Viral Hepatitis and Human Immunodeficiency Virus Testing and Linkage to Care for Individuals Enrolled in an Opioid Treatment Program.

BACKGROUND: In the United States, many opioid treatment programs (OTPs) do not offer viral hepatitis (VH) or human immunodeficiency virus (HIV) testing despite high prevalence among OTP clients. We initiated an opt-out VH and HIV testing and linkage-to-care program within our OTP. METHODS: All OTP intakes are screened for VH and HIV and evaluated for rescreening annually. A patient navigator reviews laboratory results and provides counseling in the OTP clinic. The medical record is queried to identify individuals with previously diagnosed, untreated VH or HIV. Navigation support is provided for linkage or relinkage to VH or HIV care. RESULTS: Between March 2018 and Februrary 2019, 532 individuals were screened for hepatitis C virus (HCV), 180 tested HCV antibody positive (34%), and 108 were HCV-ribonucleic acid (RNA) positive (20%). Sixty individuals were identified with previously diagnosed, untreated HCV. Of all HCV RNA+, 49% reported current injection drug use (82 of 168). Ninety-five individuals were seen by an HCV specialist (57% of HCV RNA+), 72 started treatment (43%), and 69 (41%) completed treatment. Individuals with primary care providers were most likely to start treatment. Four individuals were diagnosed with hepatitis B; 0 were diagnosed with HIV. CONCLUSIONS: The implementation of an OTP-based screening and navigation protocol has enabled significant gains in the identification and treatment of VH in this high prevalence setting.

Substance use service availability in HIV treatment programs: Data from the global IeDEA consortium, 2014-2015 and 2017.

BACKGROUND: Substance use is common among people living with HIV and has been associated with suboptimal HIV treatment outcomes. Integrating substance use services into HIV care is a promising strategy to improve patient outcomes. METHODS: We report on substance use education, screening, and referral practices from two surveys of HIV care and treatment sites participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. HIV care and treatment sites participating in IeDEA are primarily public-sector health facilities and include both academic and community-based hospitals and health facilities. A total of 286 sites in 45 countries participated in the 2014-2015 survey and 237 sites in 44 countries participated in the 2017 survey. We compared changes over time for 147 sites that participated in both surveys. RESULTS: In 2014-2015, most sites (75%) reported providing substance use-related education on-site (i.e., at the HIV clinic or the same health facility). Approximately half reported on-site screening for substance use (52%) or referrals for substance use treatment (51%). In 2017, the proportion of sites providing on-site substance use-related education, screening, or referrals increased by 9%, 16%, and 8%, respectively. In 2017, on-site substance use screening and referral were most commonly reported at sites serving only adults (compared to only children/adolescents or adults and children/adolescents; screening: 86%, 37%, and 59%, respectively; referral: 76%, 47%, and 46%, respectively) and at sites in high-income countries (compared to upper middle income, lower middle income or low-income countries; screening: 89%, 76%, 68%, and 45%, respectively; referral: 82%, 71%, 57%, and 34%, respectively). CONCLUSION: Although there have been increases in the proportion of sites reporting substance use education, screening, and referral services across IeDEA sites, gaps persist in the integration of substance use services into HIV care, particularly in relation to screening and referral practices, with reduced availability for children/adolescents and those receiving care within resource-constrained settings.

Mexican Traditional Medicine: Application of a Traditional and Complementary Medicine System to Improve Opioid Use Treatment in Latinos.

Background: Initially considered a primarily rural, White issue, opioid use and overdose rates have risen faster for Latinos (52.5%) than for White, non-Hispanics (45.8%) from 2014 to 2016. With an estimated 45% to 65% of Latino immigrant families using Mexican traditional medicine (MTM) practices before seeking Western medical services, these practices could be used as a method to increase access to care and improve outcomes. Practice Model: Although not well known, MTM is founded on a defined set of theoretical tenets that comprise a whole medical system as defined by the National Center for Complementary and Integrative Health. Whole medical systems are characterized as complete systems of theory and practice that develop independently and parallel allopathic medicine. Classifying MTM as a whole medical system to encourage further research and utilization of traditional and complementary medicine (T&CM) practices could help improve health outcomes for Latino patients. Specific T&CM practices that could be used in opioid treatment integration to decrease stigma and increase treatment utilization are then discussed. Conclusion: Incorporating T&CM practices will allow more effective, culturally competent and culturally sensitive health care provision for Latino immigrants in the United States to decrease stigma, improve health care outcomes, and address disparities in opioid use treatment.

Integrating Reproductive Health Services Into Opioid Treatment Facilities: A Missed Opportunity to Prevent Opioid-exposed Pregnancies and Improve the Health of Women Who Use Drugs.

: Opioid treatment programs (OTPs) are federally mandated to provide certain medical services to patients, and are often the only place where people with substance use disorders (SUD) obtain medical care. Just as medication for addiction treatment (MAT) should be part of comprehensive addiction care, so should reproductive health care be a part of comprehensive medical care. The most significant barrier that must be overcome is that the majority of OTPs believe that it is outside their scope of service to provide reproductive health services. Reproductive health care is basic medical care. It is imperative for the long-term health of women with SUD, their children and the community that they receive this care. OTPs can and should do better for their female clients.

Enabling factors for behavior change among people with alcohol dependency: An exploratory study in a mental health-care facility.

BACKGROUND: Alcohol dependence has become a major public health problem with many implications on the lives of dependents and their families. OBJECTIVES: The objectives of this study is to ascertain the enabling factors to seek medical help and continue behavior change among alcohol dependents and to assess the perceptions of health-care providers regarding treatment-seeking behavior of alcohol dependents. METHODS: The present study deployed the transtheoretical model (TTM) as a theoretical framework for analyzing the enabling factors to seek medical help and continue behavior change among alcohol dependents and to understand the perceptions of health-care providers dealing with alcohol dependents at a tertiary care psychiatry hospital in Guntur of Andhra Pradesh. In-depth interviews and desk review of hospital records were done. Respondents included treatment-seeking individuals for alcohol detoxification (action phase), patients attending follow-ups (maintenance phase), and mental health professionals at the study site. The study was conducted during August and September 2017. Qualitative analysis using thematic framework and MS EXCEL for quantitative data was used. RESULTS: Themes and subthemes emerging out of analysis were fitted in stages of TTM of behavior change. In the process of behavior change, there were key supportive elements such as problem awareness (precontemplation), availability and accessibility of services (contemplation), appropriate treatment modality (action), and alcohol anonymous groups (maintenance), which sustained the progress of change and yielded effective outcomes. CONCLUSIONS: Alcoholism needs to be addressed holistically rather than focusing only on biological treatment.

Using Social Media to Enhance Provider Network for HIV and Harm Reduction Service Integration in Vietnam.

Social media can potentially serve as a platform to coordinate medical care among fragmented health sectors. This paper describes procedures of using social media to enhance antiretroviral therapy (ART) and methadone maintenance treatment (MMT) providers' virtual network for integrated service for HIV-positive people who inject drugs (PWID) in Vietnam. A total of 88 ART and MMT treatment providers participated in person group sessions followed by online virtual support to improve service integration. In-person reunions were held to reinforce Facebook participation and network activities. Content analysis was used to identify keywords and topic categories of the online information exchange. Both MMT and ART providers were actively engaged in online communications. Referral and treatment adherence were the two most frequently discussed topic areas by both the MMT and ART providers. Frequent cross-agency connections were observed. Online provider networks and communities could be built and useful to support treatment providers to improve service integration.

Rapid Assessment of Nutrition Services in Los Angeles Substance Use Disorder Treatment Centers.

The objective of this study was to determine the prevalence of nutrition services and utilization of registered dietitian nutritionists at substance use disorder treatment centers in Los Angeles. This cross-sectional descriptive study utilized phone interviews with facilities within a 25-mile radius of the Los Angeles metropolitan area using the Substance Abuse and Mental Health Services Administration Treatment Services Locator to identify facilities that included a listing of substance abuse as primary focus of care (n = 128). Facilities were asked if they offered any kind of nutrition services, the type of services that were offered, and the credential of the professional providing the services. We compared facilities that offered a residential level of care to those offering outpatient services only. The Fisher's exact test was used to determine statistical significance. The study showed that only 39 sites (30.5%) offered any type of nutrition services on site, and the odds of a residential level of care offering nutrition services was 2.7 times higher than outpatient only facilities (p = 0.02). Of the 39 facilities offering nutrition services, only 8 (20.5%) utilized a registered dietitian nutritionist. Overall fewer than 7% of the facilities utilized the services of a dietitian. Recovery programs for substance use disorder should consider using a registered dietitian nutritionist as a member of the treatment team, which may contribute to better clinical outcomes.

A system-level study of initiation, engagement, and equity in outpatient substance use treatment.

Understanding the nature of variations in the quality of substance use treatment is critical to ensuring equity in service delivery and maximizing treatment effectiveness. We used adapted versions of the US Healthcare Effectiveness Data and Information Set (HEDIS) treatment initiation and engagement measures to assess care quality in specialized outpatient services for substance use in Ontario, Canada. Using administrative data, we calculated rates of outpatient treatment initiation and engagement (N = 120,394 episodes) and investigated variation by client characteristics and treatment mandates. About half of clients who entered outpatient treatment met the criteria for initiation (i.e., had a second visit within 14 days) and 30% met the criteria for engagement (i.e., had another two visits within 30 days of initiation). The likelihood of treatment initiation and engagement was greater among older people, those with more education, those who were not mandated to enter treatment, and those with greater substance use at admission. People who entered treatment for cannabis were less likely to engage. Engagement was less likely among men than women, but gender differences were slight overall. This study demonstrates the feasibility of using adapted versions of two common measures to characterise care quality in substance use treatment services in the Canadian context. Overall, the magnitude of associations with client characteristics were quite small, suggesting that initiation and engagement were not overly localized to specific client subgroups. Findings suggest that the Ontario system has difficulty retaining clients who enter treatment and that most outpatient treatment involves care episodes of limited duration.

Cannabis use, other substance use, and co-occurring mental health concerns among youth presenting for substance use treatment services: Sex and age differences.

Cannabis use among youth is of significant concern given the potential negative health impacts on young people. This study describes the mental health characteristics, cannabis use, and substance use profiles of youth aged 14 to 24 years seen at the Youth Addiction and Concurrent Disorders Service at the Centre for Addiction and Mental Health, through an age and gender lens. Almost all participating youth indicated lifetime cannabis use. Substance use and mental health profiles among those indicating a history of cannabis use differed along sex and age. Male youth were more likely to use cannabis more frequently, while female youth were more likely to use greater variety of substances and display more co-occurring mental health problems. Adolescent problematic substance use tended to co-occur with externalizing problems whereas problematic young adult substance use tended to co-occur with internalizing problems. Implications for the integrated, coordinated care of substance use and mental health concerns, with attention to the unique needs of subgroups of youth, are discussed.

Integration of Care in the Implementation of the Affordable Care Act: Changes in Treatment Services in a National Sample of Centers Treating Substance Use Disorders.

This study examined patterns of medicalization in substance use disorder (SUD) that are aligned with the goals of the Affordable Care Act (ACA). Using a nationally representative sample of SUD treatment programs, we examined changes in several treatment domains. While observed changes were modest, they were in directions that support the thrust of the ACA. Specifically, we found an increase in the percentage of treatment referrals from other health care providers. We found an increase in the number of physicians for programs that did have a physician on staff, and an increase in counselors certified in treating alcohol and drug addiction. There was significant growth in the availability of oral and injectable naltrexone but not of other pharmacotherapies. There was a decrease in support for the 12-step model and an increase on the emphasis of a medicalized treatment model. Finally, we found a shift away from federal block grants and other public funding, consistent with the expectations of the ACA. These data indicate that, while progress is slow, the environment of the recent past has been supportive of the goal of SUD treatment's integration into mainstream medical care.

An organisational change intervention for increasing the delivery of smoking cessation support in addiction treatment centres: study protocol for a randomized controlled trial.

BACKGROUND: The provision of smoking cessation support in Australian drug and alcohol treatment services is sub-optimal. This study examines the cost-effectiveness of an organisational change intervention to reduce smoking amongst clients attending drug and alcohol treatment services. METHODS/DESIGN: A cluster-randomised controlled trial will be conducted with drug and alcohol treatment centres as the unit of randomisation. Biochemically verified (carbon monoxide by breath analysis) client 7-day-point prevalence of smoking cessation at 6 weeks will be the primary outcome measure. The study will be conducted in 33 drug and alcohol treatment services in four mainland states and territories of Australia: New South Wales, Australian Capital Territory, Queensland, and South Australia. Eligible services are those with ongoing client contact and that include pharmacotherapy services, withdrawal management services, residential rehabilitation, counselling services, and case management services. Eligible clients are those aged over 16 years who are attending their first of a number of expected visits, are self-reported current smokers, proficient in the English language, and do not have severe untreated mental illness as identified by the service staff. Control services will continue to provide usual care to the clients. Intervention group services will receive an organisational change intervention, including assistance in developing smoke-free policies, nomination of champions, staff training and educational client and service resources, and free nicotine replacement therapy in order to integrate smoking cessation support as part of usual client care. DISCUSSION: If effective, the organisational change intervention has clear potential for implementation as part of the standard care in drug and alcohol treatment centres. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry, ACTRN12615000204549 . Registered on 3 March 2015.

An exploratory qualitative assessment of self-reported treatment outcomes and satisfaction among patients accessing an innovative voluntary drug treatment centre in Malaysia.

BACKGROUND: In Malaysia, compulsory drug detention centres (CDDCs) hold suspected drug users for two years without adjudication. Acute detoxification without healthcare access has been documented. CDDCs are criticized globally due to ineffectiveness in treating addiction and human rights violations. In response, the Malaysian government began transitioning these facilities into voluntary drug treatment centres known as "Cure and Care" (C&C) centres that embrace a holistic treatment-based approach to drug addiction rehabilitation. METHODS: An explorative qualitative study was undertaken to explore patient perspectives and satisfaction regarding treatment and services at the new Cure and Care centre in Kota Bharu, Malaysia. A convenience sample of 20 patients was recruited to participate in semi-structured in-depth interviews. Content analysis was used to identify the salient themes. RESULTS: Patients identified methadone treatment, psychosocial programs, religious instruction, and recreational activities as important factors contributing to treatment success for addressing both health and addiction needs. Though many had previously been in a CDDC, adherence to treatment in the C&C centre was perceived to be facilitated by the degree of social support, the voluntary nature and the array of new programs available for selection. CONCLUSION: C&Cs represents a dramatic shift in the Malaysian government's approach to drug addiction. Our findings demonstrate positive patient experiences associated with the holistic treatment-based approach of these centres. This exploratory study provides additional evidence to document this ongoing policy transition and may guide continued expansion of new holistic drug treatment programs across the country.

What Influences Participation in QI? A Randomized Trial of Addiction Treatment Organizations.

Healthcare providers have increased the use of quality improvement (QI) techniques, but organizational variables that affect QI uptake and implementation warrant further exploration. This study investigates organizational characteristics associated with clinics that enroll and participate over time in QI. The Network for the Improvement of Addiction Treatment (NIATx) conducted a large cluster-randomized trial of outpatient addiction treatment clinics, called NIATx 200, which randomized clinics to one of four QI implementation strategies: (1) interest circle calls, (2) coaching, (3) learning sessions, and (4) the combination of all three components. Data on organizational culture and structure were collected before, after randomization, and during the 18-month intervention. Using univariate descriptive analyses and regression techniques, the study identified two significant differences between clinics that enrolled in the QI study (n = 201) versus those that did not (n = 447). Larger programs were more likely to enroll and clinics serving more African Americans were less likely to enroll. Once enrolled, higher rates of QI participation were associated with clinics' not having a hospital affiliation, being privately owned, and having staff who perceived management support for QI. The study discusses lessons for the field and future research needs.

Dedicated 'cannabis only' treatment clinics in New South Wales, Australia: client and treatment characteristics and associations with first-time treatment seeking.

INTRODUCTION AND AIMS: Over the past decade, there has been significant investment in dedicated cannabis-only treatment clinics in New South Wales. This study aims to describe the characteristics of clients and compares first-time treatment seeking history and treatment completion rates between dedicated and non-dedicated clinics. DESIGN AND METHODS: An observational study of administrative information from 209,012 drug and alcohol treatment episodes from services reporting to the New South Wales Alcohol and Other Drug Treatment Services Minimum Dataset, July 2003-June 2008. RESULTS: Across all episodes, cannabis was the second most prevalent primary drug of concern (17.8%, n = 37,242). The majority of clients primarily seeking treatment for cannabis were male (69.4%, 26,088), with a mean age of 29 years. Counselling was the most common cannabis treatment (34.1%, n = 12,713), with 11.6% (n = 1476) of those receiving counselling having done so at a cannabis clinic. Those treated in cannabis clinics were older (30.12 years vs. 27.95 years; P < 0.0001); had shorter episode durations (10.95 weeks vs. 12.71 weeks; P < 0.0001); and were more likely to be naïve to treatment (53.7% vs. 47.7%; P < 0.0001). Indigenous Australian treatment seekers were more likely to complete cannabis treatment in a dedicated cannabis clinic (49.6%) than in a non-dedicated clinic (40.5%; P < 0.05). DISCUSSION AND CONCLUSION: Cannabis clinics have attracted groups traditionally difficult to attract and retain in treatment. As the cohort of daily cannabis users age, it is important that service models are attractive to older clients, new to treatment. Rigorous, prospective research examining client treatment outcomes are now warranted.

Organizational capacity for service integration in community-based addiction health services.

OBJECTIVES: We examined factors associated with readiness to coordinate mental health, public health, and HIV testing among community-based addiction health services programs. METHODS: We analyzed client and program data collected in 2011 from publicly funded addiction health services treatment programs in Los Angeles County, California. We analyzed a sample of 14 379 clients nested in 104 programs by using logistic regressions examining odds of service coordination with mental health and public health providers. We conducted a separate analysis to examine the percentage of clients receiving HIV testing in each program. RESULTS: Motivational readiness and organizational climate for change were associated with higher odds of coordination with mental health and public health services. Programs with professional accreditation had higher odds of coordinating with mental health services, whereas programs receiving public funding and methadone and residential programs (compared with outpatient) had a higher percentage of clients receiving coordinated HIV testing. CONCLUSIONS: These findings provide an evidentiary base for the role of motivational readiness, organizational climate, and external regulation and funding in improving the capacity of addiction health services programs to develop integrated care.

Tuberculosis screening in a novel substance abuse treatment center in Malaysia: implications for a comprehensive approach for integrated care.

People who use drugs (PWUD) represent a key high risk group for tuberculosis (TB). The prevalence of both latent TB infection (LTBI) and active disease in drug treatment centers in Malaysia is unknown. A cross-sectional convenience survey was conducted to assess the prevalence and correlates of LTBI among attendees at a recently created voluntary drug treatment center using a standardized questionnaire and tuberculin skin testing (TST). Participants (N=196) were mostly men (95%), under 40 (median age=36 years) and reported heroin use immediately before treatment entry (75%). Positive TST prevalence was 86.7%. Nine (4.6%) participants were HIV-infected. Previous arrest/incarcerations (AOR=1.1 for every entry, p<0.05) and not being HIV-infected (AOR=6.04, p=0.03) were significantly associated with TST positivity. There is an urgent need to establish TB screening and treatment programs in substance abuse treatment centers and to tailor service delivery to the complex treatment needs of patients with multiple medical and psychiatric co-morbidities.

Drug use and treatment success among gang and non-gang members in El Salvador: a prospective cohort study.

BACKGROUND: This article focuses on examining drug abuse treatment (DAT) in El Salvador highlighting gang vs. non-gang membership differences in drug use and treatment outcomes. METHODS: Cross-sectional and prospective cohort designs were employed to examine the study aims. The 19 centers that met the study's inclusion criteria of one year or less in planned treatment offered varying treatment services: individual, group, family, and vocational therapy, dual diagnosis treatment, psychological testing, 12-step program, and outreach and re-entry aftercare. Most directors describe their treatment approach as "spiritual." Data were collected from 625 patients, directors, and staff from the 19 centers at baseline, of which 34 patients were former gang members. Seventy-two percent (72%) of the former patients (448) were re-interviewed six-months after leaving treatment and 48% were randomly tested for drug use. RESULTS: Eighty-nine percent (89%) of the DAT patients at baseline were classified as heavy alcohol users and 40% were using illegal drugs, i.e., crack, marijuana, cocaine, tranquilizers, opiates, and amphetamines. There were large decreases after treatment in heavy alcohol and illegal drug use, crime, and gang related risk activities. Gang members reported illegal drug use, crime, and gang related risk activity more than non-gang members, yet only 5% of the study participants were gang members; further, positive change in treatment outcomes among gang members were the same or larger as compared to non-gang members. CONCLUSIONS: Alcohol use is the drug of choice among DAT patients in El Salvador with gang member patients having used illegal drugs more than non-gang members. The study shows that DAT centers successfully reduced the use of illegal drugs and alcohol among gang and non-gang members. Although our study could not include a control group, we believe that the DAT treatment centers in El Salvador contributed to producing this treatment success among former patients. These efforts should be continued and complemented by funding support from the Salvadoran government for DAT centers that obtain certification. In addition, tailored/alternative treatment modalities are needed for gang members in treatment for heavy drinking.

Managing psychiatric comorbidity within versus outside of methadone treatment settings: a randomized and controlled evaluation.

BACKGROUND AND AIMS: Integrating psychiatric services within substance abuse treatment settings is a promising service delivery model, but has not been evaluated using random assignment to psychiatric treatment setting and controlled delivery of psychiatric care. This study evaluates the efficacy of on-site and integrated psychiatric service delivery in an opioid-agonist treatment program on psychiatric and substance use outcomes. DESIGN: Participants at the Addiction Treatment Services (ATS) were assigned randomly to receive on-site and integrated substance abuse and psychiatric care (on-site: n = 160) versus off-site and non-integrated substance abuse and psychiatric care (off-site: n = 156), and observed for 1 year. On-site participants received all psychiatric care within the substance abuse program by the same group of treatment providers. The same type and schedule of psychiatric services were available to off-site participants at a community psychiatry program. SETTING: All participants received routine methadone maintenance at the ATS program in Baltimore, Maryland, USA. PARTICIPANTS: Participants were opioid-dependent men and women with at least one comorbid psychiatric disorder, as assessed by the Structured Clinical Interview for DSM-IV and confirmed by expert clinical reappraisal. MEASUREMENTS: Outcomes included psychiatric service utilization and retention, Hopkins Symptom Checklist Global Severity Index (GSI) change scores and urinalysis test results. FINDINGS: On-site participants were more likely to initiate psychiatric care 96.9 to 79.5%; P < 0.001), remain in treatment longer (195.9 versus 101.9 days; P < 0.001), attend more psychiatrist appointments (12.9 versus 2.7; P < 0.001) and have greater reductions in GSI scores (4.2 versus 1.7; P = 0.003) than off-site participants; no differences were observed for drug use. CONCLUSIONS: On-site and integrated psychiatric and substance misuse services in a methadone treatment setting might improve psychiatric outcomes compared with off-site and non-integrated substance misuse and psychiatric care. However, this might not translate into improved substance misuse outcomes.