Perspectives and Practice in the Identification and Treatment of Opioid Use, Alcohol Use, and Depressive Disorders

Implementation of Alcohol Use Disorder Training Curriculum Improves Perceived Confidence in Treating Alcohol-Related Liver Disorder Amongst Gastroenterology Fellows

BACKGROUND

Alcohol use disorder and alcohol-associated liver disease is increasing in the US, with subsequent and expected increases in morbidity and mortality due to these conditions.

AIMS

To determine the impact of an educational intervention regarding alcohol use disorder on gastroenterology fellows.

METHODS

A before-after survey study was carried out. Subjects were gastroenterology fellows at an urban tertiary care facility, who completed a pre-questionnaire and then attended a one-hour educational lecture on alcohol use disorder, alcohol-related liver disease, and treatment/resources available for patients. Immediately after the 1-h lecture, fellows were asked to complete a post-questionnaire and then a delayed questionnaire three months later. Pre- and post-answers were averaged out of a scale of 5 and analyzed using t-tests.

RESULTS

The study included eight fellows. Post-intervention, 12% of fellows felt more confident in having adequate training to provide alcohol use disorder counseling to their patients, 25% felt more confident in who they should refer their patients to for alcohol use disorder, and 16% felt more comfortable in being able to speak with their patients regarding alcohol use disorder and help effectively reduce their patients' consumption of alcohol (p value < 0.05).

CONCLUSION

A 1-h presentation discussing the complexities associated with diagnosing and treating alcohol use disorder, and the methods of helping destigmatize the disease in the medical community, can increase trainees' confidence and knowledge base to help treat patients with alcohol use disorder in the clinic setting and reducing liver morbidity.

Physician Reluctance to Intervene in Addiction: A Systematic Review

Importance

The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low.

Objective

To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions.

Data Sources

A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021.

Study Selection

Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included.

Data Extraction and Synthesis

Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons.

Main Outcomes and Measures

The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria.

Results

A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug.

Conclusions and Relevance

In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.

Primary care provider confidence in addressing opioid use disorder: A concept analysis

Primary care providers (PCPs) are well-positioned to provide care for opioid use disorder (OUD), yet very few address OUD regularly. One contributing factor may be PCPs' lack of confidence in their ability to effectively treat OUD. Evidence demonstrates that clinician confidence in home care and hospital settings is associated with improved care delivery and patient outcomes. However, a conceptual definition of PCP confidence in addressing OUD has yet to be established. The aim of this concept analysis is to enhance conceptual understanding of PCP confidence in addressing OUD and inform future measurement strategies. Following Walker and Avant's method of concept analysis, PubMed, PsycINFO, and Google Scholar were searched in October 2021. Manuscripts were included if they referenced confidence in relation to PCPs who provide care to adult patients with OUD. Studies conducted outside the US and not published in English were excluded. The search resulted in 18 studies which were synthesized to conceptualize PCP confidence in addressing OUD. Defining attributes include self-efficacy, experience, and readiness to address OUD. These attributes may be influenced by organizational culture, training, support, and resources. Consequences of PCP confidence addressing OUD may include improved patient outcomes, improved delivery of and access to OUD care, and PCP attitude changes. This concept analysis-which grounds the concept of PCP confidence in addressing OUD in the theoretical and empirical literature-lays the framework for future measurement of the concept. This represents a critical first step towards developing strategies to enhance PCP confidence in addressing OUD.

Behavioral Health Within Primary Care Postgraduate Dental Curricula: A Mixed Methods Study

PURPOSE

This study evaluated the integration of behavioral health topics (anxiety disorder, depressive disorder, eating disorders, opioid use disorder, and intimate partner violence) into primary care postgraduate dental curricula.

METHODS

We used a sequential mixed methods approach. We sent a 46-item online questionnaire to directors of 265 Advanced Education in Graduate Dentistry programs and General Practice Residency programs asking about inclusion of behavioral health content in their curriculum. Multivariate logistic regression analysis was used to identify factors associated with inclusion of this content. We also interviewed 13 of the program directors, conducted content analysis, and identified themes pertaining to inclusion.

RESULTS

A total of 111 program directors completed the survey (42% response rate). Less than 50% of programs taught their residents to identify anxiety disorder, depressive disorder, eating disorders, and intimate partner violence (86% taught identification of opioid use disorder). From the interviews, we identified 8 main themes: influences on the inclusion of behavioral health in the curriculum; training strategies; reasons for incorporating the training strategies; training outcomes (ie, ways in which residents were evaluated); training outputs (ie, ways in which a program's success was quantified); barriers to inclusion; solutions to barriers; and reflections on how the current program can be made better. Programs housed in settings with no to minimal integration were 91% less likely (odds ratio = 0.09; 95% CI, 0.02-0.47) to include identifying depressive disorder in their curriculum compared with programs in settings with close to full integration. Other influences for including behavioral health content were organizational/government standards and patient populations. Barriers to including behavioral health training included organizational culture and lack of time.

CONCLUSIONS

Advanced Education in General Dentistry and General Practice Residency programs need to make greater efforts to include in their curricula training on behavioral health conditions, particularly anxiety disorder, depressive disorder, eating disorders, and intimate partner violence.

The Association Between Depression and Substance Use Among Primary Care Patients With Comorbid Medical and Behavioral Health Conditions

INTRODUCTION

The scope of primary care increasingly encompasses patient behavioral health problems, manifest typically through depression screening and treatment. Although substance use is highly comorbid with depression, it is not commonly identified and addressed in the primary care context. This study aimed to examine the association between the likelihood of substance use disorder and increased depression severity, both cross-sectionally and longitudinally, among a sample of 2409 patients from 41 geographically dispersed and diverse primary care clinics across the US.

METHODS

This is secondary analysis of data obtained from a multi-site parent study of integrated behavioral health in primary care, among patients with both chronic medical and behavioral health conditions. Patient reported outcome surveys were gathered from patients at 3 time points. The primary care practices were blind to which of their patients completed surveys. Included were standardized measures of depression severity (Patient Health Questionnaire-9) [PHQ-9] and substance use disorder likelihood (Global Appraisal of Individual Needs-Short Screener [GSS]).

RESULTS

Four percent of the study population screened positive for substance use disorder. PHQ-9 scores indicated depression among 43% of all patients. There was a significant association between the likelihood of substance use disorder and depression initially, at a 9-month follow-up, and over time. These associations remained significant after adjusting for age, gender, race, ethnicity, education, income, and other patient and contextual characteristics.

CONCLUSIONS

The findings suggest that substance use disorder is associated with depression severity cross-sectionally and over time. Primary care clinics and health systems might consider implementing substance use screening in addition to the more common screening strategies for depression. Especially for patients with severe depression or those who do not respond to frontline depression treatments, the undermining presence of a substance use disorder should be explored.

Impact of the international collaborative addiction medicine research fellowship on physicians' future engagement in addiction research

Background: To evaluate how an international one-year intensive research training program for addiction medicine physicians contributed to subsequent research involvement and productivity. Methods: We prospectively compared addiction medicine physician fellows admitted to a one-year training program with non-admitted controls, using baseline questionnaire and peer-reviewed publication data. Participants' publication activity was assessed from fellowship application date onwards using biomedical databases (e.g., PubMed, Embase). Results: Between July 2014 and June 2020, which is six years of cohorts, 56 (39 women) physicians, both fellows (n = 25) and non-admitted applicants (n = 31), were observed and included in the study, contributing 261 person-years of observation. At baseline, in the fellows' cohort: 76% of participants (19/25) reported past research involvement, 24% (6/25) had one or more advanced graduate degrees (e.g., MPH), and the median number of peer-reviewed, first author publications was one (Interquartile Range [IQR] = 0-2). At baseline, in the controls' cohort: 84% of participants (26/31) reported past research involvement, 39% (12/31) had one or more advanced graduate degrees, and the median number of peer-reviewed, first author publications was zero. The physicians' training included internal medicine (n = 8), family medicine (n = 33), psychiatry (n = 5) and others (n = 4). At follow up, there was a significant difference between fellows (n = 25) and controls (n = 31) in total number of publications (Rate Ratio [RR] = 13.09, 95% Confidence Interval [CI], 5.01 - 34.21, p < 0.001), as well as first author publications (RR = 5.59, 95% CI, 2.23 - 14.06, p < 0.001). Conclusion: In the six-year observation period, fellows' productivity indicates undertaking this fellowship was associated with significant research outputs in comparison to controls, signaling successful training of addiction physicians to help recruit addiction medicine physicians to participate in addiction research.

Rural-Urban Differences in Physician Bias Toward Patients With Opioid Use Disorder

OBJECTIVE

Effective treatments for opioid use disorder exist, but rural areas of the United States have a shortage of services offering such treatments. Physician bias toward patients with opioid use disorder can also limit care access, but no studies have assessed whether physician bias is a more acute barrier in rural compared with urban communities.

METHODS

In total, 408 board-certified physicians in Ohio, a state with a high rate of opioid overdoses, completed an online survey examining perspectives on clinical care for patients who misuse opioids. Respondents with missing county-level data were excluded, leaving a total sample of 274. The authors used t tests to determine rural-urban differences in bias, key predictors of bias, and availability of opioid services. Multivariable regression modeling was used to estimate rural-urban differences in bias independent of key bias predictors.

RESULTS

Physicians in rural areas (N=37) reported higher levels of bias toward patients with opioid use disorder than did their urban counterparts (N=237). This difference remained statistically significant even after accounting for known bias predictors and physician specialty. Physicians specializing in addiction medicine reported lower bias than did physicians not working in this specialty.

CONCLUSIONS

Given existing disparities in harm reduction and addiction treatment services in rural areas, increased physician bias in counties lacking these services suggests that rural patients with opioid use disorder face numerous challenges to finding effective treatment. Bias reduction interventions should target health care professionals in rural communities where such efforts may have the most pronounced impact on improving health care access.

"It's way more than just writing a prescription": A qualitative study of preferences for integrated versus non-integrated treatment models among individuals with opioid use disorder

Background

Increasingly, treatment for opioid use disorder (OUD) is offered in integrated treatment models addressing both substance use and other health conditions within the same system. This often includes offering medications for OUD in general medical settings. It remains uncertain whether integrated OUD treatment models are preferred to non-integrated models, where treatment is provided within a distinct treatment system. This study aimed to explore preferences for integrated versus non-integrated treatment models among people with OUD and examine what factors may influence preferences.

Methods

This qualitative study recruited participants (n = 40) through Craigslist advertisements and flyers posted in treatment programs across the United States. Participants were 18 years of age or older and scored a two or higher on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool. Each participant completed a demographic survey and a telephone interview. The interviews were coded and content analyzed.

Results

While some participants preferred receiving OUD treatment from an integrated model in a general medical setting, the majority preferred non-integrated models. Some participants preferred integrated models in theory but expressed concerns about stigma and a lack of psychosocial services. Tradeoffs between integrated and non-integrated models were centered around patient values (desire for anonymity and personalization, fear of consequences), the characteristics of the provider and setting (convenience, perceived treatment effectiveness, access to services), and the patient-provider relationship (disclosure, trust, comfort, stigma).

Conclusions

Among this sample of primarily White adults, preferences for non-integrated versus integrated OUD treatment were mixed. Perceived benefits of integrated models included convenience, potential for treatment personalization, and opportunity to extend established relationships with medical providers. Recommendations to make integrated treatment more patient-centered include facilitating access to psychosocial services, educating patients on privacy, individualizing treatment, and prioritizing the patient-provider relationship. This sample included very few minorities and thus findings may not be fully generalizable to the larger population of persons with OUD. Nonetheless, results suggest a need for expansion of both OUD treatment in specialty and general medical settings to ensure access to preferred treatment for all.

Identification and Management of Opioid Use Disorder in Primary Care: an Update

PURPOSE OF REVIEW

The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs.

RECENT FINDINGS

The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.