Substance Use and Co-occurring Physical Health Problems: File Review of a Residential Drug and Alcohol Treatment Service

Nurse-Led Physical Screening of Patients With Substance Use Disorders: A Cross-Sectional Study

INTRODUCTION

Somatic comorbidity is the main cause of reduced life expectancy in patients with substance use disorders (SUDs).

AIM

This study aims to investigate somatic health challenges in patients with SUDs using the USS. Patient self-management of somatic health and quality of life were also assessed.

METHOD

In our study, a stratified random sample of 136 clients who received treatment at a specialist addiction facility was drawn to investigate their physical health and lifestyle behaviours using the Utrecht Somatic Screening 2.0 (USS 2.0). The sample included three subgroups, that is, patients receiving outpatient treatment through Flexible Assertive Community Treatment (FACT), Heroin-Assisted Treatment (HAT) and Opioid Replacement Therapy (ORT). Pain, self-management and quality of life were also measured. Descriptive statistics were used to analyse the data.

RESULTS

The findings indicate that many patients experience a large number of somatic health problems, including pain and exhaustion. The most prevalent conditions in this study are cardiovascular disease (25%) and COPD (20%), underweight and poor oral health. Tobacco smoking is prevalent among 88% of patients. Fifty percent of the patients expressed a need for support in managing their physical health.

IMPLICATIONS FOR PRACTICE

Somatic health care and lifestyle promotion should be tailored to the specific characteristics of patients.

CONCLUSION

Patients with SUDs suffer from poor physical health and show unhealthy lifestyle behaviours, which demand the promotion of tailored somatic health.

Finding the optimal length of stay for veterans in substance use disorder residential treatment using generalized propensity score modeling

Substance use disorder (SUD) residential treatment provides critical services to patients with complex clinical needs. The Department of Veterans Affairs (VA) has over 70 SUD residential programs to meet the needs of veterans with severe SUD. Prior research is mixed on what SUD residential length of stay (LOS) duration maximizes average treatment outcomes, with some studies advocating for around 30 days and others advocating for at least 90 days. Much of this research is limited by methodological issues and fails to consider both outcomes for established patients and timely access for prospective patients. The present study sought to clarify the relative benefits of different LOSs to be considered by SUD residential program decision-makers as default LOSs, upon which to be personalized by individual patient needs and clinical assessment. Using medical record data associated with N = 15,889 veterans discharging from a VA SUD residential center between 10/1/2021 and 9/30/2022, we identified an optimal LOS range balancing average treatment outcomes and ensuring new patient access/minimizing established patient diminished returns from treatment. Using a generalized propensity-weighted dose-response curve, we identified key LOSs between 35 and 49 days with different tradeoffs between enhancing outcomes and access.

Stress Exposure and PTSD in a Cross-Sectional Residential Substance Use Treatment Sample

BACKGROUND

Aim 1 of this cross-sectional, observational study with people in residential treatment for substance use disorders (SUDs) was to document stress exposure. Aim 2 was to assess potential sociodemographic and health differences based on probable posttraumatic stress disorder (PTSD) status. Aim 3 was to assess relative contributions of Diagnostic and Statistical Manual (DSM)-congruent versus DSM-incongruent stressors (Criterion A vs non-Criterion A) to mental and physical health. We hypothesized that both types of stressors would significantly contribute to impairment across indicators and that DSM-congruent stressor exposure would be more strongly associated with impairment than DSM-incongruent exposure.

METHODS

We assessed exposure to DSM-congruent traumatic stressors and DSM-incongruent life stressors, PTSD and depressive symptoms, emotion regulation difficulties, substance use recovery capital, and physical/mental health-related quality of life among 136 people in residential SUD treatment who were 64% men, 36% women; 49% white, 41% Black, 11% multiracial/another race; 18% lesbian, gay, or bisexual (LGB+); mean age = 39.82 (standard deviation = 12.24) years.

RESULTS

Participants reported experiencing a mean of 9.76 (SD = 6.11) DSM-congruent events. Those with probable PTSD were younger and more likely to be LGB+ than those without probable PTSD (P < .05). Experiencing higher numbers of DSM-congruent events was associated with more severe PTSD and depressive symptoms, emotion regulation difficulties, and lower physical health-related quality of life (P < .05). DSM-incongruent stressor exposure was not independently associated with any indicators. Recovery capital was not associated with either type of stress exposure.

CONCLUSIONS

Stressful event exposure among people in residential SUD treatment is very high. Those who are younger or LGB+ in residential SUD treatment may be at greater risk of developing PTSD. DSM-congruent stressors are more consistently associated with mental health indicators than are DSM-incongruent stressors. Prioritizing treatment targets and identifying implementable treatment strategies can be challenging with this complex population.

Neurocognitive function and medical care utilization in Veterans treated for substance use disorder

BACKGROUND

Veterans with substance use disorder (SUD) are at high risk for cognitive problems due to neurotoxic effects of chronic drug and alcohol use coupled in many cases with histories of traumatic brain injury (TBI). These problems may in turn result in proneness to SUD relapse and reduced adherence to medical self-care regimens and therefore reliance on health care systems. However, the direct relationship between cognitive function and utilization of Veterans Health Administration (VHA) SUD and other VHA health care services has not been evaluated. We sought initial evidence as to whether neurocognitive performance relates to repeated health care engagement in Veterans as indexed by estimated VHA care costs.

METHODS

Neurocognitive performance in 76 Veterans being treated for SUD was assessed using CNS-Vital Signs, a commercial computerized cognitive testing battery, and related to histories of outpatient and inpatient/residential care costs as estimated by the VHA Health Economics Resource Center.

RESULTS

After controlling for age, an aggregate metric of overall neurocognitive performance (Neurocognition Index) correlated negatively with total VHA health care costs, particularly with SUD-related outpatient care costs but also with non-mental health-related care costs. Barratt Impulsiveness Scale scores also correlated positively with total VHA care costs.

CONCLUSIONS

In Veterans receiving SUD care, higher impulsivity and lower cognitive performance were associated with greater health care utilization within the VHA system. This suggests that veterans with SUD who show lower neurocognitive performance are at greater risk for continued health problems that require healthcare engagement. Cognitive rehabilitation programs developed for brain injury and other neurological conditions could be tried in Veterans with SUD to improve their health outcomes.

Substance use disorders in hospice palliative care: A narrative review of challenges and a case for physician intervention

OBJECTIVES

Substance use disorders (SUDs) are frequently encountered in hospice palliative care (HPC) and pose substantial quality-of-life issues for patients. However, most HPC physicians do not directly treat their patients' SUDs due to several institutional and personal barriers. This review will expand upon arguments for the integration of SUD treatment into HPC, will elucidate challenges for HPC providers, and will provide recommendations that address these challenges.

METHODS

A thorough review of the literature was conducted. Arguments for the treatment of SUDs and recommendations for physicians have been synthesized and expanded upon.

RESULTS

Treating SUD in HPC has the potential to improve adherence to care, access to social support, and outcomes for pain, mental health, and physical health. Barriers to SUD treatment in HPC include difficulties with accurate assessment, insufficient training, attitudes and stigma, and compromised pain management regimens. Recommendations for physicians and training environments to address these challenges include developing familiarity with standardized SUD assessment tools and pain management practice guidelines, creating and disseminating visual campaigns to combat stigma, including SUD assessment and intervention as fellowship competencies, and obtaining additional training in psychosocial interventions.

SIGNIFICANCE OF RESULTS

By following these recommendations, HPC physicians can improve their competence and confidence in working with individuals with SUDs, which will help meet the pressing needs of this population.

Effectiveness of residential treatment services for veterans with substance use disorders: A propensity score matching evaluation

BACKGROUND

Prior reviews of substance use disorder (SUD) treatment have found mixed support for residential level of care but are limited by methodology problems and the ethical concerns of randomizing patients with severe SUD to lower levels of care.

METHODS

The present study is the first to use a large archival SUD residential sample with a matched comparison group and one-year follow-up period to examine the benefits of residential treatment provided to adults clinically assessed as warranting SUD residential care. We used propensity score matching in our sample (N = 6177) of veterans with a SUD who were screened and accepted for Veterans Affairs (VA) SUD residential treatment between January 1st, 2019 and June 30th, 2019.

RESULTS

We found evidence that VA SUD residential treatment saves veteran lives with an average 66% all-cause mortality risk reduction during the study period (b = -1.09, exp(b) = 0.34, p <0.001). Medium-to-large residential pre- to post-treatment self-reported mental health and SUD symptom improvements (|SMDrobust| = 0.54-0.93) were sustained by one-year post-screening. These residential treatment improvements were significantly larger than estimated counterfactual outcomes across self-reported SUD and stress disorder symptoms at one-year post-screening (ps <0.001). We found mixed behavioral, service utilization, and other self-reported mental health outcomes.

CONCLUSIONS

We conclude that VA SUD residential treatment is an effective level of care for veterans warranting residential care particularly for SUD symptom improvements and reductions in mortality risk.

Substance use disorders, physical health and recovery capital: Examining the experiences of clients and the alcohol and other drug workforce

INTRODUCTION

Challenges associated with the integration of physical health within alcohol and other drug (AOD) treatment services persist. The construct of recovery capital has gained currency within the sector, however, its potential in understanding the integration of physical health within AOD treatment has not been examined. This study explores the role of physical health in the process of recovery, examining the potential of 'recovery capital' frameworks to enhance integrated care.

METHODS

Interviews were conducted with residential and outpatient AOD services across New South Wales, Australia. Qualitative data was collected from clients (n = 20) and staff (n = 13) and transcribed. Data were systematically coded and analysed using the iterative categorisation method.

RESULTS

Unmanaged physical health issues compromised recovery, particularly when associated with hopelessness and pain. Improved physical health ameliorated sources of negative recovery capital such as boredom, social isolation and mental health symptoms. When addressed during treatment, physical health facilitated recovery capital resources through knowledge and skill acquisition, increased autonomy, enjoyment and immersive experience. Benefits extended to domains of 'social capital' (social connection) and 'cultural capital' (physical appearance).

DISCUSSION AND CONCLUSIONS

Physical health offers variegated pathways for building recovery capital. Findings support calls for a more assertive approach to addressing physical health when AOD treatment occurs outside of primary care settings. Future research should examine the potential of recovery capital as a heuristic for optimising care of physical health issues and health-related behaviour within AOD treatment services.

Implementing traumatic brain injury screening in behavioral health treatment settings: results of an explanatory sequential mixed-methods investigation

BACKGROUND

Traumatic brain injury (TBI) is a complex condition common among individuals treated in behavioral healthcare, but TBI screening has not been adopted in these settings which can affect optimal clinical decision-making. Integrating evidence-based practices that address complex health comorbidities into behavioral healthcare settings remains understudied in implementation science, limited by few studies using theory-driven hypotheses to disentangle relationships between proximal and medial indicators on distal implementation outcomes. Grounded in the Theory of Planned Behavior, we examined providers' attitudes, perceived behavioral control (PBC), subjective norms, and intentions to adopt The Ohio State University TBI Identification Method (OSU TBI-ID) in behavioral healthcare settings.

METHODS

We used an explanatory sequential mixed-methods design. In Phase I, 215 providers from 25 organizations in the USA completed training introducing the OSU TBI-ID, followed by a survey assessing attitudes, PBC, norms, and intentions to screen for TBI. After 1 month, providers completed another survey assessing the number of TBI screens conducted. Data were analyzed using structural equation modeling (SEM) with logistic regressions. In Phase II, 20 providers were purposively selected for semi-structured interviews to expand on SEM results. Qualitative data were analyzed using thematic analysis, integrated with quantitative results, and combined into joint displays.

RESULTS

Only 25% (55/215) of providers adopted TBI screening, which was driven by motivations to trial the intervention. Providers who reported more favorable attitudes (OR: 0.67, p < .001) and greater subjective norms (OR: 0.12, p < .001) toward TBI screening demonstrated increased odds of intention to screen, which resulted in greater TBI screening adoption (OR: 0.30; p < .01). PBC did not affect intentions or adoption. Providers explained that although TBI screening can improve diagnostic and clinical decision-making, they discussed that additional training, leadership engagement, and state-level mandates are needed to increase the widespread, systematic uptake of TBI screening.

CONCLUSIONS

This study advances implementation science by using theory-driven hypothesis testing to disentangle proximal and medial indicators at the provider level on TBI screening adoption. Our mixed-methods approach added in-depth contextualization and illuminated additional multilevel determinants affecting intervention adoption, which guides a more precise selection of implementation strategies.

A model to understand antecedents of nursing attitudes and perceptions influencing outcomes of patients with SUD

INTRODUCTION

Substance use disorder (SUD) is a persistent and long-standing public health issue in the United States. While SUD is medically considered a chronic illness, it is also one that is viewed as self-inflicted, thereby resulting in judgmental attitudes and stigmatization from care providers, specifically from nurses.

DESIGN

In 2020, the authors completed an analytical cross-sectional study that included open-ended questions to examine nurses' knowledge and attitudes toward caring for patients with SUD across practice settings.

METHODS

A conceptual model was constructed by examining original study data and published literature on SUD, re-analyzing themes, determining constructs and variables, then coming to a consensus on critical aspects of the model.

CONCLUSION

The resulting conceptual model highlights antecedents of nursing behaviors that directly affect patient care outcomes, providing a roadmap to improving patient outcomes.

CLINICAL RELEVANCE

Understanding antecedents that affect nurses' attitudes and perceptions of patients with SUD highlights changes that can influence patient outcomes.

Systematic review of guidelines for managing physical health during treatment for substance use disorders: Implications for the alcohol and other drug workforce

ISSUES

Substance use disorders are associated with significant physical health comorbidities, necessitating an integrated treatment response. However, service fragmentation can preclude the management of physical health problems during addiction treatment. The aim of this systematic review was to synthesise the recommendations made by clinical practice guidelines for addressing the physical health of people attending alcohol and other drug (AOD) treatment.

APPROACH

An iterative search strategy of grey literature sources was conducted from September 2020 to February 2021 to identify clinical practice guidelines. Content pertaining to physical health care during AOD treatment was extracted. Quality of guidelines were appraised using the Appraisal of Guidelines Research and Evaluation II (AGREE-II) tool.

FINDINGS

Thirty-three guidelines were included for review. Fourteen guidelines were considered high quality based on AGREE-II scores. Neurological conditions (90.9%) and hepatitis (81.8%) were the most frequent health problems addressed. Most guidelines recommended establishing referral pathways to address physical health comorbidities (90.9%). Guidance on facilitating these referral pathways was less common (42.4%). Guidelines were inconsistent in their recommendations related to oral health, tobacco use, physical activity, nutrition and the use of standardised assessment tools.

IMPLICATIONS AND CONCLUSIONS

Greater consistency and specificity in the recommendations made for integrating physical health care within addiction treatment is needed. Ensuring that recommendations are applicable to the AOD workforce and to treatment services limited by funding and resource constraints should enhance implementation. Future guideline development groups should consider increased consultation with the AOD workforce and inclusion of clinical tools and decision aids to facilitate referral pathways.

Clinicians' perceptions of barriers to cervical cancer screening for women living with behavioral health conditions: a focus group study

Background

Women with behavioral health (BH) conditions (e.g., mental illness and substance abuse) receive fewer cervical cancer (CC) screenings, are diagnosed at more advanced cancer stages, and are less likely to receive specialized treatments. The aim of this study was to identify barriers that healthcare providers face in providing CC screening to women with BH conditions.

Methods

Guided by the Consolidated Framework for Implementation Research, we conducted four focus groups in North Florida with 26 primary care and BH clinicians and staff to examine perceived barriers to CC screening among their patients with BH conditions to guide the future development of a tailored cervical cancer screening and follow-up intervention. Thematic analysis was used to analyze verbatim transcripts from audiotaped focus groups.

Results

Three main themes of barriers emerged from the data: 1) BH conditions related barriers included a history of trauma, stigma and discrimination, and uncontrolled comorbid conditions, 2) System level barriers related to lack of integration between BH and primary care, and 3) Similar barriers to the general population including lack of health insurance, insufficient processes to send out reminders, and challenges with communicating with patients.

Conclusions

Tailored CC screening interventions that address the unique needs of women with BH conditions are needed. Strategies that address improving trust between patients and healthcare providers, identifying avenues to improve receipt of screening during time-limited clinical visits, connecting BH and primary care providers, and addressing the social determinants of health have potential to improve CC screening rates for women with BH conditions.

Investigating the experiences of individuals in recovery from problem substance use and their perceptions of the COVID-19 pandemic

Purpose

This paper aims to explore how enforced forms of social isolation arising from the first COVID-19 lockdown influenced experiences of problem substance use, relapse and coping strategies for recovery in individuals engaging with harm reduction recovery services.

Design/methodology/approach

A qualitative semi-structured interview design was adopted for this research. Seven participants were recruited from a harm reduction recovery organisation. During their initial interview, participants volunteered information regarding their experience of the first lockdown due to emerging concerns of the COVID-19 pandemic. Participants completed a second semi-structured interview at the end of the first lockdown regarding their experience of enforced isolation during this time.

Findings

Three themes identified from the analysis were isolation resulting in hindered human capabilities; adjusting to a new normal: an individual experience; and unexpected benefits to recovery resulting from isolation. While some participants reported boredom, loneliness and relapse events, others reported that the national response to the virus did not adversely affect them as they had already adjusted to living in a state of anxiety, isolation and uncertainty. These findings illuminate negative, neutral and positive aspects of substance use recovery throughout the COVID-19 lockdown as well as highlighting the complex and individualised role that social connectedness plays in relapse occurrence.

Originality/value

Participants reported differences in how they were affected by the pandemic, leading to theoretical implications for the effect of social isolation on recovery. For this reason, individuals with a history of dependency should be considered potentially vulnerable to the effects of enforced isolation and should be supported accordingly.

Multiple Morbidities in an Inner-City English Substance Misuse Treatment Service: Hierarchical Cluster Analysis to Derive Treatment Segments

Comorbid needs of people attending substance use treatment has been well documented although there is an assumption of heterogeneity in the treated population. This study utilized hierarchical cluster analysis to explore the extent and nature of client segments within the treated population. Methods: A retrospective review of comorbid health and social needs of a random sample of client case-notes (n = 300) was undertaken on all people known to treatment in an urban, inner-London community out-patient treatment service during 2018-2019. A hierarchical cluster analysis using Ward's linkage method was implemented to explore the data to determine and describe emergent clusters. Inter cluster differences were investigated further by modeling methods. Results: High rates of physical health (63%) and mental health (50%) need were noted across the entire treatment population. The hierarchical clustering identified three discrete segments of the treatment population. The largest segment (46% of clients) was complex, socially impacted chaotic heroin and crack misusers exhibiting a wide range of multiple morbidities including social needs such as housing, unemployment and offending. This cluster also were more likely to report acute needs such as Emergency Department attendance, utilization of ambulatory services and will and episodic disengagement disengage episodically from treatment. A second segment (24% of clients) exhibited similar drug using profiles to the largest cluster, although with fewer comorbid issues. This cluster tended to be older and more likely to report respiratory conditions. A third cluster (25% of clients) was more likely to be alcohol misusers who were new to treatment. Conclusions: Treated populations are likely to be relatively heterogeneous across a range of social harms, physical and mental health needs. Identifying multidimensional needs of segments within treatment services allows for the creation of tailored treatment interventions.

Facilitators and barriers to integrating physical health care during treatment for substance use: A socio-ecological analysis

INTRODUCTION AND AIMS

Clinical practice guidelines recommend physical health be addressed when treating substance use disorders. Yet, the integration of alcohol and other drug (AOD) treatment and physical health care is seldom actualised. This is particularly the case in the non-government sector. Using the socio-ecological model as a framework, this study aimed to examine the facilitators and barriers to integrating physical health in non-government AOD services.

DESIGN AND METHODS

Interviews were conducted with residential and outpatient AOD services across New South Wales, Australia. Qualitative data were collected from service users (n = 20) and clinicians (n = 13). Interview data were transcribed then systematically coded and analysed using iterative categorisation.

RESULTS

Most staff recognised physical health care as a fundamental component of treatment for substance use even when there were personal, professional and structural barriers for doing so. Service users reported a diverse range of health and social benefits when physical health care was incorporated in to AOD treatment. An exception to this was some negative experiences with health-care providers that were not identified by staff.

DISCUSSION AND CONCLUSIONS

Findings highlight the importance of developing resources to enhance the health literacy and capacity of non-government AOD services to address the physical health of clients. Given some clients reported negative experiences with health-care providers that were not identified by staff, services should seek regular feedback from clients regarding their experiences with external providers. The effectiveness of existing and new physical health initiatives within non-government organisation AOD services needs more formal evaluation.