our primary outcomes are medications for OUD (MOUD) access, MOUD continuity of care, depression symptoms, and PTSD symptoms. DISCUSSION Although CC is effective for improving outcomes in primary care among patients with mental health conditions, it has not been tested for COD. This article describes the CLARO CC-COD intervention and clinical trial.
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Affiliation(s)
- Lisa S Meredith
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407-2138, USA; VA HSR&D Center for Healthcare Innovation, Implementation & Policy, Sepulveda, CA, USA.
| | - Miriam S Komaromy
- Grayken Center for Addiction, Boston Medical Center, Boston, MA 02118, USA
| | - Matthew Cefalu
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407-2138, USA
| | | | - Kimberly Page
- University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Karen Chan Osilla
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407-2138, USA
| | - Alex R Dopp
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407-2138, USA
| | - Isabel Leamon
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407-2138, USA
| | - Lina Tarhuni
- University of New Mexico School of Medicine, Albuquerque, NM 87131, USA
| | - Grace Hindmarch
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407-2138, USA
| | - Vanessa Jacobsohn
- First Choice Community Healthcare, 2001 North Centro Familiar, Albuquerque, NM 87105, USA
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20
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Bertholet N, Cunningham JA. Information technology and addiction science: promises and challenges. Addict Sci Clin Pract 2021; 16:7. [PMID: 33499925 PMCID: PMC7836206 DOI: 10.1186/s13722-021-00216-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Accepted: 01/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Information technology can be used to advance addiction science and clinical practice. MAIN BODY This special issue, "Information technology (IT) interventions to advance treatment for opioid and other addictions" presents studies that expand our understanding of IT intervention efficacy, patients' perspectives, and how IT can be used to improve substance use health care and research. This editorial introduces the topics addressed in the special issue and focuses on some of the challenges that the field is currently facing, such as attrition and treatment retention, transferability of intervention paradigms, and the challenge to keep pace with rapidly changing technologies. CONCLUSIONS Increasing treatment reach is particularly crucial in the addiction field. IT empowers researchers and clinicians to reach large portions of the population who might not otherwise access standard treatment modalities, because of geographical limitations, logistical constraints, stigma, or other reasons. The use of information technology may help reduce the substance use treatment gap and contribute to public health efforts to diminish the impact of substance use and other addictive behaviors on population health.
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Affiliation(s)
- Nicolas Bertholet
- Addiction Medicine, Lausanne University Hospital and University of Lausanne, Bugnon 23A, 1011, Lausanne, Switzerland.
| | - John A Cunningham
- Center for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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21
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Sanchez K, Gryczynski J, Carswell SB, Schwartz RP. Development and Feasibility of a Spanish Language Version of the Tobacco, Alcohol, Prescription Drug, and Illicit Substance Use (TAPS) Tool. J Addict Med 2021; 15:61-67. [PMID: 32657958 DOI: 10.1097/adm.0000000000000699] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The Tobacco, Alcohol, Prescription drug, and illicit Substance use (TAPS) Tool is a validated two-stage screening and brief assessment in primary care for unhealthy substance use. We developed a Spanish language version of the TAPS Tool and conducted a small study of its feasibility, acceptability, and preliminary validity. METHODS Participants were adult primary care patients ages 18 or older with Spanish as their primary language (N = 10 for development/refinement using qualitative congnitive interviewing; N = 100 for the preliminary validation study). The Spanish language TAPS Tool was administered in both interviewer- and selfadministered tablet format (in random order). We examined disclosure of substance use on the TAPS by administration format, and compared it with established measures for identifying substance use and substance use disorders. RESULTS The Spanish language TAPS was feasible to use and participants reported high levels of acceptability. The rates of past 12-month substance use were 11% for tobacco, 28% for risky alcohol, 4% for illicit drugs, 1% for nonmedical prescription drugs and substance use disorders rates were 7% for tobacco, 2% for alcohol, and 1% for other substances. The selfadministered TAPS elicited 1, 3, and 1 additional disclosures of tobacco, risky, alcohol, and marijuana use than the interviewer-administered TAPS, respectively. Rates of disclosure on the TAPS were similar to those on established measures for past 12-month and 3-month time frames. CONCLUSIONS The current study represents a starting point for expanding the availability of the TAPS Tool beyond its original English language version into Spanish. The Spanish language TAPS Tool could expand options for substance use screening in primary care settings with Spanish-dominant/preferred populations. TRIAL REGISTRATION The studies were registered with www.clinicaltrials.gov: NCT03879785, March 19, 2019.
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Affiliation(s)
- Katherine Sanchez
- School of Social Work, University of Texas at Arlington, TX (KS); Friends Research Institute, Baltimore, MD (JG, SBC, RPS); COG Analytics, Potomac, MD
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22
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Moore SK, Saunders EC, Hichborn E, McLeman B, Meier A, Young R, Nesin N, Farkas S, Hamilton L, Marsch LA, Gardner T, McNeely J. Early implementation of screening for substance use in rural primary care: A rapid analytic qualitative study. Subst Abus 2020; 42:678-691. [PMID: 33264087 PMCID: PMC8626097 DOI: 10.1080/08897077.2020.1827125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation. Method: Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes. Results: There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients. Conclusions: Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.
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Affiliation(s)
- Sarah K. Moore
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Elizabeth C. Saunders
- The Dartmouth Institute (TDI) for Health Policy and Clinical Practice, Lebanon, Pennsylvania, USA
| | - Emily Hichborn
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Bethany McLeman
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Andrea Meier
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Robyn Young
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Noah Nesin
- Penobscot Community Health Care (PCHC), Bangor, Maine, USA
| | - Sarah Farkas
- Department of Psychiatry, New York University School of Medicine, New York, New York, USA
| | - Leah Hamilton
- Department of Population Health, New York University School of Medicine, New York, New York, USA
| | - Lisa A. Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire, USA
| | - Trip Gardner
- Penobscot Community Health Care (PCHC), Bangor, Maine, USA
| | - Jennifer McNeely
- Department of Population Health, New York University School of Medicine, New York, New York, USA
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