Sustaining alcohol and opioid use disorder treatment in primary care: a mixed methods study.

BACKGROUND: Efforts to integrate substance use disorder treatment into primary care settings are growing. Little is known about how well primary care settings can sustain treatment delivery to address substance use following the end of implementation support. METHODS: Data from two clinics operated by one multi-site federally qualified health center (FQHC) in the US, including administrative data, staff surveys, interviews, and focus groups, were used to gather information about changes in organizational capacity related to alcohol and opioid use disorder (AOUD) treatment delivery during and after a multi-year implementation intervention was executed. Treatment practices from the intervention period were compared to practices after the intervention period to examine whether the practices were sustained. Data from staff surveys and interviews were used to examine the factors related to sustainment. RESULTS: The two clinics sustained multiple components of AOUD care 1 year following the end of implementation support, including care coordination, psychotherapy, and medication-assisted treatment. Some of the practices were modified over time, for example, screening became less frequent by design, while use of care coordination and psychotherapy for AOUDs expanded. Participants identified staff training and funding for medications as key challenges to sustaining treatment. CONCLUSIONS: Following a multi-year implementation intervention, a large FQHC continued to deliver AOUD treatment. Access to external funding and staff support appeared to be critical elements for sustaining care over time. TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT01810159.

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.

Training addiction counselors to implement CBT for depression.

Many clients in publicly funded substance abuse treatment programs suffer from depression yet lack access to effective mental health treatment. This study sought to examine whether addiction counselors could be effectively trained to deliver group CBT for depression and to ascertain client perceptions of the treatment. Five counselors were trained in the therapy and treated 113 clients with depression symptoms. Counselors demonstrated high fidelity to the therapy and client perceptions of the therapy were positive. Our results suggest that training addiction counselors to deliver group CBT for depression is a promising integrated treatment approach for co-occurring depression and substance disorders.

Substance abuse with mental disorders: specialized public systems and integrated care.

Separate public financing and regulation of substance (SA) abuse treatment distinct from mental health (MH) treatment preserves a focus on the special needs of those with substance abuse but creates challenges to providing appropriate care for the large number of people with co-occurring conditions. This paper reviews recent efforts to overcome these challenges through clinical and systems approaches that better integrate care. Although much progress has been made for some subgroups of people with co-occurring disorders, further efforts to develop and sustain clinically integrated service delivery approaches within separate systems, particularly in SA treatment settings, are needed.