Co-Occurring Disorders: A Challenge for Mexican Community-Based Residential Care Facilities for Substance Use.

OBJECTIVE: In Mexico, specialized treatment services for people with co-occurring disorders are limited within public health services, while private options are deemed too costly. More than 2,000 community-based residential care facilities have risen as an alternative and are the main source of treatment for individuals with substance use disorders; however, suboptimal practices within such facilities are common. Information on the clinical characteristics of patients receiving care in these facilities is scarce and capacity to provide high-quality care for co-occurring disorders is unknown. The aims of this study were to examine the prevalence of co-occurring disorders in patients receiving treatment for substance use in these community-based residential centers and to assess whether the presence of co-occurring disorders is associated with higher severity of substance use, psychiatric symptomatology, and other health risks. METHODS: This study was conducted with 601 patients receiving treatment for substance use disorders at 30 facilities located in five Mexican states, recruited in 2013 and 2014. Patients were assessed with self-report measures on substance use, service utilization, suicidality, HIV risk behaviors, psychiatric symptomatology, and psychiatric disorder diagnostic criteria. RESULTS: The prevalence of any co-occurring disorder in this sample was 62.6%. Antisocial personality disorder was the most prevalent (43.8%), followed by major depressive disorder (30.9%). The presence of a co-occurring disorder was associated with higher severity of psychiatric symptoms (aB = .496, SE = .050, p < .05); more days of substance use (aB = .219, SE = .019, p < .05); current suicidal ideation (aOR = 5.07, 95% CI [2.58, 11.17]; p < .05), plans (aOR = 5.17 95% CI [2.44, 12.73]; p < .05), and attempts (aOR = 6.43 95% CI [1.83, 40.78]; p < .05); more sexual risk behaviors; and more contact with professional services (aOR = 1.77, 95% CI [1.26, 2.49], p < .05). CONCLUSIONS: Co-occurring disorders are highly prevalent in community-based residential centers in Mexico and are associated with significantly increased probability of other health risks. This highlights the need to develop care standards for this population and the importance of clinical research in these settings.

Offering nurse care management for opioid use disorder in primary care: Impact on emergency and hospital utilization in a cluster-randomized implementation trial.

BACKGROUND: Patients with opioid use disorder (OUD) have increased emergency and hospital utilization. The PROUD trial showed that implementation of office-based addiction treatment (OBAT) increased OUD medication treatment compared to usual care, but did not decrease acute care utilization in patients with OUD documented pre-randomization (clinicaltrials.gov/study/NCT03407638). This paper reports secondary emergency and hospital utilization outcomes in patients with documented OUD in the PROUD trial. METHODS: This cluster-randomized implementation trial was conducted in 12 clinics from 6 diverse health systems (March 2015-February 2020). Patients who visited trial clinics and had an OUD diagnosis within 3 years pre-randomization were included in primary analyses; secondary analyses added patients with OUD who were new to the clinic or with newly-documented OUD post-randomization. Outcomes included days of emergency care and hospital utilization over 2 years post-randomization. Explanatory outcomes included measures of OUD treatment. Patient-level analyses used mixed-effect regression with clinic-specific random intercepts. RESULTS: Among 1988 patients with documented OUD seen pre-randomization (mean age 49, 53 % female), days of emergency care or hospitalization did not differ between intervention and usual care; OUD treatment also did not differ. In secondary analyses among 1347 patients with OUD post-randomization, there remained no difference in emergency or hospital utilization despite intervention patients receiving 32.2 (95 % CI 4.7, 59.7) more days of OUD treatment relative to usual care. CONCLUSIONS: Implementation of OBAT did not reduce emergency or hospital utilization among patients with OUD, even in the sample with OUD first documented post-randomization in whom the intervention increased treatment.

The Learning Collaboratory: developing and evaluating public health students' skills while promoting community health.

Introduction: Complex and continuous developments in health and healthcare require innovative changes in programs that educate public health scientists and professionals. Public health change agents need critical competencies to confront today and tomorrow's leading problems including leadership, communication, interprofessional practice, and systems thinking. The context challenges in public health education: Public Health training programs teach competencies through their applied field experience and culminating project, typically late in the program, and often implemented in isolation from peers and faculty. Objectives and skills do not always align closely with community-based program needs. Students pursuing a degree in science in public health need to deeply comprehend multi-dimensional and interconnected systemic problems and communicate with diverse stakeholders across disciplines to produce relevant community-engaged research. The University of Miami Public Health Learning Collaboratory (LC) was established to transform the learning experience of public health master's students by providing opportunities to develop necessary core skills for effective public health practice early in their training, while applying these skills to address real-world public health needs in the community. The Learning Collaboratory structure pedagogical approach and programmatic details: Spanning an average of 3 semesters, the LC promotes student involvement in collaborative and impactful capstone and thesis projects. Practice-based teaching and service learning are central approaches to teaching cross-cutting competencies of leadership, communication, problem solving, collaboration, and systems thinking in public health. Significant to the approach is the engagement of previous cohorts of senior students to teach back to junior students, further integrating concepts learned. Long term alumni feedback recognized strengths of the program, including its structure, teamwork & collaboration, critical thinking & problem solving, guidance, nurture & support, teaching back, and content & curriculum. Community partners agreed the LC prepared students to practice in the field of public health. Discussion: The LC is a promising model for master's level public health education and community application, given the opportunities it provides to strengthen and integrate students' public health skills in a supportive environment, and enhance the transferability and sustainability of student and faculty's community public health work.

Health Care Provider Stigma Toward Patients With Substance Use Disorders: Protocol for a Nationally Representative Survey.

BACKGROUND: The US overdose epidemic is an escalating public health emergency, accounting for over 100,000 deaths annually. Despite the availability of medications for opioid use disorders, provider-level barriers, such as negative attitudes, exacerbate the treatment gap in clinical care settings. Assessing the prevalence and intensity of provider stigma, defined as the negative perceptions and behaviors that providers embody and enact toward patients with substance use disorders, across providers with different specialties, is critical to expanding the delivery of substance use treatment. OBJECTIVE: To thoroughly understand provider stigma toward patients with substance use disorders, we conducted a nationwide survey of emergency medicine and primary care physicians and dentists using a questionnaire designed to reveal how widely and intensely provider attitudes and stigma can impact these providers' clinical practices in caring for their patients. The survey also queried providers' stigma and clinical practices toward other chronic conditions, which can then be compared with their stigma and practices related to substance use disorders. METHODS: Our cross-sectional survey was mailed to a nationally representative sample of primary care physicians, emergency medicine physicians, and dentists (N=3011), obtained by American Medical Association and American Dental Association licensees based on specified selection criteria. We oversampled nonmetropolitan practice areas, given the potential differences in provider stigma and available resources in these regions compared with metropolitan areas. Data collection followed a recommended series of contacts with participants per the Dillman Total Design Method, with mixed-modality options offered (email, mail, fax, and phone). A gradually increasing compensation scale (maximum US$250) was implemented to recruit chronic nonresponders and assess the association between requiring higher incentives to participate and providers stigma. The primary outcome, provider stigma, was measured using the Medical Condition Regard Scale, which inquired about participants' views on substance use and other chronic conditions. Additional survey measures included familiarity and social engagement with people with substance use disorders; clinical practices (screening, treating, and referring for a range of chronic conditions); subjective norms and social desirability; knowledge and prior education; and descriptions of their patient populations. RESULTS: Data collection was facilitated through collaboration with the National Opinion Research Center between October 2020 and October 2022. The overall Council of American Survey Research Organizations completion rate was 53.62% (1240/2312.7; physicians overall: 855/1681.9, 50.83% [primary care physicians: 506/1081.3, 46.79%; emergency medicine physicians: 349/599.8, 58.2%]; dentists: 385/627.1, 61.4%). The ineligibility rate among those screened is applied to those not screened, causing denominators to include fractional numbers. CONCLUSIONS: Using systematically quantified data on the prevalence and intensity of provider stigma toward substance use disorders in health care, we can provide evidence-based improvement strategies and policies to inform the development and implementation of stigma-reduction interventions for providers to address their perceptions and treatment of substance use. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47548.

Nurse Care Management for Opioid Use Disorder Treatment: The PROUD Cluster Randomized Clinical Trial.

Importance: Few primary care (PC) practices treat patients with medications for opioid use disorder (OUD) despite availability of effective treatments. Objective: To assess whether implementation of the Massachusetts model of nurse care management for OUD in PC increases OUD treatment with buprenorphine or extended-release injectable naltrexone and secondarily decreases acute care utilization. Design, Setting, and Participants: The Primary Care Opioid Use Disorders Treatment (PROUD) trial was a mixed-methods, implementation-effectiveness cluster randomized clinical trial conducted in 6 diverse health systems across 5 US states (New York, Florida, Michigan, Texas, and Washington). Two PC clinics in each system were randomized to intervention or usual care (UC) stratified by system (5 systems were notified on February 28, 2018, and 1 system with delayed data use agreement on August 31, 2018). Data were obtained from electronic health records and insurance claims. An implementation monitoring team collected qualitative data. Primary care patients were included if they were 16 to 90 years old and visited a participating clinic from up to 3 years before a system's randomization date through 2 years after. Intervention: The PROUD intervention included 3 components: (1) salary for a full-time OUD nurse care manager; (2) training and technical assistance for nurse care managers; and (3) 3 or more PC clinicians agreeing to prescribe buprenorphine. Main Outcomes and Measures: The primary outcome was a clinic-level measure of patient-years of OUD treatment (buprenorphine or extended-release injectable naltrexone) per 10 000 PC patients during the 2 years postrandomization (follow-up). The secondary outcome, among patients with OUD prerandomization, was a patient-level measure of the number of days of acute care utilization during follow-up. Results: During the baseline period, a total of 130 623 patients were seen in intervention clinics (mean [SD] age, 48.6 [17.7] years; 59.7% female), and 159 459 patients were seen in UC clinics (mean [SD] age, 47.2 [17.5] years; 63.0% female). Intervention clinics provided 8.2 (95% CI, 5.4-∞) more patient-years of OUD treatment per 10 000 PC patients compared with UC clinics (P = .002). Most of the benefit accrued in 2 health systems and in patients new to clinics (5.8 [95% CI, 1.3-∞] more patient-years) or newly treated for OUD postrandomization (8.3 [95% CI, 4.3-∞] more patient-years). Qualitative data indicated that keys to successful implementation included broad commitment to treat OUD in PC from system leaders and PC teams, full financial coverage for OUD treatment, and straightforward pathways for patients to access nurse care managers. Acute care utilization did not differ between intervention and UC clinics (relative rate, 1.16; 95% CI, 0.47-2.92; P = .70). Conclusions and Relevance: The PROUD cluster randomized clinical trial intervention meaningfully increased PC OUD treatment, albeit unevenly across health systems; however, it did not decrease acute care utilization among patients with OUD. Trial Registration: ClinicalTrials.gov Identifier: NCT03407638.

Integration of Public Health in LCME Accredited Medical Schools in Florida: A Survey Based Study.

INTRODUCTION:  The future physician will face a career challenged by a number of significant changes in healthcare, including changes in demographics and disease, an increasing focus on population health and value-based care, and changes in healthcare funding. National organizations have called for medical schools to better prepare students for these challenges, and to incorporate more public health education in medical school. While many medical schools have responded, the topics covered, the timing in the curriculum, and the importance of these topics for graduation vary widely. Florida has been a site of growth in medical education in the last 10 years. Given that new medical schools were developed during a period of increased emphasis on the need for public health education, a survey was developed to assess the state of public health education in medical schools accredited by the Liaison Committee for Medical Education (LCME) in the state of Florida. METHODS:  The survey included questions on school location, size of the student body, date of initial LCME accreditation, presence of department or school of public health, and presence of a pathway or track in public health. The survey asked detailed questions about public health content, curricula delivery methods, and timing of the curriculum within the four-year course of study as well as the courses providing public health content. The survey asked about the value of curricular content and the survey itself. The online survey was sent to the associate or senior associate deans for education in the seven LCME accredited schools who had full or provisional accreditation as of December 2017. Data collection occurred between March 14 and March 30, 2018. RESULTS:  Six of the seven medical schools responded. Of the eleven competencies included in the survey, schools reported between five and eleven. Three schools cover nine or more of the eleven competencies. The number of competencies covered was not statistically influenced by age of the school, percentage of underrepresented students in medicine, the presence of a school or department of public health, or a special pathway or track in public health. The most common teaching method used was a didactic lecture, and the least was the structured experience with a local health organization. The fourth year of medical school saw the least amount of public health education. Five of the six respondents felt that the competencies presented here are very important to extremely important, and one school feels that they are moderately important. DISCUSSION:  Nationally, education in public health is an important component in medical education, but the topics included, educational methods used and the importance of the content varies from school to school. The state of public health education in medical schools in Florida is robust in some schools. The individuals responsible for the curriculum support the importance of these topics. The content is delivered through a diversity of pedagogical methods. The study results demonstrate a number of opportunities for enhancement. CONCLUSION:  Given the importance of public health content in medical schools, survey methodology using established competencies to assess public health curricula could be used in the US to provide an up-to-date assessment of the strengths and opportunities for improvement in this area.

Development and evaluation of addiction treatment programs in Latin America.

PURPOSE OF REVIEW: The aim of this article is to present a state-of-the-art review of the scientific studies that have evaluated healthcare systems, services and programs for addiction treatment in Latin America. As a secondary aim, this article presents a brief description and analysis of the addiction prevention and treatment resources and programs available in Latin America, based on information from the ATLAS on Substance Use (ATLAS-SU) project led by the WHO. RECENT FINDINGS: Substance use disorders (SUDs) are among the main causes associated with global burden of disease. Around the world, many initiatives have been proposed to promote policies to reduce substance use and reduce the impact of SUD, including integrating treatments into healthcare systems, increasing access to treatment programs and impacting outcome measures. In Latin America, multiple efforts have been implemented to improve addiction services and programs, although little is known about the impact they have generated. SUMMARY: International studies report the availability of strategies and public inicitatives on prevention and treatment of addiction in Latin America. These studies also report established networks of public and private services that include prevention and detoxification programs, outpatient and residential treatment, and also social reintegration initiatives. However, despite these advances, information on the evaluation of the progress, results and impact of these programs is limited.

The effects of Brief Strategic Family Therapy (BSFT) on parent substance use and the association between parent and adolescent substance use.

BACKGROUND: The effects of family therapy for adolescent substance use on parent substance use have not been explored. OBJECTIVES: To determine the effects of Brief Strategic Family Therapy® (BSFT®) on parent substance use, and the relationship between parent substance use and adolescent substance use. DESIGN: 480 adolescents and parents were randomized to BSFT or Treatment as Usual (TAU) across eight outpatient treatment programs. METHODS: Parent substance use was assessed at baseline and at 12months post-randomization. Adolescent substance use was assessed at baseline and monthly for 12months post-randomization. Family functioning was assessed at baseline, 4, 8, and 12months post-randomization. RESULTS: Parents in BSFT significantly decreased their alcohol use as measured by the ASI composite score from baseline to 12months (χ(2)(1)=4.46, p=.04). Change in family functioning mediated the relationship between Treatment Condition and change in parent alcohol use. Children of parents who reported drug use at baseline had three times as many days of reported substance use at baseline compared with children of parents who did not use or only used alcohol (χ(2)(2)=7.58, p=.02). Adolescents in BSFT had a significantly lower trajectory of substance use than those in TAU (ß=-7.82, p<.001) if their parents used drugs at baseline. CONCLUSIONS: BSFT is effective in reducing alcohol use in parents, and in reducing adolescents' substance use in families where parents were using drugs at baseline. BSFT may also decrease alcohol use among parents by improving family functioning.

Therapist adherence in brief strategic family therapy for adolescent drug abusers.

OBJECTIVE: Therapist adherence has been shown to predict clinical outcomes in family therapy. In prior studies, adherence has been represented broadly by core principles and a consistent family (vs. individual) focus. To date, these studies have not captured the range of clinical skills that are represented in complex family-based approaches or examined how variations in these skills predict different clinically relevant outcomes over the course of treatment. In this study, the authors examined the reliability and validity of an observational adherence measure and the relationship between adherence and outcome in a sample of drug-using adolescents who received brief strategic family therapy within a multisite effectiveness study. METHOD: Participants were 480 adolescents (age 12-17) and their family members, who were randomized to the Brief Strategic Family Therapist treatment condition (J. Szapocznik, U. Hervis, & S. Schwartz, 2003) or treatment as usual. The adolescents were mostly male (377 vs. 103 female) and Hispanic (213), whereas 148 were White, and 110 were Black. Therapists were also randomly assigned to treatment condition within agencies. RESULTS: Results supported the proposed factor structure of the adherence measure, providing evidence that it is possible to capture and discriminate between distinct dimensions of family therapy. Analyses demonstrated that the mean levels of the factors varied over time in theoretically and clinically relevant ways and that therapist adherence was associated with engagement and retention in treatment, improvements in family functioning, and reductions in adolescent drug use. CONCLUSIONS: Clinical implications and future research directions are discussed, including the relevance of these findings on training therapists and studies focusing on mechanisms of action in family therapy.