Literature Collection

OBJECTIVES: Individuals with co-occurring opioid use disorder (OUD) and mental health disorders experience complex treatment trajectories. The collaborative care model (CoCM) is an effective approach for improving behavioral health outcomes in primary care, but has not been tested for patients with co-occurring disorders. We sought to understand patients' experiences receiving CoCM for co-occurring OUD and depression and/or PTSD. METHODS: We conducted interviews with patients (N=24) who received CoCM for co-occurring disorders as part of a randomized trial. CoCM was delivered across 18 clinics by 10 care managers who were community health workers embedded into primary care teams. Themes were identified by 2 coders using rapid content analyses. RESULTS: We identified 4 major themes. First, patients hoped CoCM would provide an opportunity to make OUD treatment possible by helping them navigate barriers. Second, patients thought that OUD and mental health disorders were connected and that treatment should be integrated. Third, patients felt that care managers improved their treatment, emphasizing how their compassionate style and commitment facilitated access to and retention in medications for OUD and mental health disorders. Finally, patients reported experiencing barriers to accessing mental health therapy, although support from care managers sometimes helped address those barriers. CONCLUSIONS: Patients expressed how care managers facilitated their positive experience with treatment and decreased access barriers common for individuals with co-occurring conditions. Our findings inform how community health workers in the role of care managers can facilitate access to and retention in care for people with co-occurring disorders.

Aims: This study concerns the perspectives of Indigenous persons who use injection drugs (IPWIDs) and key stakeholders across multiple sectors regarding healthcare service and treatment accessibility in the United States.Methods: Sixty in-depth interviews were undertaken with selected participants (30 people who use injection drugs and 30 stakeholders) across three non-urban locations in the United States. An inductive analytic approach was used to explore perspectives regarding healthcare accessibility gaps.Results: IPWIDs described injecting stimulants, opioids, and diverted medications for opioid use disorder, as well as having unstable access to sterile syringes. Often, the most accessible treatment for IPWID substance use was engagement with punitive aspects of the criminal justice system. While local health and social services were described as providing limited or inadequate services for IPWIDs, human capital deficiencies in those agencies and institutions often reinforced barriers to accessibility for IPWIDs, further aggravating the epidemics of Hepatitis C Virus infection and overdose risk in Indigenous communities. Conclusions: Decolonizing approaches to IPWID-centered services are urgently needed to reduce disparities in transmission of infectious diseases and other health consequences of injection drug use among American Indian people. Potential pathways forward include moving away from punitive treatment of IPWIDs by the criminal justice system and toward local, tribally-centered, culturally appropriate treatment models. We identify an urgent need to provide reliable and local access to sterile injection equipment and opioid substitution treatment on or near reservations.

Aims: This study concerns the perspectives of Indigenous persons who use injection drugs (IPWIDs) and key stakeholders across multiple sectors regarding healthcare service and treatment accessibility in the United States.Methods: Sixty in-depth interviews were undertaken with selected participants (30 people who use injection drugs and 30 stakeholders) across three non-urban locations in the United States. An inductive analytic approach was used to explore perspectives regarding healthcare accessibility gaps.Results: IPWIDs described injecting stimulants, opioids, and diverted medications for opioid use disorder, as well as having unstable access to sterile syringes. Often, the most accessible treatment for IPWID substance use was engagement with punitive aspects of the criminal justice system. While local health and social services were described as providing limited or inadequate services for IPWIDs, human capital deficiencies in those agencies and institutions often reinforced barriers to accessibility for IPWIDs, further aggravating the epidemics of Hepatitis C Virus infection and overdose risk in Indigenous communities. Conclusions: Decolonizing approaches to IPWID-centered services are urgently needed to reduce disparities in transmission of infectious diseases and other health consequences of injection drug use among American Indian people. Potential pathways forward include moving away from punitive treatment of IPWIDs by the criminal justice system and toward local, tribally-centered, culturally appropriate treatment models. We identify an urgent need to provide reliable and local access to sterile injection equipment and opioid substitution treatment on or near reservations.

BACKGROUND: Mental health conditions are often underdiagnosed and undertreated in primary care, particularly in underserved areas. Integrated behavioral health models can address this gap, but their reliance on mental health professionals may limit scalability. A multi-level intervention based on the chronic care model may enhance mental health care delivery in resource-limited settings. OBJECTIVE: To evaluate the effectiveness of a chronic care model-based primary care behavioral health integration program for improving the diagnosis and management of mental health conditions in a primary care setting. DESIGN: Quasi-experimental, pre-post observational study using interrupted time series analysis over a 10-year period (2010-2019). PARTICIPANTS: In total, 59,723 adult patients aged >18 who had at least two medical visits between 2010 and 2019. The patient population was 58% non-Hispanic Black, 29% non-Hispanic White, and 64% female. INTERVENTIONS: Implementation of clinical decision support systems for common mental health conditions (e.g., depression, anxiety, ADHD), self-management support, delivery system re-design within integrated behavioral health services, and health system community support with weekly behavioral health tips. MAIN MEASURES: Changes in the rate of mental health diagnoses and follow-up care (including psychiatric medications, referrals to psychiatry or behavioral medicine, and primary care visits with a mental health diagnosis). KEY RESULTS: The rate of mental health diagnoses increased by 58.8 per 1000 person-years in the first year after intervention implementation (p = 0.001). Follow-up care in primary care increased by 102.1 per 1000 person-years (p = 0.03), while psychiatry referrals decreased by 59.8 per 1000 person-years annually after the intervention (p = 0.004). CONCLUSIONS: This chronic care model-based system-level intervention was associated with significant increases in mental health diagnosis and treatment within primary care. Expanding the role of primary care in managing mental health conditions may offer a scalable solution to mental health professional shortages, especially in underserved areas.