Rapid Initiation of Injection Naltrexone for Opioid Use Disorder: A Stepped-Wedge Cluster Randomized Clinical Trial.

Importance: Injectable extended-release (XR)-naltrexone is an effective treatment option for opioid use disorder (OUD), but the need to withdraw patients from opioid treatment prior to initiation is a barrier to implementation. Objective: To compare the effectiveness of the standard procedure (SP) with the rapid procedure (RP) for XR-naltrexone initiation. Design, Setting, and Participants: The Surmounting Withdrawal to Initiate Fast Treatment with Naltrexone study was an optimized stepped-wedge cluster randomized trial conducted at 6 community-based inpatient addiction treatment units. Units using the SP were randomly assigned at 14-week intervals to implement the RP. Participants admitted with OUD received the procedure the unit was delivering at the time of their admission. Participant recruitment took place between March 16, 2021, and July 18, 2022. The last visit was September 21, 2022. Interventions: Standard procedure, based on the XR-naltrexone package insert (approximately 5-day buprenorphine taper followed by a 7- to 10-day opioid-free period and RP, defined as 1 day of buprenorphine at minimum necessary dose, 1 opioid-free day, and ascending low doses of oral naltrexone and adjunctive medications (eg, clonidine, clonazepam, antiemetics) for opioid withdrawal. Main Outcomes and Measures: Receipt of XR-naltrexone injection prior to inpatient discharge (primary outcome). Secondary outcomes included opioid withdrawal scores and targeted safety events and serious adverse events. All analyses were intention-to-treat. Results: A total of 415 participants with OUD were enrolled (mean [SD] age, 33.6 [8.48] years; 205 [49.4%] identified sex as male); 54 [13.0%] individuals identified as Black, 91 [21.9%] as Hispanic, 290 [69.9%] as White, and 22 [5.3%] as multiracial. Rates of successful initiation of XR-naltrexone among the RP group (141 of 225 [62.7%]) were noninferior to those of the SP group (68 of 190 [35.8%]) (odds ratio [OR], 3.60; 95% CI, 2.12-6.10). Withdrawal did not differ significantly between conditions (proportion of days with a moderate or greater maximum Clinical Opiate Withdrawal Scale score (>12) for RP vs SP: OR, 1.25; 95% CI, 0.62-2.50). Targeted safety events (RP: 12 [5.3%]; SP: 4 [2.1%]) and serious adverse events (RP: 15 [6.7%]; SP: 3 [1.6%]) were infrequent but occurred more often with RP than SP. Conclusions and Relevance: In this trial, the RP of XR-naltrexone initiation was noninferior to the standard approach and saved time, although it required more intensive medical management and safety monitoring. The results of this trial suggest that rapid initiation could make XR-naltrexone a more viable treatment for patients with OUD. Trial Registration: ClinicalTrials.gov Identifier: NCT04762537.

Tapping into alcohol use during COVID: Drinking correlates among bartenders and servers.

The COVID pandemic placed a spotlight on alcohol use and the hardships of working within the food and beverage industry, with millions left jobless. Following previous studies that have found elevated rates of alcohol problems among bartenders and servers, here we studied the alcohol use of bartenders and servers who were employed during COVID. From February 12-June 16, 2021, in the midst of the U.S. COVID national emergency declaration, survey data from 1,010 employed bartender and servers were analyzed to quantify rates of excessive or hazardous drinking along with regression predictors of alcohol use as assessed by the 10-item Alcohol Use Disorders Identification Test (AUDIT). Findings indicate that more than 2 out of 5 (44%) people surveyed reported moderate or high rates of alcohol problem severity (i.e., AUDIT scores of 8 or higher)-a rate 4 to 6 times that of the heavy alcohol use rate reported pre- or mid-pandemic by adults within and outside the industry. Person-level factors (gender, substance use, mood) along with the drinking habits of one's core social group were significantly associated with alcohol use. Bartenders and servers reported surprisingly high rates of alcohol problem severity and experienced risk factors for hazardous drinking at multiple ecological levels. Being a highly vulnerable and understudied population, more studies on bartenders and servers are needed to assess and manage the true toll of alcohol consumption for industry employees.

Language-based EMA assessments help understand problematic alcohol consumption.

BACKGROUND: Unhealthy alcohol consumption is a severe public health problem. But low to moderate alcohol consumption is associated with high subjective well-being, possibly because alcohol is commonly consumed socially together with friends, who often are important for subjective well-being. Disentangling the health and social complexities of alcohol behavior has been difficult using traditional rating scales with cross-section designs. We aim to better understand these complexities by examining individuals' everyday affective subjective well-being language, in addition to rating scales, and via both between- and within-person designs across multiple weeks. METHOD: We used daily language and ecological momentary assessment on 908 US restaurant workers (12692 days) over two-week intervals. Participants were asked up to three times a day to "describe your current feelings", rate their emotions, and report their alcohol behavior in the past 24 hours, including if they were drinking alone or with others. RESULTS: Both between and within individuals, language-based subjective well-being predicted alcohol behavior more accurately than corresponding rating scales. Individuals self-reported being happier on days when drinking more, with language characteristic of these days predominantly describing socializing with friends. Between individuals (over several weeks), subjective well-being correlated much more negatively with drinking alone (r = -.29) than it did with total drinking (r = -.10). Aligned with this, people who drank more alone generally described their feelings as sad, stressed and anxious and drinking alone days related to nervous and annoyed language as well as a lower reported subjective well-being. CONCLUSIONS: Individuals' daily subjective well-being, as measured via language, in part, explained the social aspects of alcohol drinking. Further, being alone explained this relationship, such that drinking alone was associated with lower subjective well-being.

An integrated LSTM-HeteroRGNN model for interpretable opioid overdose risk prediction.

Opioid overdose (OD) has become a leading cause of accidental death in the United States, and overdose deaths reached a record high during the COVID-19 pandemic. Combating the opioid crisis requires targeting high-need populations by identifying individuals at risk of OD. While deep learning emerges as a powerful method for building predictive models using large scale electronic health records (EHR), it is challenged by the complex intrinsic relationships among EHR data. Further, its utility is limited by the lack of clinically meaningful explainability, which is necessary for making informed clinical or policy decisions using such models. In this paper, we present LIGHTED, an integrated deep learning model combining long short term memory (LSTM) and graph neural networks (GNN) to predict patients' OD risk. The LIGHTED model can incorporate the temporal effects of disease progression and the knowledge learned from interactions among clinical features. We evaluated the model using Cerner's Health Facts database with over 5 million patients. Our experiments demonstrated that the model outperforms traditional machine learning methods and other deep learning models. We also proposed a novel interpretability method by exploiting embeddings provided by GNNs to cluster patients and EHR features respectively, and conducted qualitative feature cluster analysis for clinical interpretations. Our study shows that LIGHTED can take advantage of longitudinal EHR data and the intrinsic graph structure of EHRs among patients to provide effective and interpretable OD risk predictions that may potentially improve clinical decision support.

Compassion within conflict: Toward a computational theory of social groups informed by maternal brain physiology.

Benevolent intersubjectivity developed in parent-infant interactions and compassion toward friend and foe alike are non-violent interventions to group behavior in conflict. Based on a dyadic active inference framework rooted in specific parental brain mechanisms, we suggest that interventions promoting compassion and intersubjectivity can reduce stress, and that compassionate mediation may resolve conflicts.

Where Opioid Overdose Patients Live Far From Treatment: Geospatial Analysis of Underserved Populations in New York State.

BACKGROUND: Opioid addiction and overdose have a large burden of disease and mortality in New York State (NYS). The medication naloxone can reverse an overdose, and buprenorphine can treat opioid use disorder. Efforts to increase the accessibility of both medications include a naloxone standing order and a waiver program for prescribing buprenorphine outside a licensed drug treatment program. However, only a slim majority of NYS pharmacies are listed as participating in the naloxone standing order, and less than 7% of prescribers in NYS have a buprenorphine waiver. Therefore, there is a significant opportunity to increase access. OBJECTIVE: Identifying the geographic regions of NYS that are farthest from resources can help target interventions to improve access to naloxone and buprenorphine. To maximize the efficiency of such efforts, we also sought to determine where these underserved regions overlap with the largest numbers of actual patients who have experienced opioid overdose. METHODS: We used address data to assess the spatial distribution of naloxone pharmacies and buprenorphine prescribers. Using the home addresses of patients who had an opioid overdose, we identified geographic locations of resource deficits. We report findings at the high spatial granularity of census tracts, with some neighboring census tracts merged to preserve privacy. RESULTS: We identified several hot spots, where many patients live far from the nearest resource of each type. The highest density of patients in areas far from naloxone pharmacies was found in eastern Broome county. For areas far from buprenorphine prescribers, we identified subregions of Oswego county and Wayne county as having a high number of potentially underserved patients. CONCLUSIONS: Although NYS is home to thousands of naloxone pharmacies and potential buprenorphine prescribers, access is not uniform. Spatial analysis revealed census tract areas that are far from resources, yet contain the residences of many patients who have experienced opioid overdose. Our findings have implications for public health decision support in NYS. Our methods for privacy can also be applied to other spatial supply-demand problems involving sensitive data.

Comparison of Methods for Alcohol and Drug Screening in Primary Care Clinics.

Importance: Guidelines recommend that adult patients receive screening for alcohol and drug use during primary care visits, but the adoption of screening in routine practice remains low. Clinics frequently struggle to choose a screening approach that is best suited to their resources, workflows, and patient populations. Objective: To evaluate how to best implement electronic health record (EHR)-integrated screening for substance use by comparing commonly used screening methods and examining their association with implementation outcomes. Design, Setting, and Participants: This article presents the outcomes of phases 3 and 4 of a 4-phase quality improvement, implementation feasibility study in which researchers worked with stakeholders at 6 primary care clinics in 2 large urban academic health care systems to define and implement their optimal screening approach. Site A was located in New York City and comprised 2 clinics, and site B was located in Boston, Massachusetts, and comprised 4 clinics. Clinics initiated screening between January 2017 and October 2018, and 93 114 patients were eligible for screening for alcohol and drug use. Data used in the analysis were collected between January 2017 and October 2019, and analysis was performed from July 13, 2018, to March 23, 2021. Interventions: Clinics integrated validated screening questions and a brief counseling script into the EHR, with implementation supported by the use of clinical champions (ie, clinicians who advocate for change, motivate others, and use their expertise to facilitate the adoption of an intervention) and the training of clinic staff. Clinics varied in their screening approaches, including the type of visit targeted for screening (any visit vs annual examinations only), the mode of administration (staff-administered vs self-administered by the patient), and the extent to which they used practice facilitation and EHR usability testing. Main Outcomes and Measures: Data from the EHRs were extracted quarterly for 12 months to measure implementation outcomes. The primary outcome was screening rate for alcohol and drug use. Secondary outcomes were the prevalence of unhealthy alcohol and drug use detected via screening, and clinician adoption of a brief counseling script. Results: Patients of the 6 clinics had a mean (SD) age ranging from 48.9 (17.3) years at clinic B2 to 59.1 (16.7) years at clinic B3, were predominantly female (52.4% at clinic A1 to 64.6% at clinic A2), and were English speaking. Racial diversity varied by location. Of the 93,114 patients with primary care visits, 71.8% received screening for alcohol use, and 70.5% received screening for drug use. Screening at any visit (implemented at site A) in comparison with screening at annual examinations only (implemented at site B) was associated with higher screening rates for alcohol use (90.3%-94.7% vs 24.2%-72.0%, respectively) and drug use (89.6%-93.9% vs 24.6%-69.8%). The 5 clinics that used a self-administered screening approach had a higher detection rate for moderate- to high-risk alcohol use (14.7%-36.6%) compared with the 1 clinic that used a staff-administered screening approach (1.6%). The detection of moderate- to high-risk drug use was low across all clinics (0.5%-1.0%). Clinics with more robust practice facilitation and EHR usability testing had somewhat greater adoption of the counseling script for patients with moderate-high risk alcohol or drug use (1.4%-12.5% vs 0.1%-1.1%). Conclusions and Relevance: In this quality improvement study, EHR-integrated screening was feasible to implement in all clinics and unhealthy alcohol use was detected more frequently when self-administered screening was used at any primary care visit. The detection of drug use was low at all clinics, as was clinician adoption of counseling. These findings can be used to inform the decision-making of health care systems that are seeking to implement screening for substance use. Trial Registration: ClinicalTrials.gov Identifier: NCT02963948.

Identifying risk of opioid use disorder for patients taking opioid medications with deep learning.

OBJECTIVE: The United States is experiencing an opioid epidemic. In recent years, there were more than 10 million opioid misusers aged 12 years or older annually. Identifying patients at high risk of opioid use disorder (OUD) can help to make early clinical interventions to reduce the risk of OUD. Our goal is to develop and evaluate models to predict OUD for patients on opioid medications using electronic health records and deep learning methods. The resulting models help us to better understand OUD, providing new insights on the opioid epidemic. Further, these models provide a foundation for clinical tools to predict OUD before it occurs, permitting early interventions. METHODS: Electronic health records of patients who have been prescribed with medications containing active opioid ingredients were extracted from Cerner's Health Facts database for encounters between January 1, 2008, and December 31, 2017. Long short-term memory models were applied to predict OUD risk based on five recent prior encounters before the target encounter and compared with logistic regression, random forest, decision tree, and dense neural network. Prediction performance was assessed using F1 score, precision, recall, and area under the receiver-operating characteristic curve. RESULTS: The long short-term memory (LSTM) model provided promising prediction results which outperformed other methods, with an F1 score of 0.8023 (about 0.016 higher than dense neural network (DNN)) and an area under the receiver-operating characteristic curve (AUROC) of 0.9369 (about 0.145 higher than DNN). CONCLUSIONS: LSTM-based sequential deep learning models can accurately predict OUD using a patient's history of electronic health records, with minimal prior domain knowledge. This tool has the potential to improve clinical decision support for early intervention and prevention to combat the opioid epidemic.

Association of Opioid Use Disorder With 2016 Presidential Voting Patterns: Cross-sectional Study in New York State at Census Tract Level.

BACKGROUND: Opioid overdose-related deaths have increased dramatically in recent years. Combating the opioid epidemic requires better understanding of the epidemiology of opioid poisoning (OP) and opioid use disorder (OUD). OBJECTIVE: We aimed to discover geospatial patterns in nonmedical opioid use and its correlations with demographic features related to despair and economic hardship, most notably the US presidential voting patterns in 2016 at census tract level in New York State. METHODS: This cross-sectional analysis used data from New York Statewide Planning and Research Cooperative System claims data and the presidential voting results of 2016 in New York State from the Harvard Election Data Archive. We included 63,958 patients who had at least one OUD diagnosis between 2010 and 2016 and 36,004 patients with at least one OP diagnosis between 2012 and 2016. Geospatial mappings were created to compare areas of New York in OUD rates and presidential voting patterns. A multiple regression model examines the extent that certain factors explain OUD rate variation. RESULTS: Several areas shared similar patterns of OUD rates and Republican vote: census tracts in western New York, central New York, and Suffolk County. The correlation between OUD rates and the Republican vote was .38 (P<.001). The regression model with census tract level of demographic and socioeconomic factors explains 30% of the variance in OUD rates, with disability and Republican vote as the most significant predictors. CONCLUSIONS: At the census tract level, OUD rates were positively correlated with Republican support in the 2016 presidential election, disability, unemployment, and unmarried status. Socioeconomic and demographic despair-related features explain a large portion of the association between the Republican vote and OUD. Together, these findings underscore the importance of socioeconomic interventions in combating the opioid epidemic.

A large-scale retrospective study of opioid poisoning in New York State with implications for targeted interventions.

Opioid overdose related deaths have increased dramatically in recent years. Combating the opioid epidemic requires better understanding of the epidemiology of opioid poisoning (OP). To discover trends and patterns of opioid poisoning and the demographic and regional disparities, we analyzed large scale patient visits data in New York State (NYS). Demographic, spatial, temporal and correlation analyses were performed for all OP patients extracted from the claims data in the New York Statewide Planning and Research Cooperative System (SPARCS) from 2010 to 2016, along with Decennial US Census and American Community Survey zip code level data. 58,481 patients with at least one OP diagnosis and a valid NYS zip code address were included. Main outcome and measures include OP patient counts and rates per 100,000 population, patient level factors (gender, age, race and ethnicity, residential zip code), and zip code level social demographic factors. The results showed that the OP rate increased by 364.6%, and by 741.5% for the age group > 65 years. There were wide disparities among groups by race and ethnicity on rates and age distributions of OP. Heroin and non-heroin based OP rates demonstrated distinct temporal trends as well as major geospatial variation. The findings highlighted strong demographic disparity of OP patients, evolving patterns and substantial geospatial variation.

Predicting opioid overdose risk of patients with opioid prescriptions using electronic health records based on temporal deep learning.

The US is experiencing an opioid epidemic, and opioid overdose is causing more than 100 deaths per day. Early identification of patients at high risk of Opioid Overdose (OD) can help to make targeted preventative interventions. We aim to build a deep learning model that can predict the patients at high risk for opioid overdose and identify most relevant features. The study included the information of 5,231,614 patients from the Health Facts database with at least one opioid prescription between January 1, 2008 and December 31, 2017. Potential predictors (n = 1185) were extracted to build a feature matrix for prediction. Long Short-Term Memory (LSTM) based models were built to predict overdose risk in the next hospital visit. Prediction performance was compared with other machine learning methods assessed using machine learning metrics. Our sequential deep learning models built upon LSTM outperformed the other methods on opioid overdose prediction. LSTM with attention mechanism achieved the highest F-1 score (F-1 score: 0.7815, AUCROC: 0.8449). The model is also able to reveal top ranked predictive features by permutation important method, including medications and vital signs. This study demonstrates that a temporal deep learning based predictive model can achieve promising results on identifying risk of opioid overdose of patients using the history of electronic health records. It provides an alternative informatics-based approach to improving clinical decision support for possible early detection and intervention to reduce opioid overdose.

Detection of Suicidality Among Opioid Users on Reddit: Machine Learning-Based Approach.

BACKGROUND: In recent years, both suicide and overdose rates have been increasing. Many individuals who struggle with opioid use disorder are prone to suicidal ideation; this may often result in overdose. However, these fatal overdoses are difficult to classify as intentional or unintentional. Intentional overdose is difficult to detect, partially due to the lack of predictors and social stigmas that push individuals away from seeking help. These individuals may instead use web-based means to articulate their concerns. OBJECTIVE: This study aimed to extract posts of suicidality among opioid users on Reddit using machine learning methods. The performance of the models is derivative of the data purity, and the results will help us to better understand the rationale of these users, providing new insights into individuals who are part of the opioid epidemic. METHODS: Reddit posts between June 2017 and June 2018 were collected from r/suicidewatch, r/depression, a set of opioid-related subreddits, and a control subreddit set. We first classified suicidal versus nonsuicidal languages and then classified users with opioid usage versus those without opioid usage. Several traditional baselines and neural network (NN) text classifiers were trained using subreddit names as the labels and combinations of semantic inputs. We then attempted to extract out-of-sample data belonging to the intersection of suicide ideation and opioid abuse. Amazon Mechanical Turk was used to provide labels for the out-of-sample data. RESULTS: Classification results were at least 90% across all models for at least one combination of input; the best classifier was convolutional neural network, which obtained an F1 score of 96.6%. When predicting out-of-sample data for posts containing both suicidal ideation and signs of opioid addiction, NN classifiers produced more false positives and traditional methods produced more false negatives, which is less desirable for predicting suicidal sentiments. CONCLUSIONS: Opioid abuse is linked to the risk of unintentional overdose and suicide risk. Social media platforms such as Reddit contain metadata that can aid machine learning and provide information at a personal level that cannot be obtained elsewhere. We demonstrate that it is possible to use NNs as a tool to predict an out-of-sample target with a model built from data sets labeled by characteristics we wish to distinguish in the out-of-sample target.

Gabapentin Enacarbil Extended-Release for Alcohol Use Disorder: A Randomized, Double-Blind, Placebo-Controlled, Multisite Trial Assessing Efficacy and Safety.

BACKGROUND: Several single-site alcohol treatment clinical trials have demonstrated efficacy for immediate-release (IR) gabapentin in reducing drinking outcomes among individuals with alcohol dependence. The purpose of this study was to conduct a large, multisite clinical trial of gabapentin enacarbil extended-release (GE-XR) (HORIZANT® ), a gabapentin prodrug formulation, to determine its safety and efficacy in treating alcohol use disorder (AUD). METHODS: Men and women (n = 346) who met DSM-5 criteria for at least moderate AUD were recruited across 10 U.S. clinical sites. Participants received double-blind GE-XR (600 mg twice a day) or placebo and a computerized behavioral intervention (Take Control) for 6 months. Efficacy analyses were prespecified for the last 4 weeks of the treatment period. RESULTS: The GE-XR and placebo groups did not differ significantly on the primary outcome measure, percentage of subjects with no heavy drinking days (28.3 vs. 21.5, respectively, p = 0.157). Similarly, no clinical benefit was found for other drinking measures (percent subjects abstinent, percent days abstinent, percent heavy drinking days, drinks per week, drinks per drinking day), alcohol craving, alcohol-related consequences, sleep problems, smoking, and depression/anxiety symptoms. Common side-effects were fatigue, dizziness, and somnolence. A population pharmacokinetics analysis revealed that patients had lower gabapentin exposure levels compared with those in other studies using a similar dose but for other indications. CONCLUSIONS: Overall, GE-XR at 600 mg twice a day did not reduce alcohol consumption or craving in individuals with AUD. It is possible that, unlike the IR formulation of gabapentin, which showed efficacy in smaller Phase 2 trials at a higher dose, GE-XR is not effective in treating AUD, at least not at doses approved by the U.S. Food and Drug Administration for treating other medical conditions.

Machine Learning Based Opioid Overdose Prediction Using Electronic Health Records.

Opioid addiction in the United States has come to national attention as opioid overdose (OD) related deaths have risen at alarming rates. Combating opioid epidemic becomes a high priority for not only governments but also healthcare providers. This depends on critical knowledge to understand the risk of opioid overdose of patients. In this paper, we present our work on building machine learning based prediction models to predict opioid overdose of patients based on the history of patients' electronic health records (EHR). We performed two studies using New York State claims data (SPARCS) with 440,000 patients and Cerner's Health Facts database with 110,000 patients. Our experiments demonstrated that EHR based prediction can achieve best recall with random forest method (precision: 95.3%, recall: 85.7%, F1 score: 90.3%), best precision with deep learning (precision: 99.2%, recall: 77.8%, F1 score: 87.2%). We also discovered that clinical events are among critical features for the predictions.

Novel Formulations of Buprenorphine for Treatment of Opioid Use Disorder.

Opioid use disorder (OUD) is epidemic in the United States. In addition to medical, economic, and social impairments, risk of overdose fatality is high. In 2017, there were 14,958 deaths from natural or semisynthetic opioids, 15,958 from heroin, and 29,406 from synthetic opioids, such as fentanyl. Psychosocial interventions do not add substantial efficacy to medical OUD treatments, and thus making evidence-based OUD treatments more accessible is urgent. However, considerable diversion of oral and transmucosal opioid maintenance medications has been documented. Delivery systems that reduce risks of nonadherence through diversion or altered self-administration may increase buprenorphine's effectiveness for clinical stabilization via increased treatment exposure. The article presents findings from multisite efficacy studies of two subcutaneous depot buprenorphine formulations and a long-acting implant. Novel delivery systems show promise in providing improved outcomes through intermediate- and long-acting exposure to medication while reducing the risk of medication nonadherence, diversion, and accidental exposure.

Barriers and facilitators affecting the implementation of substance use screening in primary care clinics: a qualitative study of patients, providers, and staff.

BACKGROUND: Alcohol and drug use are leading causes of morbidity and mortality that frequently go unidentified in medical settings. As part of a multi-phase study to implement electronic health record-integrated substance use screening in primary care clinics, we interviewed key clinical stakeholders to identify current substance use screening practices, barriers to screening, and recommendations for its implementation. METHODS: Focus groups and individual interviews were conducted with 67 stakeholders, including patients, primary care providers (faculty and resident physicians), nurses, and medical assistants, in two urban academic health systems. Themes were identified using an inductive approach, revised through an iterative process, and mapped to the Knowledge to Action (KTA) framework, which guides the implementation of new clinical practices (Graham et al. in J Contin Educ Health Prof 26(1):13-24, 2006). RESULTS: Factors affecting implementation based on KTA elements were identified from participant narratives. Identifying the problem: Participants consistently agreed that having knowledge of a patient's substance use is important because of its impacts on health and medical care, that substance use is not properly identified in medical settings currently, and that universal screening is the best approach. Assessing barriers: Patients expressed concerns about consequences of disclosing substance use, confidentiality, and the individual's own reluctance to acknowledge a substance use problem. Barriers identified by providers included individual-level factors such as lack of clinical knowledge and training, as well as systems-level factors including time pressure, resources, lack of space, and difficulty accessing addiction treatment. Adapting to the local context: Most patients and providers stated that the primary care provider should play a key role in substance use screening and interventions. Opinions diverged regarding the optimal approach to delivering screening, although most preferred a patient self-administered approach. Many providers reported that taking effective action once unhealthy substance use is identified is crucial. CONCLUSIONS: Participants expressed support for substance use screening as a valuable part of medical care, and identified individual-level as well as systems-level barriers to its implementation. These findings suggest that screening programs should clearly communicate the goals of screening to patients and proactively counteract stigma, address staff concerns regarding time and workflow, and provide education as well as treatment resources to primary care providers.