Journal of substance use and addiction treatment最新文献

Introduction: Established under the Affordable Care Act, Medicaid health homes are designed to provide comprehensive health care for enrollees with chronic health conditions. Given high rates of substance use disorder (SUD) in Medicaid, health homes have the potential to enhance SUD identification and treatment. Yet little is known about the extent to which they engage in these activities. In this study, we assessed the proportion of health homes that screen, treat, and refer for SUD; health homes compliance with state plan requirements for SUD screening and treatment; and the extent to which these trends differ among health homes focusing on physical versus mental health and SUD.

Methods: We administered a pilot survey in 2022 to all health care providers participating in active Medicaid health home models. Health home models were categorized as physical-, mental health-, or SUD-focused. We estimated the percentage of health homes engaged in SUD screening, treatment, and referral, and the percentage of health homes that complied with state requirements in each domain.

Results: Our sample included 113 Medicaid health homes in 15 states and the District of Columbia. Physical health-focused health homes were more likely to screen for SUD than mental health-focused and SUD-focused health homes (81.0 % versus 63.4 % and 55.0 % respectively). Most health homes referred out at least some SUD treatment (84.1 %). Among those that did refer, fewer than 20 % had a formal contractual agreement with an SUD treatment program. The majority of health homes complied with state requirements for referral. However, among health homes required by their state to offer SUD screening, 38.5 % of physical health-, 10.0 % of mental health-, and 25.0 % of SUD-focused health homes failed to do so. Similarly, 5.9 % of physical health-, 67.9 % of mental health- and 45.0 % of SUD-focused health homes did not offer onsite SUD treatment, even when required to do so.

Conclusions: While Medicaid health home plans were established to promote care coordination and integration, relatively few health homes in this study reported doing so in the case of SUD. A concerning number of health homes did not comply with state plan requirements for SUD screening and treatment.

Over the past two decades, peer support providers have increasingly formalized their roles in the addiction treatment workforce through credentialing and professionalization efforts. Despite these advancements, misconceptions regarding their professional identity persist and contribute to challenges such as burnout and high turnover. This commentary underscores the importance of viewing the peer workforce as an emerging profession using a lens that has previously been applied to other healthcare service roles. We outline key milestones in the peer workforce's professional development and ongoing labor advocacy efforts by state and national organizations. We call for a comprehensive research agenda that addresses workforce outcomes, workplace dynamics, and role competencies. Such efforts are crucial for advancing the recognition and support of peers as an integral component of the behavioral healthcare workforce.

Background: Measurement-based care (MBC), routinely measuring and reviewing treatment progress with a standardized tool, can inform clinical decision making and improve patient outcomes. Despite potential benefits, implementation of MBC in SUD treatment settings has been limited and little is known about its implementation in SUD settings. The goal of this convergent parallel mixed methods study was to understand staff experiences during early implementation of MBC in SUD treatment clinics.

Methods: The Treatment Progress Assessment-8 (TPA8) is an 8-item measure that supports MBC with an electronic system (eTPA8) allowing client completion on electronic devices and providing staff reports. The study introduced the eTPA8 into 13 clinics using external practice facilitation and implementation teams. Quantitative data examining implementation included eTPA8 system data (1672 administrations) and staff surveys (n = 70) using feasibility, acceptability, and appropriateness measures. Semi-structured interviews (n = 34) were conducted with clinic staff. To analyze data, we classified clinics into adopters, non-adopters, and sustainers using eTPA8 system data. One-way ANOVA compared these classifications on the three implementation outcome measures. Rapid qualitative analysis was used for the interviews.

Results: There were significant differences between staff in sustainer (M = 3.90) and non-adopter (M = 3.21) clinics on the feasibility measure (F(2, 68) = [4.28], p = 0.018). SUD program staff found the eTPA8 to be user-friendly, appropriate, and acceptable. There was some variation in perceived feasibility of regular use of the eTPA8, especially given competing demands and time constraints. Staff found the eTPA8 useful to support clinical interactions but varied in embracing new technology and the overall MBC concept. The inner and outer contexts influenced implementation and required attention by clinic champions and implementation teams. External practice facilitators were key to addressing barriers in an ongoing and flexible manner.

Conclusions: Implementing MBC using the eTPA8 showed promise. Staff felt the TPA8 was generally clinically useful, appropriate, and acceptable; yet feasibility was variable. Adoption of MBC faced barriers (e.g., competing demands). Implementation required relatively intensive implementation supports that were dynamic, proactive, and responsive. Findings have implications for guiding development and refinement of responsive, theory-driven implementation strategies to support MBC in SUD treatment settings, with a particular focus on addressing feasibility.

Background: Perinatal substance use is a critical public health challenge, impacting both mother and fetus. Its prevalence has increased in British Columbia, Canada, disproportionately impacting First Nations people. For specialized perinatal substance use services to be effective, they must be accessible and safe. This study aimed to explore the accessibility and cultural safety of health services for perinatal substance use from the perspective of service users.

Methods: We conducted a qualitative study from six focus group discussions, consisting of five in-person sharing circles for people with lived/living experience of pregnancy and substance use and one virtual focus group with inreach workers, for a total of 55 participants including 48 people with lived experience and seven inreach workers across the five health delivery regions in British Columbia. We interpreted results using thematic analysis and narrative inquiry to explore inductively and deductively derived themes.

Results: Participants identified a lack of perinatal substance use specific services, particularly supportive housing facilities and wrap-around community centres in the province but highlighted that community-based services they were able to access made participants feel safe and respected. Thematic analysis identified six themes related to accessibility and cultural safety: geographic disparities in access to care, importance of Indigenous culture for Indigenous client's healing, transitions as critical moments in service accessibility, safe services protect the mother-infant dyad, inconsistent access to opioid agonist treatment, and relationality as a crucial element of safe service delivery.

Conclusion: This study suggests that services that preserve the mother-infant dyad, incorporate wholistic care including Indigenous culture, and are relationship-based are experienced as accessible and safe, and those that do not are often mistrusted and avoided. This study highlights needed improvements, particularly of acute care services, through supporting instead of reporting birthing parents with substance use, ensuring continuous access to opioid agonist treatment for pregnant people with opioid use disorder, and suffusing the client-provider relationship with empathy, respect, and connection.

Introduction: A significant risk for overdose among patients prescribed opioid medications is co-use of alcohol. Community pharmacies are underutilized as a resource to prevent and address co-use. The barriers and facilitators that promote or impede the adoption of universal alcohol screening and intervention at point of opioid medication dispensing are unknown. We assessed community pharmacy leaders, pharmacists, and technician's perceptions towards the implementation of a pharmacy-based screening/intervention for the co-use of opioids and alcohol among patients.

Methods: We conducted a multi-method study that included one-time key informant interviews combined with a close-ended survey to inform our understanding of pharmacy system/practice-level barriers and facilitators for universal screening and intervention. Participants were recruited from Utah and Tennessee and were required to have active employment as pharmacy leaders, pharmacists, or technicians, be English-speaking, and believe they could provide feedback regarding co-use screening and intervention within community pharmacies. Interviews used the Consolidated Framework for Implementation Research and the Organizational Readiness for Implementing Change assessment. Qualitative analysis included both inductive and deductive coding. Themes followed a cycle of open, initial coding whereby codes were derived inductively from the data.

Results: Themes from interviews (N = 68) included a) emphasizing a need to overcome the stigma associated with patients who engage in co-use and a mindset shift to treat the challenges and risks associated, b) need for corporate-level support, management buy-in, and c) appropriate technology to support the workflow including system-wide changes to support the integration of medication therapy management services within community pharmacies. However, barriers were offset by pharmacists eager to understand their role in screening patients and reiterated a focus on patient-centered care to achieve this goal. From the ORIC assessment, 75 % (n = 51) of respondents reported that community pharmacy staff wanted to implement the screening and intervention, and 69.1 % (n = 47) reported motivation to implement the screening and intervention. Finally, 67.6 % (n = 46) felt that community pharmacies are committed to implementing the screening and intervention, but only 10.3 % (n = 7) expressed strong support to do "whatever it takes" to implement the screening and intervention.

Conclusion: These results provide critical insights into implementation strategies for the adoption of brief intervention by community pharmacists. These data are foundational to developing strategies for a powered trial and possible future system/practice-level implementation of universal alcohol screening and intervention for co-use.

Introduction: Post-traumatic stress disorder and substance use disorders commonly co-occur and are associated with worse health outcomes. Currently, only psychosocial therapies are specifically recommended for use in the co-occurring population, but these come with numerous barriers to access and engagement. This study aims to identify potential pharmacological treatments to enhance treatment options and outcomes for this population.

Methods: This systematic review identified studies on pharmacological treatment of co-occurring PTSD and SUD in humans, using validated outcome measurements, with study design of RCT, observational study, case control study or cohort study.

Results: 29 studies were identified for inclusion, looking at a range of 16 pharmacotherapies. A majority concentrated on alcohol use disorders and males, with many focused on the veteran population.

Conclusions: This is an area for further research, inclusive of more SUDs, genders and civilians. Future studies utilizing consistent dosing, populations and measurement outcomes will allow for future meta-analysis.

Introduction: Cannabis use and misuse have mental health implications, particularly affecting mood and anxiety symptoms. Vortioxetine, a potent serotonin partial agonist/antagonist reuptake inhibitor antidepressant, has well-established effects in treating depressive and anxiety disorders and may serve as a potential treatment for individuals with cannabis use disorder and comorbid mood symptoms. In the current study, we aimed to investigate the efficacy of vortioxetine for cannabis users with anxiety and depressive symptoms alongside their cannabis dependence.

Methods: This 6-month prospective, randomized controlled interventional pilot study investigated if vortioxetine could improve cannabis dependence, comorbid anxiety and/or depressive symptoms, and cognitive and functional outcomes in individuals using cannabis. Participants were randomized to receive either vortioxetine (N = 11) or standard treatment (N = 19).

Results: Participants taking vortioxetine (mean dose 10 mg/day) showed significant improvement on clinician-observed overall mood states over time (p < .05) but not on their self-reported anxiety or depressive symptoms. Cannabis users receiving standard treatment did not exhibit similar improvement. No significant differences were found on cannabis dependence, cognition and functional outcomes between the two groups otherwise.

Conclusions: The results suggest that the multimodal antidepressant vortioxetine may benefit cannabis users with depressive and anxiety symptoms in ameliorating their overall mood state.

Introduction: Rural populations have higher rates of tobacco use but are less likely to use evidence-based smoking cessation treatments than urban residents. There is limited evidence on the use of smoking cessation treatments and the factors associated with their use in rural populations. This study explored quit attempts, use of smoking cessation treatments, quitting intention and associated factors among rural residents seeking smoking cessation treatment.

Methods: Participants were adult rural or remote residents of New South Wales, Australia who enrolled in a randomized trial of smoking cessation treatment (n = 1244). Participants completed an online baseline survey assessing quit attempts, quitting intention, and prior use of smoking cessation treatments. Multivariable logistic regressions that adjusted for other variables examined associations and derived odds ratios.

Results: Almost half (48.3 %) of participants made a quit attempt in the last 12 months, and 44.6 % intended to quit in the next 30 days. Women (OR = 0.74, 95 % CI 0.56-0.99), Australian-born participants (OR = 0.67, 95 % CI 0.45-0.99) and those with moderate (OR = 0.53, 95 % CI 0.40-0.71) or high (OR = 0.42, 95 % CI 0.28-0.63) nicotine dependence had significantly lower odds of making a quit attempt in the last 12 months. Among participants who had ever made a quit attempt, most had used pharmacotherapies (82.2 %) or behavioral interventions (68.3 %) during any quit attempt. Participants with moderate (OR = 1.96, 95 % CI 1.37-2.79) or high (OR = 3.27, 95 % CI 1.66-6.45) nicotine dependence and chronic conditions (OR = 1.45, 95 % CI 1.00-2.11) had significantly greater odds of pharmacotherapy use while those who drank alcohol daily or almost daily (OR = 0.46, 95 % CI 0.26-0.81) had significantly lower odds of pharmacotherapy use. Those with moderate (OR = 1.38, 95 % CI 1.02-1.87) or high (OR = 3.31, 95 % CI 1.94-5.66) nicotine dependence, university education (OR = 1.47, 95 % CI 1.04-2.07), moderate (OR = 1.63, 95 % CI 1.19-2.22) or high (OR = 1.73, 95 % CI 1.12-2.68) financial stress, and anxiety (OR = 1.61, 95 % CI 1.16-2.22) had significantly greater odds of using behavioral treatments whereas those with depression (OR = 0.66, 95 % CI 0.47-0.92) had significantly lower odds.

Conclusions: Some sub-groups had lower odds of using smoking cessation treatments. Understanding if particular barriers hinder use of smoking cessation treatments among certain sub-groups of rural residents is needed.

Introduction: Patients with opioid use disorder (OUD) experiencing withdrawal or nonfatal overdose often present to emergency departments (EDs). While professional societies endorse the initiation of evidence-based medications for OUD (MOUD) in the ED, low uptake persists. The purpose of this systematic review is to synthesize what is known about implementation of MOUD in EDs and to identify potential strategies to improve the uptake of MOUD in the ED.

Methods: We reviewed articles that examined implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, penetration, sustainability, and cost) of MOUD in United States EDs. Peer-reviewed studies that used quantitative, qualitative, or mixed methods approaches were eligible for inclusion.

Results: Twenty-seven articles met the inclusion criteria for one or more implementation outcomes. Forty-four percent (n = 11) reported on acceptability, 78 % (n = 21) reported on adoption, 26 % (n = 7) reported on appropriateness, and 15 % (n = 4) reported on feasibility. Eleven percent (n = 3) reported on fidelity, 7 % (n = 2) reported on penetration, and 7 % (n = 2) reported on sustainability. No articles reported on implementation cost. While physicians found MOUD acceptable, their comfort levels with the intervention varied. Rates of MOUD adoption were often low, but uptake may be facilitated by implementation strategies. MOUD may constrain ED time resources and exacerbate overcrowding, hindering appropriateness.

Conclusion: Results suggest that ED physicians and administrators have encountered barriers to the initiation of MOUD. There may be opportunities to overcome these implementation barriers using multi-component strategies consisting of educational interventions that address safety and monitoring and process interventions, such as clinical decision support systems.

Introduction: Opioid use disorder is a chronic, relapsing disease and a major source of morbidity and mortality in the U.S. Medications for opioid use disorder (MOUD) have been shown to reduce opioid use; however, MOUD maintenance is often suboptimal. Depression is a well-documented risk factor for MOUD treatment disengagement; thus, behavioral interventions to address depression and support ongoing MOUD use in community settings are warranted.

Methods: We evaluated the feasibility, acceptability, and preliminary efficacy of the CoMBAT (Combined Medication and Behavioral Activation Treatment) intervention via a pilot randomized controlled trial. We hypothesized that the CoMBAT intervention, which uses behavioral activation, motivational interviewing, and problem-solving techniques, would be feasible and acceptable to participants and decrease depression, increase goal-directed activity, improve MOUD care engagement, and reduce opioid use among adults with depressive symptoms who had a missed dose or clinical MOUD visit in the past 30 days. We enrolled 32 participants prescribed methadone or buprenorphine in the community; each received 2 health navigation and substance use counseling sessions (HN_SUC) before being randomized into (a) the 8-session CoMBAT intervention + HN_SUC + treatment as usual or (b) HN_SUC + treatment as usual only. The primary outcomes were intervention feasibility and acceptability. Preliminary efficacy measures included self-reported past-30-day MOUD doses and clinical visits, depressive symptoms, behavioral activation; and opioid-positive urinalysis; each assessed at baseline and 3- and 6-month follow-up visits.

Results: The intervention was feasible (88 % of intervention sessions completed; 100 % retention at 6 months) and acceptable (86 % of intervention participants were satisfied/very satisfied with the intervention at 3-months; and intervention participants had a high level of alliance with their counselor at the mid-point: mean = 5.7 out of 7 [SD = 1.3] and end of their treatment: mean = 5.5 out of 7 [SD = 1.1]. At 6-months, intervention participants reported fewer missed MOUD doses and visits, less depressive symptoms, greater behavioral activation scores, and a lower percentage of opioid-positive toxicology screens relative to the control condition.

Conclusion: Findings provide evidence of intervention feasibility and acceptability and demonstrate initial efficacy for ongoing MOUD care engagement, depressive symptom reduction, increased behavioral activity, and reduced opioid use. Future intervention testing in a fully-powered efficacy trial is warranted.