Literature Collection

Psychoactive substance use among children in Afghanistan is an issue of concern. Somewhere around 300,000 children in the country have been exposed to opioids that either parents directly provided to them or by passive exposure. Evidence-based and culturally appropriate drug prevention and treatment programs are needed for children and families. The goals of this study were to: (1) examine lifetime psychoactive substance use in girls and boys at treatment entry; and (2) examine differential changes in substance use during and following treatment between girls and boys. Children ages 10-17 years old entering residential treatment were administered the Alcohol, Smoking and Substance Involvement Screening Test for Youth (ASSIST-Y) at pre- and post-treatment, and at three-month follow-up. Residential treatment was 45 days for children and 180 days for adolescents and consisted of a comprehensive psychosocial intervention that included education, life skills, individual and group counseling and, for older adolescents, vocational skills such as embroidery and tailoring. Girls and boys were significantly different regarding lifetime use of five substances at treatment entry, with girls less likely than boys to have used tobacco, cannabis, stimulants, and alcohol, and girls more likely than boys to have used sedatives. Differences between boys and girls were found for past-three-month use of four substances at treatment entry, with girls entering treatment with higher past-three-month use of opioids and sedatives, and boys with higher past-three-month use of tobacco, cannabis, and alcohol. Change over the course of treatment showed a general decline for both girls and boys in the use of these substances. Girls and boys in Afghanistan come to treatment with different substance use histories and differences in past-three-month use. Treatment of children for substance use problems must be sensitive to possible differences between girls and boys in substance use history.

INTRODUCTION: Previous studies show that some primary care clinicians do not feel equipped to treat patients with opioid use disorder (OUD). This study addressed the gaps in confidence and knowledge of primary care physicians and other participants (i.e., participants who were not physicians) in diagnosing, treating, prescribing, and educating patients with OUD through interactive learning sessions. METHODS: The American Academy of Family Physicians National Research Network held monthly OUD learning sessions from September 2021 to March 2022 with physicians and other participants (n = 31) from 7 practices. Participants took baseline (n = 31), post-session (n = 11-20), and post-intervention (n = 21) surveys. Questions focused on confidence, knowledge, among others. We used non-parametric tests to compare individual responses pre-versus-post participation as well as to compare responses between groups. RESULTS: All participants experienced significant changes in confidence and knowledge for most topics covered in the series. When comparing physicians to other participants, physicians had greater increases in confidence in dosing and monitoring for diversion (P = .047), but other participants had greater increases in confidence in the majority of topic areas. Physicians also had greater increases in knowledge than other participants in dosing and monitoring for safety (P = .033) and dosing and monitoring for diversion (P = .024), whereas other participants had greater increases in knowledge in most remaining topics. Participants agreed that sessions provided practical knowledge, except for relevancy of the case study portion of the session to current practice (P = .023) and the session improved participant ability to care for patients (P = .044). CONCLUSION: Through participating in interactive OUD learning sessions, knowledge and confidence increased among physicians and other participants. These changes may impact participants' decisions to diagnose, treat, prescribe, and educate patients with OUD.

OBJECTIVE: To assess the feasibility and impact of incorporating a multidisciplinary pharmacogenomics (PGx) service within an underserved behavioral health clinic, with an emphasis on clinician perceptions. METHODOLOGY: This study was conducted in two phases at the Texas A&M Family Care Clinic. Phase one involved an online cross-sectional survey of the multidisciplinary clinic team to assess their knowledge, attitudes, and readiness for PGx integration. Phase two detailed the development and implementation of a PGx service within the Integrated Behavioral Health (IBH) clinic, outlining the workflow and collaborative approach used to offer genetic testing to eligible patients. KEY FINDINGS: Of the 23 survey participants, 91% believed the PGx service would positively impact patient care, and 87% expressed interest in receiving PGx-related training. Confidence in pharmacists' ability to lead the service was reported by 65% of respondents. The primary concerns identified included cost of care, clinical utility, and potential workflow disruptions. A collaborative implementation model was developed, including preemptive and reactive testing pathways. CONCLUSION: The implementation of a pharmacist-driven PGx service in an underserved behavioral health clinic was well-received by the clinical team and deemed feasible. While concerns regarding resources and workflow were noted, strong interest in training and multidisciplinary collaboration highlights the potential for scalable PGx service models in similar settings.

BACKGROUND: Social determinants of health (SDOH) are non-medical factors that impact health outcomes. Pharmacists within integrated health system specialty pharmacies (HSSPs) are positioned to identify and address SDOH barriers. OBJECTIVE: The objective was to implement and evaluate a pharmacist-led SDOH program for HSSP patients. PRACTICE DESCRIPTION: The practice innovation was implemented within four health systems in Michigan and Massachusetts with associated HSSPs and a standard specialty pharmacy clinical management model incorporating initial patient counseling and periodic reassessments. PRACTICE INNOVATION: A SDOH screening and intervention program was developed and piloted at four health systems with associated HSSPs. Patients with HIV, rheumatoid arthritis (RA), and hyperlipidemia meeting pre-defined inclusion criteria were enrolled in the program from September 2023 through September 2024. After screening patients for SDOH barriers, pharmacists offered targeted interventions and structured follow-ups to ensure resolution of challenges. EVALUATION METHODS: Patients enrolled in the program were analyzed using data extracted from the electronic medical record and patient management platform. The primary outcome was intervention acceptance rate; secondary outcomes included intervention categories, patient-perceived value of interventions, ongoing support needs, pharmacist time spent, and clinical outcomes. RESULTS: Of the 50 patients (HIV: n=6; RA: n=27; hyperlipidemia: n=17) enrolled, 56% completed screening and 79% of those accepted interventions. Of the 19 patients who received follow-up, 63% found the interventions beneficial, and 4 required ongoing support. The most frequent interventions included food security/nutrition (46%) and physical activity (25%). The average time per intervention was 60 minutes (range: 15-180 minutes). Patients with interventions demonstrated clinical outcomes improvements, including a mean RAPID3 score reduction of 3 points (range: 1.3-27.3) and mean LDL reduction of 29.75 mg/dL (range: 44-137) for RA and hyperlipidemia, respectively. CONCLUSIONS: These pilot results suggest that a pharmacist-led SDOH program may be effective in addressing patient barriers, demonstrated by high acceptance rate and perceived benefit of interventions and improved clinical outcomes.

Evidence-based treatment of opioid use disorder, the prevention of opioid overdose and other opioid-related harms, and safe and effective pain management are priorities for the Veterans Health Administration (VHA). The VHA Office of Health Services Research and Development hosted a State-of-the-Art Conference on "Effective Management of Pain and Addiction: Strategies to Improve Opioid Safety" on September 10-11, 2019. This conference convened a multidisciplinary group to discuss and achieve consensus on a research agenda and on implementation and policy recommendations to improve opioid safety for Veterans. Participants were organized into three workgroups: (1) managing opioid use disorder; (2) Long-term opioid therapy and opioid tapering; (3) managing co-occurring pain and substance use disorder. Here we summarize the implementation and policy recommendations of each workgroup and highlight important cross-cutting issues related to telehealth, care coordination, and stepped care model implementation.

BACKGROUND: People with chronic general medical conditions who have comorbid depression experience poorer health outcomes. This problem has received scant attention in low- and middle-income countries. The aim of the ongoing study reported here is to refine and promote the scale-up of an evidence-based task-sharing collaborative care model, the Mental Health Integration (MhINT) program, to treat patients with comorbid depression and chronic disease in primary health care settings in South Africa. METHODS: Adopting a learning-health-systems approach, this study uses an onsite, iterative observational implementation science design. Stage 1 comprises assessment of the original MhINT model under real-world conditions in an urban subdistrict in KwaZulu-Natal, South Africa, to inform refinement of the model and its implementation strategies. Stage 2 comprises assessment of the refined model across urban, semiurban, and rural contexts. In both stages, population-level effects are assessed by using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) evaluation framework with various sources of data, including secondary data collection and a patient cohort study (N=550). The Consolidated Framework for Implementation Research is used to understand contextual determinants of implementation success involving quantitative and qualitative interviews (stage 1, N=78; stage 2, N=282). RESULTS: The study results will help refine intervention components and implementation strategies to enable scale-up of the MhINT model for depression in South Africa. NEXT STEPS: Next steps include strengthening ongoing engagements with policy makers and managers, providing technical support for implementation, and building the capacity of policy makers and managers in implementation science to promote wider dissemination and sustainment of the intervention.

BACKGROUND: Although costs are of key importance to clinic leadership when considering adoption of new programs, few studies examine real-world resource needs associated with implementing complex interventions for chronic conditions in primary care. This analysis sought to identify the costs necessary to implement the evidence-based collaborative care model (CoCM), an integrated behavioral health program for common mental disorders in primary care. METHODS: Ten federally qualified health centers (FQHCs) adopted CoCM as part of a larger national randomized trial evaluating implementation strategies for CoCM when adapted for perinatal mental health. The Cost of Implementing New Strategies (COINS) tool was used to assess implementation costs associated with activities completed by sites as they progressed through the implementation process. National wage norms were used to calculate cost estimates for staff time. RESULTS: On average, clinics spent $40,778 (SD=$30,611) on implementation, with clinics ranging widely from $4,502 to $103,156. Three out of 10 participating clinics achieved competency in the intervention during the 2-year implementation period. Costs among competent clinics ranged from $20,944 to $65,415 (mean=$41,788). Clinics that did not achieve competency were more varied, with both the lowest and highest resource use. Significant staff effort was required to complete all implementation stages; clinical staff and program champions showed greatest effort. CONCLUSIONS: Site implementation costs for this complex behavioral health intervention were substantial and varied dramatically, particularly among sites who did not achieve competence. Additional work is needed to identify optimal site resource investment related to implementation success for CoCM. TRIAL REGISTRATION: ClinicalTrials.gov.NCT02976025. Registered on November 23, 2016.

BACKGROUND: Little is known about effective implementation processes by which counties can improve community services to keep people with mental illness and substance use disorders out of the local jails. This study examines hypothesized implementation mechanisms (relationship building, performance monitoring, interagency coordination, capacity building, and infrastructure programming) as predictors of outcomes (improved community services) and as mediators of the effects of a national implementation intervention (Stepping Up [SU]), on community services. METHODS: A survey was conducted of mental health, substance use, jail, and probation administrators in 519 U.S. counties, of which 328 counties participated in a national jail reform effort (SU). Survey data were combined with descriptive data from the U.S. Census Bureau. Predictors included hypothesized implementation mechanisms (performance monitoring, interagency coordination teams, creating integrated systems of care, capacity building, relationship building, and quality programming). Covariates included county sociodemographic characteristics (e.g., size of county, size of jail, etc.) and general county service characteristics (e.g., primary care physicians per capita, Medicaid expansion). Implementation outcomes included number of evidence-based practices (EBPs) and evidence-based mental health treatments (MH-EBTs) for individuals with mental illness involved with justice systems. Multilevel regression analyses examined cross-sectional: (1) effects of Stepping Up on outcomes; (2) effects of implementation mechanisms on implementation outcomes; and (3) implementation mechanisms as mediators of the effects of Stepping up on implementation outcomes. FINDINGS: SU was found to significantly predict the number of EBPs and MH-EBTs controlling for various demographic characteristics of the counties. When implementation mechanisms were added to these models, SU is no longer statistically significant. Instead, two implementation mechanisms (performance monitoring and interagency coordination) and Medicaid funding significantly predicted the availability of both EBP and/or MH-EBT. Other factors that predicted MH-EBTs include relationship building size of the county, rate of primary care physicians, rate of MH providers in the county, and jail population size. Mediation models found that SU significantly predicted these evidence-based outcomes through implementation mechanisms except interagency coordination. CONCLUSIONS: Little is known about the implementation mechanisms to decarcerate and build programming for MH services in a county. SU is an important attribute to facilitate reform both directly and indirectly through implementation mechanisms. Counties can benefit from use of relationship building activities to advance policy and service reform efforts, identifying performance metrics of their system, and having infrastructure available to improve the availability of EBPs. Overall, policy changes are possible, but an emphasis should be on strategies that increase the availability of EBPs and MH-EBTs.