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Braddock AS, Bosworth KT, Ghosh P, Proffitt R, Flowers L, Montgomery E, Wilson G, Tosh AK, Koopman RJ. Clinician Needs for Electronic Health Record Pediatric and Adolescent Weight Management Tools: A Mixed-Methods Study. Appl Clin Inform 2024; 15:368-377. [PMID: 38458233 PMCID: PMC11078569 DOI: 10.1055/a-2283-9036] [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: 10/09/2023] [Accepted: 02/21/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Clinicians play an important role in addressing pediatric and adolescent obesity, but their effectiveness is restricted by time constraints, competing clinical demands, and the lack of effective electronic health record (EHR) tools. EHR tools are rarely developed with provider input. OBJECTIVES We conducted a mixed method study of clinicians who provide weight management care to children and adolescents to determine current barriers for effective care and explore the role of EHR weight management tools to overcome these barriers. METHODS In this mixed-methods study, we conducted three 1-hour long virtual focus groups at one medium-sized academic health center in Missouri and analyzed the focus group scripts using thematic analysis. We sequentially conducted a descriptive statistical analysis of a survey emailed to pediatric and family medicine primary care clinicians (n = 52) at two private and two academic health centers in Missouri. RESULTS Surveyed clinicians reported that they effectively provided health behavior lifestyle counseling at well-child visits (mean of 60 on a scale of 1-100) and child obesity visits (63); however, most felt the current health care system (27) and EHR tools (41) do not adequately support pediatric weight management. Major themes from the clinician focus groups were that EHR weight management tools should display data in a way that (1) improves clinical efficiency, (2) supports patient-centered communication, (3) improves patient continuity between visits, and (4) reduces documentation burdens. An additional theme was (5) clinicians trust patient data entered in real time over patient recalled data. CONCLUSION Study participants report that the health care system status quo and currently available EHR tools do not sufficiently support clinicians working to manage pediatric or adolescent obesity and provide health behavior counseling. Clinician input in the development and testing of EHR weight management tools provides opportunities to address barriers, inform content, and improve efficiencies of EHR use.
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Affiliation(s)
- Amy S. Braddock
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, United States
| | - K. Taylor Bosworth
- School of Medicine, University of Missouri, Columbia, Missouri, United States
| | - Parijat Ghosh
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, United States
| | - Rachel Proffitt
- School of Health Professions, University of Missouri, Columbia, Missouri, United States
| | - Lauren Flowers
- School of Medicine, University of Missouri, Columbia, Missouri, United States
| | - Emma Montgomery
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, United States
| | - Gwendolyn Wilson
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, United States
| | - Aneesh K. Tosh
- Department of Child Health, University of Missouri, Columbia, Missouri, United States
| | - Richelle J. Koopman
- Department of Family and Community Medicine, University of Missouri, Columbia, Missouri, United States
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Adeniran E, Quinn M, Wallace R, Walden RR, Labisi T, Olaniyan A, Brooks B, Pack R. A scoping review of barriers and facilitators to the integration of substance use treatment services into US mainstream health care. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100152. [PMID: 37069961 PMCID: PMC10105485 DOI: 10.1016/j.dadr.2023.100152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/19/2023]
Abstract
Background Following the national implementation of the Affordable Care Act (ACA) in 2014, barriers still exist that limit the adoption of substance use treatment (SUT) services in mainstream health care (MHC) settings in the United States. This study provides an overview of current evidence on barriers and facilitators to integrating various SUT services into MHC. Methods A systematic search was conducted with the following databases: "PubMed including MEDLINE", "CINAHL", "Web of Science", "ABI/Inform", and "PsycINFO." We identified barriers and/or facilitators affecting patients, providers, and programs/systems. Results Of the 540 identified citations, 36 were included. Main barriers were identified for patients (socio-demographics, finances, confidentiality, legal impact, and disinterest), providers (limited training, lack of time, patient satisfaction concerns, legal implications, lack of access to resources or evidence-based information, and lack of legal/regulatory clarity), and programs/systems (lack of leadership support, lack of staff, limited financial resources, lack of referral networks, lack of space, and lack of state-level support). Also, we recognized key facilitators pertaining to patients (trust for providers, education, and shared decision making), providers (expert supervision, use of support team, training with programs like Extension for Community Health Outcomes (ECHO), and receptivity), and programs/systems (leadership support, collaboration with external agencies, and policies e.g., those expanding the addiction workforce, improving insurance access and treatment access). Conclusions This study identified several factors influencing the integration of SUT services in MHC. Strategies for improving SUT integration in MHC should address barriers and leverage facilitators related to patients, providers, and programs/systems.
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Affiliation(s)
- Esther Adeniran
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
- Corresponding author at: Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States.
| | - Megan Quinn
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
| | - Richard Wallace
- Quillen College of Medicine Library, East Tennessee State University, Johnson City, TN 37614, United States
| | - Rachel R. Walden
- Quillen College of Medicine Library, East Tennessee State University, Johnson City, TN 37614, United States
| | - Titilola Labisi
- Department of Health Promotion, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Afolakemi Olaniyan
- Department of Health Promotion and Education, School of Human Sciences, University of Cincinnati, Cincinnati, OH 45221, United States
| | - Billy Brooks
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
| | - Robert Pack
- Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
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Osborne B, Larance B, Ivers R, Deane FP, Robinson LD, Kelly PJ. Systematic review of guidelines for managing physical health during treatment for substance use disorders: Implications for the alcohol and other drug workforce. Drug Alcohol Rev 2022; 41:1367-1390. [PMID: 35765725 PMCID: PMC9539873 DOI: 10.1111/dar.13504] [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: 01/13/2022] [Revised: 05/29/2022] [Accepted: 06/01/2022] [Indexed: 11/28/2022]
Abstract
ISSUES Substance use disorders are associated with significant physical health comorbidities, necessitating an integrated treatment response. However, service fragmentation can preclude the management of physical health problems during addiction treatment. The aim of this systematic review was to synthesise the recommendations made by clinical practice guidelines for addressing the physical health of people attending alcohol and other drug (AOD) treatment. APPROACH An iterative search strategy of grey literature sources was conducted from September 2020 to February 2021 to identify clinical practice guidelines. Content pertaining to physical health care during AOD treatment was extracted. Quality of guidelines were appraised using the Appraisal of Guidelines Research and Evaluation II (AGREE-II) tool. FINDINGS Thirty-three guidelines were included for review. Fourteen guidelines were considered high quality based on AGREE-II scores. Neurological conditions (90.9%) and hepatitis (81.8%) were the most frequent health problems addressed. Most guidelines recommended establishing referral pathways to address physical health comorbidities (90.9%). Guidance on facilitating these referral pathways was less common (42.4%). Guidelines were inconsistent in their recommendations related to oral health, tobacco use, physical activity, nutrition and the use of standardised assessment tools. IMPLICATIONS AND CONCLUSIONS Greater consistency and specificity in the recommendations made for integrating physical health care within addiction treatment is needed. Ensuring that recommendations are applicable to the AOD workforce and to treatment services limited by funding and resource constraints should enhance implementation. Future guideline development groups should consider increased consultation with the AOD workforce and inclusion of clinical tools and decision aids to facilitate referral pathways.
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Affiliation(s)
- Briony Osborne
- School of Psychology, University of Wollongong, Wollongong, Australia.,Centre for Health Psychology Practice and Research, Wollongong, Australia
| | - Briony Larance
- School of Psychology, University of Wollongong, Wollongong, Australia.,Centre for Health Psychology Practice and Research, Wollongong, Australia
| | - Rowena Ivers
- Graduate School of Medicine, University of Wollongong, Wollongong, Australia
| | - Frank P Deane
- School of Psychology, University of Wollongong, Wollongong, Australia.,Centre for Health Psychology Practice and Research, Wollongong, Australia
| | - Laura D Robinson
- School of Psychology, University of Wollongong, Wollongong, Australia.,Centre for Health Psychology Practice and Research, Wollongong, Australia
| | - Peter J Kelly
- School of Psychology, University of Wollongong, Wollongong, Australia.,Centre for Health Psychology Practice and Research, Wollongong, Australia
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Hallgren KA, Matson TE, Oliver M, Witkiewitz K, Bobb JF, Lee AK, Caldeiro RM, Kivlahan D, Bradley KA. Practical Assessment of Alcohol Use Disorder in Routine Primary Care: Performance of an Alcohol Symptom Checklist. J Gen Intern Med 2022; 37:1885-1893. [PMID: 34398395 PMCID: PMC9198160 DOI: 10.1007/s11606-021-07038-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/13/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Alcohol use disorder (AUD) is highly prevalent but underrecognized and undertreated in primary care settings. Alcohol Symptom Checklists can engage patients and providers in discussions of AUD-related care. However, the performance of Alcohol Symptom Checklists when they are used in routine care and documented in electronic health records (EHRs) remains unevaluated. OBJECTIVE To evaluate the psychometric performance of an Alcohol Symptom Checklist in routine primary care. DESIGN Cross-sectional study using item response theory (IRT) and differential item functioning analyses of measurement consistency across age, sex, race, and ethnicity. PATIENTS Patients seen in primary care in the Kaiser Permanente Washington Healthcare System who reported high-risk drinking on the Alcohol Use Disorder Identification Test Consumption screening measure (AUDIT-C ≥ 7) and subsequently completed an Alcohol Symptom Checklist between October 2015 and February 2020. MAIN MEASURE Alcohol Symptom Checklists with 11 items assessing AUD criteria defined in the Diagnostic and Statistical Manual for Mental Disorders, 5th edition (DSM-5), completed by patients during routine medical care and documented in EHRs. KEY RESULTS Among 11,464 patients who screened positive for high-risk drinking and completed an Alcohol Symptom Checklist (mean age 43.6 years, 30.5% female), 54.1% reported ≥ 2 DSM-5 AUD criteria (threshold for AUD diagnosis). IRT analyses demonstrated that checklist items measured a unidimensional continuum of AUD severity. Differential item functioning was observed for some demographic subgroups but had minimal impact on accurate measurement of AUD severity, with differences between demographic subgroups attributable to differential item functioning never exceeding 0.42 points of the total symptom count (of a possible range of 0-11). CONCLUSIONS Alcohol Symptom Checklists used in routine care discriminated AUD severity consistently with current definitions of AUD and performed equitably across age, sex, race, and ethnicity. Integrating symptom checklists into routine care may help inform clinical decision-making around diagnosing and managing AUD.
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Affiliation(s)
- Kevin A Hallgren
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA.
| | - Theresa E Matson
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Malia Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Katie Witkiewitz
- Department of Psychology and Center on Alcohol, Substance Use, and Addictions, University of New Mexico, Albuquerque, NM, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Ryan M Caldeiro
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Daniel Kivlahan
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veteran Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Katharine A Bradley
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, USA
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veteran Affairs Puget Sound Health Care System, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
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5
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Ni Y, Bachtel A, Nause K, Beal S. Automated detection of substance use information from electronic health records for a pediatric population. J Am Med Inform Assoc 2021; 28:2116-2127. [PMID: 34333636 PMCID: PMC8449626 DOI: 10.1093/jamia/ocab116] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/06/2021] [Accepted: 05/26/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE Substance use screening in adolescence is unstandardized and often documented in clinical notes, rather than in structured electronic health records (EHRs). The objective of this study was to integrate logic rules with state-of-the-art natural language processing (NLP) and machine learning technologies to detect substance use information from both structured and unstructured EHR data. MATERIALS AND METHODS Pediatric patients (10-20 years of age) with any encounter between July 1, 2012, and October 31, 2017, were included (n = 3890 patients; 19 478 encounters). EHR data were extracted at each encounter, manually reviewed for substance use (alcohol, tobacco, marijuana, opiate, any use), and coded as lifetime use, current use, or family use. Logic rules mapped structured EHR indicators to screening results. A knowledge-based NLP system and a deep learning model detected substance use information from unstructured clinical narratives. System performance was evaluated using positive predictive value, sensitivity, negative predictive value, specificity, and area under the receiver-operating characteristic curve (AUC). RESULTS The dataset included 17 235 structured indicators and 27 141 clinical narratives. Manual review of clinical narratives captured 94.0% of positive screening results, while structured EHR data captured 22.0%. Logic rules detected screening results from structured data with 1.0 and 0.99 for sensitivity and specificity, respectively. The knowledge-based system detected substance use information from clinical narratives with 0.86, 0.79, and 0.88 for AUC, sensitivity, and specificity, respectively. The deep learning model further improved detection capacity, achieving 0.88, 0.81, and 0.85 for AUC, sensitivity, and specificity, respectively. Finally, integrating predictions from structured and unstructured data achieved high detection capacity across all cases (0.96, 0.85, and 0.87 for AUC, sensitivity, and specificity, respectively). CONCLUSIONS It is feasible to detect substance use screening and results among pediatric patients using logic rules, NLP, and machine learning technologies.
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Affiliation(s)
- Yizhao Ni
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Corresponding Author: Yizhao Ni, PhD, Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, USA;
| | - Alycia Bachtel
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Katie Nause
- Division of Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sarah Beal
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
- Division of Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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6
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Using a health information technology survey to explore the availability of addiction treatment data in the electronic health records: A National Drug Abuse Treatment Clinical Trials Network study. J Subst Abuse Treat 2021; 112S:56-62. [PMID: 32220412 DOI: 10.1016/j.jsat.2020.01.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 01/23/2020] [Accepted: 01/24/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Healthcare data from electronic health records (EHRs) and related health information technology (IT) tools are critical data sources for pragmatic clinical trials and observational studies aimed at producing real-world evidence. To unlock the full potential of such data to advance science, the data must be complete and in structured formats to facilitate research use. METHODS A Health IT survey was conducted within the National Drug Abuse Treatment Clinical Trials Network (CTN) to explore information related to data completeness and presence of unstructured data (e.g., clinical notes, free text) for conducting the EHR-based research for substance use disorders (SUDs). The analysis was based on 36 participants from 36 facilities located in 14 states and affiliated with the CTN. RESULTS The mean age of the participants (n = 34) was 48.0 years (SD = 9.8). Of the participants enrolled, 50.0% were female and 82.4% were white. Participants' facilities were from four census-defined regions (South 35.3%, Northeast 29.4%, West 20.6%, Midwest 11.8%, Missing 2.9%) and represented diverse settings. The EHR was used by all surveyed facilities including 17 different kinds of EHR platforms or vendors, and 17.6% (n = 6) of surveyed facilities also used a separate EHR for behavioral health care (e.g., SUD care). Paper records were also used by 76.5% of surveyed facilities for clinical care (e.g., for health risk appraisal questionnaires, substance use screening or assessment, check-in screening, substance use specific intervention/treatment or referral, or labs/testing). The prevalence of using a patient portal, practice management system, and mHealth for patient care was 76.5%, 50.0%, and 29.4%, respectively. CONCLUSION While results are descriptive in nature, they reveal the heterogeneity in the existing EHRs and frequent use of paper records to document patient care tasks, especially for SUD care. The use of a separate EHR for behavioral healthcare also suggests the challenge of obtaining complete EHR data to support research for SUDs. Much EHR development, integration, and standardization needs to be done especially in regard to SUD treatment to facilitate research across disparate healthcare systems.
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7
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Moore JR, DiNitto DM, Choi NG. Associations of cannabis use frequency and cannabis use disorder with receiving a substance use screen and healthcare professional discussion of substance use. Am J Addict 2021; 30:485-495. [PMID: 34143567 DOI: 10.1111/ajad.13195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 04/14/2021] [Accepted: 05/28/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Screening, brief intervention, and referral to treatment (SBIRT) can reduce substance use, but receipt of these services by those who use cannabis frequently and have cannabis use disorder (CUD) remains unexplored. We examined cannabis use frequency and CUD's associations with the odds of receiving a substance use screening and a healthcare professional discussion among those who used healthcare services. METHODS Data came from the 2015-2019 National Survey on Drug Use and Health (N = 214,505 aged 18+). Among adults who used cannabis and attended healthcare settings in the past year (N = 36,374), multivariable logistic regression analysis was used to examine associations of cannabis use frequency and CUD with receiving a substance use screen and substance use discussion by a healthcare professional. RESULTS Cannabis use frequency was associated with higher odds of receiving a screen (adjusted odds ratio [AOR] = 1.27, 95% confidence interval [CI] = 1.14-1.41 for 300+ days of use) and a discussion among those screened (AOR = 1.83, 95% CI = 1.60-2.09 for 300+ days of use). CUD was not associated with receiving a screen, but it was positively associated with receiving a discussion among those screened (AOR = 1.22, 95% CI = 1.08-1.39). Nonmedical users were less likely to have a discussion among those screened and not screened. DISCUSSION AND CONCLUSIONS Findings indicate disparities in screening and discussion of substance use with patients, especially between medical and nonmedical users. SCIENTIFIC SIGNIFICANCE Study findings provide novel insight into differences in the reach of SBIRT services among adult cannabis users.
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Affiliation(s)
- John R Moore
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, Texas, USA
| | - Diana M DiNitto
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, Texas, USA
| | - Namkee G Choi
- Steve Hicks School of Social Work, The University of Texas at Austin, Austin, Texas, USA
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Ventuneac A, Hecht G, Forcht E, Duah BA, Tarar S, Langenbach B, Gates J, Cain D, Rendina HJ, Aberg JA, Perlman DC. Chronic High Risk Prescription Opioid Use Among Persons With HIV. FRONTIERS IN SOCIOLOGY 2021; 6:645992. [PMID: 34095287 PMCID: PMC8176351 DOI: 10.3389/fsoc.2021.645992] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/26/2021] [Indexed: 05/07/2023]
Abstract
Persons with HIV (PWH) are a population at risk for adverse sequelae of opioid use. Yet, few studies have examined correlates of chronic high risk opioid use and its impact on HIV outcomes. Trends in prescribing patterns and identification of factors that impact the use of opioid prescriptions among PWH are crucial to determine prevention and treatment interventions. This study examined electronic medical records (EMR) of patients receiving HIV care to characterize prescribing patterns and identify risk factors for chronic high risk prescription opioid use and the impact on HIV outcomes among PWH in primary care from July 1, 2016-December 31, 2017. EMR were analyzed from 8,882 patients who were predominantly male and ethnically and racially diverse with half being 50 years of age or older. The majority of the 8,744 prescriptions (98% oral and 2% transdermal preparations) given to 1,040 (12%) patients were oxycodone (71%), 8% were morphine, 7% tramadol, 4% hydrocodone, 4% codeine, 2% fentanyl, and 4% were other opioids. The number of monthly prescriptions decreased about 14% during the study period. Bivariate analyses indicated that most demographic and clinical variables were associated with receipt of any opioid prescription. After controlling for patient socio-demographic characteristics and clinical factors, the odds of receipt of any prescription were higher among patients with pain diagnoses and opioid use and mental health disorders. In addition, the odds of receipt of high average daily morphine equivalent dose (MED) prescriptions were higher for patients with pain diagnoses. Lastly, patients with substance use disorders (SUD) had an increased likelihood of detectable viral load compared to patients with no SUD, after adjusting for known covariates. Our findings show that despite opioid prescribing guidelines and monitoring systems, additional efforts are needed to prevent chronic high risk prescriptions in patients with comorbid conditions, including pain-related, mental health and substance use disorders. Evidence about the risk for chronic high risk use based on prescribing patterns could better inform pain management and opioid prescribing practices for patients receiving HIV care.
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Affiliation(s)
- Ana Ventuneac
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
- *Correspondence: Ana Ventuneac,
| | - Gavriella Hecht
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Emily Forcht
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Bianca A. Duah
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Shafaq Tarar
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Blanche Langenbach
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Jay Gates
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - Demetria Cain
- Department of Psychology, Hunter College, City University of New York, NY, NY, United States
| | - H. Jonathon Rendina
- Department of Psychology, Hunter College, City University of New York, NY, NY, United States
- Health Psychology and Clinical Science PhD Program, The Graduate Center, City University of New York, NY, NY, United States
| | - Judith A. Aberg
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
| | - David C. Perlman
- Icahn School of Medicine at Mount Sinai, Division of Infectious Diseases, NY, NY, United States
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Picco L, Middleton M, Bruno R, Kowalski M, Nielsen S. Validity and Reliability of the Computer-Administered Routine Opioid Outcome Monitoring (ROOM) Tool. PAIN MEDICINE 2020; 21:3645-3654. [PMID: 33094345 DOI: 10.1093/pm/pnaa297] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The Routine Opioid Outcome Monitoring (ROOM) tool measures outcomes with opioids using an established framework which includes domains such as pain, mood, opioid use disorder, alcohol use, and constipation. This study aims to validate and establish the test-retest reliability of the computer-administered ROOM tool. DESIGN AND SETTING Cross-sectional analysis of an online sample. SUBJECTS Participants comprised those with chronic noncancer pain who regularly used prescription opioids. METHODS Participants self-completed the online ROOM tool along with other validated measures (validation questionnaire), and those who were agreeable also completed the online test-retest questionnaire approximately two weeks later. Subcomponents of the ROOM tool (i.e., pain, mood, alcohol use, opioid use disorder, and constipation) were validated against longer measures of the same construct using Pearson correlation coefficients. Intraclass correlation coefficients were used to assess the stability of the ROOM tool over time. RESULTS A total of 324 participants completed the validation questionnaire, of whom 260 also completed the test-retest questionnaire. The opioid use disorder domain showed good sensitivity (73.6) and specificity (75.8) against the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, any opioid use disorder. All ROOM components showed moderate correlation (r = 0.55-0.73) with their longer counterparts. Test-retest reliability was fair (0.58-0.75), indicating that responses were relatively stable over time. Reliability did vary, however, based on the components being measured and how certain tools were scored. CONCLUSION The computer-administered ROOM tool is a valid approach for brief monitoring of outcomes with prescribed opioids in primary care settings and appears to be acceptable to people who are using prescribed opioids for chronic pain.
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Affiliation(s)
- Louisa Picco
- Monash Addiction Research Centre, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Melissa Middleton
- Monash Addiction Research Centre, Monash University Peninsula Campus, Frankston, Victoria, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - Michala Kowalski
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Monash University Peninsula Campus, Frankston, Victoria, Australia
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia
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Venkatesh A, Malicki C, Hawk K, D'Onofrio G, Kinsman J, Taylor A. Assessing the readiness of digital data infrastructure for opioid use disorder research. Addict Sci Clin Pract 2020; 15:24. [PMID: 32650817 PMCID: PMC7350566 DOI: 10.1186/s13722-020-00198-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/02/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Gaps in electronic health record (EHR) data collection and the paucity of standardized clinical data elements (CDEs) captured from electronic and digital data sources have impeded research efforts aimed at understanding the epidemiology and quality of care for opioid use disorder (OUD). We identified existing CDEs and evaluated their validity and usability, which is required prior to infrastructure implementation within EHRs. METHODS We conducted (a) a systematic literature review of publications in Medline, Embase and the Web of Science using a combination of at least one term related to OUD and EHR and (b) an environmental scan of publicly available data systems and dictionaries used in national informatics and quality measurement of policy initiatives. Opioid-related data elements identified within the environmental scan were compared with related data elements contained within nine common health data code systems and each element was graded for alignment with match results categorized as "exact", "partial", or "none." RESULTS The literature review identified 5186 articles for title search, of which 75 abstracts were included for review and 38 articles were selected for full-text review. Full-text articles yielded 237 CDEs, only 12 (5.06%) of which were opioid-specific. The environmental scan identified 379 potential data elements and value sets across 9 data systems and libraries, among which only 84 (22%) were opioid-specific. We found substantial variability in the types of clinical data elements with limited overlap and no single data system included CDEs across all major data element types such as substance use disorder, OUD, medication and mental health. Relative to common health data code systems, few data elements had an exact match (< 1%), while 61% had a partial match and 38% had no matches. CONCLUSIONS Despite the increasing ubiquity of EHR data standards and national attention placed on the opioid epidemic, we found substantial fragmentation in the design and construction of OUD related CDEs and little OUD specific CDEs in existing data dictionaries, systems and literature. Given the significant gaps in data collection and reporting, future work should leverage existing structured data elements to create standard workflow processes to improve OUD data capture in EHR systems.
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Affiliation(s)
- Arjun Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT, 06519, USA.
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA.
| | - Caitlin Malicki
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT, 06519, USA
| | - Kathryn Hawk
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT, 06519, USA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT, 06519, USA
| | - Jeremiah Kinsman
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT, 06519, USA
| | - Andrew Taylor
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress Ave, Suite 260, New Haven, CT, 06519, USA
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Sayre M, Lapham GT, Lee AK, Oliver M, Bobb JF, Caldeiro RM, Bradley KA. Routine Assessment of Symptoms of Substance Use Disorders in Primary Care: Prevalence and Severity of Reported Symptoms. J Gen Intern Med 2020; 35:1111-1119. [PMID: 31974903 PMCID: PMC7174482 DOI: 10.1007/s11606-020-05650-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 10/10/2019] [Accepted: 12/10/2019] [Indexed: 01/20/2023]
Abstract
BACKGROUND Most patients with substance use disorders (SUDs) never receive treatment and SUDs are under-recognized in primary care (PC) where patients can be treated or linked to treatment. Asking PC patients to directly report SUD symptoms on questionnaires might help identify SUDs but to our knowledge, this approach is previously untested. OBJECTIVE To describe the prevalence and severity of DSM-5 SUD symptoms reported by PC patients as part of routine care. DESIGN Cross-sectional study using secondary data. PARTICIPANTS A total of 241,265 adult patients who visited one of 25 PC sites in an integrated health system in Washington state and had alcohol, cannabis, or other drug use screening documented in their EHRs (March 2015-July 2018) were included in main analyses if they had a positive screen for high-risk substance use defined as AUDIT-C score 7-12 points, or report of past-year daily cannabis use or any other drug use. MAIN MEASURES The main outcome was number of SUD symptoms based on Diagnostic and Statistical Manual, 5th edition (DSM-5), reported on Symptom Checklists (0-11) for alcohol or other drugs: 2-3 mild; 4-5 moderate; 6-11 severe. RESULTS Of screened patients, 16,776 (5.7%) reported high-risk use of alcohol (2.4%), cannabis (3.9%), and/or other drugs (1.7%), and 65.0-69.9% of those completed Symptom Checklists. Of those with high-risk alcohol use, 52.5% (95% CI 50.9-54.0%) reported ≥ 2 symptoms consistent with mild-severe alcohol use disorders. Of those reporting daily cannabis use, 29.8% (28.6-30.9%) reported ≥ 2 symptoms consistent with mild-severe SUDs. Of those reporting any other drug use, 37.5% (35.7-39.3%) reported ≥ 2 symptoms consistent with mild-severe SUDs. CONCLUSIONS AND RELEVANCE Many PC patients who screened positive for high-risk substance use reported symptoms consistent with DSM-5 SUDs on self-report Symptom Checklists. Use of SUD Symptom Checklists could support PC providers in making SUD diagnoses and initiating discussions of substance use.
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Affiliation(s)
- Mikko Sayre
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA.
- Columbia-Bassett Program at Columbia University College of Physicians and Surgeons, Cooperstown, NY, USA.
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Malia Oliver
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
| | - Ryan M Caldeiro
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, USA
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12
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Marsch LA, Campbell A, Campbell C, Chen CH, Ertin E, Ghitza U, Lambert-Harris C, Hassanpour S, Holtyn AF, Hser YI, Jacobs P, Klausner JD, Lemley S, Kotz D, Meier A, McLeman B, McNeely J, Mishra V, Mooney L, Nunes E, Stafylis C, Stanger C, Saunders E, Subramaniam G, Young S. The application of digital health to the assessment and treatment of substance use disorders: The past, current, and future role of the National Drug Abuse Treatment Clinical Trials Network. J Subst Abuse Treat 2020; 112S:4-11. [PMID: 32220409 PMCID: PMC7134325 DOI: 10.1016/j.jsat.2020.02.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/30/2020] [Accepted: 02/08/2020] [Indexed: 01/17/2023]
Abstract
The application of digital technologies to better assess, understand, and treat substance use disorders (SUDs) is a particularly promising and vibrant area of scientific research. The National Drug Abuse Treatment Clinical Trials Network (CTN), launched in 1999 by the U.S. National Institute on Drug Abuse, has supported a growing line of research that leverages digital technologies to glean new insights into SUDs and provide science-based therapeutic tools to a diverse array of persons with SUDs. This manuscript provides an overview of the breadth and impact of research conducted in the realm of digital health within the CTN. This work has included the CTN's efforts to systematically embed digital screeners for SUDs into general medical settings to impact care models across the nation. This work has also included a pivotal multi-site clinical trial conducted on the CTN platform, whose data led to the very first "prescription digital therapeutic" authorized by the U.S. Food and Drug Administration (FDA) for the treatment of SUDs. Further CTN research includes the study of telehealth to increase capacity for science-based SUD treatment in rural and under-resourced communities. In addition, the CTN has supported an assessment of the feasibility of detecting cocaine-taking behavior via smartwatch sensing. And, the CTN has supported the conduct of clinical trials entirely online (including the recruitment of national and hard-to-reach/under-served participant samples online, with remote intervention delivery and data collection). Further, the CTN is supporting innovative work focused on the use of digital health technologies and data analytics to identify digital biomarkers and understand the clinical trajectories of individuals receiving medications for opioid use disorder (OUD). This manuscript concludes by outlining the many potential future opportunities to leverage the unique national CTN research network to scale-up the science on digital health to examine optimal strategies to increase the reach of science-based SUD service delivery models both within and outside of healthcare.
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Affiliation(s)
- Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA; Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA.
| | - Aimee Campbell
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA; Department of Psychiatry, Columbia University, 1051 Riverside Dr, New York, NY 10032, USA
| | - Cynthia Campbell
- Kaiser Permanente Division of Research, 2000 Broadway, Oakland, CA 94612, USA
| | - Ching-Hua Chen
- Computational Health Behavior and Decision Science Research, IBM Thomas J. Watson Research, 1101 Kitchawan Rd, Yorktown Heights, NY 10598, USA
| | - Emre Ertin
- The Ohio State University College of Engineering, 2070 Neil Ave, Columbus, OH 43210, USA
| | - Udi Ghitza
- The National Institute on Drug Abuse, 6001 Executive Blvd, Rockville, MD 20852, USA
| | - Chantal Lambert-Harris
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA
| | - Saeed Hassanpour
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA
| | - August F Holtyn
- Psychiatry and Behavioral Sciences, Johns Hopkins Medicine, 5255 Loughboro Road, N.W., Washington, DC 20016, USA
| | - Yih-Ing Hser
- Department of Psychiatry and Behavioral Sciences at the UCLA Integrated Substance Abuse Programs, 11075 Santa Monica Blvd., Ste. 200, Los Angeles, CA 90025, USA
| | - Petra Jacobs
- The National Institute on Drug Abuse, 6001 Executive Blvd, Rockville, MD 20852, USA
| | - Jeffrey D Klausner
- Epidemiology UCLA Fielding School of Public Health, Box 951772, Los Angeles, CA 90095-1772, USA
| | - Shea Lemley
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA
| | - David Kotz
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA
| | - Andrea Meier
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA
| | - Bethany McLeman
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA
| | - Jennifer McNeely
- Department of Population Health, Department of Medicine, NYU School of Medicine, 227 East 30th Street, Seventh Floor, New York, NY 10016, USA
| | - Varun Mishra
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA
| | - Larissa Mooney
- Resnick Neuropsychiatric Hospital at UCLA, Ronald Reagan UCLA Medical Center, 150 Medical Plaza Driveway, Los Angeles, CA 90095, USA
| | - Edward Nunes
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA; Department of Psychiatry, Columbia University, 1051 Riverside Dr, New York, NY 10032, USA
| | | | - Catherine Stanger
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA
| | - Elizabeth Saunders
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, 46 Centerra Dr, Lebanon, NH 03766, USA
| | - Geetha Subramaniam
- The National Institute on Drug Abuse, 6001 Executive Blvd, Rockville, MD 20852, USA
| | - Sean Young
- University of California, Irvine, UC Institute for Prediction Technology, Donald Bren Hall: 6135, Irvine, CA 92697, USA
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Development and validation of a virtual agent to screen tobacco and alcohol use disorders. Drug Alcohol Depend 2018; 193:1-6. [PMID: 30321739 DOI: 10.1016/j.drugalcdep.2018.08.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 08/08/2018] [Accepted: 08/24/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Substance use disorders are under-detected and not systematically diagnosed or screened for by primary care. In this study, we present the acceptability and validity of an Embodied Conversational Agent (ECA) designed to screen tobacco and alcohol use disorder, in individuals who did not seek medical help for these disorders. METHODS Individuals were included from June 2016 to May 2017 in the Outpatient Sleep Clinic of the University Hospital of Bordeaux. DSM-5 diagnoses of tobacco and alcohol use disorders were assessed by human interviewers. The ECA interview integrated items from the Cigarette Dependence Scale-5 (CDS-5) for tobacco use disorder screening, and the "Cut Down, Annoyed, Guilty, Eye-opener" (CAGE) questionnaire for alcohol use disorder screening. Paper version of CDS-5 and CAGE questionnaires and acceptability questionnaire was also self-administered. RESULTS Of the 139 participants in the study (mean age 43.0 [SD = 13.7] years), 71 were women, and 68 were men. The ECA was well accepted by the patients. Paper self-administered CDS-5 and CAGE scores had a strong agreement with the ECA (p < 0.0001). The Receiver Operating Characteristic (ROC) analysis of the ECA interview showed AUC of 0.97 (95% CI, 0.93-1.0) and 0.84 (95% CI, 0.69-0.98) for CDS-5 and CAGE respectively with p-value <0.0001. CONCLUSIONS This ECA was acceptable and valid to screen tobacco or alcohol use disorder among patients not requesting treatment for addiction. The ECA could be used in hospitals and potentially in primary care settings to help clinicians to better screen their patients for alcohol and tobacco use disorders.
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Rautiainen E, Ryynänen OP, Reissell E, Kauhanen J, Laatikainen T. Alcohol-related social and health service use patterns as predictors of death and remission in patients with AUD. J Subst Abuse Treat 2018; 96:65-74. [PMID: 30466551 DOI: 10.1016/j.jsat.2018.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 10/26/2018] [Accepted: 10/29/2018] [Indexed: 11/24/2022]
Affiliation(s)
- Elina Rautiainen
- Institute of Public Health and Clinical Nutrition, PO Box 1627, FI-70211, University of Eastern Finland, Kuopio, Finland.
| | - Olli-Pekka Ryynänen
- Institute of Public Health and Clinical Nutrition, PO Box 1627, FI-70211, University of Eastern Finland, Kuopio, Finland; General Practice Unit, Kuopio University Hospital, Primary Health Care, PO Box 100, FI-70029 KUH, Kuopio, Finland
| | - Eeva Reissell
- National Institute for Health and Welfare, PO Box 30, FI-00271 Helsinki, Finland
| | - Jussi Kauhanen
- Institute of Public Health and Clinical Nutrition, PO Box 1627, FI-70211, University of Eastern Finland, Kuopio, Finland
| | - Tiina Laatikainen
- Institute of Public Health and Clinical Nutrition, PO Box 1627, FI-70211, University of Eastern Finland, Kuopio, Finland; National Institute for Health and Welfare, PO Box 30, FI-00271 Helsinki, Finland; Joint Municipal Authority for North Karelia Social and Health Services (Siun sote), Tikkamäentie 16, 80210 Joensuu, Finland
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15
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Rautiainen E, Ryynänen OP, Laatikainen T. Care outcomes and alcohol-related treatment utilisation profiles of patients with alcohol-use disorder: A prospective cohort study using electronic health records. NORDIC STUDIES ON ALCOHOL AND DRUGS 2018; 35:329-343. [PMID: 32934536 PMCID: PMC7434146 DOI: 10.1177/1455072518783972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 05/22/2018] [Indexed: 11/16/2022] Open
Abstract
Background: We examined the probabilities of longitudinal care outcomes of working-aged
patients with alcohol-use disorder (AUD) and their alcohol-related treatment
utilisation patterns across the healthcare services, by using linked
electronic health records. Methods: A random sample (n = 396) of patients with alcohol-related
visits to healthcare services in 2011–2012 was collected retrospectively
from the electronic health record data in the North Karelia region of
Finland and followed prospectively in time until the end of 2016. Data on
care outcomes and alcohol-related healthcare use were gathered from the
electronic health records. Three outcome groups were identified: (1) dead,
(2) present AUD, and (3) remission. Group differences in alcohol-related
health service use were compared. Results: At the end of the follow-up period, an increased mortality rate of 22.9% was
observed, and 18.4% had achieved stable remission, while for the majority
(56%), the AUD remained. Most of those in remission had contact with either
specialised AUD services or mental health services. Conversely, the majority
of those who had died had no contact with specialised AUD services during
the follow-up period. Conclusions: The electronic-health-record-based register analysis captured mainly
individuals with advanced forms of AUD. An excess mortality rate and other
negative health consequences were observed. Training providers to identify
and treat earlier the less severe forms of AUD could have major benefit to
patients and also reduce health system costs.
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John WS, Zhu H, Mannelli P, Schwartz RP, Subramaniam GA, Wu LT. Prevalence, patterns, and correlates of multiple substance use disorders among adult primary care patients. Drug Alcohol Depend 2018; 187:79-87. [PMID: 29635217 PMCID: PMC5959766 DOI: 10.1016/j.drugalcdep.2018.01.035] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Revised: 01/26/2018] [Accepted: 01/27/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Addressing multiple substance use disorders (SUDs) in primary care-based screening and intervention may improve SUD treatment access, engagement, and outcomes. To inform such efforts, research is needed on the prevalence and patterns of multiple SUDs among primary care patients. METHODS Data were analyzed from a sample of 2000 adult (aged ≥ 18) primary care patients recruited for a multisite National Drug Abuse Treatment Clinical Trials Network (CTN) study (CTN-0059). Past-year DSM-5 SUDs (tobacco, alcohol, and drug) were assessed by the modified Composite International Diagnostic Interview. Prevalence and correlates of multiple versus single SUDs were examined. Latent class analysis (LCA) was used to explore patterns of multiple SUDs. RESULTS Multiple SUDs were found among the majority of participants with SUD for alcohol, cannabis, prescription opioids, cocaine, and heroin. Participants who were male, ages 26-34, less educated, and unemployed had increased odds of multiple SUDs compared to one SUD. Having multiple SUDs was associated with greater severity of tobacco or alcohol use disorder. LCA of the sample identified three classes: class 1 (83.7%) exhibited low prevalence of all SUDs; class 2 (12.0%) had high-moderate prevalence of SUDs for tobacco, alcohol, and cannabis; class 3 (4.3%) showed high prevalence of SUD for tobacco, opioids, and cocaine. LCA-defined classes were distinguished by sex, age, race, education, and employment status. CONCLUSIONS Findings suggest that primary care physicians should be aware of multiple SUDs when planning treatment, especially among adults who are male, younger, less educated, or unemployed. Interventions that target multiple SUDs warrant future investigation.
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Affiliation(s)
- William S. John
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC 27710, USA
| | - He Zhu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC 27710, USA
| | - Paolo Mannelli
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC 27710, USA
| | - Robert P. Schwartz
- Friends Research Institute, Inc., 1040 Park Ave #103, Baltimore, MD 21201, USA
| | - Geetha A. Subramaniam
- National Institute on Drug Abuse, 6001 Executive Blvd #5128, Rockville, MD 20852, USA
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC 27710, USA,Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, 40 Duke Medicine Circle, Durham, NC 27710, USA,Duke Clinical Research Institute, Duke University Medical Center, 2400 Pratt Street, Durham, NC 27705, USA,Center for Child and Family Policy, Sanford School of Public Policy, Duke University, 302 Towerview Road, Durham, NC, 27708 USA
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Abstract
OBJECTIVES To examine trends and correlates of cannabis-involved emergency department (ED) visits in the United States from 2004 to 2011. METHODS Data were obtained from the 2004 to 2011 Drug Abuse Warning Network. We analyzed trend in cannabis-involved ED visits for persons aged ≥12 years and stratified by type of cannabis involvement (cannabis-only, cannabis-polydrug). We used logistic regressions to determine correlates of cannabis-involved hospitalization versus cannabis-involved ED visits only. RESULTS Between 2004 and 2011, the ED visit rate increased from 51 to 73 visits per 100,000 population aged ≥12 years for cannabis-only use (P value for trend = 0.004) and from 63 to 100 for cannabis-polydrug use (P value for trend < 0.001). Adolescents aged 12-17 years showed the largest increase in the cannabis-only-involved ED visit rate (rate difference = 80 per 100,000 adolescents). Across racial/ethnic groups, the most prevalent ED visits were noted among non-Hispanic blacks. Among cannabis-involved visits, the odds of hospitalization (vs ED visits only) increased with age strata compared with age 12 to 17 years. CONCLUSIONS These findings suggest a notable increase in the ED visit numbers and rates for both the use of cannabis-only and cannabis-polydrug during the studied period, particularly among young people and non-Hispanic blacks.
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Wu LT, McNeely J, Subramaniam GA, Brady KT, Sharma G, VanVeldhuisen P, Zhu H, Schwartz RP. DSM-5 substance use disorders among adult primary care patients: Results from a multisite study. Drug Alcohol Depend 2017; 179:42-46. [PMID: 28753480 PMCID: PMC5599360 DOI: 10.1016/j.drugalcdep.2017.05.048] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 05/24/2017] [Accepted: 05/26/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND There are limited data about the extent of DSM-5 substance use disorders (SUDs) among primary care patients. METHODS This study analyzed data from a multisite validation study of a substance use screening instrument conducted in a diverse sample of 2000 adults aged ≥18 years recruited from five primary care practices in four states. Prevalence and correlates of 12-month DSM-5 SUDs were examined. RESULTS Overall, 75.5% of the sample used any substance, including alcohol (62.0%), tobacco (44.1%), or illicit drugs/nonmedical medications (27.9%) in the past 12 months (marijuana 20.8%, cocaine 7.3%, opioids 4.8%, sedatives 4.1%, heroin 3.9%). The prevalence of any 12-month SUD was 36.0% (mild disorder 14.2%, moderate/severe disorder 21.8%): tobacco 25.3% (mild 11.5%, moderate/severe 13.8%); alcohol 13.9% (mild 6.9%, moderate/severe 7.0%); and any illicit/nonmedical drug 14.0% (mild 4.0%, moderate/severe 10.0%). Among past 12-month users, a high proportion of tobacco or drug users met criteria for a disorder: tobacco use disorder 57.4% (26.1% mild, 31.3% moderate/severe) and any drug use disorder 50.2% (14.3% mild, 35.8% moderate/severe); a lower proportion of alcohol users (22.4%) met criteria for alcohol use disorder (11.1% mild, 11.3% moderate/severe). Over 80% of adults with opioid/heroin use disorder met criteria for a moderate/severe disorder. Younger ages, male sex, and low education were associated with increased odds of having SUD. CONCLUSION These findings reveal the high prevalence of SUDs in primary care and underscore the need to identify and address them.
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Affiliation(s)
- Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA; Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA; Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, NC, USA.
| | - Jennifer McNeely
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | | | - Kathleen T. Brady
- South Carolina Clinical and Translational Research Institute, Medical University of South Carolina, Charleston, SC, USA
| | | | | | - He Zhu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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Wu LT, Zhu H, Mannelli P, Swartz MS. Prevalence and correlates of treatment utilization among adults with cannabis use disorder in the United States. Drug Alcohol Depend 2017; 177:153-162. [PMID: 28599214 PMCID: PMC5538354 DOI: 10.1016/j.drugalcdep.2017.03.037] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 03/23/2017] [Accepted: 03/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The increase in cannabis potency may have treatment implications for cannabis use disorder (CUD). Given the reported increase in prevalence of cannabis use among adults, there is a need to understand substance use treatment needs for CUD. METHODS We examined demographics and behavioral health indicators of adults aged ≥18 years that met criteria for past-year CUD (n=10,943) in the 2005-2013 National Surveys on Drug Use and Health. We determined prevalence and correlates of past-year treatment use for alcohol/drug, any drug, and cannabis use related problems, to inform treatment efforts for CUD. RESULTS The majority of adults with past-year CUD were young adults aged 18-25 or men, had low income, and did not attend college. Two-thirds of adults with CUD met criteria for cannabis dependence, which was comparatively common among younger adults, women, low-income or publicly insured adults, and college-educated adults. Nicotine dependence (40.92%) and alcohol (44.07%) or other drug use disorder (19.70%) were prevalent among adults with CUD. Overall, less than 13% of adults with CUD had received alcohol/drug use treatment the past year; only 7.8% received cannabis-specific treatment. There was no significant yearly variation in treatment use prevalence over 9 years. In particular, Asian-Americans, women, and college-educated adults underutilized cannabis-specific treatment. CONCLUSIONS This large sample of adults with CUD reveals pervasive underutilization of cannabis-related treatment, especially in women, married adults, and those with college education, despite a high proportion of comorbid behavioral health problems.
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Affiliation(s)
- Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA; Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA; Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, NC, USA.
| | - He Zhu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham,NC, USA
| | - Paolo Mannelli
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham,NC, USA
| | - Marvin S. Swartz
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham,NC, USA
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Quinn AE, Stewart MT, Brolin M, Horgan C, Lane NE. Massachusetts Substance Use Disorder Treatment Organizations' Perspectives on the Affordable Care Act: Changes in Payment, Services, and System Design. J Psychoactive Drugs 2017; 49:151-159. [PMID: 28350232 PMCID: PMC5701571 DOI: 10.1080/02791072.2017.1301600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The Affordable Care Act (ACA) expanded insurance benefits and coverage for substance use disorder (SUD) treatment and encouraged delivery and payment reforms. Massachusetts passed a similar reform in 2006. This study aims to assess Massachusetts SUD treatment organizations' responses to the ACA. Organizational interviews addressing challenges of and responses to the ACA were conducted in person June-December 2014 with 31 leaders at 12 treatment organizations across Massachusetts. Many organizations were affiliated with medical or social services and offered a range of SUD services. Sampling was based on services offered (detoxification only, detoxification and outpatient, outpatient only). Framework analysis was used. Challenges identified were considered similar to ongoing challenges, not unique to the ACA. Organizations experienced insurance expansions in 2006 and faced new challenges, including insurance coverage, payment arrangements, expansion of services, and system design. System design efforts included care coordination/integration, workforce development, and health information technology. Differences in responses related to connections with medical and social service organizations. Many organizations engaged in efforts to respond to changing policies by expanding capacity and services. Offering a range of SUD treatment (e.g., detoxification and outpatient) and affiliating with a medical organization could enable organizations to respond to new insurance, delivery, and payment reforms.
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Affiliation(s)
- Amity E. Quinn
- Senior Research Associate (AEQ); Scientist (MTS); Scientist (MB);
Professor and Director (CH) Institute for Behavioral Health, The Heller School for
Social Policy and Management, Brandeis University, Waltham, MA
| | - Maureen T. Stewart
- Senior Research Associate (AEQ); Scientist (MTS); Scientist (MB);
Professor and Director (CH) Institute for Behavioral Health, The Heller School for
Social Policy and Management, Brandeis University, Waltham, MA
| | - Mary Brolin
- Senior Research Associate (AEQ); Scientist (MTS); Scientist (MB);
Professor and Director (CH) Institute for Behavioral Health, The Heller School for
Social Policy and Management, Brandeis University, Waltham, MA
| | - Constance Horgan
- Senior Research Associate (AEQ); Scientist (MTS); Scientist (MB);
Professor and Director (CH) Institute for Behavioral Health, The Heller School for
Social Policy and Management, Brandeis University, Waltham, MA
| | - Nancy E. Lane
- Senior VP, Population Health Management, Vanderbilt University
Medical Center and Assistant Clinical Professor of Psychiatry, Vanderbilt Medical
School, Nashville, TN
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Hser YI, Mooney LJ, Saxon AJ, Miotto K, Bell DS, Huang D. Chronic pain among patients with opioid use disorder: Results from electronic health records data. J Subst Abuse Treat 2017; 77:26-30. [PMID: 28476267 DOI: 10.1016/j.jsat.2017.03.006] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 03/08/2017] [Accepted: 03/08/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE To examine the prevalence of comorbid chronic pain among patients with opioid use disorder (OUD) and to compare other comorbidities (substance use disorder (SUD), mental health disorders, health/disease conditions) among patients in four categories: no chronic pain (No Pain), OUD prior to pain (OUD First), OUD and pain at the same time (Same Time), or pain condition prior to OUD (Pain First). METHODS Using an electronic health record (EHR) database from 2006-2015, the study assessed 5307 adult patients with OUD in a large healthcare system; 35.6% were No Pain, 9.7% were OUD First, 14.9% were Same Time, and 39.8% were Pain First. RESULTS Most OUD patients (64.4%) had chronic pain conditions, and among them 61.8% had chronic pain before their first OUD diagnosis. Other SUDs occurred more frequently among OUD First patients than among other groups in terms of alcohol (33.4% vs. 25.4% for No Pain, 20.7% for Same Time, and 20.3% for Pain First), cocaine (19.0%, vs. 13.8%, 9.4%, 7.1%), and alcohol or drug-induced disorders. OUD First patients also had the highest rates of HIV (4.7%) and hepatitis C virus (HCV; 28.2%) among the four groups. Pain First patients had the highest rates of mental disorder (81.7%), heart disease (72.0%), respiratory disease (68.4%), sleep disorder (41.8%), cancer (23.4%), and diabetes (19.3%). CONCLUSIONS The alarming high rates of chronic pain conditions occurring before OUD and the associated severe mental health and physical health conditions require better models of assessment and coordinated care plans to address these complex medical conditions.
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Affiliation(s)
- Yih-Ing Hser
- University of California, Los Angeles, United States.
| | | | - Andrew J Saxon
- Veterans Affairs Puget Sound Health Care System, United States
| | - Karen Miotto
- University of California, Los Angeles, United States
| | | | - David Huang
- University of California, Los Angeles, United States
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Harris SK, Aalsma MC, Weitzman ER, Garcia-Huidobro D, Wong C, Hadland SE, Santelli J, Park MJ, Ozer EM. Research on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go? J Adolesc Health 2017; 60:249-260. [PMID: 28011064 PMCID: PMC5549464 DOI: 10.1016/j.jadohealth.2016.10.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Revised: 09/06/2016] [Accepted: 10/11/2016] [Indexed: 01/22/2023]
Abstract
We reviewed research regarding system- and visit-level strategies to enhance clinical preventive service delivery and quality for adolescents and young adults. Despite professional consensus on recommended services for adolescents, a strong evidence base for services for young adults, and improved financial access to services with the Affordable Care Act's provisions, receipt of preventive services remains suboptimal. Further research that builds off successful models of linking traditional and community clinics is needed to improve access to care for all youth. To optimize the clinical encounter, promising clinician-focused strategies to improve delivery of preventive services include screening and decision support tools, particularly when integrated into electronic medical record systems and supported by training and feedback. Although results have been mixed, interventions have moved beyond increasing service delivery to demonstrating behavior change. Research on emerging technology-such as gaming platforms, mobile phone applications, and wearable devices-suggests opportunities to expand clinicians' reach; however, existing research is based on limited clinical settings and populations. Improved monitoring systems and further research are needed to examine preventive services facilitators and ensure that interventions are effective across the range of clinical settings where youth receive preventive care, across multiple populations, including young adults, and for more vulnerable populations with less access to quality care.
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Affiliation(s)
- Sion K Harris
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Matthew C Aalsma
- Department of Pediatrics, Section of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Elissa R Weitzman
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Diego Garcia-Huidobro
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota; Department of Family Medicine, School of Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Charlene Wong
- Division of Adolescent Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Scott E Hadland
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts; Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - John Santelli
- Department of Population and Family Health, Columbia University Mailman School of Public Health, New York, New York
| | - M Jane Park
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - Elizabeth M Ozer
- Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California, San Francisco, San Francisco, California; Office of Diversity and Outreach, University of California, San Francisco, San Francisco, California.
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Transformational Impact of Health Information Technology on the Clinical Practice of Child and Adolescent Psychiatry. Child Adolesc Psychiatr Clin N Am 2017; 26:55-66. [PMID: 27837942 DOI: 10.1016/j.chc.2016.07.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Compared with other medical specialties, psychiatrists have been slower adopters of health information technology (IT) practices, such as electronic health records (EHRs). This delay in implementation could compromise patient safety and impede integration into accountable care organizations and multidisciplinary treatment settings. This article focuses on optimizing use of EHRs for clinical practice, leveraging health IT to improve quality of care, and focusing on the potential for future growth in health IT in child and adolescent psychiatric practice. Aligning with other medical fields and focusing on transparency of mental health treatment will help psychiatrists reach parity with other medical specialties.
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Quinn AE, Reif S, Evans B, Creedon TB, Stewart MT, Garnick DW, Horgan CM. How health plans promote health IT to improve behavioral health care. THE AMERICAN JOURNAL OF MANAGED CARE 2016; 22:810-815. [PMID: 27982663 PMCID: PMC5629964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES Given the large numbers of providers and enrollees with which they interact, health plans can encourage the use of health information technology (IT) to advance behavioral health care. The manner and extent to which commercial health plans promote health IT to improve behavioral health care is unknown. This study aims to address that gap. STUDY DESIGN Cross-sectional study. METHODS Data are from a nationally representative survey of commercial health plans regarding administrative and clinical dimensions of behavioral health services in 2010. Data are weighted to be representative of commercial managed care products in the United States (n = 8427; 88% response rate). Approaches within the domains of provider support, access to care, and assessment and treatment were investigated as examples of how health plans can promote health IT to improve behavioral health care delivery. RESULTS Health plans were using health IT approaches in each domain. About a quarter of products offered financial support for electronic health records, but technical assistance was rare. Primary care providers could bill for e-mail contact with patients for behavioral health in about a quarter of products. Few products offered member-provider e-mail, and none offered online appointment scheduling. However, online referral systems and online provider directories were common, and nearly all offered an online self-assessment tool; most offered online counseling and online personalized responses to questions or problems. CONCLUSIONS In 2010, commercial health plans encouraged the use of health IT strategies for behavioral health care. Health plans have an important role to play for increasing health IT as a tool for behavioral health care.
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Affiliation(s)
- Amity E Quinn
- Brandeis University, 415 South St, MS035, Waltham, MA 02453. E-mail:
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Stein BD, Mendelsohn J, Gordon AJ, Dick AW, Burns RM, Sorbero M, Shih RA, Liccardo Pacula R. Opioid analgesic and benzodiazepine prescribing among Medicaid-enrollees with opioid use disorders: The influence of provider communities. J Addict Dis 2016; 36:14-22. [PMID: 27449904 DOI: 10.1080/10550887.2016.1211784] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Opioid analgesic and benzodiazepine use in individuals with opioid use disorders can increase the risk for medical consequences and relapse. Little is known about rates of use of these medications or prescribing patterns among communities of prescribers. The goal of this study was to examine rates of prescribing to Medicaid-enrollees in the calendar year after an opioid use disorder diagnosis, and to examine individual, county, and provider community factors associated with such prescribing. 2008 Medicaid claims data were used from 12 states to identify enrollees diagnosed with opioid use disorders, and 2009 claims data were used to identify rates of prescribing of each drug. Social network analysis was used to identify provider communities, and multivariate regression analyses was used to to identify patient, county, and provider community level factors associated with prescribing these drugs. The authors also examined variation in rates of prescribing across provider communities. Among Medicaid-enrollees identified with an opioid use disorder, 45% filled a prescription for an opioid analgesic, 37% filled a prescription for a benzodiazepine, and 21% filled a prescription for both in the year following their diagnosis. Females, older individuals, individuals with pain syndromes, and individuals residing in counties with higher rates of poverty were more likely to fill prescriptions. Prescribing rates varied substantially across provider communities, with rates in the highest quartile of prescribing communities over 2.5 times the rates in the lowest prescribing communities. Prescribing opioid analgesics and benzodiazepines to individuals diagnosed with opioid use disorders may increase risk of relapse and overdose. Interventions should be considered that target provider communities with the highest rates of prescribing and individuals at the highest risk.
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Affiliation(s)
- Bradley D Stein
- a RAND Corporation , Pittsburgh , Pennsylvania , USA.,b University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA
| | | | - Adam J Gordon
- b University of Pittsburgh School of Medicine , Pittsburgh , Pennsylvania , USA.,d Center for Health Equity Research and Promotion , VA Pittsburgh Healthcare System , Pittsburgh , Pennsylvania , USA
| | | | | | - Mark Sorbero
- a RAND Corporation , Pittsburgh , Pennsylvania , USA
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Press A, DeStio C, McCullagh L, Kapoor S, Morley J, Conigliaro J. Usability Testing of a National Substance Use Screening Tool Embedded in Electronic Health Records. JMIR Hum Factors 2016; 3:e18. [PMID: 27393643 PMCID: PMC4958139 DOI: 10.2196/humanfactors.5820] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/19/2016] [Accepted: 06/11/2016] [Indexed: 11/21/2022] Open
Abstract
Background Screening, brief intervention, and referral to treatment (SBIRT) is currently being implemented into health systems nationally via paper and electronic methods. Objective The purpose of this study was to evaluate the integration of an electronic SBIRT tool into an existing paper-based SBIRT clinical workflow in a patient-centered medical home. Methods Usability testing was conducted in an academic ambulatory clinic. Two rounds of usability testing were done with medical office assistants (MOAs) using a paper and electronic version of the SBIRT tool, with two and four participants, respectively. Qualitative and quantitative data was analyzed to determine the impact of both tools on clinical workflow. A second round of usability testing was done with the revised electronic version and compared with the first version. Results Personal workflow barriers cited in the first round of testing were that the electronic health record (EHR) tool was disruptive to patient’s visits. In Round 2 of testing, MOAs reported favoring the electronic version due to improved layout and the inclusion of an alert system embedded in the EHR. For example, using the system usability scale (SUS), MOAs reported a grade “1” for the statement, “I would like to use this system frequently” during the first round of testing but a “5” during the second round of analysis. Conclusions The importance of testing usability of various mediums of tools used in health care screening is highlighted by the findings of this study. In the first round of testing, the electronic tool was reported as less user friendly, being difficult to navigate, and time consuming. Many issues faced in the first generation of the tool were improved in the second generation after usability was evaluated. This study demonstrates how usability testing of an electronic SBRIT tool can help to identify challenges that can impact clinical workflow. However, a limitation of this study was the small sample size of MOAs that participated. The results may have been biased to Northwell Health workers’ perceptions of the SBIRT tool and their specific clinical workflow.
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Affiliation(s)
- Anne Press
- Hofstra Northwell School of Medicine, Manhasset, NY, United States.
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Fields D, Riesenmy K, Blum TC, Roman PM. Implementation of Electronic Health Records and Entrepreneurial Strategic Orientation in Substance Use Disorder Treatment Organizations. J Stud Alcohol Drugs 2016; 76:942-51. [PMID: 26562603 DOI: 10.15288/jsad.2015.76.942] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This research studied the relationships of the components of entrepreneurial strategic orientation (ESO) with implementation of electronic health records (EHRs) within organizations that treat patients with substance use disorders (SUDs). METHOD A national sample of 317 SUD treatment providers were studied in a period after the Health Information Technology for Economic and Clinical Health (HITECH) Act was enacted (2009) and meaningful use EHR requirements were established (2010), but before implementation of the Affordable Care Act. The study sample was selected using stratified random sampling and was part of a longitudinal study of treatment providers across the United States. RESULTS After we controlled for potentially confounding variables, four components of ESO had a significant relationship with EHR implementation. Levels of slack resources in an organization moderated the relationship of ESO with meaningful use of EHRs, increasing the strength of the relationship for some components but reducing the strength of others. CONCLUSIONS From a policy and practice perspective, the results suggest that training and education to develop higher levels of ESO within SUD treatment organizations are likely to increase their level of meaningful use of EHRs, which in turn may enhance the integration of SUD treatment with primary medical providers, better preparing SUD treatment providers for the environmental changes of the Affordable Care Act.
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Affiliation(s)
- Dail Fields
- Center for Research on Behavioral Health and Human Services Delivery, Institute for Behavioral Research, University of Georgia, Athens, Georgia
| | | | - Terry C Blum
- Institute for Leadership and Entrepreneurship, Georgia Institute of Technology, Atlanta, Georgia
| | - Paul M Roman
- Center for Research on Behavioral Health and Human Services Delivery, Institute for Behavioral Research, University of Georgia, Athens, Georgia.,Department of Sociology, University of Georgia, Athens, Georgia
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Nápoles AM, Appelle N, Kalkhoran S, Vijayaraghavan M, Alvarado N, Satterfield J. Perceptions of clinicians and staff about the use of digital technology in primary care: qualitative interviews prior to implementation of a computer-facilitated 5As intervention. BMC Med Inform Decis Mak 2016; 16:44. [PMID: 27094928 PMCID: PMC4837549 DOI: 10.1186/s12911-016-0284-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 04/12/2016] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Digital health interventions using hybrid delivery models may offer efficient alternatives to traditional behavioral counseling by addressing obstacles of time, resources, and knowledge. Using a computer-facilitated 5As (ask, advise, assess, assist, arrange) model as an example (CF5As), we aimed to identify factors from the perspectives of primary care providers and clinical staff that were likely to influence introduction of digital technology and a CF5As smoking cessation counseling intervention. In the CF5As model, patients self-administer a tablet intervention that provides 5As smoking cessation counseling, produces patient and provider handouts recommending next steps, and is followed by a patient-provider encounter to reinforce key cessation messages, provide assistance, and arrange follow-up. METHODS Semi-structured in-person interviews of administrative and clinical staff and primary care providers from three primary care clinics. RESULTS Thirty-five interviews were completed (12 administrative staff, ten clinical staff, and 13 primary care providers). Twelve were from an academic internal medicine practice, 12 from a public hospital academic general medicine clinic, and 11 from a public hospital HIV clinic. Most were women (91 %); mean age (SD) was 42 years (11.1). Perceived usefulness of the CF5As focused on its relevance for various health behavior counseling purposes, potential gains in counseling efficiency, confidentiality of data collection, occupying patients while waiting, and serving as a cue to action. Perceived ease of use was viewed to depend on the ability to accommodate: clinic workflow; heavy patient volumes; and patient characterisitics, e.g., low literacy. Social norms potentially affecting implementation included beliefs in the promise/burden of technology, priority of smoking cessation counseling relative to other patient needs, and perception of CF5As as just "one more thing to do" in an overburdened system. The most frequently cited facilitating conditions were staffing levels and smoking cessation resources and training; the most cited hindering factors were visit time constraints and patients' complex health care needs. CONCLUSIONS Integrating CF5As and other technology-enhanced behavioral counseling interventions in primary care requires flexibility to accommodate work flow and perceptions of overload in dynamic environments. Identifying factors that promote and hinder CF5As adoption could inform implementation of other CF behavioral health interventions in primary care.
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Affiliation(s)
- Anna María Nápoles
- />Division of General Internal Medicine, Department of Medicine, University of California San Francisco (UCSF), Box 0856, 3333 California Street, Suite 335, San Francisco, CA 94118 USA
| | - Nicole Appelle
- />Division of General Internal Medicine, Department of Medicine, UCSF, Box 0320, 1545 Divisadero St., San Francisco, CA 94115 USA
| | - Sara Kalkhoran
- />Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, 50 Staniford St, 9th Floor, Boston, MA 02114 USA
| | - Maya Vijayaraghavan
- />UCSF, Box 1364, 1001 Potrero Ave., San Francisco General Hospital 90, Room 1311E, San Francisco, USA
| | - Nicholas Alvarado
- />Division of General Internal Medicine, Department of Medicine, UCSF, Box 0320, 2200 Post St., MZ Bldg C Room C126B, San Francisco, CA 94115 USA
| | - Jason Satterfield
- />Division of General Internal Medicine, Department of Medicine, UCSF, Box 1731, 1701 Divisadero St., Room 500, San Francisco, CA 94115 USA
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Addressing substance misuse in adolescents: a review of the literature on the screening, brief intervention, and referral to treatment model. Curr Opin Pediatr 2016; 28:258-65. [PMID: 26867164 DOI: 10.1097/mop.0000000000000333] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Adolescent substance use is a major public health concern in the United States. Pediatricians are in a unique position via the medical home to address this issue. Screening, brief intervention, and referral to treatment (SBIRT) is a comprehensive approach that aims to prevent, identify, and reduce substance use. SBIRT has been heavily studied in adults, but research with adolescents is still ongoing. This review examines the SBIRT model and highlights recent applicable research. RECENT FINDINGS This research indicates that alcohol and drug use has a negative impact on the developing brain. In 2011, the American Academy of Pediatrics (AAP) released a policy statement recommending the use of SBIRT. An adolescent SBIRT algorithm can be used clinically. Recent studies focus on individual components of SBIRT; however, there have been no studies that examine all three components together in adolescents. Nevertheless, research indicates that SBIRT is an important tool to assess and intervene regarding adolescent substance use. SUMMARY SBIRT is recommended by the AAP as a way to address adolescent substance use. Pediatricians should be screening adolescents for substance use at every well exam, and acute care visits when possible, with a validated tool. Although more research is needed, SBIRT is an effective method to address adolescent substance use.
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Wu LT, Brady KT, Spratt SE, Dunham AA, Heidenfelder B, Batch BC, Lindblad R, VanVeldhuisen P, Rusincovitch SA, Killeen TK, Ghitza UE. Using electronic health record data for substance use Screening, Brief Intervention, and Referral to Treatment among adults with type 2 diabetes: Design of a National Drug Abuse Treatment Clinical Trials Network study. Contemp Clin Trials 2016; 46:30-38. [PMID: 26563446 PMCID: PMC4695300 DOI: 10.1016/j.cct.2015.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 10/31/2015] [Accepted: 11/07/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND The Affordable Care Act encourages healthcare systems to integrate behavioral and medical healthcare, as well as to employ electronic health records (EHRs) for health information exchange and quality improvement. Pragmatic research paradigms that employ EHRs in research are needed to produce clinical evidence in real-world medical settings for informing learning healthcare systems. Adults with comorbid diabetes and substance use disorders (SUDs) tend to use costly inpatient treatments; however, there is a lack of empirical data on implementing behavioral healthcare to reduce health risk in adults with high-risk diabetes. Given the complexity of high-risk patients' medical problems and the cost of conducting randomized trials, a feasibility project is warranted to guide practical study designs. METHODS We describe the study design, which explores the feasibility of implementing substance use Screening, Brief Intervention, and Referral to Treatment (SBIRT) among adults with high-risk type 2 diabetes mellitus (T2DM) within a home-based primary care setting. Our study includes the development of an integrated EHR datamart to identify eligible patients and collect diabetes healthcare data, and the use of a geographic health information system to understand the social context in patients' communities. Analysis will examine recruitment, proportion of patients receiving brief intervention and/or referrals, substance use, SUD treatment use, diabetes outcomes, and retention. DISCUSSION By capitalizing on an existing T2DM project that uses home-based primary care, our study results will provide timely clinical information to inform the designs and implementation of future SBIRT studies among adults with multiple medical conditions.
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Affiliation(s)
- Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
| | - Kathleen T Brady
- South Carolina Clinical and Translational Research Institute, Medical University of South Carolina, Charleston, SC, USA
| | - Susan E Spratt
- Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
| | - Ashley A Dunham
- Duke Translational Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Brooke Heidenfelder
- Duke Translational Research Institute, Duke University Medical Center, Durham, NC, USA
| | - Bryan C Batch
- Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
| | | | | | | | - Therese K Killeen
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Udi E Ghitza
- National Institute on Drug Abuse, Bethesda, MD, USA
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Teaching residents screening, brief intervention, and referral to treatment (SBIRT) skills for alcohol use: Using chart-stimulated recall to assess curricular impact. Subst Abus 2015; 37:419-426. [PMID: 26675123 DOI: 10.1080/08897077.2015.1127869] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Screening, brief intervention, and referral to treatment (SBIRT) improves identification and intervention for patients at risk for developing an alcohol use disorder (AUD). Residency curriculum is designed to teach SBIRT skills, but resources are needed to promote skill implementation. The electronic health record (EHR) can facilitate implementation through integration of decision-support tools. The authors developed electronic tools to facilitate documentation of alcohol assessment and brief intervention and to reinforce skills from an SBIRT curriculum. This prospective cohort study assessed primary care internal medicine residents' use of SBIRT skills and EHR tools in practice using chart-stimulated recall (CSR). METHODS Postgraduate year 2 and 3 residents received a 5-hour SBIRT curriculum with skills practice and instruction on SBIRT electronic tools. Participants were then given a list of their patients seen in a 1-year period who were drinking at/above the recommended limit. Trainees selected 3 patients to review with a faculty member in a CSR. Faculty used a 24-item chart checklist to assess application of SBIRT skills and electronic tool use and met with residents to complete a CSR interview. CSR interview notes were analyzed qualitatively to understand application of SBIRT skills and EHR tool use. RESULTS Eighteen of 20 residents participated in the CSR, and 5 faculty reviewed 46 patient charts. Residents documented alcohol use (84.2% of charts) and assessment of quantity/frequency of use (71.0%) but were less likely to document assessment for an AUD (34%), an appropriate plan (50.0%), or follow-up (55%). Few residents used EHR tools. Residents reported barriers in addressing alcohol use, including lack of knowledge, patient barriers, and time constraints. CONCLUSIONS More intensive training in SBIRT with opportunities for practice and feedback may be necessary for residents to consistently apply SBIRT skills in practice. EHR tools need to be better integrated into the clinic workflow in order to be useful.
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Zoorob R, Gonzalez SJ, Snell H, O'Hara H, Sidani M. SBI and EHR: understanding, adoption, and implementation in family medicine clinics. Addict Sci Clin Pract 2015. [PMCID: PMC4597604 DOI: 10.1186/1940-0640-10-s2-o48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Al Kazzi ES, Lau B, Li T, Schneider EB, Makary MA, Hutfless S. Differences in the Prevalence of Obesity, Smoking and Alcohol in the United States Nationwide Inpatient Sample and the Behavioral Risk Factor Surveillance System. PLoS One 2015; 10:e0140165. [PMID: 26536469 PMCID: PMC4633065 DOI: 10.1371/journal.pone.0140165] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 09/22/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The lack of adequate and standardized recording of leading risk factors for morbidity and mortality in medical records have downstream effects on research based on administrative databases. The measurement of healthcare is increasingly based on risk-adjusted outcomes derived from coded comorbidities in these databases. However inaccurate or haphazard assessment of risk factors for morbidity and mortality in medical record codes can have tremendous implications for quality improvement and healthcare reform. OBJECTIVE We aimed to compare the prevalence of obesity, overweight, tobacco use and alcohol abuse of a large administrative database with a direct data collection survey. MATERIALS AND METHODS We used the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for four leading risk factors in the United States Nationwide Inpatient Sample (NIS) to compare them with a direct survey in the Behavioral Risk Factor Surveillance System (BRFSS) in 2011. After confirming normality of the risk factors, we calculated the national and state estimates and Pearson's correlation coefficient for obesity, overweight, tobacco use and alcohol abuse between NIS and BRFSS. RESULTS Compared with direct participant questioning in BRFSS, NIS reported substantially lower prevalence of obesity (p<0.01), overweight (p<0.01), and alcohol abuse (p<0.01), but not tobacco use (p = 0.18). The correlation between NIS and BRFSS was 0.27 for obesity (p = 0.06), 0.09 for overweight (p = 0.55), 0.62 for tobacco use (p<0.01) and 0.40 for alcohol abuse (p<0.01). CONCLUSIONS The prevalence of obesity, overweight, tobacco smoking and alcohol abuse based on codes is not consistent with prevalence based on direct questioning. The accuracy of these important measures of health and morbidity in databases is critical for healthcare reform policies.
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Affiliation(s)
- Elie S. Al Kazzi
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Brandyn Lau
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Division of Health Sciences Informatics, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland, United States of America
| | - Tianjing Li
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Eric B. Schneider
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Martin A. Makary
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Susan Hutfless
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Sterling S, Kline-Simon AH, Satre DD, Jones A, Mertens J, Wong A, Weisner C. Implementation of Screening, Brief Intervention, and Referral to Treatment for Adolescents in Pediatric Primary Care: A Cluster Randomized Trial. JAMA Pediatr 2015; 169:e153145. [PMID: 26523821 PMCID: PMC4779618 DOI: 10.1001/jamapediatrics.2015.3145] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
IMPORTANCE Early intervention for substance use is critical to improving adolescent outcomes. Studies have found promising results for Screening, Brief Intervention, and Referral to Treatment (SBIRT), but little research has examined implementation. OBJECTIVE To compare SBIRT implementation in pediatric primary care among trained pediatricians, pediatricians working in coordination with embedded behavioral health care practitioners (BHCPs), and usual care (UC). DESIGN, SETTING, AND PARTICIPANTS The study is a 2-year (November 1, 2011, through October 31, 2013), nonblinded, cluster randomized, hybrid implementation and effectiveness trial examining SBIRT implementation outcomes across 2 modalities of implementation and UC. Fifty-two pediatricians from a large general pediatrics clinic in an integrated health care system were randomized to 1 of 3 SBIRT implementation arms; patients aged 12 to 18 years were eligible. INTERVENTIONS Two modes of SBIRT implementation, (1) pediatrician only (pediatricians trained to provide SBIRT) and (2) embedded BHCP (BHCP trained to provide SBIRT), and (3) UC. MAIN OUTCOMES AND MEASURES Implementation of SBIRT (primary outcome), which included assessments, brief interventions, and referrals to specialty substance use and mental health treatment. RESULTS The final sample included 1871 eligible patients among 47 pediatricians; health care professional characteristics did not differ across study arms. Patients in the pediatrician-only (adjusted odds ratio [AOR], 10.37; 95% CI, 5.45-19.74; P < .001) and the embedded BHCP (AOR, 18.09; 95% CI, 9.69-33.77; P < .001) arms had higher odds of receiving brief interventions compared with patients in the UC arm. Patients in the embedded BHCP arm were more likely to receive brief interventions compared with those in the pediatrician-only arm (AOR, 1.74; 95% CI, 1.31-2.31; P < .001). The embedded BHCP arm had lower odds of receiving a referral compared with the pediatrician-only (AOR, 0.58; 95% CI, 0.43-0.78; P < .001) and UC (AOR, 0.65; 95% CI, 0.48-0.89; P = .006) arms; odds of referrals did not differ between the pediatrician-only and UC arms. CONCLUSIONS AND RELEVANCE The intervention arms had better screening, assessment, and brief intervention rates than the UC arm. Patients in the pediatrician-only and UC arms had higher odds of being referred to specialty treatment than those in the embedded BHCP arm, suggesting lingering barriers to having pediatricians fully address substance use in primary care. Findings also highlight age and ethnic groups less likely to receive these important services. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT02408952.
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Affiliation(s)
- Stacy Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland
| | | | - Derek D. Satre
- Division of Research, Kaiser Permanente Northern California, Oakland; Department of Psychiatry, University of California, San Francisco
| | - Ashley Jones
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jennifer Mertens
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Anna Wong
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland; Department of Psychiatry, University of California, San Francisco
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Wu LT, Ghitza UE, Batch BC, Pencina MJ, Rojas LF, Goldstein BA, Schibler T, Dunham AA, Rusincovitch S, Brady KT. Substance use and mental diagnoses among adults with and without type 2 diabetes: Results from electronic health records data. Drug Alcohol Depend 2015; 156:162-169. [PMID: 26392231 PMCID: PMC4633379 DOI: 10.1016/j.drugalcdep.2015.09.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/07/2015] [Accepted: 09/07/2015] [Indexed: 11/13/2022]
Abstract
BACKGROUND Comorbid diabetes and substance use diagnoses (SUD) represent a hazardous combination, both in terms of healthcare cost and morbidity. To date, there is limited information about the association of SUD and related mental disorders with type 2 diabetes mellitus (T2DM). METHODS We examined the associations between T2DM and multiple psychiatric diagnosis categories, with a focus on SUD and related psychiatric comorbidities among adults with T2DM. We analyzed electronic health record (EHR) data on 170,853 unique adults aged ≥18 years from the EHR warehouse of a large academic healthcare system. Logistic regression analyses were conducted to estimate the strength of an association for comorbidities. RESULTS Overall, 9% of adults (n=16,243) had T2DM. Blacks, Hispanics, Asians, and Native Americans had greater odds of having T2DM than whites. All 10 psychiatric diagnosis categories were more prevalent among adults with T2DM than among those without T2DM. Prevalent diagnoses among adults with T2MD were mood (21.22%), SUD (17.02%: tobacco 13.25%, alcohol 4.00%, drugs 4.22%), and anxiety diagnoses (13.98%). Among adults with T2DM, SUD was positively associated with mood, anxiety, personality, somatic, and schizophrenia diagnoses. CONCLUSIONS We examined a large diverse sample of individuals and found clinical evidence of SUD and psychiatric comorbidities among adults with T2DM. These results highlight the need to identify feasible collaborative care models for adults with T2DM and SUD related psychiatric comorbidities, particularly in primary care settings, that will improve behavioral health and reduce health risk.
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Affiliation(s)
- Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA; Duke Clinical Research Institute, Duke University, Durham, NC, USA.
| | - Udi E Ghitza
- National Institute on Drug Abuse, Bethesda, MD, USA
| | - Bryan C Batch
- Division of Endocrinology, Duke University Medical Center, Durham, NC, USA
| | - Michael J Pencina
- Duke Clinical Research Institute, Duke University, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | | | - Benjamin A Goldstein
- Duke Clinical Research Institute, Duke University, Durham, NC, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Tony Schibler
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Ashley A Dunham
- Duke Translational Research Institute, Duke University, Durham, NC, USA
| | | | - Kathleen T Brady
- South Carolina Clinical and Translational Research Institute, Medical University of South Carolina, Charleston, SC, USA
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Ghitza UE, Tai B. Challenges and opportunities for integrating preventive substance-use-care services in primary care through the Affordable Care Act. J Health Care Poor Underserved 2015; 25:36-45. [PMID: 24583486 DOI: 10.1353/hpu.2014.0067] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Undertreated or untreated substance use disorders (SUD) remain a pervasive, medically-harmful public health problem in the United States, particularly in medically underserved and low-income populations lacking access to appropriate treatment. The need for greater access to SUD treatment was expressed as policy in the Final Rule on standards related to essential health benefits, required to be covered through the 2010 Affordable Care Act (ACA) health insurance exchanges. SUD treatment services have been included as an essential health benefit, in a manner that complies with the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008. Consequently, with the ACA, a vast expansion of SUD-care services in primary care is looming. This commentary discusses challenges and opportunities under the ACA for equipping health care professionals with appropriate workforce training, infrastructure, and resources to support and guide science-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) for SUD in primary care.
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Harris SK, Knight JR, Van Hook S, Sherritt L, Brooks TL, Kulig JW, Nordt CA, Saitz R. Adolescent substance use screening in primary care: Validity of computer self-administered versus clinician-administered screening. Subst Abus 2015. [PMID: 25774878 DOI: 10.1080/08897077.2015.1014615.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
BACKGROUND Computer self-administration may help busy pediatricians' offices increase adolescent substance use screening rates efficiently and effectively, if proven to yield valid responses. The CRAFFT screening protocol for adolescents has demonstrated validity as an interview, but a computer self-entry approach needs validity testing. The aim of this study was to evaluate the criterion validity and time efficiency of a computerized adolescent substance use screening protocol implemented by self-administration or clinician-administration. METHODS Twelve- to 17-year-old patients coming for routine care at 3 primary care clinics completed the computerized screen by both self-administration and clinician-administration during their visit. To account for order effects, we randomly assigned participants to self-administer the screen either before or after seeing their clinician. Both were conducted using a tablet computer and included identical items (any past-12-month use of tobacco, alcohol, drugs; past-3-month frequency of each; and 6 CRAFFT items). The criterion measure for substance use was the Timeline Follow-Back, and for alcohol/drug use disorder, the Adolescent Diagnostic Interview, both conducted by confidential research assistant interview after the visit. Tobacco dependence risk was assessed with the self-administered Hooked on Nicotine Checklist (HONC). Analyses accounted for the multisite cluster sampling design. RESULTS Among 136 participants, mean age was 15.0 ± 1.5 years, 54% were girls, 53% were black or Hispanic, and 67% had ≥3 prior visits with their clinician. Twenty-seven percent reported any substance use (including tobacco) in the past 12 months, 7% met criteria for an alcohol or cannabis use disorder, and 4% were HONC positive. Sensitivity/specificity of the screener were high for detecting past-12-month use or disorder and did not differ between computer and clinician. Mean completion time was 49 seconds (95% confidence interval [CI]: 44-54) for computer and 74 seconds (95% CI: 68-87) for clinician (paired comparison, P < .001). CONCLUSIONS Substance use screening by computer self-entry is a valid and time-efficient alternative to clinician-administered screening.
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Affiliation(s)
- Sion Kim Harris
- a Department of Pediatrics , Harvard Medical School , Boston , Massachusetts , USA.,b Division of Developmental Medicine , Boston Children's Hospital , Boston , Massachusetts , USA.,c Division of Adolescent/Young Adult Medicine , Boston Children's Hospital , Boston , Massachusetts , USA.,d The Center for Adolescent Substance Abuse Research (CeASAR) , Boston Children's Hospital , Boston , Massachusetts , USA
| | - John Rogers Knight
- a Department of Pediatrics , Harvard Medical School , Boston , Massachusetts , USA.,b Division of Developmental Medicine , Boston Children's Hospital , Boston , Massachusetts , USA.,c Division of Adolescent/Young Adult Medicine , Boston Children's Hospital , Boston , Massachusetts , USA.,d The Center for Adolescent Substance Abuse Research (CeASAR) , Boston Children's Hospital , Boston , Massachusetts , USA
| | - Shari Van Hook
- e Inova Health Care Services , Falls Church , Virginia , USA
| | - Lon Sherritt
- a Department of Pediatrics , Harvard Medical School , Boston , Massachusetts , USA.,b Division of Developmental Medicine , Boston Children's Hospital , Boston , Massachusetts , USA.,d The Center for Adolescent Substance Abuse Research (CeASAR) , Boston Children's Hospital , Boston , Massachusetts , USA
| | - Traci L Brooks
- f Department of Pediatrics , Cambridge Health Alliance , Cambridge , Massachusetts , USA
| | - John W Kulig
- g Department of Pediatrics , Tufts Medical Center-Floating Hospital for Children , Boston , Massachusetts , USA
| | - Christina A Nordt
- h Department of Pediatrics , Boston Medical Center , Boston , Massachusetts , USA
| | - Richard Saitz
- i Departments of Community Health Sciences and Medicine , Boston University Schools of Medicine and Public Health , Boston , Massachusetts , USA.,j Clinical Addiction Research and Education (CARE) Unit , Section of General Internal Medicine , Boston Medical Center , Boston , Massachusetts , USA
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Harris SK, Knight JR, Van Hook S, Sherritt L, Brooks TL, Kulig JW, Nordt CA, Saitz R. Adolescent substance use screening in primary care: Validity of computer self-administered versus clinician-administered screening. Subst Abus 2015; 37:197-203. [PMID: 25774878 DOI: 10.1080/08897077.2015.1014615] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Computer self-administration may help busy pediatricians' offices increase adolescent substance use screening rates efficiently and effectively, if proven to yield valid responses. The CRAFFT screening protocol for adolescents has demonstrated validity as an interview, but a computer self-entry approach needs validity testing. The aim of this study was to evaluate the criterion validity and time efficiency of a computerized adolescent substance use screening protocol implemented by self-administration or clinician-administration. METHODS Twelve- to 17-year-old patients coming for routine care at 3 primary care clinics completed the computerized screen by both self-administration and clinician-administration during their visit. To account for order effects, we randomly assigned participants to self-administer the screen either before or after seeing their clinician. Both were conducted using a tablet computer and included identical items (any past-12-month use of tobacco, alcohol, drugs; past-3-month frequency of each; and 6 CRAFFT items). The criterion measure for substance use was the Timeline Follow-Back, and for alcohol/drug use disorder, the Adolescent Diagnostic Interview, both conducted by confidential research assistant interview after the visit. Tobacco dependence risk was assessed with the self-administered Hooked on Nicotine Checklist (HONC). Analyses accounted for the multisite cluster sampling design. RESULTS Among 136 participants, mean age was 15.0 ± 1.5 years, 54% were girls, 53% were black or Hispanic, and 67% had ≥3 prior visits with their clinician. Twenty-seven percent reported any substance use (including tobacco) in the past 12 months, 7% met criteria for an alcohol or cannabis use disorder, and 4% were HONC positive. Sensitivity/specificity of the screener were high for detecting past-12-month use or disorder and did not differ between computer and clinician. Mean completion time was 49 seconds (95% confidence interval [CI]: 44-54) for computer and 74 seconds (95% CI: 68-87) for clinician (paired comparison, P < .001). CONCLUSIONS Substance use screening by computer self-entry is a valid and time-efficient alternative to clinician-administered screening.
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Affiliation(s)
- Sion Kim Harris
- a Department of Pediatrics , Harvard Medical School , Boston , Massachusetts , USA.,b Division of Developmental Medicine , Boston Children's Hospital , Boston , Massachusetts , USA.,c Division of Adolescent/Young Adult Medicine , Boston Children's Hospital , Boston , Massachusetts , USA.,d The Center for Adolescent Substance Abuse Research (CeASAR) , Boston Children's Hospital , Boston , Massachusetts , USA
| | - John Rogers Knight
- a Department of Pediatrics , Harvard Medical School , Boston , Massachusetts , USA.,b Division of Developmental Medicine , Boston Children's Hospital , Boston , Massachusetts , USA.,c Division of Adolescent/Young Adult Medicine , Boston Children's Hospital , Boston , Massachusetts , USA.,d The Center for Adolescent Substance Abuse Research (CeASAR) , Boston Children's Hospital , Boston , Massachusetts , USA
| | - Shari Van Hook
- e Inova Health Care Services , Falls Church , Virginia , USA
| | - Lon Sherritt
- a Department of Pediatrics , Harvard Medical School , Boston , Massachusetts , USA.,b Division of Developmental Medicine , Boston Children's Hospital , Boston , Massachusetts , USA.,d The Center for Adolescent Substance Abuse Research (CeASAR) , Boston Children's Hospital , Boston , Massachusetts , USA
| | - Traci L Brooks
- f Department of Pediatrics , Cambridge Health Alliance , Cambridge , Massachusetts , USA
| | - John W Kulig
- g Department of Pediatrics , Tufts Medical Center-Floating Hospital for Children , Boston , Massachusetts , USA
| | - Christina A Nordt
- h Department of Pediatrics , Boston Medical Center , Boston , Massachusetts , USA
| | - Richard Saitz
- i Departments of Community Health Sciences and Medicine , Boston University Schools of Medicine and Public Health , Boston , Massachusetts , USA.,j Clinical Addiction Research and Education (CARE) Unit , Section of General Internal Medicine , Boston Medical Center , Boston , Massachusetts , USA
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Ghitza UE, Gore-Langton RE, Lindblad R, Tai B. NIDA Clinical Trials Network Common Data Elements Initiative: Advancing Big-Data Addictive-Disorders Research. Front Psychiatry 2015; 6:33. [PMID: 25784882 PMCID: PMC4347299 DOI: 10.3389/fpsyt.2015.00033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/17/2015] [Indexed: 11/19/2022] Open
Affiliation(s)
- Udi E Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health , Bethesda, MD , USA
| | | | | | - Betty Tai
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health , Bethesda, MD , USA
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Tai B, Sparenborg S, Ghitza UE, Liu D. Expanding the National Drug Abuse Treatment Clinical Trials Network to address the management of substance use disorders in general medical settings. Subst Abuse Rehabil 2014; 5:75-80. [PMID: 25114611 PMCID: PMC4114899 DOI: 10.2147/sar.s66538] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The Patient Protection and Affordable Care Act (2010) and the Mental Health Parity and Addiction Equity Act (2008) expand substance use disorder (SUD) care services in the USA into general medical settings. Care offered in these settings will engage substance-using patients in an integrated and patient-centered environment that addresses physical and mental health comorbidities and follows a chronic care model. This expansion of SUD services presents a great need for evidence-based practices useful in general medical settings, and reveals several research gaps to be addressed. The National Drug Abuse Treatment Clinical Trials Network of the National Institute on Drug Abuse can serve an important role in this endeavor. High-priority research gaps are highlighted in this commentary. A discussion follows on how the National Drug Abuse Treatment Clinical Trials Network can transform to address changing patterns in SUD care to efficiently generate evidence to guide SUD treatment practice within the context of recent US health care legislation.
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Affiliation(s)
- Betty Tai
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA
| | - Steven Sparenborg
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA
| | - Udi E Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA
| | - David Liu
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA
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Wu LT, Blazer DG, Gersing KR, Burchett B, Swartz MS, Mannelli P. Comorbid substance use disorders with other Axis I and II mental disorders among treatment-seeking Asian Americans, Native Hawaiians/Pacific Islanders, and mixed-race people. J Psychiatr Res 2013; 47:1940-8. [PMID: 24060266 PMCID: PMC3846388 DOI: 10.1016/j.jpsychires.2013.08.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Revised: 08/29/2013] [Accepted: 08/29/2013] [Indexed: 02/06/2023]
Abstract
Little is known about behavioral healthcare needs of Asian Americans (AAs), Native Hawaiians/Pacific Islanders (NHs/PIs), and mixed-race people (MRs)-the fastest growing segments of the U.S. population. We examined substance use disorder (SUD) prevalences and comorbidities among AAs, NHs/PIs, and MRs (N = 4572) in a behavioral health electronic health record database. DSM-IV diagnoses among patients aged 1-90 years who accessed behavioral healthcare from 11 sites were systematically captured: SUD, anxiety, mood, personality, adjustment, childhood-onset, cognitive/dementia, dissociative, eating, factitious, impulse-control, psychotic/schizophrenic, sleep, and somatoform diagnoses. Of all patients, 15.0% had a SUD. Mood (60%), anxiety (31.2%), adjustment (30.9%), and disruptive (attention deficit-hyperactivity, conduct, oppositional defiant, disruptive behavior diagnosis, 22.7%) diagnoses were more common than others (psychotic 14.2%, personality 13.3%, other childhood-onset 11.4%, impulse-control 6.6%, cognitive 2.8%, eating 2.2%, somatoform 2.1%). Less than 1% of children aged <12 years had SUD. Cannabis diagnosis was the primary SUD affecting adolescents aged 12-17. MRs aged 35-49 years had the highest prevalence of cocaine diagnosis. Controlling for age at first visit, sex, treatment setting, length of treatment, and number of comorbid diagnoses, NHs/PIs and MRs were about two times more likely than AAs to have ≥ 2 SUDs. Regardless of race/ethnicity, personality diagnosis was comorbid with SUD. NHs/PIs with a mood diagnosis had elevated odds of having SUD. Findings present the most comprehensive patterns of mental diagnoses available for treatment-seeking AAs, NHs/PIs, and MRs in the real-world medical setting. In-depth research is needed to elucidate intraracial and interracial differences in treatment needs.
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Affiliation(s)
- Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Dan G. Blazer
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Kenneth R. Gersing
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Bruce Burchett
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Marvin S. Swartz
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Paolo Mannelli
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - NIDA AAPI Workgroup
- National Institute on Drug Abuse Asian American and Pacific Islander Researchers and Scholars Workgroup, Bethesda, MD, USA
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Wu LT, Blazer DG. Substance use disorders and psychiatric comorbidity in mid and later life: a review. Int J Epidemiol 2013; 43:304-17. [PMID: 24163278 DOI: 10.1093/ije/dyt173] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Globally, adults aged 65 years or older will increase from 516 million in 2009 to an estimated 1.53 billion in 2050. Due to substance use at earlier ages that may continue into later life, and ageing-related changes in medical conditions, older substance users are at risk for substance-related consequences. METHODS MEDLINE and PsychInfo databases were searched using keywords: alcohol use disorder, drug use disorder, drug misuse, substance use disorder, prescription drug abuse, and substance abuse. Using the related-articles link, additional articles were screened for inclusion. This review focused on original studies published between 2005 and 2013 to reflect recent trends in substance use disorders. Studies on psychiatric comorbidity were also reviewed to inform treatment needs for older adults with a substance use disorder. RESULTS Among community non-institutionalized adults aged 50+ years, about 60% used alcohol, 3% used illicit drugs and 1-2% used nonmedical prescription drugs in the past year. Among adults aged 50+, about 5% of men and 1.4% of women had a past-year alcohol use disorder. Among alcohol users, about one in 14 users aged 50-64 had a past-year alcohol use disorder vs one in 30 elder users aged 65+. Among drug users aged 50+, approximately 10-12% had a drug use disorder. Similar to depressive and anxiety disorders, substance use disorders were among the common psychiatric disorders among older adults. Older drug users in methadone maintenance treatment exhibited multiple psychiatric or medical conditions. There have been increases in treatment admissions for illicit and prescription drug problems in the United States. CONCLUSIONS Substance use in late life requires surveillance and research, including tracking substance use in the racial/ethnic populations and developing effective care models to address comorbid medical and mental health problems.
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Affiliation(s)
- Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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Manuel JK, Newville H, Larios SE, Sorensen JL. Confidentiality protections versus collaborative care in the treatment of substance use disorders. Addict Sci Clin Pract 2013; 8:13. [PMID: 23972141 PMCID: PMC3766245 DOI: 10.1186/1940-0640-8-13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 07/31/2013] [Indexed: 11/10/2022] Open
Abstract
Practitioners in federally-assisted substance use disorder (SUD) treatment programs are faced with increasingly complex decisions when addressing patient confidentiality issues. Recent policy changes, intended to make treatment more available and accessible, are having an impact on delivery of SUD treatment in the United States. The addition of electronic health records provides opportunity for more rapid and comprehensive communication between patients' primary and SUD care providers while promoting a collaborative care environment. This shift toward collaborative care is complicated by the special protections that SUD documentation receives in SUD treatment programs, which vary depending on what care is provided and the setting where the patient is treated. This article explores the special protections for substance abuse documentation, discrepancies in treatment documentation, ways to deal with these issues in clinical practice, and the need for more knowledge about how to harmonize treatment in the SUD and primary care systems.
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Affiliation(s)
- Jennifer K Manuel
- University of California, San Francisco at San Francisco General Hospital, Bldg 20, Ste. 2100, Rm 2127 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Howard Newville
- University of California, San Francisco at San Francisco General Hospital, Bldg 20, Ste. 2100, Rm 2127 1001 Potrero Avenue, San Francisco, CA 94110, USA
- St. Luke’s-Roosevelt Hospital, Behavioral Science Research Unit, 1111 Amsterdam Avenue, New York, NY 10025, USA
| | - Sandra E Larios
- University of California, San Francisco at San Francisco General Hospital, Bldg 20, Ste. 2100, Rm 2127 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - James L Sorensen
- University of California, San Francisco at San Francisco General Hospital, Bldg 20, Ste. 2100, Rm 2127 1001 Potrero Avenue, San Francisco, CA 94110, USA
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Chapman SLC, Wu LT. Substance Use among Adolescent Mothers: A Review. CHILDREN AND YOUTH SERVICES REVIEW 2013; 35:806-815. [PMID: 23641120 PMCID: PMC3638998 DOI: 10.1016/j.childyouth.2013.02.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Maternal substance abuse is a critical problem, and adolescent mothers appear to be at high risk for such behaviors. We review studies on postpartum adolescent substance use to explore the extent of this problem and avenues for new research. Authors screened 1,300 studies, identifying 12 articles on substance use among postpartum adolescent mothers for this review. Adolescent mothers reported greater substance use before pregnancy compared to other adolescent females. Although some adolescents continued substance use during pregnancy, most stopped using only to resume within six months after birth. Comparisons of use to national samples of nulliparous adolescent females showed a higher prevalence of substance use in this population. Substances used often varied by race/ethnicity, with white mothers more likely to smoke cigarettes and use marijuana, and Black mothers more likely than whites to drink and use drugs. Of all identified studies, only one focused on Hispanics. Beliefs about drug use grew less negative as girls transitioned from pregnancy to parenthood. As they transitioned to adulthood, substance use remained prevalent and stable. Psychological distress and low self-esteem appeared to influence continued use. Friends' cigarette smoking predicted early initiation of and persistent smoking, while increased education predicted quitting. Early initiation of substances often predicted problem behaviors. Adolescent mothers are a vulnerable population, implicating use of problem behavior theory or the self-medication hypothesis in future research. Multiple avenues for new studies are needed to help identify effective treatment and intervention for this understudied population.
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Affiliation(s)
- Shawna L. Carroll Chapman
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC, USA
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Using electronic health records data to assess comorbidities of substance use and psychiatric diagnoses and treatment settings among adults. J Psychiatr Res 2013; 47:555-63. [PMID: 23337131 PMCID: PMC3581730 DOI: 10.1016/j.jpsychires.2012.12.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 12/18/2012] [Accepted: 12/20/2012] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To examine prevalences of substance use disorders (SUD) and comprehensive patterns of comorbidities among psychiatric patients ages 18-64 years (N = 40,099) in an electronic health records (EHR) database. METHOD DSM-IV diagnoses among psychiatric patients in a large university system were systematically captured: SUD, anxiety (AD), mood (MD), personality (PD), adjustment, childhood-onset, cognitive/dementia, dissociative, eating, factitious, impulse-control, psychotic (schizophrenic), sexual/gender identity, sleep, and somatoform diagnoses. Comorbidities and treatment types among patients with a SUD were examined. RESULTS Among all patients, 24.9% (n = 9984) had a SUD, with blacks (35.2%) and Hispanics (32.9%) showing the highest prevalence. Among patients with a SUD, MD was prevalent across all age groups (50.2-56.6%). Patients aged 18-24 years had elevated odds of comorbid PD, adjustment, childhood-onset, impulse-control, psychotic, and eating diagnoses. Females had more PD, AD, MD, eating, and somatoform diagnoses, while males had more childhood-onset, impulse-control, and psychotic diagnoses. Blacks had greater odds than whites of psychotic and cognitive/dementia diagnoses, while whites exhibited elevated odds of PA, AD, MD, childhood-onset, eating, somatoform, and sleep diagnoses. Women, blacks, and Native American/multiple-race adults had elevated odds of using inpatient treatment; men, blacks, and Hispanics had increased odds of using psychiatric emergency care. Comorbid MD, PD, adjustment, somatoform, psychotic, or cognitive/dementia diagnoses increased inpatient treatment. CONCLUSION Patients with a SUD, especially minority members, use more inpatient or psychiatric emergency care than those without. Findings provide evidence for research on understudied diagnoses and underserved populations in the real-world clinical settings.
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Wu LT, Swartz MS, Pan JJ, Burchett B, Mannelli P, Yang C, Blazer DG. Evaluating brief screeners to discriminate between drug use disorders in a sample of treatment-seeking adults. Gen Hosp Psychiatry 2013; 35:74-82. [PMID: 22819723 PMCID: PMC3504628 DOI: 10.1016/j.genhosppsych.2012.06.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Revised: 06/19/2012] [Accepted: 06/19/2012] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective was to identify a potential core set of brief screeners for the detection of individuals with a substance use disorder (SUD) in medical settings. METHOD Data were from two multisite studies that evaluated stimulant use outcomes of an abstinence-based contingency management intervention as an addition to usual care (National Drug Abuse Treatment Clinical Trials Network trials 006-007). The sample comprised 847 substance-using adults who were recruited from 12 outpatient substance abuse treatment settings across the United States. Alcohol and drug use disorders were assessed by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Checklist. Data were analyzed by factor analysis, item response theory (IRT), sensitivity and specificity procedures. RESULTS Comparatively prevalent symptoms of dependence, especially inability to cut down for all substances, showed high sensitivity for detecting an SUD (low rate of false negative). IRT-defined severe (infrequent) and low discriminative items, especially withdrawal for alcohol, cannabis and cocaine, had low sensitivity in identifying cases of an SUD. IRT-defined less severe (frequent) and high discriminative items, including inability to cut down or taking larger amounts than intended for all substances and withdrawal for amphetamines and opioids, showed good-to-high values of area under the receiver operating characteristic curve in classifying cases and noncases of an SUD. CONCLUSION Findings suggest the feasibility of identifying psychometrically reliable substance dependence symptoms to develop a two-item screen for alcohol and drug disorders.
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Affiliation(s)
- Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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Tai B, Gore-Langton RE, Ghitza UE, Lindblad R, Subramaniam G, Shide D. Response to commentaries. Addiction 2013; 108:12-3. [PMID: 23279355 DOI: 10.1111/j.1360-0443.2012.03979.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Betty Tai
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD 20892, USA.
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Ghitza UE, Gore-Langton RE, Lindblad R, Shide D, Subramaniam G, Tai B. Common data elements for substance use disorders in electronic health records: the NIDA Clinical Trials Network experience. Addiction 2013; 108:3-8. [PMID: 22563741 DOI: 10.1111/j.1360-0443.2012.03876.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS Electronic health records (EHRs) are essential in improving quality and enhancing efficiency of health-care delivery. By 2015, medical care receiving service reimbursement from US Centers for Medicare and Medicaid Services (CMS) must show 'meaningful use' of EHRs. Substance use disorders (SUD) are grossly under-detected and under-treated in current US medical care settings. Hence, an urgent need exists for improved identification of and clinical intervention for SUD in medical settings. The National Institute on Drug Abuse Clinical Trials Network (NIDA CTN) has leveraged its infrastructure and expertise and brought relevant stakeholders together to develop consensus on brief screening and initial assessment tools for SUD in general medical settings, with the objective of incorporation into US EHRs. METHODS Stakeholders were identified and queried for input and consensus on validated screening and assessment for SUD in general medical settings to develop common data elements to serve as shared resources for EHRs on screening, brief intervention and referral to treatment (SBIRT), with the intent of supporting interoperability and data exchange in a developing Nationwide Health Information Network. RESULTS Through consensus of input from stakeholders, a validated screening and brief assessment instrument, supported by Clinical Decision Support tools, was chosen to be used at out-patient general medical settings. CONCLUSIONS The creation and adoption of a core set of validated common data elements and the inclusion of such consensus-based data elements for general medical settings will enable the integration of SUD treatment within mainstream health care, and support the adoption and 'meaningful use' of the US Office of the National Coordinator for Health Information Technology (ONC)-certified EHRs, as well as CMS reimbursement.
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Affiliation(s)
- Udi E Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD 20892-9557, USA
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Tai B, Volkow ND. Treatment for substance use disorder: opportunities and challenges under the affordable care act. SOCIAL WORK IN PUBLIC HEALTH 2013; 28:165-74. [PMID: 23731411 PMCID: PMC4827339 DOI: 10.1080/19371918.2013.758975] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Addiction is a chronic brain disease with consequences that remain problematic years after discontinuation of use. Despite this, treatment models focus on acute interventions and are carved out from the main health care system. The Patient Protection and Affordable Care Act (2010) brings the opportunity to change the way substance use disorder (SUD) is treated in the United States. The treatment of SUD must adapt to a chronic care model offered in an integrated care system that screens for at-risk patients and includes services needed to prevent relapses. The partnering of the health care system with substance abuse treatment programs could dramatically expand the benefits of prevention and treatment of SUD. Expanding roles of health information technology and nonphysician workforces, such as social workers, are essential to the success of a chronic care model.
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Affiliation(s)
- Betty Tai
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD 20892, USA.
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Ghitza UE, Wu LT, Tai B. Integrating substance abuse care with community diabetes care: implications for research and clinical practice. Subst Abuse Rehabil 2013; 4:3-10. [PMID: 23378792 PMCID: PMC3558925 DOI: 10.2147/sar.s39982] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Cigarette smoking and alcohol use are prevalent among individuals with diabetes in the US, but little is known about screening and treatment for substance use disorders in the diabetic population. This commentary discusses the scope and clinical implications of the public health problem of coexisting substance use and diabetes, including suggestions for future research. Diabetes is the seventh leading cause of death in the US, and is associated with many severe health complications like cardiovascular disease, stroke, kidney damage, and limb amputations. There are an estimated 24 million adults in the US with type 2 diabetes. Approximately 20% of adults aged 18 years or older with diabetes report current cigarette smoking. The prevalence of current alcohol use in the diabetic population is estimated to be around 50%-60% in epidemiological surveys and treatment-seeking populations. Cigarette smoking is associated with an increased risk of type 2 diabetes in a dose-dependent manner and is an independent modifiable risk factor for development of type 2 diabetes. Diabetic patients with an alcohol or other drug use disorder show a higher rate of adverse health outcomes. For example, these patients experience more frequent and severe health complications as well as an increased risk of hospitalization, and require longer hospital stays. They are also less likely to seek routine care for diabetes or adhere to diabetes treatment than those without an alcohol or other drug use disorder. The Affordable Care Act of 2010 and the Mental Health Parity Act and Addiction Equity Act of 2008 provide opportunities for facilitating integration of preventive services and evidence-based treatments for substance use disorders with diabetes care in community-based medical settings. These laws also offer emerging areas for research.
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Affiliation(s)
- Udi E Ghitza
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Betty Tai
- Center for the Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, United States Department of Health and Human Services, Bethesda, MD, USA
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