Experiences of and recommendations for LGBTQ+-affirming substance use services: an exploratory qualitative descriptive study with LGBTQ+ people who use opioids and other drugs.

BACKGROUND: Lesbian, gay, bisexual, transgender, queer, and other LGBTQ populations (LGBTQ+; e.g., asexual individuals) have higher rates of substance use (SU) and disorders (SUD) compared to heterosexual and cisgender populations. Such disparities can be attributed to minority stress, including stigma and discrimination in healthcare settings. LGBTQ+-affirming SU treatment and related services remain limited. The purpose of this exploratory qualitative descriptive study was to characterize LGBTQ+ people's experiences in SU services and recommendations for LGBTQ+- affirming care. METHODS: We conducted demographic surveys (characterized using descriptive statistics) and individual qualitative interviews with N = 23 LGBTQ+ people. We employed flexible coding and a thematic analysis approach to describe participants' experiences with stigma, discrimination, and support within SU services at the patient-, staff-, and organizational-level; and participant recommendations for how to make such services LGBTQ+-affirming. We highlighted components of minority stress and mitigators of adverse stress responses throughout our thematic analysis. RESULTS: Patient-level experiences included bullying, name-calling, sexual harassment, and physical distancing from peers; and support via community-building with LGBTQ+ peers. Staff-level experiences included name-calling, denial of services, misgendering, lack of intervention in peer bullying, and assumptions about participants' sexuality; and support via staff advocacy for LGBTQ+ patients, holistic treatment models, and openly LGBTQ+ staff. Organizational-level experiences included stigma in binary gendered program structures; and support from programs with gender-affirming groups and housing, and in visual cues (e.g., rainbow flags) of affirming care. Stigma and discrimination led to minority stress processes like identity concealment and stress coping responses like SU relapse; support facilitated SU treatment engagement and retention. Recommendations for LGBTQ+-affirming care included non-discrimination policies, LGBTQ+-specific programming, hiring LGBTQ+ staff, routine staff sensitivity training, and gender-inclusive program structures. CONCLUSIONS: LGBTQ+ people experience stigma and discrimination within SU services; supportive and affirming care is vital to reducing treatment barriers and promoting positive health outcomes. The current study offers concrete recommendations for how to deliver LGBTQ+-affirming care, which could reduce SU disparities and drug overdose mortality overall.

Culturally tailored digital therapeutic for substance use disorders with urban Indigenous people in the United States: A randomized controlled study.

INTRODUCTION: Indigenous people experience health disparities, including higher rates of substance use disorders (SUDs). Digital therapeutics are a growing platform for treatment services and have the potential to expand access to culturally responsive interventions for Indigenous people. As one of the first randomized controlled trials for SUDs for American Indian and Alaska Native (AI/AN) adults, the aim of this study was to pilot test the efficacy of a culturally tailored intervention among urban Indigenous adults. METHODS: The study used a randomized controlled parallel design of 12 weeks of treatment-as-usual (TAU) (n = 26) versus TAU + Therapeutic Education System-Native Version (TES-NAV) (n = 27) with follow-up assessments at end of treatment and week 24 in an urban outpatient addiction treatment program for Native American adults. TAU consisted of individual/group counseling and cultural activities. The TES-NAV arm comprised TAU + 26 self-directed culturally tailored digital skills-based modules grounded in the community reinforcement approach with contingency management for abstinence and module completion. Primary outcome was longest consecutive weeks of abstinence from drugs and heavy drinking measured using self-report (Timeline Followback) and urine alcohol and drug toxicology screen during 12 weeks of treatment. Secondary outcomes were percent days abstinence during and posttreatment, coping strategies, social connectedness, and substance use and sexual risk behaviors. RESULTS: The study enrolled fifty-three (52.8 % male) AI/AN adults seeking treatment for a SUD. Although the study did not detect a benefit of TAU+TES-NAV over TAU on the primary outcome (Median = 2 consecutive weeks of abstinence for both arms) at end of treatment (treatment effect: Z = -0.78, p = 0.437), TAU+TES-NAV participants did demonstrate significantly greater percent days of abstinence at the week 24 follow-up (69.3 % versus 49.0 % for TAU; t = 2.08, p = 0.045) and significantly greater change in social connectedness mean score, baseline to week 12 (Z = -2.66, p = 0.011), compared to TAU. The study detected no differences between treatment arms for coping strategies or risk behaviors. CONCLUSION: The addition of TES-NAV to TAU did not significantly improve consecutive weeks of abstinence from drugs or heavy drinking; however, several secondary findings suggest promise for a culturally tailored digital therapeutic SUD intervention among urban Indigenous people. CLINICAL TRIALS: GOV REGISTRATION: #NCT03363256.

Experiences of and recommendations for LGBTQ+-affirming substance use services: A qualitative study with LGBTQ+ people who use opioids and other drugs.

Background: Lesbian, gay, bisexual, transgender, queer, and other LGBTQ populations (LGBTQ+; e.g., non-binary individuals) have higher rates of substance use (SU) and disorders (SUD) compared to heterosexual and cisgender populations. Such disparities can be attributed to minority stress, including stigma and discrimination in healthcare settings. LGBTQ+-affirming SU treatment and related services remain limited. The purpose of this qualitative study was to characterize LGBTQ + people's experiences in SU services and recommendations for LGBTQ+-affirming care. Methods: We conducted demographic surveys (characterized using descriptive statistics) and individual qualitative interviews with N = 23 LGBTQ + people. We employed a flexible coding approach to describe participants' experiences with stigma, discrimination, and support within SU services; and participant recommendations for how to make such services LGBTQ+-affirming at the patient-, staff-, and organizational-level. We highlighted components of minority stress and mitigators of adverse stress responses throughout our thematic analysis. Results: Patient-level experiences included bullying, name-calling, sexual harassment, and physical distancing from peers; and support via community-building with LGBTQ + peers. Staff-level experiences included name-calling, denial of services, misgendering, lack of intervention in peer bullying, and assumptions about participants' sexuality; and support via staff advocacy for LGBTQ + patients, holistic treatment models, and openly LGBTQ + staff. Organizational-level experiences included stigma in binary gendered program structures; and support from programs with gender-affirming groups and housing, and in visual cues (e.g., rainbow flags) of affirming care. Stigma and discrimination led to minority stress processes like identity concealment and stress coping responses like SU relapse; support facilitated SU treatment engagement and retention. Recommendations for LGBTQ+-affirming care included non-discrimination policies, routine pronoun sharing, LGBTQ+-specific programming, hiring LGBTQ + staff, routine staff sensitivity training, and gender-inclusive program structures. Conclusions: LGBTQ + people experience stigma and discrimination within SU services; supportive and affirming care is vital to reducing treatment barriers and promoting positive health outcomes. The current study offers concrete recommendations for how to deliver LGBTQ+-affirming care, which could reduce SU disparities and drug overdose mortality overall.

Exploring the performance of during-treatment substance use outcome measures in predicting longer-term psychosocial functioning and post-treatment abstinence.

BACKGROUND: The selection of appropriate efficacy endpoints in clinical trials has been a long-standing challenge for the substance use disorder field. Using data from a large, multi-site National Drug Abuse Treatment Clinical Trials Network trial (CTN-0044; n=474), this secondary data analysis aimed to explore whether specific proximal (during-treatment) substance use outcome measures predict longer-term improvements in psychosocial functioning and post-treatment abstinence, and whether predictions vary depending on the specific substance (cannabis, cocaine/stimulants, opioids, and alcohol). METHODS: Generalized linear mixed models examined associations between six during-treatment substance use outcome measures and social functioning impairment (Social Adjustment Scale Self-Report) and severity of psychiatric symptoms (Brief Symptom Inventory-18) at end-of-treatment, and 3- and 6-months after treatment as well as post-treatment abstinence. RESULTS: Maximum days of consecutive abstinence, proportion of days abstinent, ≥3 weeks of continuous abstinence, and the proportion of urine specimens negative for the primary substance were associated with post-treatment psychiatric and social functioning improvement and abstinence. However, only the effects of abstinence during the last 4 weeks of the treatment period on all three post-treatment outcomes was stable over time and did not differ between primary substance groups. In contrast, complete abstinence during the 12-week treatment period was not consistently associated with functioning improvements. CONCLUSIONS: Substance use outcome measures capturing the duration of primary substance abstinence during treatment are suitable predictors of post-treatment abstinence and longer-term psychosocial functioning improvement. Binary outcomes, such as end-of-treatment abstinence, may be particularly stable predictors and attractive given their ease of computation and straightforward clinical interpretability.

Centering culture in the treatment of opioid use disorder with American Indian and Alaska Native Communities: Contributions from a National Collaborative Board.

American Indian/Alaska Native (AI/AN) communities are disproportionally impacted by the opioid overdose epidemic. There remains a dearth of research evaluating methods for effectively implementing treatments for opioid use disorder (OUD) within these communities. We describe proceedings from a 2-day Collaborative Board (CB) meeting tasked with developing an implementation intervention for AI/AN clinical programs to improve the delivery of medications to treat OUD (MOUD). The CB was comprised of Elders, cultural leaders, providers, individuals with lived experience with OUD, and researchers from over 25 communities, organizations, and academic institutions. Conversations were audio-recorded, transcribed, and coded by two academic researchers with interpretation oversight provided by the CB. These proceedings provided a foundation for ongoing CB work and a frame for developing the program-level implementation intervention using a strength-based and holistic model of OUD recovery and wellbeing. Topics of discussion posed to the CB included engagement and recovery strategies, integration of extended family traditions, and addressing stigma and building trust with providers and clients. Integration of traditional healing practices, ceremonies, and other cultural practices was recommended. The importance of centering AI/AN culture and involving family were highlighted as priorities for the intervention.

Safety and efficacy of a digital therapeutic for substance use disorder: Secondary analysis of data from a NIDA clinical trials network study.

Background: Traditional treatments for substance use disorders (SUDs) rely heavily on face-to-face interactions, which pose substantial limitations for patients. A clinical trial of a digital therapeutic (DT), delivering behavioral therapy demonstrated safety and efficacy in a population including patients with opioid use disorder (OUD) not treated with buprenorphine, which is not a guideline-recommended approach. This study re-analyzed the data excluding patients with OUD to more closely approximate real-world patient populations. Methods: Secondary analysis of patients with substance use disorders related to alcohol, cannabis, cocaine, or other stimulants (n = 399, patients with OUD excluded) from a previously-published randomized controlled trial. Patients received 12-weeks of outpatient treatment-as-usual (TAU; n = 193) or TAU with reduced counseling plus a DT (n = 206) providing computerized cognitive behavioral therapy and contingency management. Primary outcomes were abstinence in weeks 9-12 and retention in treatment. Results: The 399 patients in this analysis (206 in the DT group and 193 in the TAU group) reported substance use disorders related to alcohol, cannabis, cocaine, or other stimulants (e.g., methamphetamines). Demographic and baseline characteristics including age, sex, race, education, and reported primary substance use disorder were balanced between treatment groups. Abstinence was significantly higher in the DT group compared to TAU (40.3 vs. 17.6%; p < 0.001) as was retention in therapy (76.2 vs. 63.2%, p = 0.004). Intergroup adverse event rates were not significantly different (p = 0.68). Conclusions: The results demonstrate that use of a DT safely increased abstinence (reduced substance use) and retention in treatment among patients with substance use disorders related to alcohol, cannabis, cocaine, or other stimulants (including methamphetamines).

Engagement patterns with a digital therapeutic for substance use disorders: Correlations with abstinence outcomes.

INTRODUCTION: Patient engagement may play a key role in the success or failure of treatments for substance use disorder (SUD). This exploratory analysis of data from a large, multisite effectiveness trial (NCT01104805) sought to determine how patient engagement with a digital therapeutic for SUD delivered at clinics was associated with abstinence outcomes. METHODS: The study evaluated engagement for 206 participants enrolled in a treatment program for SUDs related to cocaine, alcohol, cannabis, or other stimulants who were randomized to receive treatment as usual (TAU) or reduced TAU plus the digital Therapeutic Education System (TES) for 12 weeks. Participants were eligible for contingency management incentives for module completion (modules cover Community Reinforcement Approach topic areas) and negative urine drug screens. Analyses examined the association of module completion with end-of-treatment abstinence. RESULTS: Participants completed a mean of 38.8 (range 0-72) TES modules over 12 weeks of treatment. Study completers (n = 157) completed a mean of 45.5 (range 9-72) TES modules, whereas study noncompleters (n = 49) completed a mean of 17.4 (range 0-45) TES modules. The study observed a strong positive correlation between TES engagement (i.e., total number of modules completed) and the probability of abstinence during weeks 9-12 of treatment among 157 study completers (OR = 1.11; 95% CI 1.08-1.14). Each module completed increased the odds of abstinence during weeks 9-12 by approximately 11% for study completers and 9% for the full sample. The study observed a similar, but weaker, association between engagement and abstinence among 49 patients who did not complete the study (OR = 1.02; 95% CI 0.98-1.07). CONCLUSIONS: Greater engagement with a digital therapeutic for patients with SUD (i.e., number of modules completed over time) was strongly associated with the probability of abstinence in the last four weeks of treatment among those who completed the recommended 12-week treatment. TRIALS REGISTRATION: ClinicalTrials.gov Identifier: NCT01104805.

Exploring gender differences among treatment-seekers who use opioids versus alcohol and other drugs.

Identifying clinical differences between opioid users (OU) and alcohol and other drug users (AOD) may help to tailor treatment to OU, particularly among the majority of OU who are not on opioid agonist treatments. Given the dearth of research on these differences, this study explored gender differences in demographic and clinical characteristics between OU and AOD. Participants (N = 506) were from a multisite, randomized controlled clinical trial of an Internet-delivered psychosocial intervention conducted in 2010-2011. Logistic regression models explored differences in demographic and clinical characteristics by substance use category within and between women and men. Women OU were more likely to be younger, White, employed, benzodiazepine users, and less likely to have children or use cocaine and cannabis than women AOD. Men OU, compared to men AOD, were more likely to be younger, White, younger at first abuse/dependence, benzodiazepine users, and reported greater psychological distress, but were less likely to be involved in criminal justice or use stimulants. Interactions by gender and substance use were also detected for age of first abuse/dependence, employment, and criminal justice involvement. These findings provide a nuanced understanding of gender differences within substance use groups to inform providers for OU seeking treatment.

DSM-5 substance use disorder symptom clusters and HIV antiretroviral therapy (ART) adherence.

This study examines self-reported 30-day antiretroviral therapy (ART) adherence among 101 people living with HIV and substance use disorders (SUD) in New York City in terms of Diagnostic and Statistical Manual - 5th Edition (DSM-5) SUD symptom clusters: impaired control, social impairment, risky use and pharmacological criteria. Overall, 60.4% met DSM-5 criteria for stimulant, 55.5% for alcohol, 34.7% for cannabis and 25.7% for opioid SUD. Of the 76 participants with a current ART prescription, 75.3% reported at least 90% 30-day adherence. Participants with vs. without alcohol SUD were significantly less likely to report ART adherence (64.3% vs. 88.2%, p = .017). Endorsement of social impairment significantly differed among adherent vs. non-adherent participants with alcohol SUDs (74.1% vs. 100%, p = .038) and with opioid SUDs (94.1% vs. 50.0%, p = .040). Understanding specific SUD symptom clusters may assist providers and patients in developing strategies to improve ART adherence.

Interpretation and integration of the federal substance use privacy protection rule in integrated health systems: A qualitative analysis.

BACKGROUND: Federal regulations (42 CFR Part 2) provide special privacy protections for persons seeking treatment for substance use disorders. Primary care providers, hospitals, and health care organizations have struggled to balance best practices for medical care with adherence to 42 CFR Part 2, but little formal research has examined this issue. The aim of this study was to explore institutional variability in the interpretation and implementation of 42 CFR Part 2 regulations related to health systems data privacy practices, policies, and information technology architecture. METHODS: This was a cross-sectional qualitative study using purposive sampling to conduct interviews with privacy/legal officers (n = 17) and information technology specialists (n = 10) from 15 integrated healthcare organizations affiliated with three research nodes of the National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network (CTN). Trained staff completed a short survey and digitally recorded semi-structured qualitative interview with each participant. Interviews were transcribed and coded within Atlas.ti. Framework analysis was used to identify and organize key themes across selected codes. RESULTS: Participants voiced concern over balancing patient safety with 42 CFR Part 2 privacy protections. Although similar standards of protection regarding release of information outside of the health system was described, numerous workarounds were used to manage intra-institutional communication and care coordination. To align 42 CFR Part 2 restrictions with electronic health records, health systems used sensitive note designation, "break the glass" technology, limited role-based access for providers, and ad hoc solutions (e.g., provider messaging). CONCLUSIONS: In contemporary integrated care systems, substance-related EHR records (e.g., patient visit history, medication logs) are often accessible internally without specific consent for sharing despite the intent of 42 CFR Part 2. Recent amendments to 42 CFR Part 2 have not addressed information sharing needs within integrated care settings.

Future directions for medication assisted treatment for opioid use disorder with American Indian/Alaska Natives.

The U.S. is experiencing an alarming opioid epidemic, and although American Indians and Alaska Natives (AI/ANs) are especially hard hit, there is a paucity of opioid-related treatment research with these communities. AI/ANs are second only to Whites in the U.S. for overdose mortality. Thus, the National Institute on Drug Abuse convened a meeting of key stakeholders to elicit feedback on the acceptability and uptake of medication assisted treatment (MAT) for opioid use disorders (OUDs) among AI/ANs. Five themes from this one-day meeting emerged: 1) the mismatch between Western secular and reductionistic medicine and the AI/AN holistic healing tradition; 2) the need to integrate MAT into AI/AN traditional healing; 3) the conflict between standardized MAT delivery and the traditional AI/AN desire for healing to include being medicine free; 4) systemic barriers; and 5) the need to improve research with AI/ANs using culturally relevant methods. Discussion is organized around key implementation strategies informed by these themes and necessary for the successful adoption of MAT in AI/AN communities: 1) type of medication; 2) educational interventions; 3) coordination of care; and 4) adjunctive psychosocial counseling. Using a community-based participatory research approach is consistent with a "two eyed seeing" approach that integrates Western and Indigenous worldviews. Such an approach is needed to develop impactful research in collaboration with AI/AN communities to address OUD health disparities.

Neurocognitive Profiling of Adult Treatment Seekers Enrolled in a Clinical Trial of a Web-delivered Intervention for Substance Use Disorders.

OBJECTIVE: This study is a secondary descriptive analysis that explores and compares the cognitive profiles of adults entering treatment at geographically diverse community-based substance use disorder treatment facilities. METHODS: Performance on cognitive measures at baseline was compared across 5 primary substance subgroups of individuals (alcohol = 104; cocaine = 102; stimulants = 69; opioids = 108; marijuana = 114) enrolled in a web-based psychosocial treatment study conducted within the National Drug Abuse Treatment Clinical Trials Network. MicroCog subtests were used to assess cognitive domains of attention and mental control, reasoning and cognitive flexibility, and spatial processing. RESULTS: The average age of onset for a substance use disorder was early to mid-20s, with marijuana users reporting the earliest age of onset (mean 19.9, SD 7.5) and stimulant users reporting the latest (mean 25.2, SD 9.9). Among the total sample, half (49.7%) demonstrated impairment in cognitive flexibility and reasoning, and over one-third (37.3%) had impairment in verbal learning and memory. Stimulant (37.68%) and cocaine (34.31%) users showed significantly greater clinical impairment in attention and mental control compared with alcohol users (17.31%) and opioid (21.30%) users (stimulant subgroup only) (χ [4] = 10.97, P = 0.027). Cocaine users showed the greatest overall impairment across total and proficiency subtest scores, although these were not statistically different from other subgroups. CONCLUSIONS: These findings confirmed previous studies, indicating a high prevalence of significant cognitive dysfunction across all substance use categories among treatment-seeking adults, and found that cocaine use appears to be associated with the most impairment. Increasing knowledge of similarities and differences between primary substance subgroups can help guide substance use disorder treatment planning.

Web-based treatment for substance use disorders: differential effects by primary substance.

INTRODUCTION: This secondary analysis of data from a large, multi-site effectiveness trial (NCT01104805) sought to determine whether effects of a web-based behavioral treatment (Therapeutic Education System [TES]) differed by participants' self-identified primary drug of abuse. METHODS: The all-comers sample of individuals entering outpatient psychosocial counseling treatment for substance abuse (N=497) cited cannabis (22.9%; n=114), stimulants (34.4%, n=171), opioids (21.7%, n=108), or alcohol (20.9%, n=104) as their primary substance of abuse. Participants were randomly assigned to receive treatment-as-usual (TAU) with or without TES substituted for approximately 2h of usual counseling. Multivariate analyses of abstinence outcomes examined interactions of treatment effects with primary substance. RESULTS: Adjusted odds ratios (AORs) demonstrated that primary stimulant users receiving TES were more likely to be abstinent in the final four weeks of treatment compared to stimulant users receiving TAU (AOR=3.59, 95% CI=1.25-10.27). Adjusted odds ratios for alcohol (AOR=3.15, 95% CI=0.85-11.65) and cannabis (AOR=2.64, 95% CI=0.73-9.52) also were of similar magnitude to stimulants but did not reach significance. Abstinence among primary opioid users was not improved by the TES intervention (AOR=0.35, 95% CI=0.09-1.47). CONCLUSIONS: This study supports the TES web-delivered treatment as a viable intervention for the majority of substance users entering outpatient counseling treatment, with demonstrated effectiveness among stimulant users and promising effects in alcohol and cannabis users but little or no effect in primary opioid users. Web-delivered treatments hold promise for expanding the availability of effective behavioral interventions for the majority of substance use disorders.

Characteristics of an outpatient treatment sample by primary substance of abuse.

OBJECTIVE: This study examines sociodemographic and clinical characteristics, as a function of primary substance of abuse, among clients approached, screened, and assessed for eligibility in a 10-site effectiveness trial of a Web-based psychosocial intervention for substance use disorders. Consistent with the design of effectiveness trials, eligibility criteria were broad and exclusion criteria minimal; thus, the recruited sample may be viewed as relatively representative of patients seeking treatment throughout the United States. METHODS: χ tests for categorical variables and F tests for continuous variables were used to analyze demographic, substance use, physical and mental health, and sexual risk data collected at screening and baseline; pairwise comparisons between primary substance subgroups for baseline data were conducted if the test statistic P value was 0.01 or less. RESULTS: Few participants expressed disinterest in the study at screening because of the computer-assisted intervention. A diverse sample of substance users completed baseline and were enrolled: 22.9% marijuana; 21.7% opiates; 20.9% alcohol; 20.5% cocaine; and 13.9% stimulants users. Marijuana users demonstrated the greatest differences across primary substances: they were younger, less likely to be married or attend 12-step meetings, and more likely to be in treatment as a result of criminal justice involvement. All patients, even marijuana users, reported comparable rates of co-occurring mental health disorders and sexual risk and substantial rates of polysubstance use disorders. CONCLUSIONS: Primary substance of abuse may be a less important indicator of overall severity compared with co-occurring disorders and other factors common across treatment seekers, further demonstrating the need for integrated treatment services and care and comprehensive pretreatment assessment.