Evaluating the Implementation of a Model of Integrated Behavioral Health in Primary Care: Perceptions of the Healthcare Team.

OBJECTIVES: This study aims to compare primary care providers and medical assistants in degrees of comfort, confidence, and consistency when addressing behavioral health concerns with patients before and after the implementation of a model of integrated behavioral health in primary care (IBHPC), and evaluate whether these perceptions differ based on increased access to behavioral health clinicians. METHODS: This longitudinal study was conducted at 2 primary care clinics in Northern California while implementing an IBHPC model. The Integrated Behavioral Health Staff Perceptions Survey was administered to assess the comfort, confidence, and consistency of behavioral health practices. Confidential online surveys were distributed to primary care faculty and staff members before and post-implementation. Responses from providers and medical assistants were compared between pre- and post-implementation with linear regression analyses. The relationships between accessibility to behavioral health clinicians and a change in comfort, confidence, and consistency of behavioral health practices were explored using a linear mixed-effects model. RESULTS: A total of 35 providers and medical assistants completed the survey both before and post-implementation of IBHPC. Over time, there were increasingly positive perceptions about the consistency of behavioral health screening (P = .03) and overall confidence in addressing behavioral health concerns (P = .005). Comfort in addressing behavioral health concerns did not significantly change for either providers or staff over time. Medical assistants were initially more confident and comfortable addressing behavioral health concerns than providers, but providers' attitudes increased post-IBHPC implementation. Improved access to behavioral health clinicians was associated with greater consistency of screening and referral to specialty mental health care (P < .001). CONCLUSION: The present study is the first to explore differences in provider and medical assistant perceptions during the course of an IBHPC implementation. Findings underscore the importance of integrating medical assistants, along with providers, into all phases of the implementation process.

Addressing Methamphetamine Use in Primary Care: Provider Perspectives.

INTRODUCTION: The opioid epidemic has evolved into a combined stimulant epidemic, with escalating stimulant and fentanyl-related overdose deaths. Primary care providers are on the frontlines grappling with patients' methamphetamine use. Although effective models exist for treating opioid use disorder in primary care, little is known about current clinical practices for methamphetamine use. METHODS: Six semistructured group interviews were conducted with 38 primary care providers. Interviews focused on provider perceptions of patients with methamphetamine use problems and their care. Data were analyzed using inductive and thematic analysis and summarized along the following dimensions: (1) problem identification, (2) clinical management, (3) barriers and facilitators to care, and (4) perceived needs to improve services. RESULTS: Primary care providers varied in their approach to identifying and treating patient methamphetamine use. Unlike opioid use disorders, providers reported lacking standardized screening measures and evidence-based treatments, particularly medications, to address methamphetamine use. They seek more standardized screening tools, Food and Drug Administration-approved medications, reliable connections to addiction medicine specialists, and more training. Interest in novel behavioral health interventions suitable for primary care settings was also noteworthy. CONCLUSIONS: The findings from this qualitative analysis revealed that primary care providers are using a wide range of tools to screen and treat methamphetamine use, but with little perceived effectiveness. Primary care faces multiple challenges in effectively addressing methamphetamine use among patients singularly or comorbid with opioid use disorders, including the lack of Food and Drug Administration-approved medications, limited patient retention, referral opportunities, funding, and training for methamphetamine use. Focusing on patients' medical issues using a harm reduction, motivational interviewing approach, and linkage with addiction medicine specialists may be the most reasonable options to support primary care in compassionately and effectively managing patients who use methamphetamines.

Wait No Longer: Reducing Medication Wait-Times for Individuals with Co-Occurring Disorders.

Objective: Community addiction treatment agencies have utilized Network for the Improvement of Addiction Treatment (NIATx), a proven implementation strategy, to reduce appointment wait-times. However, its effectiveness at reducing medication access wait-times has not been explored. Thus, we conducted an exploratory analysis to evaluate the impact of the NIATx implementation strategies on reduced wait-times to addiction, psychotropic or both medications for individuals with co-occurring disorders (COD). Methods: In a cluster-randomized waitlist control group design, community addiction treatment agencies (n = 49) were randomized to receive the NIATx strategy (Cohort 1, n = 25) or to a Waitlist control (Cohort 2, n = 24). All agencies had a 12-month active intervention period. The primary outcome was the medication encounter wait-time. A univariate general linear model analysis utilizing a logarithmic (log10) transformation examined medication wait-times improvements. Results: The intent-to-treat analysis for psychotropic medications and both medications (reflecting integrated treatment) showed significant main effects for intervention and time, especially comparing Baseline and Year 1 to Year 2. Conversely, only the main effect for time was significant for addiction medications. Wait-time reductions in Cohort 1 agencies was delayed and occurred in the sustainment phase. Wait-times to a psychotropic, addiction, or both medications encounter declined by 3 days, 4.9 days, and 6.8 days, respectively. For Cohort 2 agencies, reduced wait-times were seen for psychotropic (3.4 days), addiction (6 days), and both medications (4.9 days) during their active implementation period. Same- or next-day medication access also improved. Conclusions: NIATx implementation strategies reduced medication encounter wait-times but timing of agency improvements varied. Despite a significant improvement, a three-week wait-time to receive integrated pharmacological interventions is clinically suboptimal for individuals with a COD in need of immediate intervention. Community addiction treatment agencies should identify barriers and implement changes to improve medication access so that their patients "wait no longer" to receive integrated treatment and medications for their COD.

Sustainment of Integrated Care in Addiction Treatment Settings: Primary Outcomes From a Cluster-Randomized Controlled Trial.

OBJECTIVE: Integrated treatment services are the gold standard for addressing co-occurring mental and substance use disorders, yet they are not readily available. The Network for the Improvement of Addiction Treatment (NIATx) was hypothesized to be an effective strategy to implement and sustain integrated mental health and substance use care in addiction treatment programs. This study examined sustainment of integrated services for up to 2 years after the active implementation phase. METHODS: The effectiveness of NIATx strategies to implement and sustain integrated services was evaluated by using a cluster-randomized, waitlist control group design. Forty-nine addiction treatment organizations were randomly assigned to either NIATx1 (active implementation strategy) or NIATx2 (waitlist control). The Dual Diagnosis Capability in Addiction Treatment Index was used to evaluate organizations' capability to provide integrated care. The NIATx Stages of Implementation Completion scale was used to assess participation in and adherence to the NIATx implementation process. Linear mixed-effects modeling was used to evaluate changes from baseline to end of the sustainment period. RESULTS: Both cohorts sustained their capability to provide integrated treatment services. Both groups achieved successful implementation and sustained integrated services to a similar degree, regardless of sustainment year. Sustainment did not vary as a function of NIATx adherence. CONCLUSIONS: The delivery of integrated treatment services was sustained for 2 years after receipt of active implementation support. Future research should consider how contextual factors may predict, mediate, and moderate sustainment outcomes.

What Are Patient Preferences for Integrated Behavioral Health in Primary Care?

Background: Behavioral health services, integrated into primary care practices, have become increasingly implemented. Although patient satisfaction has been studied, limited information exists about patient preferences for integrated behavioral health in primary care and how perceptions may vary. Objective: To determine patient preferences for integrated behavioral health within primary care and explore differences across patient groups. Methods: A self-report survey was distributed within a quality improvement initiative in an academic health system. A brief 8-item self-report questionnaire of perceptions and preferences for integrated behavioral health was administered to 752 primary care patients presenting before their visits at two primary care clinics. Participation was voluntary, responses were anonymous, and all patients presenting during a three-week timeframe were eligible. Results: In general, patients preferred to have behavioral health concerns addressed within primary care (n = 301; 41%) rather than referral to a specialist (7.5%; n = 55). There was no evidence of variation in preferences by demographic characteristics. Comfort levels to receive behavioral health services (P < .001) and perceived needs being met were significantly associated with preferences for receiving IBHPC (P < .001). Conclusion: This project provided valuable data to support the implementation of integrated behavioral health services in primary care clinics. In general, patients prefer to have behavioral health issues addressed within their primary care experience rather than being referred to specialty mental health care. This study adds to an expanding pool of studies exploring patient preferences for integrated behavioral health in primary care.

The Integrating Medications for Addiction Treatment (IMAT) Index: A measure of capability at the organizational level.

Primary care provides a treatment opportunity for many persons with opioid use disorder (OUD). The push to integrate and expand reach and adoption of medications for opioid use disorder (MOUD) within primary care has been a major focus of national, state and health systems endeavors. To guide high capability MOUD practice, we introduce the Integrating Medications for Addiction Treatment (IMAT) Index. The research team has developed IMAT along similar lines to other organizational measures of integrated services capability. We present the development and validation of the measure, and suggest its applicability for systems and organizations, as well as for process improvement and implementation research. Forty-one primary care clinics completed the IMAT at two time points: baseline and 9-month follow-up. Findings support the IMAT Index as psychometrically acceptable and pragmatically useful. It has good internal consistency, as well as concurrent and predictive validity. Changes in IMAT scores between baseline and follow-up significantly predicted increases in proportion of patients on MOUD. The IMAT has the potential to support both scientific and public health care activities.

A mapping review of NIDA-funded implementation research studies on treatments for opioid and/or stimulant use disorders.

BACKGROUND: The biomedical research enterprise invests greatly in discovery-oriented science, but significantly less in how to implement the most effective of these innovations. The return on investment in public health benefit is therefore low. In the context of substance-related overdose epidemics, presently with opioids and/or stimulants, the gap in proven treatments and routine access is amplified. Implementation research is designed to deepen understanding of how best to scale-up proven treatments. This study assessed how implementation research has been deployed in the National Institute on Drug Abuse (NIDA) efforts to address the opioid and stimulant epidemics. METHODS: Adapting a procedure developed to categorize HIV-focused research, a four-stage systematic mapping review of NIDA-funded R01, R34, R61, and U studies pertaining to opioids and/or stimulants funded between 2015 and 2019 was performed. Abstracts were retrieved using NIH Research Portfolio Online Reporting Tools. Key study characteristics were abstracted and coded by two independent reviewers. RESULTS: An initial search across NIH institutes yielded 5963 relevant records. Of these, 666 (11.2 %) were NIDA funded. One-hundred-and-thirty-four (20.1 %) of the 666 studies were opioid and/or stimulant treatment related. Of these, 28 (4.2 %) were categorized as Implementation Preparation (IP), and 16 (2.4 %) were categorized as Implementation Research (IR). Over the five-year period, there was a gradual increase in both IP and IR studies. CONCLUSIONS: Implementation research is a small but slowly growing component of the federal portfolio to address substance-related public health issues. To more effectively respond to contemporary overdose epidemics, implementation research must take on an even more significant role.

What constitutes "behavioral health"? Perceptions of substance-related problems and their treatment in primary care.

BACKGROUND: Integrating behavioral health in primary care is a widespread endeavor. Yet rampant variation exists in models and approaches. One significant question is whether frontline providers perceive that behavioral health includes substance use. The current study examined front line providers': 1. definition of behavioral health, and 2. levels of comfort treating patients who use alcohol and other drugs. Frontline providers at two primary care clinics were surveyed using a 28-item instrument designed to assess their comfort and knowledge of behavioral health, including substance use. Two questions from the Integrated Behavioral Health Staff Perceptions Survey pertaining to confidence in clinics' ability to care for patients' behavioral health needs and comfort dealing with patients with behavioral health needs were used for the purposes of this report. Participants also self-reported their clinic role. Responses to these two items were assessed and then compared across roles. Chi square estimates and analysis of variance tests were used to examine relationships between clinic roles and comfort of substance use care delivery. RESULTS: Physicians, nurses/nurse practitioners, medical assistants, and other staff (N = 59) participated. Forty-nine participants included substance use in their definition of behavioral health. Participants reported the least comfort caring for patients who use substances (M = 3.5, SD = 1.0) compared to those with mental health concerns (M = 4.1, SD = 0.7), chronic medical conditions (M = 4.2, SD = 0.7), and general health concerns (M = 4.2, SD = 0.7) (p < 0.001). Physicians (M = 3.0, SD = 0.7) reported significantly lower levels of comfort than medical assistants (M = 4.2, SD = 0.9) (p < 0.001) caring for patients who use substances. CONCLUSIONS: In a small sample of key stakeholders from two primary care clinics who participated in this survey, most considered substance use part of the broad umbrella of behavioral health. Compared to other conditions, primary care providers reported being less comfortable addressing patients' substance use. Level of comfort varied by role, where physicians were least comfortable, and medical assistants most comfortable.

Preliminary Efficacy of a Cognitive Behavioral Therapy Text Messaging Intervention Targeting Alcohol Use and Antiretroviral Therapy Adherence: A Randomized Clinical Trial.

TRIAL REGISTRATION: This trial was registered with ClinicalTrials.gov, NCT02603471.

Preliminary Outcomes of a Computerized CBT/MET Intervention for Depressed Cannabis Users in Psychiatry Care.

Although depression is common among cannabis users, there is a paucity of targeted interventions addressing depression and cannabis use disorders concurrently. In the present pilot study, we examine the feasibility, acceptability, and preliminary outcomes of a computer-assisted intervention combining cognitive behavioral therapy (CBT) and motivational enhancement therapy (MET) techniques for adults with comorbid major depressive disorder (MDD) and cannabis use disorder (CUD) presenting for care in a psychiatric setting. Adults with MDD and CUD (N=26) recruited from mental health care settings were enrolled in a 10-week, computer-assisted psychosocial intervention: Self-Help for Alcohol and other Drug Use and Depression (SHADE). Feasibility, acceptability, perceived helpfulness, treatment retention, completion, and clinical outcomes including cannabis use and depression were assessed. Participants found the SHADE intervention to be acceptable and helpful in facilitating action towards their therapeutic goals concerning depression and cannabis use. Treatment completion, achieved by the majority (85%) of participants, was excellent. On average, participants reduced their past 30 day cannabis use from baseline (mean percentage of days using = 69%) to follow-up (M=44%) (t(22)= 2.3, p<0.05; Effect Size= 0.79). Concurrently, they evidenced reductions in depressive symptom severity, from the moderately severe range at baseline to the mild range at follow-up (t(24)=7.3, p<0.001; Effect Size=1.52). Addressing comorbid CUD and MDD using a computer-assisted, evidence-based treatment strategy is feasible in a psychiatric care setting, and may produce improvements in both depressive symptoms and cannabis use.

Barriers to initiation of extended release naltrexone among HIV-infected adults with alcohol use disorders.

Alcohol consumption is a major risk factor for the acquisition of HIV/AIDS and is associated with greater disease burden and mortality among those who become HIV-infected. Of the extant pharmacological treatments for alcohol use disorders, naltrexone is recognized as one of the most efficacious, producing robust reductions in alcohol craving and use. Given that treatment with oral naltrexone has been limited by problems with adherence, which are particularly prevalent among individuals with multiple chronic, co-occurring conditions, long-acting formulations may be a promising approach for HIV-infected substance users. However, little is known about the barriers to initiation of extended-release naltrexone (XR-NTX) treatment among alcohol users living with HIV. In this report we present and discuss the content analysis of open-ended survey questions, as well as lessons learned, with regards to barriers to initiation and maintenance of XR-NTX treatment collected as part of an RCT evaluating a cognitive behavioral text messaging intervention for HIV-infected adults with alcohol use disorders. Barriers to initiation and maintenance of XR-NTX pharmacotherapy among HIV+ individuals with alcohol use disorders seem to fall in one of two categories: [1] barriers that are amenable to change, which include distance and transportation issues, fear of injections, and belief that alcohol use does not warrant pharmacotherapy, and [2] barriers that are not amenable to change, such as the potential interaction of XR-NTX with another medication regimen.

A Cognitive Behavioral Therapy-Based Text Messaging Intervention Versus Medical Management for HIV-Infected Substance Users: Study Protocol for a Pilot Randomized Trial.

BACKGROUND: Evidence-based psychosocial interventions for addictions and related conditions such as cognitive behavioral therapy (CBT) are underutilized. Obstacles to implementation of CBT in clinical settings include limited availability of quality training, supervision, and certification in CBT for clinicians; high rates of clinician turnover and high caseloads; and limited qualifications of the workforce to facilitate CBT expertise. OBJECTIVE: Mobile phone-based delivery of CBT, if demonstrated to be feasible and effective, could be transformative in broadening its application and improving the quality of addiction treatment. No experimental interventions that deliver CBT targeting both drug use and medication adherence using text messaging have been previously reported; as such, the objective of this study is to develop and test an SMS-based treatment program for HIV-positive adults with comorbid substance use disorders. METHODS: With user input, we developed a 12-week CBT-based text messaging intervention (TXT-CBT) targeting antiretroviral (ART) adherence, risk behaviors, and drug use in a population of HIV-infected substance users. RESULTS: The intervention has been developed and is presently being tested in a pilot randomized clinical trial. Results will be reported later this year. CONCLUSIONS: This investigation will yield valuable knowledge about the utility of a cost-effective, readily deployable text messaging behavioral intervention for HIV-infected drug users.

Eyebrow tissue expansion: an underappreciated entity in thyroid-associated orbitopathy.

OBJECTIVES: To report photographic evidence of eyebrow tissue expansion in patients with thyroid-associated orbitopathy (TAO) and to demonstrate consistency in grading through the use of standardized photographs. METHODS: A retrospective cohort study of patients referred for evaluation of TAO in an orbitofacial tertiary care center between January 1, 2000, and December 31, 2010. A grading key was produced with representative views of each of 4 grades (0 [no expansion] to 3 [severe expansion]), corresponding to increasing severity of eyebrow tissue expansion. Photographs of each study patient, including both premorbid and morbid photographs, were retrieved from an electronic medical record system and graded by 6 independent, masked observers using this 4-point system. RESULTS: Seventy-five patients with TAO were identified for inclusion. The average grade was 0.3 for premorbid eyes and 1.1 for morbid eyes. Intraclass correlation coefficients for the premorbid photographs were 0.705 and 0.632 for the right and left eyes, respectively. Intraclass correlation coefficients for the morbid photographs were 0.921 and 0.916 for the right and left eyes, respectively. CONCLUSIONS: Eyebrow tissue expansion is a common manifestation in TAO. Comparison of premorbid and morbid photographs is a useful means to identify and characterize the extent of brow involvement. The use of a grading key improves the consistency of identifying and grading eyebrow tissue expansion. Recognition of the eyebrow tissue as distinct anatomically in TAO may be crucial to rehabilitation of these patients, which may entail multiple surgical procedures.

Thyroid-associated periorbitopathy: eyebrow fat and soft tissue expansion in patients with thyroid-associated orbitopathy.

OBJECTIVE: To compare soft tissue and fat volumes in the supraorbital area of healthy patients and patients with thyroid-associated orbitopathy (TAO) using 3-dimensional reconstruction software. METHODS: The superiolateral orbital area was delineated on a bony framework. Three-dimensional reconstruction and volumetric calculation of the retro-orbicularis oculi fat (brow fat), galeal fat (including the retro-orbicularis oculi fat), and soft-tissue muscle were performed. RESULTS: We analyzed 100 computed tomographic scans from 48 patients with TAO and 52 control subjects. All patients showed an age-related increase of fat volumes. The mean total eyebrow volume was greater in patients with TAO vs healthy control subjects (P < .001). Galeal fat (P = .02) and retro-orbicularis oculi fat (P = .01) volumes were significantly higher in patients with TAO vs control subjects. Soft-tissue muscle volume decreased with age in healthy females but remained constant in the aging female group with TAO. Both total volume and brow thickness did not appear to change with age in healthy patients but exhibited an increase in the female population with TAO. CONCLUSIONS: This study brings into focus the clinicopathologic entity of thyroid-associated periorbitopathy. Three-dimensional evaluation of computed tomographic scans can provide information on volumetric changes in the eyebrow profile of patients with TAO. Further investigation of the biologic and morphologic changes of eyebrow fat and soft tissue in patients with TAO may help better characterize, classify, and guide their treatment.