Integrating intervention for substance use disorder in a healthcare setting: practice and outcomes in New York City STD clinics

Assessing the acceptability of implementing a Screening, Brief Intervention and Referral to Treatment for alcohol use among transgender women in Bangkok, Thailand: A mixed-method pre-implementation study using the Consolidated Framework for Implementation Research

BACKGROUND AND AIMS

Health inequities related to alcohol use exist for transgender individuals. While the Thailand Ministry of Public Health recently published a clinical guideline to implement a Screening, Brief Intervention and Referral to Treatment (SBIRT) in primary care, there has been no study regarding transgender women's (TGW) alcohol use and the acceptability of implementing SBIRT in a Thai context, a gap this study aimed to fill.

DESIGN

A mixed-method approach was used. In the first phase, TGW service users and health-care providers (HCPs) completed a survey on the acceptability of prospective implementation of SBIRT. TGW service users completed the Alcohol Use Disorder Identification Test-Consumption (AUDIT-C). In the second phase, TGW service users, HCPs, clinic administrators and national-level alcohol, HIV and transgender health policymakers participated in in-depth qualitative interviews.

SETTING

The Tangerine Clinic, a transgender-led sexual health clinic in Bangkok, Thailand.

PARTICIPANTS

In the first phase, TGW service users (n = 100) and HCP (n = 8) were surveyed. In the second phase, 22 stakeholders (n = 10 TGW service users; n = 8 HCP; n = 1 clinic administrator; n = 3 policymakers) were interviewed.

MEASUREMENTS

Simple proportions were calculated for each survey item. Differences in acceptability by various demographic factors were calculated using univariate analysis. The qualitative data were coded using thematic analysis and a deductive approach. The results were mapped to the Consolidated Framework for Implementation Research domains and constructs. The quantitative and qualitative results were triangulated to expand understanding.

FINDINGS

Fifty per cent of the TGW participants exhibited problematic drinking levels (AUDIT-C ≥ 4). Implementing SBIRT was highly acceptable, as more than 95% of participants reported agreeing or completely agreeing to receive SBIRT for alcohol use. Barriers, such as complexity, time constraint and lack of knowledge and skills, were anticipated. Adaptability, such as tailoring the content of brief intervention to suit TGW health needs and SBIRT to fit with existing clinic procedures, might facilitate successful implementation.

CONCLUSION

Screening, Brief Intervention and Referral to Treatment (SBIRT) for alcohol use has the potential to be successfully implemented in transgender-led sexual health clinic settings, with some adaptations to overcome anticipated barriers.

Communicable Disease Screening and Human Immunodeficiency Virus Prevention in the Emergency Department

Emergency departments (ED) provide care to populations with high rates of communicable diseases, like HIV, hepatitis C virus, and syphilis. For many patients, the ED is their sole entry point into the healthcare system and they do not routinely access screening and prevention services elsewhere. As such, the ED can serve an important public health role through communicable disease identification, treatment, and prevention. In this article, we examine national recommendations, peer-reviewed literature, and expert consensus to provide cutting edge strategies for implementing communicable infectious disease screening and prevention programs into routine ED care.

The Intersection of Substance Use Disorders and Infectious Diseases in the Emergency Department

Substance use disorders (SUDs) intersect clinically with many infectious diseases, leading to significant morbidity and mortality if either condition is inadequately treated. In this article, we will describe commonly seen SUDs in the emergency department (ED) as well as their associated infectious diseases, discuss social drivers of patient outcomes, and introduce novel ED-based interventions for co-occurring conditions. Clinicians should come away from this article with prescriptions for both antimicrobial medications and pharmacotherapy for SUDs, as well as an appreciation for social barriers, to care for these patients.

Perspectives on unhealthy alcohol use among men who have sex with men prescribed HIV pre-exposure prophylaxis: A qualitative study

Unhealthy alcohol use is a common, often unaddressed behavior associated with increased risk for acquisition of HIV and may also be associated with decreased adherence to oral pre-exposure prophylaxis (PrEP) among gay, bisexual, and other men who have sex with men (MSM) living in the United States. To inform future alcohol-reduction interventions among individuals engaging in PrEP care, we sought to explore perspectives on alcohol use, PrEP adherence, and the acceptability of alcohol use treatment options for MSM prescribed oral formulations of PrEP in the Northeastern United States. Between February 2019 and July 2020, we conducted semi-structured interviews with 15 MSM without HIV who were prescribed PrEP and screened positive for unhealthy alcohol use with AUDIT-C ≥ 4 and were receiving care in Providence, Rhode Island or New Haven, Connecticut. Interviews were coded and analyzed using thematic analysis. Three themes emerged: 1) Consequences of fluctuations in drinking 2) Alcohol use negatively impacts health and relationships; and 3) Desire for a multimodal approach to treatment of unhealthy alcohol use. Our findings support the need to raise awareness of potential alcohol-related harms, address the spectrum of unhealthy alcohol use among MSM prescribed PrEP, and the acceptability and preferences for alcohol reduction interventions within PrEP programs.

Characterizing HIV Syndemics and the Role of Incarceration Among Men Who have Sex with Men Presenting for Care at a Sexually Transmitted Infections Clinic

Men who have sex with men (MSM) with a history of incarceration experience unique risk factors for HIV acquisition. The current study examined unique risk factors for HIV among MSM with a history of incarceration presenting to a sexually transmitted infections (STI) clinic. We analyzed self-reported behavioral data from clinical encounters among patients attending the clinic between January 2012 and April 2021. There were 17,221 unique visits, of which 5988 were MSM. Of these, 4.34% (N = 206) were MSM with a history of incarceration. MSM with a history of incarceration were significantly more likely to report a range of behavioral risk factors for HIV, yet also were significantly less likely to perceive themselves at risk for HIV. Future research and practice should develop culturally tailored biobehavioral HIV prevention services and consider embedding these programs within criminal justice settings to better reach this at-risk group.

Using SBIRT (Screen, Brief Intervention, and Referral Treatment) Training to Reduce the Stigmatization of Substance Use Disorders Among Students and Practitioners

Negative attitudes and stigmatization of substance-using patients lead to treatment avoidance and poor physical and health outcomes. Research suggests that training in substance use disorders is a vital tool to abate negative attitudes among health workers. The present longitudinal study trained students and experienced practitioners from various disciplines on the evidence-based Screening, Brief Intervention, and Referral to Treatment (SBIRT) model. The study found significant improvements in the attitudes of students-but not practitioners-who were trained during the program. The paper discusses policy and implementation implications to support and complement sustained impact of training on models such as SBIRT.

Retrospective Cohort Study Examining the Correlates of Reported Lifetime Stimulant Use in Persons Diagnosed With Infectious Syphilis in Alberta, Canada, 2018 to 2019

BACKGROUND

We sought to examine the correlates for stimulant use in persons diagnosed with infectious syphilis during an outbreak in Alberta to help guide public health interventions.

METHODS

Infectious syphilis data were extracted from the Communicable Disease and Outbreak Management database from January 1, 2018, to December 31, 2019. Behavioral, demographic, and lifetime reported stimulant use data were obtained. Descriptive analyses and logistic regression were performed for 3 subpopulations (gay, bisexual, and other men who have sex with men; men who have sex with women; and women).

RESULTS

Of 3627 individuals diagnosed with infectious syphilis, 23.9% (n = 867) cases were not interviewed for substance use and were removed from further analysis. Of the remaining 2759 people, 41.8% (n = 1153) self-reported lifetime stimulant use. Gay, bisexual, and other men who have sex with men reported stimulant use less often than women (24.6% vs. 44.1%; P < 0.0001) and men who have sex with women (24.6% vs. 46.2%; P < 0.0001). Multivariable analyses demonstrated that stimulant use was associated with persons who injected drugs, had correctional involvement, or reported multiple sex partners. Men who have sex with women were more likely to self-report First Nations ethnicity (adjusted odds ratio, 1.76 [95% confidence interval, 1.25-2.49]), and women were more likely to have a concurrent gonorrhea infection (adjusted odds ratio, 1.62 [95% confidence interval, 1.15-2.28]).

CONCLUSIONS

Nearly half of infectious syphilis cases in Alberta reported lifetime nonprescription stimulant use. Infectious syphilis cases with stimulant use were associated with injection drug use, multiple sex partners, and correctional involvement. Our observations highlight the need for integration of sexual health services into programs for people who use substances and those in corrections custody.

US trends in binge drinking by gender, occupation, prestige, and work structure among adults in the midlife, 2006-2018

BACKGROUND

Rates of binge drinking have nearly doubled among US women ages 30-49 since 2006. Employment influences alcohol use and varies by the prestige and structure (e.g., authority, autonomy, expertise) of one's occupation.

METHODS

We examined trends in binge drinking among adults ages 30-49 in the labor force in 2006-2018 National Health Interview Surveys (N = 108,981) by occupation, work prestige (General Social Survey's occupational prestige score), work structure (occupational authority, autonomy, automation, expertise), and gender. We estimated odds of binge drinking by year with survey-weighted logistic regression controlled for sociodemographics, smoking, and disability.

RESULTS

In 2018, 30% of women and 43% of men reported binge drinking; drinking increased annually from 2006-2018 (OR for women = 1.08, OR for men = 1.03). Work status, prestige, and work structure modified the association. Women in high- (OR = 1.10, 95% CI: 1.09-1.12) versus low-prestige (OR = 1.05, 95% CI: 1.04-1.06) jobs had higher increases, as did men in high-prestige jobs (OR = 1.04, 95% CI: 1.03-1.05). Respondents in higher relative to lower authority, autonomy, and expertise jobs increased binge drinking.

CONCLUSIONS

Though all strata of workforce adults increased binge drinking, increases were concentrated among women in higher-status careers, implicating gendered shifts in labor as one determinant of recent national alcohol trends.

Bacterial sexually transmitted infection testing and diagnoses among men who have sex with men and report prescription opioid misuse--American Men's Internet Survey, 2017-2018

PURPOSE

Prescription opioid misuse is associated with behaviors which increase bacterial sexually transmitted diseases (STD) risk among men who have sex with men (MSM). Annual syphilis, gonorrhea, and chlamydia screening is recommended for sexually active MSM at anatomical sites of contact, regardless of condom use. We describe the prevalence of self-reported bacterial STD testing and diagnoses in the past 12 months among sexually active MSM who report prescription opioid misuse.

METHODS

We used data from the 2017 and 2018 American Men's Internet Survey to examine the prevalence of self-reported bacterial STD testing and diagnoses in the past 12 months. We calculated unadjusted prevalence ratios, adjusted prevalence ratios (APR), and 95% confidence intervals (CI) to compare bacterial STD testing prevalence across demographic, clinical, and behavioral factors.

RESULTS

Of 932 sexually active MSM who reported prescription opioid misuse, 433 (46.5%) self-reported bacterial STD testing in the past 12 months. Of those who reported being tested, 131 (30.2%) self-reported ≥ 1 bacterial STD. Approximately 50% of respondents who reported condomless anal sex (CAS), casual sex, or exchange sex reported bacterial STD testing in past 12 months. Factors associated with bacterial STD testing among MSM who misused prescription opioids included visiting a healthcare provider in the past 12 months (APR = 1.70, 95% CI = 1.09-2.67), ever disclosing same-sex behavior to a healthcare provider (APR = 1.78, 95% CI = 1.27-2.50), and CAS in the past 12 months (APR = 1.51, 95% CI = 1.10-2.04).

CONCLUSIONS

Prevalence of self-reported bacterial STD testing in this sample was low and one-third of tested MSM reported ≥ 1 bacterial STD in the past 12 months. Innovative approaches to identify MSM who misuse prescription opioids and expand bacterial STD testing in this population are needed.

The Reemergence of Syphilis: Clinical Pearls for Consideration

Despite the near-eradication of syphilis in the United States in the late 1990s, new infections have surged over the past 20 years. Dubbed, "the great imitator," syphilis infections often can be misdiagnosed and resultantly untreated. This leads to people inadvertently infecting others. This article reviews the history of syphilis, including the unethical studies undertaken in the past; current epidemiology; treatment guidelines; and strategies to reduce new infections.

Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Practice: A Quality Improvement Project in the Maryland Adolescent and Young Adult Health Collaborative Improvement and Innovation Network

The American Academy of Pediatrics recommends pediatric providers routinely screen for, assess, and treat substance use and substance use disorders among adolescents, a process called "Screening, Brief Intervention, and Referral to Treatment," or "SBIRT." Because there are limited data on how Maryland pediatric practices have adopted SBIRT, a quality improvement initiative was developed within the Maryland Adolescent and Young Adult Health Collaborative Improvement and Innovation Network using a "Plan/Do/Study/Act" approach. A 2-part provider training was conducted regarding screening and motivational interviewing, and the "CRAFFT" screening tool was integrated into the practice's electronic medical record. Results from evaluation demonstrated significant improvements in provider knowledge, attitudes, and screening behavior. The association between substance use and sexual behavior suggests a need for further expansion of this model with inclusion of sexual health screening. Overall, this study demonstrates that SBIRT implementation into a general pediatric practice is highly feasible, acceptable, and shows preliminary effectiveness.

Implementation and evaluation of SBIRT training in a Community Health nursing course

OBJECTIVE

The purpose of this paper is to report on the implementation and evaluation of a Screening, Brief Intervention and Referral to Treatment (SBIRT) educational program into an undergraduate nursing curriculum and to recommend modifications for future trainings.

DESIGN AND SAMPLE

A one-group pre-test/post-test design was used. The sample consisted of senior level undergraduate nursing students.

MEASURES

Core knowledge, perceived competency, and program satisfaction were measured. Process evaluation activities were performed to gather feedback on the training and solicit ideas and recommendations for improvement.

RESULTS

Of the 354 nursing students enrolled in the training, 249 (70%) participated in the research portion, with 240 (96%) completed the pre- and post-training evaluations. All four core knowledge components and 13 perceived competency indicators were statistically significant (p ≤ .001) when comparing pre- and post-t test values. Process evaluation data collected through 25 telephone interviews found that the training improved the students' confidence and ability to screen for substance misuse with patients.

CONCLUSION

Findings support the implementation of SBIRT training into an undergraduate nursing curriculum. Modifications for future training and research are proposed.

Association between trends in county-level opioid prescribing and reported rates of gonorrhea cases in the United States

PURPOSE

We investigated the association between county-level trends in opioid prescribing rates, a proxy for opioid misuse, and rates of reported gonorrhea (GC) among males in the United States.

METHODS

We used linear mixed-model regression analyses to evaluate the association between county-level trends in opioid prescribing rates and rates of reported GC among males during 2010-2015.

RESULTS

There was a positive association between trends in county-level opioid prescribing rates and rates of GC among males (β = 0.068, 95% confidence interval [CI] = 0.030, 0.105) during 2010-2015. However, the magnitude of this association decreased significantly over time in counties where opioid prescribing rates decreased (β = -0.018, 95% CI = -0.030, -0.006) and remained stable (β = -0.020, 95% CI = -0.038, -0.002) but was unchanged in counties where opioid prescribing rates increased (β = -0.029, 95% CI = -0.058, 0.001).

CONCLUSIONS

During 2010-2015, we found a positive association between increases in county-level opioid prescribing rates, a proxy for opioid misuse, and rates of reported GC among males especially in counties most affected by the opioid crisis. Integrating sexual health with opioid misuse interventions might be beneficial in addressing the GC burden in the United States.

Optimizing the impact of alcohol and drug screening and early intervention in a high-risk population receiving services in New York City sexual health clinics: A process and outcome evaluation of Project Renew

Unhealthy substance use is associated with increased rates of STDs, including HIV. Within three high-risk New York City (NYC) sexual health clinics between 2008 and 2012 (n = 146,657), 17% of patients screened positive for a current SUD but only 5.3% ever received prior treatment. The goal of Project Renew was to expand the reach of substance use early intervention services within and across sexual health clinics citywide and decrease substance use, poor mental health, and risky sexual behavior. To accomplish this goal, Screening, Brief Intervention, and Referral to Treatment (SBIRT), an evidence-based substance use early intervention model, was implemented in all eight NYC sexual health clinics February 2012-January 2015. Clinic patients were screened for substance misuse using the AUDIT/DAST-10, and those who screened positive were eligible for on-site brief intervention. Overall, 130,597 substance misuse screenings were conducted (66,989, or 51%, positive), and 17,474 on-site brief interventions and 1238 referrals were provided (not unique to individual patients). A 10% sample of 14,709 unique patients who screened positive were interviewed using a federal data collection tool at baseline and six months later to assess changes in substance use, sexual risk behaviors, mental health, and health status (n = 1328). At six-month follow-up, patients reported reduced substance use, less sexual activity, improved overall health, and fewer days of depression and anxiety compared to measures at baseline (p < 0.05). Based on positive results, Project Renew SBIRT services have been sustained, ensuring essential care which may help prevent acquisition of HIV/STDs among a large population of high-risk New Yorkers.

Pilot Studies Examining Feasibility of Substance Use Disorder Screening and Treatment Linkage at Urban Sexually Transmitted Disease Clinics

BACKGROUND

Sexually transmitted disease (STD) clinics provide critical public health services for screening and treatment of sexually transmitted infections throughout the United States. These settings serve high-risk populations, often on a walk-in basis, and may be promising venues for integrating substance use disorder (SUD) services.

METHODS

We report findings from 2 pilot studies conducted at Baltimore City Health Department's STD clinics. The screening study characterized rates of SUDs among STD clinic patients. Patients waiting for services completed a diagnostic interview mapping to Diagnostic and Statistical Manual of Mental Disorders, 5th Edition SUD criteria (n = 100). The Treatment Linkage Feasibility study examined the feasibility of linking STD clinic patients with opioid and/or cocaine use disorders to SUD treatment in the community (n = 21), using SUD-focused Patient Navigation services for 1 month after the STD clinic visit. Assessments were conducted at baseline and 1-month follow-up.

RESULTS

In the screening study, the majority of STD clinic patients met diagnostic criteria for alcohol and/or drug SUD (57%). Substance-specific SUD rates among patients were 35% for alcohol, 31% for cannabis, 11% for opioids, and 8% for stimulants (cocaine/amphetamines). In the Treatment Linkage Feasibility study, 57% (12/21) of participants attended at least 1 SUD service, and 38% (8/21) were actively enrolled in SUD treatment by 1-month follow-up. The sample reported significant reductions in past 30-day cocaine use from baseline to follow-up (P = 0.01).

CONCLUSIONS

SUD rates are high among STD clinic patients. STD clinics are viable settings for initiating SUD treatment linkage services. Larger-scale research on integrating SUD services in these settings is needed.

High Substance Use and HIV Risk Behavior Among Young Argentine Men Who Have Sex with Men

In the United States young men who have sex with men have higher rates of substance use, higher HIV incidence, and less frequent HIV testing than their heterosexual counterparts and older MSM. Less is known about comparable populations in Latin America. As part of an epidemiological study, MSM were recruited through Respondent Driven Sampling in the metropolitan area of Buenos Aires, Argentina and answered a computerized behavioral survey. From the total of 500 MSM enrolled, a sub-sample of 233 aged 18-25 was analyzed. The sample was concentrated among lower socioeconomic strata, and only 16% identified as gay. Nearly half reported male, female, and transvestite sexual partners. Reported substance use was widespread ranging from 61% for marijuana to 20% for pasta base (cocaine sulfate). Seventy percent of the sample had never been tested for HIV infection; 3% tested positive for HIV and 8% for syphilis during the study.

Utilization of outpatient medical care and substance use among rural stimulant users: Do the number of visits matter?

Rural substance users are less likely than their urban peers to use formal substance use treatment. It is therefore important to understand how the utilization of potentially more appealing care options, such as outpatient medical care (OMC), may affect substance use over time. This study sought to examine whether the number of OMC visits, after controlling for important covariates, was associated with days of alcohol, crack and powder cocaine, and methamphetamine use among a sample of rural stimulant users over a three year period. Data were collected from a natural history study of 710 stimulant users living in rural communities in Arkansas, Kentucky, and Ohio. Participants were adults, not in drug treatment, and reporting stimulant use in the last 30days. In terms of alcohol use, for participants with higher employment-related problems, having 3 or more OMC visits (relative to none) was associated with fewer days of alcohol use. The results for days of cocaine and methamphetamine use were mixed. However, we did find that for participants reporting at least one substance use treatment or mutual help care visit in the past 6-months, having 1-2 OMC visits (compared to none) was associated with fewer days of crack cocaine use. Regarding methamphetamine use, results showed that for participants without medical insurance, having 3 or more OMC visits (compared to none) was associated with significantly fewer days of methamphetamine use if they also reported greater than or equal to a high school education. The findings from this study may help us begin to understand some of the characteristics of rural drug users, who utilize OMCs, associated with reductions in substance use. These findings may help health care administrators better plan, coordinate, and allocate resources to rural OMCs to more effectively address substance use in this population.

Correlates of three-year outpatient medical care use among rural stimulant users

Outpatient medical care (OMC) settings are a care context in which effective management of unhealthy substance use can occur. However, no studies have documented rates of OMC use and characteristics of OMC use among rural substance users. This study sought to examine the rates and frequency of OMC use in a sample of rural drug users over a three-year period. We also explored characteristics of participants associated with use of OMCs over time. Data were collected from June 2005 to September 2007 from a natural history study of 710 stimulant users living in rural communities. Participants were adults, not in drug treatment, and reporting recent methamphetamine, crack cocaine or powder cocaine use. Between 34 and 39% of participants reported any use of an OMC over the three-year follow-up period, with a mean average number of visits ranging from one to two at each follow-up. Having medical insurance, reporting any use of substance use disorder-related care (including formal substance use treatment or mutual-help groups), and higher Addiction Severity Index (ASI) medical and psychiatric composite scores were associated with greater odds of any OMC use and higher frequency of OMC use over time. Being male and having higher ASI alcohol and drug composite scores were associated with lower odds of any OMC use and lower frequency of OMC use. Our findings support the importance of public health efforts to increase OMC use among male rural drug users and those with more severe drug and alcohol use, the important role(s) of Federally Qualified Health Centers and other OMCs in rural communities that serve those with low rates of health insurance, and the need for public health efforts to increase the use of OMCs among rural drug users not experiencing more severe medical or psychiatric health problems.

A Systematic Review of Interventions to Reduce Problematic Substance Use Among Transgender Individuals: A Call to Action

Persons who are transgender (i.e., individuals who are assigned one sex at birth, but who do not identify with that sex) are at elevated risk for developing problematic substance use. Recent studies indicate that transgender persons have high rates of alcohol use, illicit drug use, and nonmedical use of prescription drugs and evince more severe misuse of these substances compared with nontransgender individuals. Despite the high rates of substance use among transgender persons and the multiple conceptual and narrative recommendations for substance use treatments, there is a lack of consensus or awareness of empirically tested interventions and programs effective for this population. Thus, it is critical to examine current substance use interventions for transgender individuals to identify gaps in the field and to immediately put forth efforts to reduce problematic substance use. This systematic review is the first to attempt a comprehensive identification and synthesis of the available evidence on interventions for reducing problematic substance use among transgender persons. Reflective of the state of the field regarding transgender care for substance use, we found a deficiency of studies to include in this systematic review (n=2). Perhaps the most important conclusion of this review is that well-designed, theoretically informed culturally sensitive research focused on developing and rigorously testing interventions for substance use among transgender individuals is alarmingly scarce. This review discusses barriers to intervention design and synthesizes treatment recommendations for future work.