Understanding the characteristics of Latino individuals with first-time DUI offenses to facilitate effective interventions.

Literature shows that Latinos who drink are more likely to experience alcohol-related consequences and less likely to seek care for alcohol misuse than Whites. We aim to understand characteristics, consumption patterns, and openness to treatment among Latino first-time offenders driving under the influence. Latino participants were significantly younger (29.0 years) than non-Latinos (37.7 years). In adjusted models, Latino participants were significantly more likely than non-Latinos to binge drink, but there were no significant group differences in amount of alcohol consumed in a typical week. There was no significant difference in incidence of alcohol-related consequences, readiness to change drinking, and driving behaviors in this sample.

Effect of culinary education curriculum on Mediterranean diet adherence and food cost savings in families: a randomised controlled trial.

OBJECTIVE: Diet-related diseases are the leading cause of morbidity and mortality in the USA. While the critical aspects of a healthy diet are well known, the relationship between community-based, teaching kitchen education and dietary behaviours is unclear. We examined the effect of a novel culinary medicine education programme on Mediterranean diet adherence and food cost savings. DESIGN: Families were randomised to a hands-on, teaching kitchen culinary education class (n = 18) or non-kitchen-based dietary counselling (n = 23) for 6 weeks. The primary outcome was adherence to the validated nine-point Mediterranean diet score, and the secondary outcome was food cost savings per family. SETTING: The Goldring Center for Culinary Medicine, a community teaching kitchen in New Orleans. PARTICIPANTS: Families (n = 41) of at least one child and one parent. RESULTS: Compared with families receiving traditional dietary counselling, those participating in hands-on, kitchen-based nutrition education were nearly three times as likely to follow a Mediterranean dietary pattern (OR 2·93, 95% CI 1·73, 4·95; P  <  0·001), experiencing a 0·43-point increase in Mediterranean diet adherence after 6 weeks (B  =  0·43; P  <  0·001). Kitchen-based nutrition education projects to save families $US 21·70 per week compared with standard dietary counselling by increasing the likelihood of consuming home-prepared v. commercially-prepared meals (OR 1·56, 95% CI 1·08, 2·25; P  =  0·018). CONCLUSIONS: Community-based culinary medicine education improves Mediterranean diet adherence and associates with food cost savings among a diverse sample of families. Hands-on culinary medicine education may be a novel evidence-based tool to teach healthful dietary habits and prevent chronic disease.

Facilitators and barriers to implementing pharmacist-prescribed hormonal contraception in California independent pharmacies.

In 2013, California passed legislation to expand the scope of pharmacist practice, including authorizing pharmacists to prescribe hormonal contraception. Pharmacist-prescribed contraception was largely unavailable across the state in 2017. This study aimed to identify barriers and facilitators to offering this service in California independent pharmacies. To do so, we thematically analyzed qualitative data from structured interviews with 36 pharmacists working in independent pharmacies in 2016-17. We found that pharmacists anticipated general benefits from expanding their roles to prescribe contraception, including increasing health care access and decreasing costs. In contrast, described barriers were concrete, including lack of financial incentives and business risks for independent pharmacies. Specific barriers to prescribing hormonal contraception included time required to screen and counsel women about contraception and concerns that pharmacist-prescribed contraception would increase liability and lead to patients seeking health care less frequently. This study suggests that incentives and barriers identified by the respondents are likely to have varied and unequal impacts, with immediate barriers being potentially prohibitive for pharmacists to prescribe contraception. For independent pharmacies, perceived business risks and lack of insurance reimbursement may outweigh professional support for prescribing contraception, limiting the public health impact of legislation that should increase contraceptive access.

Randomized Clinical Trial Examining Cognitive Behavioral Therapy for Individuals With a First-Time DUI Offense.

BACKGROUND: Driving under the influence (DUI) programs are a unique setting to reduce disparities in treatment access to those who may not otherwise access treatment. Providing evidence-based therapy in these programs may help prevent DUI recidivism. METHODS: We conducted a randomized clinical trial of 312 participants enrolled in 1 of 3 DUI programs in California. Participants were 21 and older with a first-time DUI offense who screened positive for at-risk drinking in the past year. Participants were randomly assigned to a 12-session manualized cognitive behavioral therapy (CBT) or usual care (UC) group and then surveyed 4 and 10 months later. We conducted intent-to-treat analyses to test the hypothesis that participants receiving CBT would report reduced impaired driving, alcohol consumption (drinks per week, abstinence, and binge drinking), and alcohol-related negative consequences. We also explored whether race/ethnicity and gender moderated CBT findings. RESULTS: Participants were 72.3% male and 51.7% Hispanic, with an average age of 33.2 (SD = 12.4). Relative to UC, participants receiving CBT had lower odds of driving after drinking at the 4- and 10-month follow-ups compared to participants receiving UC (odds ratio [OR] = 0.37, p = 0.032, and OR = 0.29, p = 0.065, respectively). This intervention effect was more pronounced for females at 10-month follow-up. The remaining 4 outcomes did not significantly differ between UC versus CBT at 4- and 10-month follow-ups. Participants in both UC and CBT reported significant within-group reductions in 2 of 5 outcomes, binge drinking and alcohol-related consequences, at 10-month follow-up (p < 0.001). CONCLUSIONS: In the short-term, individuals receiving CBT reported significantly lower rates of repeated DUI than individuals receiving UC, which may suggest that learning cognitive behavioral strategies to prevent impaired driving may be useful in achieving short-term reductions in impaired driving.

Changes in In-Person, Audio-Only, and Video Visits in California's Federally Qualified Health Centers, 2019-2022.

This study assesses telehealth visit trends among California federally qualified health centers from 2019 to 2022.

The intended and unintended consequences of quality improvement interventions for small practices in a community-based electronic health record implementation project.

BACKGROUND: Despite the rapid rise in the implementation of electronic health records (EHR), commensurate improvements in health care quality have not been consistently observed. OBJECTIVES: To evaluate whether the implementation of EHRs and complementary interventions-including clinical decision support, technical assistance, and financial incentives-improved quality of care. RESEARCH DESIGN: The study included 143 practices that implemented EHRs as part of the Primary Care Information Project-a long-standing community-based EHR implementation initiative. A total of 71 practices were randomized to receive financial incentives and quality feedback and 72 were randomized to feedback alone. All practices received technical assistance and had clinical decision support in their EHR. Using data from 2009 to 2011, we estimated measure-level fixed effects models to evaluate the association between exposure to clinical decision support, technical assistance, financial incentives, and quality of care. Associations were estimated separately for 4 cardiovascular measures that were rewarded by the financial incentive program and 4 measures that were not rewarded by incentives. RESULTS: Financial incentives for quality were consistently associated with higher performance for the incentivized measures [+10.1 percentage points at 18 mo of exposure (approximately +22%), P<0.05] and lower performance for the unincentivized measures [-8.3 percentage points at 12 mo of exposure (approximately -20%), P<0.05]. Technical assistance was associated with higher quality for the unincentivized measures, but not for the incentivized measures. CONCLUSIONS: Technical assistance and financial incentives-alongside EHR implementation-can improve quality of care. Financial incentives for quality may not result in similar improvements for incentivized and unincentivized measures.

Patient-centered medical home among small urban practices serving low-income and disadvantaged patients.

PURPOSE: Research on the patient-centered medical home (PCMH) model and practice redesign has not focused on the unique challenges and strengths of very small primary care practices serving disadvantaged patient populations. We analyzed the practice characteristics, prior experiences, and dimensions of the PCMH model that exist in such practices participating in the Primary Care Information Project (PCIP) of the New York City Department of Mental Health and Hygiene. METHODS: We obtained descriptive data, focusing on PCMH, for 94 primary care practices with 5 or fewer clinicians serving high volumes of Medicaid and minority patient populations in New York City. Data included information extracted from PCIP administrative data and survey data collected specifically for this study. RESULTS: Survey results indicated substantial implementation of key aspects of the PCMH among small practices serving disadvantaged patient populations, despite considerable potential challenges to achieving PCMH implementation. Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH. CONCLUSIONS: Small practices can achieve important aspects of the PCMH model of primary care, often with informal rather than formal mechanisms and strategies. The use of flexible, less formal strategies is important to keep in mind when considering implementation and assessment of PCMH-like initiatives in small practices.

Sustained improvement in clinical preventive service delivery among independent primary care practices after implementing electronic health record systems.

INTRODUCTION: Studies showing sustained improvements in the delivery of clinical preventive services are limited. Fewer studies demonstrate sustained improvements among independent practices that are not affiliated with hospitals or integrated health systems. This study examines the continued improvement in clinical quality measures for a group of independent primary care practices using electronic health records (EHRs) and receiving technical support from a local public health agency. METHODS: We analyzed clinical quality measure performance data from a cohort of primary care practices that implemented an EHR at least 3 months before October 2009, the study baseline. We assessed trends for 4 key quality measures: antithrombotic therapy, blood pressure control, smoking cessation intervention, and hemoglobin A1c (HbA1c) testing based on monthly summary data transmitted by the practices. RESULTS: Of the 151 practices, 140 were small practices and 11 were community health centers; average time using an EHR was 13.7 months at baseline. From October 2009 through October 2011, average rates increased for antithrombotic therapy (from 58.4% to 74.8%), blood pressure control (from 55.3% to 64.1%), HbA1c testing (from 46.4% to 57.7%), and smoking cessation intervention (from 29.3% to 46.2%). All improvements were significant. CONCLUSION: During 2 years, practices showed significant improvement in the delivery of several key clinical preventive services after implementing EHRs and receiving support services from a public health agency.

Perceptions of Pediatric Endocrinologists and Neurologists on the Drivers of Telehealth Use.

OBJECTIVE: To assess the extent and drivers of telehealth use variation across clinicians within the same pediatric subspecialties. METHODS: In this mixed methods study, 8 pediatric medical groups in California shared data for eleven subspecialties. We calculated the proportion of total visits delivered via telehealth by medical group for each subspecialty and identified the 8 most common International Classification of Diseases 10 diagnoses for telehealth and in-person visits in endocrinology and neurology. We conducted semi-structured interviews with 32 pediatric endocrinologists and neurologists and applied a positive deviance approach comparing high versus low utilizers to identify factors that influenced their level of telehealth use. RESULTS: In 2019, medical groups that submitted quantitative data conducted 1.8 million visits with 549,306 unique pediatric patients. For 3 subspecialties, there was relatively little variation in telehealth use across medical groups: urology (mean: 16.5%, range: 9%-23%), orthopedics (mean: 7.2%, range: 2%-14%), and cardiology (mean: 11.2%, range: 2%-24%). The remaining subspecialties, including neurology (mean: 58.6%, range: 8%-93%) and endocrinology (mean: 49.5%, range: 24%-92%), exhibited higher levels of variation. For both neurology and endocrinology, the top diagnoses treated in-person were similar to those treated via telehealth. There was limited consensus on which clinical conditions were appropriate for telehealth. High telehealth utilizers were more comfortable conducting telehealth visits for new patients and often worked in practices with innovations to support telehealth. CONCLUSIONS: Clinicians perceive that telehealth may be appropriate for a range of clinical conditions when the right supports are available.

Experiences of Health Centers in Implementing Telehealth Visits for Underserved Patients During the COVID-19 Pandemic: Results from the Connected Care Accelerator Initiative.

In early 2020, as the coronavirus disease 2019 (COVID-19) pandemic emerged, widespread social-distancing efforts suspended much of the delivery of nonurgent health care. Telehealth proved to be a viable alternative to in-person care, at least on a temporary basis, and utilization skyrocketed. Many Federally Qualified Health Centers (FQHCs) serving low-income patients started delivering telehealth visits in high volume in March 2020 to help maintain access to care. This sudden and dramatic change in health care delivery posed numerous challenges. Health centers had to quickly make changes to technology, workflows, and staffing to accommodate telehealth visits. To support health centers in these efforts, the California Health Care Foundation established the Connected Care Accelerator (CCA) program, a quality improvement initiative that was launched in July 2020. RAND researchers evaluated the progress of FQHCs that participated in the CCA initiative by investigating changes in telehealth utilization and health center staff experiences with implementation. In this research, researchers review recent literature on telehealth implementation in safety net settings. They also present new information on the experiences of the 45 CCA health centers, drawing from data on visit trends, interviews with health center leaders, and surveys of health center providers and staff. Telehealth has the potential to increase access to care and deliver care that is more convenient and patient-centered; however, ongoing research is needed to ensure that telehealth is implemented in a way that ensures high-quality care and health equity.

Opioid Use Disorder Among Clients of Community Mental Health Clinics: Prevalence, Characteristics, and Treatment Willingness.

OBJECTIVE: The authors examined the prevalence of co-occurring opioid use disorder and willingness to engage in treatment among clients of eight Los Angeles County Department of Mental Health outpatient clinics. METHODS: Adults presenting for an appointment over a 2-week period were invited to complete a voluntary, anonymous health survey. Clients who indicated opioid use in the past year were offered a longer survey assessing probable opioid use disorder. Willingness to take medication and receive treatment also was assessed. RESULTS: In total, 3,090 clients completed screening. Among these, 8% had a probable prescription (Rx) opioid use disorder and 2% a probable heroin use disorder. Of the clients with probable Rx opioid use or heroin use disorder, 49% and 25% were female, respectively. Among those with probable Rx opioid use disorder, 43% were Black, 33% were Hispanic, and 12% were White, and among those with probable heroin use disorder, 24% were Black, 22% were Hispanic, and 39% were White. Seventy-eight percent of those with Rx opioid use disorder had never received any treatment, and 82% had never taken a medication for this disorder; 39% of those with heroin use disorder had never received any treatment, and 39% had never received a medication. The strongest predictor of willingness to take a medication was believing that it would help stop opioid use (buprenorphine, ß=13.54, p=0.003, and naltrexone long-acting injection, ß=15.83, p<0.001). CONCLUSIONS: These findings highlight the need to identify people with opioid use disorder and to educate clients in mental health settings about medications for these disorders.

Use of Telehealth Across Pediatric Subspecialties Before and During the COVID-19 Pandemic.

Importance: The identification of variation in health care is important for quality improvement. Little is known about how different pediatric subspecialties are using telehealth and what is driving variation. Objective: To characterize trends in telehealth use before and during the COVID-19 pandemic across pediatric subspecialties and the association of delivery change with no-show rates and access disparities. Design, Setting, and Participants: In this cohort study, 8 large pediatric medical groups in California collaborated to share aggregate data on telehealth use for 11 pediatric subspecialties from January 1, 2019, to December 31, 2021. Main Outcomes and Measures: Monthly in-person and telehealth visits for 11 subspecialties, characteristics of patients participating in in-person and telehealth visits, and no-show rates. Monthly use rates per 1000 unique patients were calculated. To assess changes in no-show rates, a series of linear regression models that included fixed effects for medical groups and calendar month were used. The demographic characteristics of patients served in person during the prepandemic period were compared with those of patients who received in-person and telehealth care during the pandemic period. Results: In 2019, participating medical groups conducted 1.8 million visits with 549 306 unique patients younger than 18 years (228 120 [41.5%] White and 277 167 [50.5%] not Hispanic). A total of 72 928 patients (13.3%) preferred a language other than English, and 250 329 (45.6%) had Medicaid. In specialties with lower telehealth use (cardiology, orthopedics, urology, nephrology, and dermatology), telehealth visits ranged from 6% to 29% of total visits from May 1, 2020, to April 30, 2021. In specialties with higher telehealth use (genetics, behavioral health, pulmonology, endocrinology, gastroenterology, and neurology), telehealth constituted 38.8% to 73.0% of total visits. From the prepandemic to the pandemic periods, no-show rates slightly increased for lower-telehealth-use subspecialties (9.2% to 9.4%) and higher-telehealth-use subspecialties (13.0% to 15.3%), but adjusted differences (comparing lower-use and higher-use subspecialties) in changes were not statistically significant (difference, 2.5 percentage points; 95% CI, -1.2 to 6.3 percentage points; P = .15). Patients who preferred a language other than English constituted 6140 in-person visits (22.2%) vs 2707 telehealth visits (11.4%) in neurology (P < .001). Conclusions and Relevance: There was high variability in adoption of telehealth across subspecialties and in patterns of use over time. The documentation of variation in telehealth adoption can inform evolving telehealth policy for pediatric patients, including the appropriateness of telehealth for different patient needs and areas where additional tools are needed to promote appropriate use.

Syndromic surveillance during pandemic (H1N1) 2009 outbreak, New York, New York, USA.

We compared emergency department and ambulatory care syndromic surveillance systems during the pandemic (H1N1) 2009 outbreak in New York City. Emergency departments likely experienced increases in influenza-like-illness significantly earlier than ambulatory care facilities because more patients sought care at emergency departments, differences in case definitions existed, or a combination thereof.

Study of electronic prescribing rates and barriers identified among providers using electronic health records in New York City.

BACKGROUND: Increased electronic prescribing (eRx) rates have the potential to prevent errors, increase patient safety, and curtail fraud. US Federal meaningful use guidelines require at least a 40% electronic prescribing rate. OBJECTIVE: We evaluated eRx rates among primary care providers in New York City in order to determine trends as well as identify any obstacles to increased eRx rates required by meaningful use guidelines. METHODS: The data we analysed included automatic electronic data transmissions from providers enrolled in the Primary Care Information Project (PCIP) from 1 January 2009 to 1 July 2010 and follow-up telephone calls to a subset of these providers to identify potential barriers to increased eRx usage. RESULTS: Over the course of the study, these providers increased the eRx rate from 12.9 to 27.5%, with an average rate of 24.1%. Conversations with providers identified their perceived barriers to increased eRx use as primarily patient preference for paper prescriptions and a belief that many pharmacies do not accept eRx. CONCLUSIONS: The data gathered from our providers indicate that there is an increasing trend in the eRx rate to 27.5% by July 2010, but still short of the 40% meaningful use level. However, obstacles to increased rates remain primarily providers' belief that many patients prefer paper prescriptions and many pharmacies are not yet prepared to accept electronic prescriptions.

Effects of motivational interviewing fidelity on substance use treatment engagement in primary care.

OBJECTIVE: Primary care (PC) may be an opportune setting to engage patients with opioid and alcohol use disorders (OAUDs) in treatment. We examined whether motivational interviewing (MI) fidelity was associated with engagement in primary care-based OAUD treatment in an integrated behavioral health setting. METHODS: We coded 42 first session therapy recordings and examined whether therapist MI global ratings and behavior counts were associated with patient engagement, defined as the patient receiving one shot of extended-release injectable naltrexone or any combination of at least two additional behavioral therapy, sublingual buprenorphine/naloxone prescriptions, or OAUD-related medical visits within 30days of their initial behavioral therapy visit. RESULTS: Autonomy/support global ratings were higher in the non-engaged group (OR=0.28, 95%CI: 0.09-0.93; p=0.037). No other MI fidelity ratings were significantly associated with engagement. CONCLUSION: We did not find positive associations between MI fidelity and engagement in primary care-based OAUD treatment. More research with larger samples is needed to examine how providing autonomy/support to patients who are not ready to change may affect engagement. PRACTICE IMPLICATIONS: Training providers to strategically use MI to reinforce change as opposed to the status quo is needed. This may be especially important in primary care where patients may not be specifically seeking help for their OAUDs.

Predictors of treatment initiation for alcohol use disorders in primary care.

BACKGROUND: We identified predictors of receiving treatment (brief therapy [BT] and/or extended-release injectable naltrexone [XR-NTX]) for the treatment of alcohol use disorders (AUDs) in primary care. We also examined the relationship between receiving BT and XR-NTX. METHODS: Secondary data analysis of SUMMIT, a randomized controlled trial of collaborative care. Participants were 290 individuals with AUDs who reported no past 30-day opioid use and who were receiving primary care at a multi-site Federally Qualified Health Center. Bivariate and multivariate analyses examined predictors of BT and/or XR-NTX. RESULTS: Thirty-two percent (N = 93) received either BT or XR-NTX, 28% (N = 82) received BT and 13% (N = 37) received XR-NTX; 9% (N = 26) received both BT and XR-NTX. Older age, white race, talking with a professional about alcohol use and having more negative consequences all predicted receipt of evidence-based treatment; being homeless was a negative predictor. The predictors of receiving BT included not being homeless and previously talking with a professional; the predictors of receiving XR-NTX included older age, white race and experiencing more negative consequences. In 80% of those who received both BT and XR-NTX, receipt of BT preceded XR-NTX. CONCLUSIONS: Patient factors were important predictors of receiving primary-care based AUD treatment and differed by type of treatment received. Receiving BT was associated with subsequent use of XR-NTX and may be associated with a longer duration of XR-NTX treatment. Providers should consider these findings when considering ways to increase primary-care based AUD treatment.

Patient predictors of substance use disorder treatment initiation in primary care.

INTRODUCTION: Primary care clinics are opportune settings in which to deliver substance use disorder (SUD) treatment, but little is known about which patients initiate treatment in these settings. METHODS: Using secondary data from a RCT that aimed to integrate SUD treatment into a federally qualified health center (FQHC) using an organizational readiness and collaborative care (CC) intervention, we examined patient-level predictors of initiation of evidence-based practices for opioid and/or alcohol use disorders (OAUDs): a brief behavioral treatment (BT) based on motivational interviewing and cognitive behavioral therapy and medication-assisted treatment (MAT) (extended-release injectable naltrexone (XR-NTX) for patients with an alcohol use disorder or opioid use disorder and buprenorphine/naloxone (BUP/NX) for patients with an opioid use disorder). Using the Andersen model of health care access, we tested bivariate and multivariate logistic regression models to assess associations between patient factors and initiation of BT and MAT. RESULTS: Twenty-three percent of all participants (N = 392) received BT and 13% received MAT. In the multivariate model examining factors associated with initiation of BT, being of "other" or "multiple" races compared with being White (OR = 0.45, CI = 0.22, 0.92), being homeless (OR = 0.45, CI = 0.21, 0.97) and having been arrested within 90 days of baseline (OR = 0.21 CI = 0.63, 0.69) were associated with significantly lower odds of initiating BT. Greater self-stigma (OR = 1.60, CI = 1.06, 2.42), receiving MAT (OR = 5.52, CI = 2.34, 12.98), and having received the CC study intervention (OR = 12.95, CI = 5.91, 28.37) were associated with higher odds of initiating BT. In the multivariate model examining patient factors associated with initiating MAT, older age (OR = 1.07, CI = 1.03, 1.11), female gender (OR = 3.05, CI = 1.25, 7.46), having a diagnosis of heroin abuse or dependence (with or without alcohol abuse or dependence compared with have a diagnosis of alcohol dependence only (OR = 3.03, CI = 1.17, 7.86), and having received at least one session of BT (OR = 6.42, CI = 2.59, 15.94), were associated with higher odds of initiating MAT. CONCLUSIONS: Individuals who initiate BT for OAUDs in a FQHC are less likely to be homeless and more likely to have greater self-stigma. Those who receive MAT are more likely to be of older age, female, and to have a diagnosis of heroin abuse or dependence, with or without concomitant alcohol abuse or dependence, rather than alcohol abuse or dependence alone. Receiving collaborative care (e.g., a warm handoff, and follow-up by a care coordinator) may be critical to initiating BT. Receiving at least one session of BT is associated with higher odds of receiving MAT, and receiving MAT is associated with higher odds of receiving BT. The Andersen model of health care access provides some insight into who initiates BT and MAT for OAUD treatment in FQHC-based primary care; further research is needed to explore system-level factors that may also influence treatment initiation.

Initiation and engagement as mechanisms for change caused by collaborative care in opioid and alcohol use disorders.

BACKGROUND: To assess the mechanism by which a collaborative care (CC) intervention improves self-reported abstinence among primary care patients with opioid and alcohol use disorders (OAUD) compared to treatment as usual. METHODS: Secondary data analysis of SUMMIT, a randomized controlled trial of CC for OAUD. Participants were 258 patients with OAUD receiving primary care at a multi-site Federally Qualified Health Center. Using a mediation analysis decomposition of a total effect into a mediated and a direct effect, we examined the effect of CC on abstinence at six months, attributable to the HEDIS treatment initiation and engagement measures for the total sample, for individuals with alcohol use disorders alone, and for those with a co-morbid opioid use disorder. RESULTS: Although the CC intervention led to an increase in both initiation and engagement, among the full sample, only initiation mediated the effect of the intervention on abstinence (3.8%, CI=[0.4%, 8.3%]; 32% proportion of the total effect). In subgroup analyses, among individuals with comorbid alcohol and opioid use disorders, almost 100% of the total effect was mediated by engagement, but the effect was not significant. This was not observed among the alcohol use disorder only group. CONCLUSIONS: Among primary care patients with OAUDs, treatment initiation partially mediated the effect of CC on abstinence at 6-months. The current study emphasizes the importance of primary care patients returning for a second substance-use related visit after identification. CC may work differently for people with co-morbid opioid use disorders vs. alcohol use disorders alone.