Investing in Certified Community Behavioral Health Centers to Fulfill Their Promise

Certified community behavioral health centers (CCBHCs) were established under section 223 of the Protecting Access to Medicare Act of 2014. CCBHCs had the goal of expanding access to care for people with behavioral health needs "regardless of ability to pay and place of residence." The authors used descriptive tables and a heat map to compare the geographic distribution of CCBHCs with county-level rates of mental illness, poverty, and population density. Regression models were employed to determine which county-level characteristics are most strongly associated with the establishment of a CCBHC. The authors found that population density is a stronger predictor of CCBHC presence than are rates of poverty or serious mental illness. Holding all other local characteristics constant, the authors observed that going from the population density typical of the most rural counties to that of the most urban counties was associated with an approximately 28-percentage-point increase (from 7% to 35%) in the likelihood of being served by a CCBHC. Expanding CCBHC services to areas with lower population densities likely requires an approach that is different from the current method of allocation of grant funds by the Substance Abuse and Mental Health Services Administration (SAMHSA). Two features of the program might be modified. The first would build on flexibilities incorporated into the most recent round of SAMHSA grantmaking, which explicitly aim to build infrastructure and capacity to develop a CCBHC. A second modification might seek to identify which certification requirements are essential to supporting CCBHC quality and access and eliminate nonessential requirements.

Changes in State Laws Related to Coverage for Substance Use Disorder Treatment Across Insurance Sectors, 2006-2020

OBJECTIVE

The authors assessed changes in state insurance laws related to coverage for substance use disorder treatment across public and private insurance sectors from 2006 through 2020 in all 50 U.S. states.

METHODS

Structured policy surveillance methods, including a coding protocol with duplicate coding and quality controls, were used to track changes in state laws during the 2006-2020 period. The legal database Westlaw was used to identify relevant statutes within each state's commercial insurance (large group, small group, and individual), state employee health benefits, and Medicaid codes. The legal coding instrument included six questions across four themes: parity, mandated coverage, definition of substance use disorders, and enforcement and compliance. Scores were calculated to reflect the comprehensiveness of states' laws and to interpret changes in scores over time.

RESULTS

Comprehensiveness scores across all sectors (on a 0-9 scale) increased, on average, from 1.47 in 2006 to 2.84 in 2020. In 2006, mean scores ranged from 0.47 (state employee sector) to 2.80 (large-group sector) and in 2020, from 1.22 (state employee) to 4.26 (large group).

CONCLUSIONS

Comprehensiveness of state insurance laws in relation to substance use disorder treatment improved across all insurance sectors in 2006-2020. The State Substance Use Disorder Insurance Laws Database created in this study will aid future legal epidemiology studies in assessing the cumulative effects of parity-related insurance laws on outcomes of substance use disorder treatments.

Peer Support Services in Behavioral Health Facilities: Secondary Analysis From Two National Surveys

OBJECTIVE

Peer support providers are part of the behavioral health workforce. Research indicates that peer support helps care recipients achieve recovery and engage with behavioral health services. This article investigated how many U.S. behavioral health facilities offer peer support services and compared the frequencies of peer support services in facilities providing mental health and substance use services.

METHODS

The authors conducted a secondary analysis of facilities in the Substance Abuse and Mental Health Services Administration's National Mental Health Services Survey (N=11,582) and the National Survey of Substance Abuse Treatment Services (N=13,585), including descriptive and comparative analyses on reported mental health and substance use treatment services in the 50 U.S. states in 2017.

RESULTS

The findings revealed state-to-state variation in the number and availability of mental health and substance use service facilities and in facilities that reported providing peer support services. Facilities providing substance use treatment services offered peer support services at more than twice the rate (56.6%) found in mental health facilities (24.7%). The authors also identified program characteristics associated with the inclusion of peer support services in behavioral health. Provision of peer support services was more frequently reported by public facilities than by for-profit and nonprofit facilities.

CONCLUSIONS

Behavioral health facilities that serve individuals with serious mental illness and co-occurring substance use and mental health conditions reported offering peer support at a higher rate than did other facilities. Inconsistent definitions of peer support in the two surveys limited the comparability of the findings between the two reports.

Transitions in Prescription Benzodiazepine Use and Misuse and in Substance Use Disorder Symptoms Through Age 50

OBJECTIVE

Prescription benzodiazepines are among the most commonly used and misused controlled medications. The authors aimed to examine transitions from medical use of prescription benzodiazepines to prescription benzodiazepine misuse, prescription opioid misuse, and substance use disorder symptoms during adulthood.

METHODS

Eleven national cohorts of U.S. 12th graders (N=26,575) were followed up from ages 18 (1976-1986) to 50 (2008-2018). Prescription benzodiazepine misuse, prescription opioid misuse, and substance use disorder symptoms were examined with prevalence estimates and multivariable logistic regression.

RESULTS

By age 35, 70.9% of respondents had not used or misused prescription benzodiazepines, 11.3% reported medical use only, 9.8% indicated both medical use and misuse, and 14.1% reported misuse only. In analyses adjusted for demographic and other characteristics, adults reporting only medical use of prescription benzodiazepines by age 35 had higher odds of later prescription benzodiazepine misuse (adjusted OR [AOR]=2.17, 95% CI=1.72-2.75) and prescription opioid misuse (AOR=1.40, 95% CI=1.05-1.86) than respondents ages 35-50 who never used prescription benzodiazepines. More frequent medical use of prescription benzodiazepines by age 35 was associated with increased risk for substance use disorder symptoms at ages 40-50. Any history of prescription benzodiazepine misuse by age 35 was associated with higher odds of later prescription benzodiazepine misuse, prescription opioid misuse, and substance use disorder symptoms, compared with no misuse.

CONCLUSIONS

Prescription benzodiazepine use or misuse may signal later prescription drug misuse or substance use disorders. Medical use of prescription benzodiazepines by age 35 requires monitoring for prescription drug misuse, and any prescription benzodiazepine misuse warrants an assessment for substance use disorder.

Are problem buying and problem gambling addictive, impulsive, or compulsive in nature? A network analysis and latent dimension analysis study in Italian community-dwelling adults

Prominent scholars suggested that the impulsive-obsessive compulsive continuum may represent a framework to understand both substance and behavioral addictions. However, the characterization of pathological buying (PB) and problem gambling (PG) within the compulsive-impulsive spectrum has not been extensively investigated. To explore the relationships among PB, PG, alcohol and substance abuse, DSM-5 obsessive-compulsive and related disorders, and impulsive dimensions, a sample of 1,005 Italian community-dwelling adult participants (55.5% female), was administered self-reported measures of PB, PG, and other theoretically-relevant constructs. We expected to observe a multidimensional structure in our data; moreover, DSM-5 obsessive compulsive and related disorders were hypothesized to be accounted for by a common dimension. Three dimensions were identified and replicated across two different, non-redundant methods (i.e., exploratory graph analysis and exploratory factor analysis), namely, substance use and gambling, obsessive and compulsive phenomena, and impulsivity dimensions. Specifically, PG seemed to represent a behavioral variant of addiction vulnerability, PB seemed more akin to obsessive-compulsive spectrum disorders, and disinhibition dimension represented the common core of negative urgency, lack of premeditation, lack of perseverance, sensation seeking (SS), and positive urgency. Our findings may be helpful in improving our knowledge on the similarities and differences between PB and PG.

Peer Health Navigation Experiences Before and After Prison Release Among People With Opioid Use Disorder

OBJECTIVE

Recently incarcerated people with opioid use disorder are at high risk of overdose and adverse outcomes as a result of biopsychosocial risk factors. Peer support models aiming to improve these outcomes have expanded in recent years. This qualitative study aimed to document participants' experiences with peer health navigation before and after prison release, examine participants' perspectives on the role of peer health navigators, and understand participants' views on service improvements.

METHODS

The authors conducted in-depth, semistructured interviews with 39 recipients of peer health navigation at release, 30 of whom also completed a follow-up interview 3 months later. Interviews were analyzed via cross-case analysis.

RESULTS

Interviewees differently valued the various types of support they received. Participants appreciated working with someone with shared lived experience with whom they could establish a trusting relationship. Nevertheless, structural and policy barriers meant that certain key needs-such as housing and employment-could not always be met.

CONCLUSIONS

Peer health navigators can connect participants to evidence-based treatment and help them address their psychosocial needs and develop skills to support long-term wellness. Further research is needed to assess the impact of peer health navigation on participant outcomes, such as overdose reduction, treatment engagement, and sustained recovery.

Health Diagnoses and Service Utilization in the Year Before Youth and Young Adult Suicide

OBJECTIVE

Suicide rates among young people are rising. Health care visits provide opportunities for identification and intervention, yet studies have been limited by small or circumscribed samples. This study sought to expand the knowledge base by examining health care encounters and diagnoses among young people who later died by suicide.

METHODS

This case-control study examined diagnoses of mental and general medical disorders and health care utilization in the 30 and 365 days before suicide death in nine large U.S. health care systems. Data (years 2000-2015) from 445 suicide decedents ages 10-24 years were matched with data from 4,450 control group patients.

RESULTS

Suicide decedents were more likely to have at least one mental disorder diagnosis (51% vs. 16%; adjusted OR [AOR]=5.74, 95% CI=4.60-7.18) and had higher rates of nearly all mental health conditions. Substance use disorders were common (12%) and more likely (AOR=8.50, 95% CI=5.53-13.06) among suicide decedents. More than one in three (42%) suicide decedents had a health care visit in the month before death, and nearly all (88%) had a visit in the previous year.

CONCLUSIONS

Despite the greater likelihood of suicide associated with mental disorder diagnoses, such disorders were present among only 51% of suicide decedents. High rates of health care utilization among suicide decedents indicate a need for improving identification of mental health conditions and suicide risk across the health care system. Increased substance use screening may help identify youths at high risk because substance use disorders were significantly more prevalent and likely among suicide decedents.

Trends in Alcohol Use Disorder Treatment Utilization and Setting From 2008 to 2017

OBJECTIVE

Little is known about recent trends in treatment for alcohol use disorder. The authors used national data to examine treatment trends among individuals with alcohol use disorder.

METHODS

A sample of nonelderly adults (ages 18-64 years, N=36,707) with alcohol use disorder was identified from the National Survey on Drug Use and Health. Multinomial logistic regression analysis was conducted to examine trends in treatment for alcohol use disorder in 2008-2010, 2011-2013, and 2014-2017 in any medical setting (hospitals, rehabilitation centers, mental health centers, emergency departments, and private doctors' offices), self-help groups only (no medical setting), and no setting (i.e., no treatment). Additional analyses investigated trends in mental health treatment. Regression models adjusted for predisposing, enabling, and need-related characteristics.

RESULTS

Among those with an alcohol use disorder, the percentage who received any treatment was significantly lower in 2011-2013 (5.6%) than in 2008-2010 (6.9%) (p<0.05). In adjusted analyses, the probability of receiving no treatment increased by 1.5 percentage points in 2014-2017 (95% CI=0.5-2.5) compared with the 2008-2010 baseline. Significant declines were observed in the receipt of any treatment in a medical setting (marginal effect [ME]=-1.0%, 95% CI=-2.0 to -0.0) and self-help treatment only (ME=-0.5%, 95% CI=-0.8 to -0.1) in 2014-2017 compared with the baseline period. The probability of receiving any mental health treatment did not change during the study period.

CONCLUSIONS

Among persons with an alcohol use disorder, treatment declined from 2008 to 2017. Future studies should examine the mechanisms that may be responsible for this decline.

Housing Outcomes of Adults Who Were Homeless at Admission to Substance Use Disorder Treatment Programs Nationwide

OBJECTIVE

Substance use disorders affect 30%-50% of single homeless adults, and specialized homelessness service programs enable homeless persons to exit homelessness at rates of about 80%. However, many such adults are treated in substance use disorder treatment programs. This study examined housing outcomes in these programs.

METHODS

Data from the Treatment Episode Data Set: Discharges database were used to examine housing status at discharge from substance use disorder treatment programs of adults who were homeless at admission. Associations of outcomes with sociodemographic characteristics, treatment programs and processes, and clinical variables were further evaluated with bivariate and multivariate logistic regressions. Odds ratios of ≥1.5 or ≤0.67 were considered meaningful.

RESULTS

Of 1,200,105 persons admitted to the programs, 192,838 (16.1%) were homeless at admission; 68.7% remained homeless at discharge, 16.3% were discharged to dependent housing, and only 15.0% were discharged to independent housing. Factors associated with remaining homeless included being age ≥55 years, being unemployed, admission for detoxification (vs. rehabilitation or residential treatment or ambulatory treatment), shorter stays, and program noncompletion. Factors associated with discharge to independent versus dependent housing included employment, admission to nonintensive outpatient treatment, and, unexpectedly, shorter stays.

CONCLUSIONS

Most adults experiencing homelessness at admission to substance use disorder treatment programs remained homeless at discharge, and only half of those no longer homeless were independently housed. These outcomes are considerably worse than outcomes typically reported by specialized homelessness service programs. Evidence-based service models that support exit from homelessness could be provided through augmented internal programming or links with specialized programs.

Addiction Treatment and Telehealth: Review of Efficacy and Provider Insights During the COVID-19 Pandemic

OBJECTIVE

Addiction treatment via telehealth expanded to unprecedented levels during the COVID-19 pandemic. This study aimed to clarify whether the research evidence on the efficacy of telehealth-delivered substance use disorder treatment and the experience of providers using telehealth during the pandemic support continued use of telehealth after the pandemic and, if so, under what circumstances.

METHODS

Data sources included a literature review on the efficacy of telehealth for substance use disorder treatment, responses to a 2020 online survey from 100 California addiction treatment providers, and interviews with 30 California treatment providers and other stakeholders.

RESULTS

Eight published studies were identified that compared addiction treatment via telehealth with in-person treatment. Seven found telehealth treatment as effective but not more effective than in-person treatment in terms of retention, therapeutic alliance, and substance use. One Canadian study found that telehealth facilitated methadone prescribing and improved retention. In the survey results reported here, California addiction treatment providers said that more than 50% of their patients were being treated via telehealth for intensive outpatient treatment, individual counseling, group counseling, and intake assessment. They were most confident that individual counseling via telehealth was as effective as in-person individual counseling and less sure about the relative effectiveness of telehealth-delivered medication management, group counseling, and intake assessments.

CONCLUSIONS

Telehealth may help engage patients in addiction treatment by improving access and convenience. Additional research is needed to confirm that benefit and to determine how best to tailor telehealth to each patient's circumstances and with what mix of in-person and telehealth services.

Well-Being of Health Care Professionals Treating Opioid Use Disorder During the COVID-19 Pandemic: Results From a National Survey

OBJECTIVE

The COVID-19 pandemic has dramatically affected health care delivery, effects that are juxtaposed with health care professional (HCP) burnout and mental distress. The Opioid Use Disorder Provider COVID-19 Survey was conducted to better understand the impact of COVID-19 on clinical practice and HCP well-being.

METHODS

The cross-sectional survey was e-mailed to listservs with approximately 157,000 subscribers of diverse professions between July 14 and August 15, 2020. Two dependent variables evaluated HCP functioning and work-life balance. Independent variables assessed organizational practices and HCP experiences. Covariates included participant demographic characteristics, addiction board certification, and practice setting. Multilevel multivariate logistic regression models were used.

RESULTS

Among 812 survey respondents, most were men, White, and physicians, with 46% located in urban settings. Function-impairing anxiety was reported by 17%, and 28% reported more difficulty with work-life balance. Difficulty with functioning was positively associated with having staff who were sick with COVID-19 and feeling close to patients, and was negatively associated with being male and having no staff changes. Difficulty with work-life balance was positively associated with addiction board certification; working in multiple settings; having layoffs, furloughs, or reduced hours; staff illness with COVID-19; and group well-being check-ins. It was negatively associated with male gender, older age, and no staff changes.

CONCLUSIONS

Demographic, provider, and organizational-practice variables were associated with reporting negative measures of well-being during the COVID-19 pandemic. These results should inform HCPs and their organizations on factors that may lead to burnout, with particular focus on gender and age-related concerns and the role of well-being check-ins.

Use of Electronic Health Information Technology in a National Sample of Hospitals That Provide Specialty Substance Use Care

OBJECTIVE

Most U.S. acute care hospitals have adopted basic electronic health record (EHR) functionality and health information exchange (HIE) (84% and 88%, respectively, in 2017). This study examined whether rates of EHR and HIE adoption by hospital-based substance use disorder programs are lower than rates by acute care hospitals.

METHODS

Data from the 2017 National Survey on Substance Abuse Treatment Services were analyzed to examine adoption of basic EHR functionality (i.e., assessment, progress monitoring, discharge, labs, and prescription dispensing) and use of HIE by hospital-based programs. Analyses used weighted multivariable models of EHR and HIE outcomes, adjusted for nonresponse.

RESULTS

Of 894 hospital-based substance use disorder programs with EHR information, two-thirds (N=606, 68%) reported use of basic EHR functionality. Psychiatric hospitals were less likely than acute care hospitals to have adopted EHR (odds ratio [OR]=0.49, 95% confidence interval [CI]=0.35-0.71). Compared with nonprofit hospitals, for-profit (OR=0.23, 95% CI=0.16-0.35) and government-owned (OR=0.52, 95% CI=0.33-0.83) hospitals were less likely to use basic EHR functionality. Hospital-based programs providing medications for alcohol or opioid use disorders were more likely than those not providing such medications to use basic EHR (OR=1.95, 95% CI=1.31-2.90). Of 839 hospitals with information on HIE use, 598 (71%) reported using electronic HIE. Adoption of basic EHR functionality was the strongest predictor of HIE use (OR=4.73, 95% CI=3.29-6.79).

CONCLUSIONS

Hospital-based substance use disorder programs trail behind U.S. acute care hospitals in adoption of basic EHR and electronic HIE. Findings raise concerns about missed opportunities to improve hospital-based substance use disorder care quality and performance measurement.

North Carolina Specialty Courts, Treatment Access, and the Substance Use Crisis: A Promising but Underfunded Model

Treatment courts aim to reduce criminal recidivism by addressing the behavioral health care needs of persons with psychiatric or substance use disorders that contribute to their offending. Stable funding and access to behavioral health providers are crucial elements of success for the treatment court model. What happens when courts lose state funding and must rely on local initiatives and resources? In this study, a survey of North Carolina treatment court professionals identified resource gaps and unmet needs. The authors argue that continuing state investment could make treatment courts more viable and effective. Medicaid expansion is a potential new resource for these problem-solving courts.

HIV Testing and Counseling at U.S. Substance Use Treatment Facilities: A Missed Opportunity for Early Identification

OBJECTIVE

The objective of this study was to determine the availability and national distribution of HIV testing and counseling at substance use treatment facilities in the United States.

METHODS

Analyses of data from the 2018 National Survey of Substance Abuse Treatment Services assessed HIV testing and counseling availability in U.S. substance use treatment facilities (excluding those in U.S. territories). Facilities were subcategorized by availability of mental health services and medication for opioid use disorders and compared by using logistic models. Descriptive statistics were calculated to characterize the availability of HIV testing and counseling by state, state HIV incidence, and facility characteristics.

RESULTS

Among U.S. substance use treatment facilities (N=14,691), 29% offered HIV testing, 53% offered HIV counseling, 23% offered both, and 41% offered neither. Across states, the proportions of facilities offering HIV testing ranged from 9.0% to 62.8%, and the proportion offering counseling ranged from 19.2% to 83.3%. In only three states was HIV testing offered by at least 50% of facilities. HIV testing was significantly more likely to be offered in facilities that offered medication for opioid use disorder (48.0% versus 16.0% in those not offering such medication) or mental health services (31.2% versus 24.1% in those not offering such services). Higher state-level HIV incidence was related to an increased proportion of facilities offering HIV testing.

CONCLUSIONS

Only three in 10 substance use treatment facilities offered HIV testing in 2018. This finding represents a missed opportunity for early identification of HIV among people receiving treatment for substance use disorders.

Identification and Treatment of Addiction in Medicaid Health Homes

OBJECTIVE

Coordinated care models, such as the Medicaid health home, may be well positioned to identify and address addiction, yet little is known about the strategies health home plans use to identify and treat this condition. This study examined state requirements of active Medicaid health home plans.

METHODS

Content analyses of all 35 active Medicaid health home plans were conducted to identify state requirements related to enrollment eligibility; provision of addiction screening, treatment, and prevention services; inclusion of addiction treatment professionals within the health home provider care team; and outcomes monitoring.

RESULTS

Apart from health homes specifically focused on addiction, few states require health home plans to screen (44% of primary care-based and 33% of psychiatric health homes), treat (0% and 13%, respectively), and monitor treatment services for addiction (25% and 13%, respectively).

CONCLUSIONS

Limited screening and treatment of addiction within health homes may limit the model's effectiveness in improving overall health.

Effects of the ACA on Health Care Coverage for Adults With Substance Use Disorders

OBJECTIVE

The authors assessed changes in health care coverage in nationally representative samples of low- and middle-income adults with and without substance use disorders following the 2014 Affordable Care Act marketplace launch and Medicaid expansion.

METHODS

Data from the 2012-2018 (N=407,985) National Survey on Drug Use and Health identified low- and middle-income nonelderly adults with alcohol, marijuana, cocaine, or heroin use disorders. A sociodemographically adjusted difference-in-differences analysis assessed the trends in Medicaid and individually purchased private insurance between adults with and without substance use disorders.

RESULTS

Between 2012-2013 and 2015-2016, the percentages without health insurance significantly declined for adults with substance use disorders (from 27.8% to 18.7%) and for those without these disorders (from 22.6% to 14.6%). These trends were related to gains in Medicaid and in individually purchased private insurance but not to gains in employer-based private insurance coverage. Between 2015-2016 and 2017-2018, however, the percentages without health insurance among adults with substance use disorders (18.7% to 18.4%) and without these disorders (14.7% to 14.7%) was little changed.

CONCLUSIONS

With insurance gains having stalled and the downturn of the U.S. economy, there is renewed urgency to extend health care coverage to middle- and low-income adults with substance use disorders that meets their substance use and general health needs.

Addiction Medicine Practice-Based Research Network (AMNet): Building Partnerships

This column describes the collaboration among the American Psychiatric Association (APA), American Society of Addiction Medicine, Friends Research Institute, and the National Institute on Drug Abuse to create the Addiction Medicine Practice-Based Research Network (AMNet). The collaboration, which aims to address the opioid overdose epidemic in the United States, leverages the APA's clinical data registry (PsychPRO) and is recruiting office-based addiction medicine and addiction psychiatry practices for AMNet. AMNet aims to address knowledge gaps regarding patient care in such practices, facilitate performance improvement efforts, and serve as a research platform.

Health Care Utilization Due to Substance Abuse Among Homeless and Nonhomeless Children and Young Adults in New York

OBJECTIVE

Substance abuse, particularly among homeless youths, is a significant public health challenge in the United States. Detailed data about health care utilization resulting from this preventable behavior remain sparse. This study aimed to compare health care utilization rates related to substance abuse among homeless and nonhomeless youths.

METHODS

A secondary data analysis evaluated records of homeless and nonhomeless patients under age 25 with a primary diagnosis of substance abuse, identified in 2013 and 2014 New York Statewide Inpatient and Emergency Department (ED) Databases. Outcomes included ED visit rate, hospitalization rate, in-hospital mortality, cost, length of stay (LOS), intensive care unit (ICU) utilization, and revisit or readmission rate. Multivariable regression models with a year fixed effect and facility random effect were used to evaluate the association between homelessness and each outcome.

RESULTS

A total of 68,867 cases included hospitalization or an ED visit related to substance abuse (68,118 nonhomeless and 749 homeless cases). Rates of ED visits related to substance abuse were 9.38 and 4.96, while rates of hospitalizations related to substance abuse were 10.53 and 1.01 per 1,000 homeless and nonhomeless youths, respectively. Homeless patients were more likely to utilize and revisit the ICU, be hospitalized or readmitted, incur higher costs, and have longer LOS than nonhomeless youths (all p<0.01).

CONCLUSIONS

The hospitalization and ED visit rates related to substance abuse were 10 and two times higher among homeless youths compared with nonhomeless youths, respectively. Detailed observation is needed to clarify whether homeless youths receive high-quality care for substance abuse when necessary.

Gambling, Family Dysfunction and Psychological Disorders: A Cross- Sectional Study

The present study aimed to identify predictors and effects of problem gambling and examine the moderating role of family dysfunction between problem gambling and its effects. A sample of 104 gamblers (all were men, Mean = 26.2, SD = 6.8), was recruited from gambling venues in an urban area of Musanze district, Northern Province of Rwanda. Participants were aged above the legal age of 16 years. Data were collected using the Problem Gambling Severity Index (PGSI), the Brief Michigan Alcoholism Screening Test (Brief MAST), Drug Abuse Screening Test (DAST-10), the Psychopathy Checklist-Revised (PCL-R), the Big Five Inventory (BFI), the Insomnia Severity Index (ISI) and the Family Dysfunction Test. SPSS (version22) was used to carry out all statistical analyses. Results showed that personality traits predicted problem gambling. Additionally, problem gambling was associated with alcohol use, drug abuse, sleep deprivation, antisocial tendency and family dysfunction. Family dysfunction moderated the effects of problem gambling on drug abuse, alcohol use and sleep deprivation. Gambling is a complex but assessable phenomenon and future studies may explore further its correlates.

Addiction Treatment Capacity in Health Centers: The Role of Medicaid Reimbursement and Targeted Grant Funding

OBJECTIVE

Expanding access to addiction screening and treatment in primary care, particularly in underserved communities, is a key part of the fight against the opioid epidemic. This study explored correlates of addiction treatment capacity in federally qualified health centers participating in the Midwest Clinicians' Network (MWCN).

METHODS

Two surveys were fielded to 132 MWCN health centers: the Health Center Survey and the Behavioral Health and Diabetes Provider Survey. A total of 77 centers and 515 primary care clinicians, respectively, responded to the surveys. Data were combined with data from the 2016 Uniform Data System and information about receipt of targeted Health Resources and Services Administration (HRSA) grant funding for addiction treatment capacity. Multivariable models examined associations between Medicaid reimbursement for addiction services, HRSA targeted grant funding, and different types of on-site addiction treatment capacity: psychiatrist and certified addiction counselor staffing, addiction counseling services, and medication-assisted treatment (MAT) for opioid addiction.

RESULTS

Health centers that received Medicaid behavioral health reimbursement were five times as likely as those that did not to offer addiction counseling and to employ certified addiction counselors. Health centers that received targeted HRSA funding for addiction services were more than 20 times as likely as those that did not to provide MAT and more than three times as likely to employ psychiatrists. Training needs and privacy protections on data related to addiction treatment were cited as barriers to building addiction treatment capacity.

CONCLUSIONS

Medicaid funding and targeted grant funding were associated with addiction treatment capacity in health centers.

Acute alcohol intoxication as a confounding factor for mild traumatic brain injury

BACKGROUND

Acute alcohol intoxication is universally considered a risk factor for traumatic brain injury (TBI), therefore an indication for head CT scan. There is no evidence in the literature for this attitude. Aim of this study is to assess the need for head CT scan in acutely alcohol-intoxicated subjects with mTBI and the role of Glasgow coma scale (GCS) score in this kind of patients.

METHODS

We retrospectively analyzed all 3358 consecutive patients presenting to our department in Switzerland, with TBI as chief complaint between January 2014 and January 2018.

RESULTS

Alcohol was a statistically significant factor for presentation with a GCS score lower than 15. As for bleedings in mild TBI patients, the results were somewhat contradictory with GCS 15 patients showing a higher percentage of hemorrhages than GCS 14 patients. By dividing alcohol-intoxicated subjects into groups per blood alcohol concentration, the higher was the alcohol level, the lower the GCS score.

CONCLUSIONS

We can affirm that GCS score is underestimated in acutely intoxicated head trauma patients. In this kind of patient, alcohol is a confounding factor and mild TBI could be safely managed by watchful waiting.

Stress, Coping, and Context: Examining Substance Use Among LGBTQ Young Adults With Probable Substance Use Disorders

OBJECTIVE

The authors qualitatively examined how lesbian, gay, bisexual, transgender, and queer (LGBTQ) young adults with probable substance use disorders conceptualized their substance use vis-à-vis their LGBTQ identities.

METHODS

Individual, in-depth, semistructured interviews were conducted with 59 LGBTQ young adults (ages 21-34) who were participants in a larger longitudinal cohort study and who met criteria for a probable substance use disorder. Data were analyzed via iterative, thematic analytic processes.

RESULTS

Participants' narratives highlighted processes related to minority stress that shape substance use, including proximal LGBTQ stressors (e.g., self-stigma and expectations of rejection) and distal LGBTQ stressors (e.g., interpersonal and structural discrimination) and associated coping. Participants also described sociocultural influences, including the ubiquitous availability of substances within LGBTQ social settings, as salient contributors to their substance use and development of substance use disorders. Participants who considered themselves transgender or other gender minorities, all of whom identified as sexual minorities, described unique stressors and coping at the intersection of their minority identities (e.g., coping with two identity development and disclosure periods), which shaped their substance use over time.

CONCLUSIONS

Multilevel minority stressors and associated coping via substance use in adolescence and young adulthood, coupled with LGBTQ-specific sociocultural influences, contribute to the development of substance use disorders among some LGBTQ young adults. Treatment providers should address clients' substance use vis-à-vis their LGBTQ identities and experiences with related stressors and sociocultural contexts and adopt culturally humble and LGBTQ-affirming treatment approaches. Efforts to support LGBTQ youths and young adults should focus on identifying ways of socializing outside of substance-saturated environments.

Neonatal Abstinence Syndrome and Childhood Mental Health Conditions, 2009-2015: Commercial Versus Medicaid Populations

OBJECTIVE

This study aimed to examine mental health conditions of children diagnosed with neonatal abstinence syndrome (NAS) in a commercially insured population and compare them with a multistate Medicaid-insured population identified in prior research.

METHODS

Data from the IBM MarketScan Commercial Database from January 1, 2009, to September 30, 2015, were used to identify mental health conditions among children ages 1-5 both with and without NAS. Frequency analyses were conducted to ascertain intrapopulation differences and differences between the commercially insured and Medicaid populations.

RESULTS

The NAS rate in the Medicaid population was 28.7 times higher than in the commercially insured population. Although the sample of children with NAS was small, and the results must be interpreted with caution, elevated rates of childhood mental health conditions observed in the commercially insured population were comparable to the Medicaid population.

CONCLUSIONS

This analysis emphasizes the difference in rates of NAS between commercially insured and Medicaid populations.

Engagement With Project ECHO to Increase Medication-Assisted Treatment in Rural Primary Care

OBJECTIVE

The purpose of this study was to understand the barriers and facilitators that affect engagement with Project ECHO (Extension for Community Healthcare Outcomes) to implement medication-assisted treatment (MAT) in primary care settings.

METHODS

A 12-session weekly curriculum was delivered to participating primary care providers and clinic staff (N=24 participants from 13 clinics). Participants completed attendance logs and a qualitative interview in order to identify factors that influence engagement in the ECHO sessions and the potential integration of MAT.

RESULTS

Primary care providers and staff valued the ECHO sessions, but overall attendance was low and variable. Participants generally valued the didactic and interactive nature of the sessions but identified system-level constraints that limited engagement. Major barriers to participation included competing demands in patient care and the low degree of endorsement by clinic leadership.

CONCLUSIONS

This brief report identifies key systematic challenges that may directly limit primary care providers' engagement in telementoring models such as Project ECHO.

The Opioid Epidemic and Psychiatry: The Time for Action Is Now

The number of people with opioid use disorder and the number of overdose deaths in the United States have increased dramatically over the past 20 years. U.S. Congress passed the SUPPORT for Patients and Communities Act, which was signed into law in 2018, authorizing almost $8 billion to address the crisis. As experts in the treatment of central nervous systems disorders, psychiatrists can play a leading role in expanding treatment for people with opioid use disorder and in advocating for policy changes to support community treatment for this group.

Perspectives and Practice in the Identification and Treatment of Opioid Use, Alcohol Use, and Depressive Disorders

OBJECTIVE

Little research has focused on the treatment of adults with substance use disorders in primary care despite the high occurrence, morbidity, and mortality associated with these disorders.

METHODS

An electronic survey was administered to primary care providers in a large health system to assess screening and treatment practices and comfort managing opioid use, alcohol use, and depressive disorders. A total of 146 providers completed the survey (32%).

RESULTS

Providers were significantly less likely to screen for or treat opioid use disorders and alcohol use disorders, compared with depression. Providers reported feeling significantly less confident, less prepared, less expected to treat, less sure of the appropriateness of treating, and less able to navigate community resources in the treatment of opioid and alcohol use disorders, compared with depression.

CONCLUSIONS

Given the preponderance of substance use disorders in primary care, increased attention to equipping primary care providers to treat these conditions is warranted.

Mental Health Treatment and Unmet Mental Health Care Need Among Pregnant Women With Major Depressive Episode in the United States

OBJECTIVE

Perinatal mental health is a major public health issue in the United States. Yet, much is unknown about unmet mental health care need among pregnant women with a major depressive episode and the reasons for unmet need.

METHODS

Using a nationally representative data set, the study examined mental health treatment utilization, unmet mental health care need, and the reasons for unmet mental health care needs among pregnant women with a major depressive episode compared with nonpregnant women with a major depressive episode (weighted N=128,000).

RESULTS

Of pregnant women who had experienced a major depressive episode, 49% reported receiving any mental health treatment, compared with 57% of nonpregnant women with a major depressive episode. The study also found financial barriers to be the primary reason for unmet mental health care need.

CONCLUSIONS

Despite current treatment guidelines and policy initiatives, most women with major depressive episodes go without any treatment utilization and perceive an unmet need for their mental health care.

Barriers Faced by Physicians in Screening for Substance Use Disorders Among Adolescents

OBJECTIVE

This study identifies key barriers faced by primary care providers (PCP) in implementation of screening, brief intervention, and referral to treatment (SBIRT) services for substance use disorders among adolescents.

METHODS

The authors used mixed methods, including 12 key informant interviews and a survey with 75 PCPs, to identify key barriers to PCP implementation of SBIRT services.

RESULTS

Time constraints, challenges related to parental involvement, a perceived lack of effectiveness of brief intervention services, and lack of training in providing brief intervention were barriers to screening and brief intervention. Referral to treatment was frequently perceived as a challenge. Increased reimbursement and dedicated resources were important interventions for improving screening rates.

CONCLUSIONS

Increased reimbursement could support workflow enhancements to improve the consistency of SBIRT procedures and alleviate time constraints. Consistent SBIRT applications for all adolescents could also be supported by increasing PCP training in brief intervention.

Changes in Residential Substance Use Treatment Service Access Resulting From Recent Medicaid Section 1115 Waivers

Medicaid stands to play a significant role in addressing the needs of individuals with a substance use disorder; however, many state Medicaid programs do not cover a full continuum of care. A growing number of states are taking advantage of Section 1115 demonstration waivers to augment their covered benefits, including experimenting with financing residential treatment services that previously were not eligible for reimbursement. Concerns over potential overuse of these services or increased spending due to this service expansion may be tempered by complementary delivery system transformation focused on reining in costs and improving care quality.

Benzodiazepine Use and Misuse Among Adults in the United States

OBJECTIVE

Goals were to determine the prevalence of benzodiazepine use (as prescribed and misuse), characterize misuse, and examine variation by age.

METHODS

A cross-sectional analysis was conducted of 2015 and 2016 National Survey on Drug Use and Health data limited to adults ≥18 (N=86,186) and data from those respondents reporting benzodiazepine use (N=10,290). Measurements included past-year prescription benzodiazepine use and misuse ("any way a doctor did not direct"), substance use disorders, mental illness, and demographic characteristics. Misuse was compared between younger (18-49) and older (≥50) adults.

RESULTS

A total of 30.6 million adults (12.6%) reported past-year benzodiazepine use-25.3 million (10.4%) as prescribed and 5.3 million (2.2%) misuse. Misuse accounted for 17.2% of overall use. Adults ages 50-64 had the highest prescribed use (12.9%). Those ages 18-25 had the highest misuse (5.2%), and those ages ≥65 had the lowest (.6%). Misuse and abuse of or dependence on prescription opioids or stimulants were strongly associated with benzodiazepine misuse. Benzodiazepine misuse without a prescription was the most common type of misuse, and a friend or relative was the most common source. Adults ages ≥50 were more likely than younger adults to use a benzodiazepine more often than prescribed and to use a benzodiazepine to help with sleep.

CONCLUSIONS

Benzodiazepine use among U.S. adults was higher than previously reported, and misuse accounted for nearly 20% of use overall. Use by adults ages 50-64 now exceeds use by those ages ≥65. Patients also prescribed stimulants or opioids should be monitored for benzodiazepine misuse. Improved access to behavioral interventions for sleep or anxiety may reduce some misuse.

Participation in Accountable Care Organizations Among Hospitals Offering Substance Use Disorder and Mental Health Services

Accountable care organizations (ACOs) can potentially improve value in behavioral health care. However, little is known about the likelihood of ACO participation among hospitals with behavioral health services. The authors explore statistical predictors of ACO participation among hospitals, particularly among those offering behavioral health services. After adjusting for other hospital characteristics, the analysis found that behavioral health specialty hospitals were less likely to participate in an ACO and general medical-surgical hospitals with behavioral health services were more likely to participate, compared with general medical-surgical hospitals without behavioral health services. A better understanding is needed of barriers to ACO participation within behavioral health specialty hospitals and how ACO participation may affect quality of behavioral health care.

Violence narratives of Mexican women treated in mutual-aid residential centers for addiction treatment

Background

Violence against women is a social and public health issue in Mexico. The aim of this article is to explore violence among an understudied group of women, who attended Mutual-Aid Residential Centers for Addiction Treatment and experienced stigma both as women and addicts. These centers are particular kind of addiction treatment services that stem from 12-step philosophy, but that have been found to manipulate said philosophy and exercise extreme forms of psychological and physical violence.

Methods

Thirteen semi-structured interviews were carried in 2014 and 2015 out with women who resided in at least one of these centers to understand their experiences of violence prior and during their rehabilitation process. The interview guide covered questions regarding substance use initiations, family violence and dynamics, and rehabilitation experiences. Qualitative data was analyzed using interpretative-phenomenological analysis.

Results

Two categories emerged: violence and substance use and abuse, and violence against women in recovery. Results show that all participants experienced violence in their family since childhood, particularly sexual and physical violence. As a result, participants experienced guilt, sadness and shame, which led them to contexts of consumption. Violence continued as they explored alcohol and drug use, even though women felt empowered.

Conclusions

Treatment reproduced masculine violence constantly, but women felt that they were in a context that helped them understand their addiction. Even though women felt these centers played a crucial role in their recovery, women’s particular needs and experiences are not considered in the treatment program.