Student peer mentoring: Feasibility and acceptability of mHealth-based tool for alcohol and substance abuse prevention by peer mentors at a university in Kenya.

OBJECTIVE: The use of mobile health (mHealth)-based interventions for the prevention of alcohol and other psychoactive substances use is an emerging practice for which new evidence is required. This study evaluated the feasibility and acceptability of a mHealth-based peer mentoring tool for early screening, brief intervention, and referral of students who abuse alcohol and other psychoactive substances. It compared the implementation of a mHealth-delivered intervention to the paper-based practice that is the standard at the University of Nairobi. METHODS: A quasi-experimental study using purposive sampling was used to select a cohort of n = 100 (51 experimental, 49 control) first-year student peer mentors on two campuses of the University of Nairobi in Kenya. Data were collected on the mentors' sociodemographic characteristics as well as the feasibility and acceptability of the interventions by way of, the magnitude of reach, feedback to investigators, referral of cases, and perceived ease of use. RESULTS: The mHealth-based peer mentoring tool scored high with 100% of users rating it as feasible and acceptable. Among the two study cohorts, there were no differences in the acceptability of the peer mentoring intervention. When comparing the feasibility of the peer mentoring practice, actual use of the interventions, and intervention reach, the mHealth-based cohort mentored four mentees for every one mentored by the standard practice cohort. CONCLUSION: The mHealth-based peer mentoring tool had high feasibility and acceptability among student peer mentors. The intervention provided evidence for the need to expand the availability of screening services for alcohol and other psychoactive substances use among students in the university and promote the appropriate management practices within and outside the university.

The Cultural Adaption of a Sobriety Support App for Alaska Native and American Indian People: Qualitative Feasibility and Acceptability Study.

BACKGROUND: Despite high rates of alcohol abstinence, Alaska Native and American Indian (ANAI) people experience a disproportionate burden of alcohol-related morbidity and mortality. Multiple barriers to treatment exist for this population, including a lack of culturally relevant resources; limited access to or delays in receiving treatment; and privacy concerns. Many ANAI people in the state of Alaska, United States, live in sparsely populated rural areas, where treatment access and privacy concerns regarding peer-support programs may be particularly challenging. In addition, prior research demonstrates that many ANAI people prefer a self-management approach to sobriety, rather than formal treatment. Taken together, these factors suggest a potential role for a culturally adapted smartphone app to support ANAI people interested in changing their behavior regarding alcohol use. OBJECTIVE: This study was the first phase of a feasibility and acceptability study of a culturally tailored version of an off-the-shelf smartphone app to aid ANAI people in managing or reducing their use of alcohol. The aim of this qualitative needs assessment was to gather insights and preferences from ANAI people and health care providers serving ANAI people to guide feature development, content selection, and cultural adaptation before a pilot test of the smartphone app with ANAI people. METHODS: From October 2018 to September 2019, we conducted semistructured interviews with 24 ANAI patients aged ≥21 years and 8 providers in a tribal health care organization in south-central Alaska. RESULTS: Participants generally endorsed the usefulness of a smartphone app for alcohol self-management. They cited anonymity, 24/7 access, peer support, and patient choice as key attributes of an app. The desired cultural adaptations included ANAI- and land-themed design elements, cultural content (eg, stories from elders), and spiritual resources. Participants considered an app especially useful for rural-dwelling ANAI people, as well as those who lack timely access to treatment services or prefer to work toward managing their alcohol use outside the clinical setting. CONCLUSIONS: This needs assessment identified key features, content, and cultural adaptations that are being implemented in the next phase of the study. In future work, we will determine the extent to which these changes can be accommodated in a commercially available app, the feasibility of implementation, and the acceptability of the culturally adapted version of the app among ANAI users.

Measuring Attitudes About Alcohol Misuse and Dependence Among Alaska Native People Within a Tribal Health Care System.

OBJECTIVES: Attitudes about alcohol misuse and dependence influence alcohol use and help-seeking behavior. Alaska Native and American Indian (AN/AI) people have higher rates of alcohol-related morbidity and mortality but engage in treatment at lower rates than the general population. No validated instruments exist to assess attitudes of AN/AI people about alcohol misuse and dependence to inform treatment and prevention efforts. This study aimed to develop an instrument to assess public attitudes among AN/AI people of alcohol misuse and dependence. METHODS: This multiphase, mixed-methods study was conducted at Southcentral Foundation, a tribally owned health system serving 65,000 AN/AI people in Alaska. We conducted focus groups and interviews with health system users, providers, and leaders to adapt the Public Attitudes About Addiction Survey. The adapted instrument was piloted with 200 people. Cognitive interviews and exploratory and confirmatory factor analyses were used to refine the instrument, which were then administered to 777 AN/AI people. RESULTS: Initial exploratory factor analysis identified 5 factors, including 3 from the original Public Attitudes About Addiction Survey (moral, disease, nature), a combined psychology and sociology factor (psychosocial), and a new factor (environment). A final 4-factor model (psychosocial, moral, disease, nature) with 14 items had good fit with root mean square error of approximation (0.035; comparative fit index = 0.977; Tucker-Lewis index = 0.970; standardized root mean residual = 0.040) and loadings ranging from 0.41 to 0.80. CONCLUSIONS: This study developed the first instrument to assess AN/AI attitudes about alcohol misuse and dependence. This instrument has potential to inform alcohol-related treatment in AN/AI communities. Future research is warranted to adequately measure place-based contributors salient to AN/AI people.

Cognitive Processing Therapy or Relapse Prevention for comorbid Posttraumatic Stress Disorder and Alcohol Use Disorder: A randomized clinical trial.

OBJECTIVE: To compare a Posttraumatic Stress Disorder (PTSD) treatment (Cognitive Processing Therapy; CPT), an Alcohol Use Disorder (AUD) treatment (Relapse Prevention; RP), and assessment-only (AO) for those meeting diagnostic criteria for both PTSD and AUD. METHOD: Participants with current PTSD/AUD (N = 101; mean age = 42.10; 56% female) were initially randomized to CPT, RP, or AO and assessed post-treatment or 6-weeks post-randomization (AO). AO participants were then re-randomized to CPT or RP. Follow-ups were at immediate post-treatment, 3-, and 12-months. Mixed effects intent-to-treat models compared conditions on changes in PTSD symptom severity, drinking days, and heavy drinking days. RESULTS: At post-treatment, participants assigned to CPT showed significantly greater improvement than those in AO on PTSD symptom severity (b = -9.72, 95% CI [-16.20, -3.23], d = 1.22); the RP and AO groups did not differ significantly on PTSD. Both active treatment conditions significantly decreased heavy drinking days relative to AO (CPT vs. AO: Count Ratio [CR] = 0.51, 95% CI [0.30, 0.88]; RP vs. AO: CR = 0.34, 95% CI [0.19, 0.59]). After re-randomization both treatment conditions showed substantial improvements in PTSD symptoms and drinking between pre-treatment and post-treatment over the 12-month follow-up period, with RP showing an advantage on heavy drinking days. CONCLUSION: Treatments targeting one or the other aspects of the PTSD/AUD comorbidity may have salutary effects on both PTSD and drinking outcomes. These preliminary results suggest that people with this comorbidity may have viable treatment options whether they present for mental health or addiction care. TRIAL REGISTRATION: The trial is registered at clinicaltrials.gov (NCT01663337).

Discrimination, acculturative stress, alcohol use and their associations with alcohol-related consequences among Latino immigrant men.

Latino immigrant men are at increased risk for unhealthy alcohol use and related consequences due to social stressors associated with immigration. We assessed the associations of, and examined whether social stressors moderated associations between, alcohol use and alcohol-related consequences in a community-based sample of Latino immigrant men in Washington (N = 187). The mean Alcohol Use Disorders Identification Test Consumption (AUDIT-C) score was 6.3 (scores ≥ 4 indicate unhealthy alcohol use). More than half of the men (61.5%) reported experiencing discrimination in at least one setting and mean acculturative stress score was 18.3 indicating moderate levels of acculturative stress. Linear regression models were fit to assess main effects (associations between both alcohol use and social stressors and alcohol-related consequences) and moderation (whether the association between alcohol use and consequences varied based on experience of social stressors using multiplicative interaction) after adjustment for potential confounders. Alcohol use (ß = 0.47, 95% CI = 0.20-0.73; p = .001), discrimination (ß = 0.85, 95% CI = 0.27-1.43; p = .004), and acculturative stress (ß = 0.13, 95% CI = 0.02-0.24; p = .025) were all associated with increased experience of alcohol-related consequences. The association between alcohol use and alcohol-related consequences was stronger for those with high levels of acculturative stress (p = .025) but not experience of discrimination (p = .587). Findings underscore the importance of social and cultural context in alcohol use and related consequences. Efforts to reduce negative consequences of drinking may include focus on reducing exposure to discrimination and acculturative stress.

Contingency management for alcohol use disorder reduces cannabis use among American Indian and Alaska Native adults.

OBJECTIVE: Determine whether a culturally tailored contingency management (CM) intervention targeting alcohol abstinence resulted in secondary effects on cannabis use among American Indian and Alaska Native (AI/AN) adults. METHODS: The research team conducted this secondary data analysis to examine cannabis abstinence using data from a randomized control trial of CM for alcohol use among three AI/AN-serving organizations. One hundred and fifty-eight adults met the randomization criteria (i.e., submission of 50% or more urine samples and one alcohol-positive urine test during a 4-week, pre-randomization, observation period). For 12 weeks after randomization, participants received incentives for submitting a urine test negative for ethyl glucuronide (EtG < 150 ng/mL, CM group) or incentives for submitting a urine sample regardless of abstinence (Non-contingent [NC] Control group). Generalized linear mixed effects models assessed group differences in cannabis abstinence during the intervention, verified by urine tetrahydrocannabinol negative tests (11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid <50 ng/mL). RESULTS: At baseline, 42.2% (n = 35) of participants in the NC group and 40.0% (n = 30) of those in the CM group had a cannabis positive urine test. An overall intervention by time interaction was detected for a cannabis negative urine test (χ2 = 13.40, p = 0.001). Compared to the NC group, the CM group had 3.92 (95% CI:1.23-12.46) times higher odds of having a cannabis negative urine test during the intervention period and 5.13 (95% CI:1.57-16.76) times higher odds of having a negative cannabis test at the end of intervention period. CONCLUSION: CM addressing alcohol misuse may be an effective strategy for decreasing cannabis use among AI/AN adults. TRIAL REGISTRATION: ClinicalTrials.gov number, Identifier: NCT02174315.

Effect of Incentives for Alcohol Abstinence in Partnership With 3 American Indian and Alaska Native Communities: A Randomized Clinical Trial.

Importance: Many American Indian and Alaska Native communities are disproportionately affected by problems with alcohol use and seek culturally appropriate and effective interventions for individuals with alcohol use disorders. Objective: To determine whether a culturally tailored contingency management intervention, in which incentives were offered for biologically verified alcohol abstinence, resulted in increased abstinence among American Indian and Alaska Native adults. This study hypothesized that adults assigned to receive a contingency management intervention would have higher levels of alcohol abstinence than those assigned to the control condition. Design, Setting, and Participants: This multisite randomized clinical trial, the Helping Our Native Ongoing Recovery (HONOR) study, included a 1-month observation period before randomization and a 3-month intervention period. The study was conducted at 3 American Indian and Alaska Native health care organizations located in Alaska, the Pacific Northwest, and the Northern Plains from October 10, 2014, to September 2, 2019. Recruitment occurred between October 10, 2014, and February 20, 2019. Eligible participants were American Indian or Alaska Native adults who had 1 or more days of high alcohol-use episodes within the last 30 days and a current diagnosis of alcohol dependence. Data were analyzed from February 1 to April 29, 2020. Interventions: Participants received treatment as usual and were randomized to either the contingency management group, in which individuals received 12 weeks of incentives for submitting a urine sample indicating alcohol abstinence, or the control group, in which individuals received 12 weeks of incentives for submitting a urine sample without the requirement of alcohol abstinence. Regression models fit with generalized estimating equations were used to assess differences in abstinence during the intervention period. Main Outcomes and Measures: Alcohol-negative ethyl glucuronide (EtG) urine test result (defined as EtG<150 ng/mL). Results: Among 1003 adults screened for eligibility, 400 individuals met the initial criteria. Of those, 158 individuals (39.5%; mean [SD] age, 42.1 [11.4] years; 83 men [52.5%]) met the criteria for randomization, which required submission of 4 or more urine samples and 1 alcohol-positive urine test result during the observation period before randomization. A total of 75 participants (47.5%) were randomized to the contingency management group, and 83 participants (52.5%) were randomized to the control group. At 16 weeks, the number who submitted an alcohol-negative urine sample was 19 (59.4%) in the intervention group vs 18 (38.3%) in the control group. Participants randomized to the contingency management group had a higher likelihood of submitting an alcohol-negative urine sample (averaged over time) compared with those randomized to the control group (odds ratio, 1.70; 95% CI, 1.05-2.76; P = .03). Conclusions and Relevance: The study's findings indicate that contingency management may be an effective strategy for increasing alcohol abstinence and a tool that can be used by American Indian and Alaska Native communities for the treatment of individuals with alcohol use disorders. Trial Registration: ClinicalTrials.gov Identifier: NCT02174315.

Prevalence of Moderate and Acute Suicidal Ideation among a National Sample of Tribal College and University Students 2014-2015.

OBJECTIVES: To examine the relationship between suicide risk and hazardous drinking, depression, and anxiety, adjusting for demographics, among tribal college students across the United States. Methods. We invited tribal college students enrolled in 22 tribal colleges from fall 2014 and 2015 to participate in the Creating Campus Change study, a cross-sectional online/paper survey assessing alcohol use patterns and mental health outcomes. 3,239 students participated in the survey, yielding a response rate of 31.3%. We assessed alcohol use, depression, and general anxiety, along with demographic characteristics. We used the Mini-International Neuropsychiatric Interview to assess suicide risk. Results. 8.5% indicated moderate or high suicide risk. In the final adjusted model, moderate/high depression was significantly associated with moderate/high suicide risk (OR = 6.64; 3.91-11.28, p < 0.001), as was moderate/high general anxiety (OR = 2.80; 1.58-4.97, p < 0.001), and moderate/high hazardous drinking (OR = 2.09; 1.19-3.66, p < 0.001). Conclusions. Students attending tribal colleges who report moderate/high levels of depression, anxiety, or hazardous drinking have a greater risk of suicidality. Identifying factors buffering the risk of suicidality could support policy changes necessary to address this critical public health issue.

Risk and Protective Factors Associated with Moderate and Acute Suicidal Ideation among a National Sample of Tribal College and University Students 2015-2016.

OBJECTIVES: We examined the relationship between suicide risk and disability status, as well as risk and protective factors, adjusting for demographic characteristics, among students attending 22 Tribal Colleges and Universities (TCU; 20 rural and 2 urban) across the United States in fall 2015 and 2016. METHODS: Tribal college students (N = 3,239) participated in a cross-sectional online or paper survey assessing alcohol use patterns and mental health outcomes, yielding a response rate of 31.3%. RESULTS: Of the students surveyed, 8.8% indicated moderate or high suicide risk. Hearing impairment was significantly associated with moderate/high suicide risk (OR = 2.11; 1.24-3.61, P = .006), as was vision impairment (OR = 3.03; 1.92-4.77, P < .001), having a physical/mental/or emotional condition (OR = 2.12; 1.75-2.57, P < .001), experiencing critical appraisal (OR = 1.30; 1.24-1.36, P < .001), and experiencing critical isolation (OR = 1.83; 1.66-2.01, P < .001). Scoring high on resilience (OR = 0.93; 0.92-0.95, P < .001), reporting higher emotional social support (OR = 0.75; 0.70-0.79, P < .001), and reporting higher levels of instrumental social support (OR = 0.69, 0.62-0.76, P < .001) were significantly associated with lower suicide risk. CONCLUSIONS: Students attending tribal colleges who experience hearing impairment, sight impairment, or a physical/emotional/mental condition have a greater risk of suicidality. Students experiencing critical appraisal and critical isolation may benefit from behavioral health interventions to reframe these experiences and develop resiliency skills. Developing avenues of emotional and instrumental social support within TCU settings offers key protective factors to buffer the risk of suicidality. Examining additional ways to build resiliency may also offer protection from suicide risk in this population.

Participant engagement in a community based participatory research study to reduce alcohol use among Latino immigrant men.

Although Latino immigrant men experience many health disparities, they are underrepresented in research to understand and address disparities. Community Based Participatory Research (CBPR) has been identified to encourage participant engagement and increase representation in health disparities research. The CBPR conceptual model describes how partnership processes and study design impact participant engagement in research. Using this model, we sought to describe how these domains influenced participant engagement in a pilot randomized controlled trial of brief intervention for unhealthy alcohol use (n = 121) among Latino immigrant men. We conducted interviews with a sample of study participants (n = 25) and reviewed logs maintained by 'promotores'. We identified facilitators of participant engagement, including the relevance of the study topic, alignment with participants' goals to improve their lives, partnerships with study staff that treated participants respectfully and offered access to resources. Further, men reported that the study time and location were convenient and that they appreciated being compensated for their time. Barriers to participant engagement included survey questions that were difficult to understand and competing demands of work responsibilities. Findings suggest that engaging underserved communities requires culturally responsive and community engagement strategies that promote trust. Future studies should further investigate how CBPR partnership processes can inform intervention research.

Alcohol and substance use among first-year students at the University of Nairobi, Kenya: Prevalence and patterns.

OBJECTIVE: Increase in alcohol and substance use among college students is a global public health concern. It is associated with the risk of alcohol and substance use disorders to the individual concerned and public health problems to their family and society. Among students there is also the risk of poor academic performance, taking longer to complete their studies or dropping out of university. This study determined the prevalence and patterns of alcohol and substance use of students at the entry to the university. METHOD: A total of 406 (50.7% male) students were interviewed using the Assessment of Smoking and Substance Involvement Test (ASSIST) and the Alcohol Use Disorder Identification Tool (AUDIT). Bivariate logistic regression analyses were used to examine associations between substance use and students' socio-demographic characteristics. Multivariate logistic regression analysis was conducted to examine the predictors of the lifetime and current alcohol and substance use. RESULTS: Lifetime and current alcohol and substance use prevalence were 103 (25%) and 83 (20%) respectively. Currently frequently used substances were alcohol 69 (22%), cannabis 33 (8%) and tobacco 28 (7%). Poly-substance use was reported by 48 (13%) respondents, the main combinations being cannabis, tobacco, and alcohol. Students living in private hostels were four times more likely to be current substance users compared with those living on campus (OR = 4.7, 95% CI: 2.0, 10.9). CONCLUSION: A quarter of the study respondents consumed alcohol and/or substances at the entry to university pushing the case for early intervention strategies to delay initiation of alcohol and substance use and to reduce the associated harmful consequences.

Impact of 12 step mutual help groups on drug use disorder patients across six clinical trials.

BACKGROUND: 12 step mutual help groups are widely accessed by people with drug use disorder but infrequently subjected to rigorous evaluation. Pooling randomized trials containing a condition in which mutual help group attendance is actively facilitated presents an opportunity to assess the effectiveness of 12 step groups in large, diverse samples of drug use disorder patients. METHODS: Data from six federally-funded randomized trials were pooled (n = 1730) and subjected to two-stage instrumental variables modelling, and, fixed and random effects regression models. All trials included a 12 step group facilitation condition and employed the Addiction Severity Index as a core measure. RESULTS: The ability of 12 step facilitation to increase mutual help group participation among drug use disorder patients was minimal, limiting ability to employ two-stage instrumental variable models that correct for selection bias. However, traditional fixed and random effect regression models found that greater 12 step mutual help group attendance by drug use disorder patients predicted reduced use of and problems with illicit drugs and also with alcohol. CONCLUSION: Facilitating significant and lasting involvement in 12 step groups may be more challenging for drug use disorder patients than for alcohol use disorder patients, which has important implications for clinical work and for effectiveness evaluations. Though selection bias could explain part of the results of traditional regression models, the finding that participation in 12 step mutual help groups predicts lower illicit drug and alcohol use and problems in a large, diverse, sample of drug use disorder patients is encouraging.

Dosage of booster phone calls following an SBIRT intervention in the emergency department for reducing substance use.

Brief Interventions (BIs) for problematic drug use in general medical settings, including in Emergency Departments (EDs), have shown disappointing results compared to those that target problematic alcohol use. Telephone booster calls may augment the impact of a BI delivered in the ED. The current study uses data from the National Drug Abuse Treatment Clinical Trials Network (CTN) Protocol 0047, "Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED)", a multisite randomized clinical trial conducted in six EDs in the U.S. We examine dose effects of telephone boosters (0, 1, or 2 calls completed) with non-treatment seeking patients who we randomized to the BI-Booster condition and who endorsed problematic drug use during their ED visit (N = 427). We assessed primary outcomes at 3-, 6-, and 12-month follow-ups, which included past month use of the primary drug of choice, use of any drug, and heavy drinking. There were no significant differences among those completing 0, 1, or 2 booster calls on any of the three main outcomes at 3-, 6-, and 12-months post-BI in the ED. Patients who were older were significantly more likely to complete booster calls. Taken together, these findings raise questions about the clinical utility of booster phone calls following screening and BIs targeting heterogeneous drug use in the ED.

Participant Satisfaction and Acceptability of a Culturally Adapted Brief Intervention to Reduce Unhealthy Alcohol Use Among Latino Immigrant Men.

Latino immigrant men are at increased risk for unhealthy alcohol use, yet few interventions have been designed to meet their unique needs. The current study assessed participant satisfaction and acceptability of a culturally adapted brief intervention to reduce unhealthy alcohol use in this population. Adaptations to the brief intervention included delivering it in Spanish by promotores in a community setting. The mixed methods approach included surveys (N = 73) and in-depth interviews (N = 20) with participants in a pilot randomized controlled trial. The study drew on Sekhon's theoretical framework of acceptability to asses affective attitude, burden, and perceived effectiveness of the intervention, along with satisfaction with the content, setting, and promotor. Participants' survey responses indicated that they were highly satisfied with the content, setting, and delivery of the brief intervention. In interviews participants noted that the brief intervention helped them reflect on their drinking behaviors, that they perceived promotores to be a trusted source of health information, and that they liked receiving personalized feedback via tablets. Some participants found the feedback did not match their own perceptions of their alcohol use and wanted clearer advice on how to reduce their drinking. Men felt they would benefit from more contact with promotores. These findings suggest that Latino immigrant men in this study were receptive to the culturally adapted brief intervention. Future interventions may be more effective if they include multiple contacts with promotores and more directive guidance on strategies to reduce drinking.

Assessing the Predictive Validity of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) in Alaska Native and American Indian People.

OBJECTIVES: The objective of this study was to examine the predictive validity of the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES) among Alaska Native and American Indian (ANAI) people with an alcohol use disorder. METHODS: The sample was 170 ANAI adults with an alcohol use disorder living in Anchorage, Alaska who were part of a larger alcohol intervention study. The primary outcome of this study was alcohol use as measured by mean urinary ethyl glucuronide (EtG). EtG urine tests were collected at baseline and then up to twice a week for four weeks. We conducted bivariate linear regression analyses to evaluate associations between mean EtG value and each of the three SOCRATES subscales (Recognition, Ambivalence, and Taking Steps) and other covariates such as demographic characteristics, alcohol use history, and chemical dependency service utilization. We then performed multivariable linear regression modeling to examine these associations after adjusting for covariates. RESULTS: After adjusting for covariates, mean EtG values were negatively associated with the Taking Steps (P = 0.017) and Recognition (P = 0.005) subscales of the SOCRATES among ANAI people living in Alaska. We did not find an association between mean EtG values and the Ambivalence subscale (P = 0.129) of the SOCRATES after adjusting for covariates. CONCLUSIONS: Higher scores on the Taking Steps and Recognition subscales of the SOCRATES at baseline among ANAI people predicted lower mean EtG values. This study has important implications for communities and clinicians who need tools to assist ANAI clients in initiating behavior changes related to alcohol use.

Racism as Experienced by Physicians of Color in the Health Care Setting.

BACKGROUND AND OBJECTIVES: The purpose of this study was to examine the impact of racism experienced by physicians of color in the workplace. METHODS: We utilized a mixed-methods, cross-sectional, survey design. Seventy-one participants provided qualitative responses describing instances of racism from patients, colleagues, and their institutions. These responses were then coded in order to identify key domains and categories. Participants also completed quantitative measures of their professional quality of life and the incidence of microaggressions experienced while at work. RESULTS: We found that physicians of color were routinely exposed to instances of racism and discrimination while at work. Twenty-three percent of participants reported that a patient had directly refused their care specifically due to their race. Microaggressions experienced at work and symptoms of secondary traumatic stress were significantly correlated. The qualitative data revealed that a majority of participants experienced significant racism from their patients, colleagues, and institutions. Their ideas for improving diversity and inclusion in the workplace included providing spaces to openly discuss diversity work, constructing institutional policies that promote diversity, and creating intentional hiring practices that emphasize a more diverse workforce. CONCLUSIONS: Physicians of color are likely to experience significant racism while providing health care in their workplace settings, and they are likely to feel unsupported by their institutions when these experiences occur. Institutions seeking a more equitable workplace environment should intentionally include diversity and inclusion as part of their effort.

Service utilization and chronic condition outcomes among primary care patients with substance use disorders and co-occurring chronic conditions.

BACKGROUND: Patients with a substance use disorder (SUD) often present with co-occurring chronic conditions in primary care. Despite the high co-occurrence of chronic medical conditions and SUD, little is known about whether chronic condition outcomes or related service utilization in primary care varies between patients with versus without documented SUDs. This study examined whether having a SUD influenced the use of primary care services and common chronic condition outcomes for patients with diabetes, hypertension, and obesity. METHODS: A longitudinal cohort observational study examined electronic health record data from 21 primary care clinics in Washington and Idaho to examine differences in service utilization and clinical outcomes for diabetes, hypertension, and obesity in patients with and without a documented SUD diagnosis. Differences between patients with and without documented SUD diagnoses were compared over a three-year window for clinical outcome measures, including hemoglobin A1c, systolic and diastolic blood pressure, and body mass index, as well as service outcome measures, including number of encounters with primary care and co-located behavioral health providers, and orders for prescription opioids. Adult patients (N = 10,175) diagnosed with diabetes, hypertension, or obesity before the end of 2014, and who had ≥2 visits across a three-year window including at least one visit in 2014 (baseline) and at least one visit occurring 12 months or longer after the 2014 visit (follow-up) were examined. RESULTS: Patients with SUD diagnoses and co-occurring chronic conditions were seen by providers more frequently than patients without SUD diagnoses (p's < 0.05), and patients with SUD diagnoses were more likely to be prescribed opioid medications. Chronic condition outcomes were no different for patients with versus without SUD diagnoses. DISCUSSION: Despite the higher visit rates to providers in primary care, a majority of patients with SUD diagnoses and chronic medical conditions in primary care did not get seen by co-located behavioral health providers, who can potentially provide and support evidence informed care for both SUD and chronic conditions. Patients with chronic medical conditions also were more likely to get prescribed opioids if they had an SUD diagnosis. Care pathway innovations for SUDs that include greater utilization of evidence-informed co-treatment of SUDs and chronic conditions within primary care settings may be necessary for improving care overall for patients with comorbid SUDs and chronic conditions.

Prevalence of documented alcohol and opioid use disorder diagnoses and treatments in a regional primary care practice-based research network.

BACKGROUND: Most people with alcohol or opioid use disorders (AUD or OUD) are not diagnosed or treated for these conditions in primary care. This study takes a critical step toward quantifying service gaps and directing improvement efforts for AUD and OUD by using electronic health record (EHR) data from diverse primary care organizations to quantify the extent to which AUD and OUD are underdiagnosed and undertreated in primary care practices. METHODS: We extracted and integrated diagnosis, medication, and behavioral health visit data from the EHRs of 21 primary care clinics within four independent healthcare organizations representing community health centers and rural hospital-associated clinics in the Pacific Northwest United States. Rates of documented AUD and OUD diagnoses, pharmacological treatments, and behavioral health visits were evaluated over a two-year period (2015-2016). RESULTS: Out of 47,502 adult primary care patients, 1476 (3.1%) had documented AUD; of these, 115 (7.8%) had orders for AUD medications and 271 (18.4%) had at least one documented visit with a non-physician behavioral health specialist. Only 402 (0.8%) patients had documented OUD, and of these, 107 (26.6%) received OUD medications and 119 (29.6%) had at least one documented visit with a non-physician behavioral health specialist. Rates of AUD diagnosis and AUD and OUD medications were higher in clinics that had co-located non-physician behavioral health specialists. CONCLUSIONS: AUD and OUD are underdiagnosed and undertreated within a sample of independent primary care organizations serving mostly rural patients. Primary care organizations likely need service models, technologies, and workforces, including non-physician behavioral health specialists, to improve capacities to diagnose and treat AUD and OUD.

Impact of Abstinence and of Reducing Illicit Drug Use Without Abstinence on Human Immunodeficiency Virus Viral Load.

BACKGROUND: Substance use is common among people living with human immunodeficiency virus (PLWH) and a barrier to achieving viral suppression. Among PLWH who report illicit drug use, we evaluated associations between HIV viral load (VL) and reduced use of illicit opioids, methamphetamine/crystal, cocaine/crack, and marijuana, regardless of whether or not abstinence was achieved. METHODS: This was a longitudinal cohort study of PLWH from 7 HIV clinics or 4 clinical studies. We used joint longitudinal and survival models to examine the impact of decreasing drug use and of abstinence for each drug on viral suppression. We repeated analyses using linear mixed models to examine associations between change in frequency of drug use and VL. RESULTS: The number of PLWH who were using each drug at baseline ranged from n = 568 (illicit opioids) to n = 4272 (marijuana). Abstinence was associated with higher odds of viral suppression (odds ratio [OR], 1.4-2.2) and lower relative VL (ranging from 21% to 42% by drug) for all 4 drug categories. Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with VL suppression (OR, 2.2, 1.6, respectively). Reducing frequency of illicit opioid or methamphetamine/crystal use without abstinence was associated with lower relative VL (47%, 38%, respectively). CONCLUSIONS: Abstinence was associated with viral suppression. In addition, reducing use of illicit opioids or methamphetamine/crystal, even without abstinence, was also associated with viral suppression. Our findings highlight the impact of reducing substance use, even when abstinence is not achieved, and the potential benefits of medications, behavioral interventions, and harm-reduction interventions.