Stimulant use among patients in opioid treatment settings: Provider perspectives.

INTRODUCTION: Methadone maintenance therapy (MMT) has been a pillar of opioid addiction treatment. Opioid treatment programs (OTPs) have been faced with an escalating threat of stimulant use and related overdose deaths among patients. We know little about how providers currently address stimulant use while maintaining treatment for opioid use disorder. METHODS: We conducted 5 focus groups with 36 providers (n = 11 prescribers; 25 behavioral health staff), and collected an additional 46 surveys (n = 7 prescribers; 12 administrators; 27 behavioral health staff). Questions focused on perceptions of patient stimulant use and interventions. We applied inductive analysis to identify themes relevant to identification of stimulant use, use trends, intervention approaches, and perceived needs to improve care. RESULTS: Providers indicated a trend of rising stimulant use among patients, especially those experiencing homelessness or comorbid health conditions. They reported a range of approaches to patient screening and intervention, including medication and harm reduction, improving treatment engagement, increasing level of care, and providing incentives. Providers expressed less agreement as to which of these interventions were effective, and though providers saw stimulant use as a common and severe problem, they reported little problem recognition and interest in treatment from their patients. A particular concern of providers was the prevalence and danger of synthetic opioids, such as fentanyl. They sought more research and resources to identify effective interventions and medications to address these issues. Also notable was an interest in contingency management (CM) and use of reinforcements/rewards to encourage stimulant use reduction. CONCLUSION: Providers face challenges in treating patients who use both opioids and stimulants. Although methadone is available to treat opioid use, no such "silver bullet" exists for stimulant use disorder. The rise in stimulant and synthetic opioid (e.g., fentanyl) combination products is presenting an extraordinary challenge for providers whose patients are at unprecedented risk for overdose. Providing OTPs with more resources to address polysubstance use is critical. Existing research indicates strong support for CM in OTPs, but providers reported regulatory and financial barriers to implementation. Further research should develop effective interventions that are accessible to providers in OTPs.

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.

Preliminary results of the evaluation of the California Hub and Spoke Program.

In August 2017, California launched the Hub and Spoke Program to address the growing number of opioid overdose deaths in the state. The program connects opioid treatment programs ("hubs") with office based opioid treatment settings, like primary care clinics ("spokes") to build a network of treatment expertise and referral resources. A key objective of this program is to expand access to medications for opioid use disorders (MOUD), with a particular focus on getting more buprenorphine into spokes. This article describes the preliminary results of the evaluation of the California Hub and Spoke program. Using a mixed methods approach, this portion of the evaluation measures changes in numbers of MOUD patients and providers, and barriers and facilitators to implementation. Findings reveal that, in the first 15 months of the program, 3480 new patients started buprenorphine in 118 spokes, increasing treatment initiations by 94.7% over baseline. The number of waivered spoke providers also increased 52.4% to 268. Although these data demonstrate promising growth in the network, challenges to expanding treatment access remain. Provider activity was among the most notable. Despite growth in the number of spoke providers with waivers to prescribe buprenorphine, only 68.7% (n = 184) were actively prescribing to patients. A survey of providers found that those who were not yet using their waivers lacked the confidence and mentorship they needed to prescribe. Provider knowledge and attitudes toward MOUD, fear of legal consequences, and limited patient outreach were also contributing factors. Recommendations for strengthening Hub and Spoke program implementation include facilitating mentor linkage for prescribers, expanding the support offered to spoke providers, and offering additional training and technical assistance aimed at provider stigma. Efforts to address these recommendations are described in a companion paper (Miele et al., under review).

Implementation of the hub and spoke model for opioid use disorders in California: Rationale, design and anticipated impact.

As part of the State Targeted Response to the opioid epidemic, California has adopted the Hub and Spoke model to expand access to medications for opioid use disorder, particularly buprenorphine, throughout the state. By aligning opioid treatment programs as hubs with primary care, office-based practitioners, and other health care settings as spokes, a broader treatment model can reach more people with opioid use disorder, improve access to medications for opioid use disorders, and decrease overdose deaths. Expanding access requires expanding knowledge and intensive implementation support of new practices. This paper describes the rationale, specific activities and anticipated impact of the implementation plan in California's Hub and Spoke system. Training and technical assistance are designed to: increase the number and capacity of waivered prescribers; enhance skills of prescribers and multidisciplinary teams; and create systems change. Activities include buprenorphine waiver trainings and provider support, a practice facilitator program, Project ECHO sessions, webinars, clinical skills trainings, and regional learning collaboratives. This overview highlights the steps California is taking to build treatment capacity to address the opioid epidemic.

Self-reported substance use in Iraq: findings from the Iraqi National Household Survey of Alcohol and Drug Use, 2014.

AIMS: To estimate the prevalence of tobacco, alcohol and drug use in Iraq using data from the Iraqi National Household Survey of Alcohol and Drug Use (INHSAD). DESIGN: A cross-sectional survey was conducted using a multi-stage cluster sampling method. Trained surveyors conducted face-to-face household interviews. SETTING: Iraq, from April 2014 to December 2014. PARTICIPANTS: A total of 3200 adult, non-institutionalized Iraqi citizens residing across all 18 governorates of Iraq. MEASUREMENTS: We estimated weighted prevalence and 95% confidence intervals (CIs) for life-time, past-year and past-month use of a variety of substances (tobacco, alcohol, prescription drugs and illicit drugs). For each substance, we also estimated whether individuals knew people who currently use the substance. FINDINGS: Self-reported past-month tobacco use was 23.2% (95% CI = 21.40, 25.19). Past-month alcohol use was 3.2% (95% CI = 2.58, 3.93). Women reported significantly lower prevalence for both tobacco and alcohol use compared with men (P-value < 0.01 for both). Only 1.4% (95% CI = 0.67, 3.02) reported past-month non-medical use of any prescription drugs. None of the women reported using any illicit drugs, and only 0.2% (95% CI = 0.07, 0.49) of men reported using any illicit drugs in the past month. Approximately 90.5% (95% CI = 88.58, 92.11) knew someone who uses tobacco, 42.4% (95% CI = 39.53, 45.24) knew someone who drinks alcohol, 27.9% (95% CI = 25.53, 30.45) knew someone who uses medication outside a doctor's instructions and 9.2% (95% CI = 7.87, 10.75) knew someone who uses an illicit drug. CONCLUSIONS: Psychoactive drug use is generally low in Iraq, tobacco being highest at an estimated 23.2%. Iraqi women report significantly less substance use than Iraqi men, which may be related to cultural gender norms. Discrepancy between self-report and 'knowing someone who uses a substance' suggests under-reporting in this population.

The Implementation of Integrated Behavioral Health Protocols In Primary Care Settings in Project Care.

PURPOSE: The majority of adults with mental health (MH) and substance use (SU) disorders in the United States do not receive treatment. The Affordable Care Act will create incentives for primary care centers to begin providing behavioral health (MH and SU) services, thus promising to address the MH and SU treatment gaps. This paper examines the implementation of integrated care protocols by three primary care organizations. METHODS: The Behavioral Health Integration in Medical Care (BHIMC) tool was used to evaluate the integrated care capacity of primary care organizations that chose to participate in the Kern County (California) Mental Health Department's Project Care annually for 3years. For a subsample of clinics, change over time was measured. Informed by the Conceptual Model of Evidence-Based Practice Implementation in Public Service Sectors, inner and outer contextual factors impacting implementation were identified and analyzed using multiple data sources and qualitative analytic methods. RESULTS: The primary care organizations all offered partially integrated (PI) services throughout the study period. At baseline, organizations offered minimally integrated/partially integrated (MI/PI) services in the Program Milieu, Clinical Process - Treatment, and Staffing domains of the BHIMC, and scores on all domains were at the partially integrated (PI) level or higher in the first and second follow-ups. Integrated care services emphasized the identification and management of MH more than SU in 52.2% of evaluated domains, but did not emphasize SU more than MH in any of them. Many of the gaps between MH and SU emphases were associated with limited capacities related to SU medications. Several outer (socio-political context, funding, leadership) and inner (organizational characteristics, individual adopter characteristics, leadership, innovation-values fit) contextual factors impacted the development of integrated care capacity. CONCLUSIONS: This study of a small sample of primary care organizations showed that it is possible to improve their integrated care capacity as measured by the BHIMC, though it may be difficult or unfeasible for them to provide fully integrated behavioral health services. Integrated services emphasized MH more than SU, and enhancing primary care clinic capacities related to SU medications may help close this gap. Both inner and outer contextual factors may impact integrated service capacity development in primary care clinics. Study findings may be used to inform future research on integrated care and inform the implementation of efforts to enhance integrated care capacity in primary care clinics.

An analysis of relapse prevention factors and their ability to predict sustained abstinence following treatment completion.

BACKGROUND & OBJECTIVES: This study assessed the role of 14 specific relapse-prevention activities and their underlying factors in maintaining abstinence among subjects (N = 302) completing outpatient treatment for stimulant dependence. METHODS: We examined what broader dimensions might subsume the 14 items constituting the Drug Avoidance Activities checklist (Farabee et al. J Subst Abuse Treat 2002;23:343-350), and how well these derived factors predicted concurrent drug use at baseline and again 3 and 12 months later. RESULTS: Although four factors were identified consistently for the three time points, only avoidance strategies had sufficient internal consistency to be retained for further analysis. Controlling for age, gender, and ethnicity, the avoidance subscale was a significant predictor of UA results at all time periods: a one-point increase in the avoidance strategies scale was associated with an 86% increase in odds of a negative UA at baseline (OR = 1.86, 95% CI = 1.37-2.53, p < .001), a 77% increase at 3-month follow-up (OR = 1.77, CI = 1.37-2.29, p < .001), and a 37% increase at 12-month follow-up (OR = 1.37, CI = 1.04-1.81, p = .026). CONCLUSIONS: Although correlations of individual items with UA results showed statistically significant (p < .05) results for 8 of 14 items at one or more observation points, avoidance-related behaviors showed the strongest associations with sustained abstinence.

A comparison of four telephone-based counseling styles for recovering stimulant users.

The continuing development and refinement of empirically supported interventions to increase participation in posttreatment care and promote sustained abstinence from illicit drug use is a priority for the addictions field. The purpose of this study was to assess the combined and relative effectiveness of four types of counseling styles, delivered by telephone, relative to a no call control condition. Stimulant users (N = 302) were randomized to one of four low-cost, telephone support protocols (unstructured/nondirective, unstructured/directive, structured/nondirective, structured/directive) or a standard referral to aftercare without telephone counseling (control). All of the study participants were nearing the completion of (or had completed) an intensive phase of structured, outpatient stimulant abuse treatment. Drug use and aftercare participation were assessed at 3 and 12 months following randomization. Intent-to-treat analyses showed no significant time-by-group interactions for these primary outcomes. Subsequent analyses, however, revealed a significant difference between the aggregated call groups and the control group at the time of the 3-month follow-up. The mean ASI drug use severity composite score for subjects in the call conditions declining from .058 at baseline to .048 at 3 months, whereas the no call/control group average score increased from .053 to .062 (χ (1) = 4.95, p = .026). A similar-and slightly stronger-effect was found when the study sample was restricted to those reporting any use during the month prior to the baseline interview (n = 152). This study provides modest support for the telephone-based counseling approaches strategies examined in this project. Subsequent research will assess interactions between patient characteristics and counseling styles, and improved identification of which treatment graduates might be more likely to benefit from this type of continuing support. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

The California Integration Learning Collaborative: a forum to address challenges of SUD-primary care service integration.

The California Substance Use Disorder (SUD)/Health Care Integration Learning Collaborative (CILC) aims to provide an interactive forum where county administrators, SUD provider organization representatives, and other key stakeholders can collaborate to identify successful models and processes for SUD integration into primary health care, as well as common barriers and solutions. We present the topics discussed within the CILC that have focused on common barriers to SUD and health care integration (documentation/data privacy, financing, and partnering with primary care providers). This article describes the discussions, presentations, and lessons learned from the CILC addressing each of these three barriers.

Perceptions of mental health and substance use disorder services integration among the workforce in primary care settings.

It is important to understand the perceptions of staff members who will be implementing the expected integration of mental health and substance use services into primary care. Surveys were administered to mental health/substance use disorder (MH/SUD) staff, support staff (SS), and primary care providers (PCPs) from three organizations (seven sites) that were participating in an initiative to promote the integration of MH/SUD services into primary care in Kern County, California. Results suggest that integration and MH/SUD services are highly valued among all staff types, and that staff are uniformly interested in further MH/SUD training. However, there were significant differences in staff perceptions. MH/SUD staff and services were valued by PCPs more than MH/SUD staff perceived being valued by PCPs, and MH/SUD staff were less likely to agree that communication with PCPs was good. Information seemed to flow better from MH/SUD staff to PCPs than in the other direction.

Integrating substance use disorder services with primary care: the experience in California.

Integrating substance use disorder (SUD) services with primary care (PC) can improve access to SUD services for the 20.9 million Americans who need SUD treatment but do not receive it, and help prevent the onset of SUDs among the 68 million Americans who use psychoactive substances in a risky manner. We lay out the reasons for integrating SUD and PC services and then explore the models used and the experiences of providers as they have begun SUD/PC integration in California.

Utilization, measurement, and funding of recovery supports and services.

An environmental survey was conducted regarding substance abuse recovery supports and services (RSS) delivered across California, where these services are offered, and by whom. Inquiries were made regarding RSS measurement efforts, funding mechanisms, and technical assistance needs. A survey was disseminated to all 57 administrators of county alcohol and other drug or behavioral departments. Results indicate that 62% (23 of 37) of responding counties offer RSS. Overall, certified addiction counselors (CACs) were the staff most utilized to provide RSS, followed by peers, clinicians, and volunteers. Among recovery-community organizations (RCOs), peers, volunteers, and CACs were the most utilized staff. Sober living homes were the most prevalent type of RCO, followed by recovery centers, faith-based/recovery ministries, and recovery schools. Forty-five percent of counties reported funding RSS; 37.8% collect data. RSS may provide valuable support services for individuals recovering from alcohol/drug use; however, the field must further define RSS and develop measurement strategies to justify RSS funding.