Substance Use Disorder Clinics Research Articles

Identifying best practices for substance-related intimate partner violence screening and referral: a narrative review.

Substance use is strongly associated with intimate partner violence (IPV) and is a modifiable risk factor for IPV. However, lack of comprehensive screening and referral for co-occurring IPV and substance use, along with their psychiatric sequalae, limits the identification and implementation of effective interventions for substance-related IPV. This narrative review (1) investigates the literature on screening and referral practices for IPV, and if these include screening for substance use or other psychiatric comorbidities, (2) provides recommendations for current best practices, and (3) suggests future directions for research and practice aimed at identifying and reducing substance-related IPV. A narrative literature review examined studies investigating IPV screening and referral programs in clinics. Selected studies were reviewed for: (1) effectiveness, (2) barriers to implementation and sustainability, and (3) responsivity to psychiatric comorbidity, including substance use and substance use disorders (SUD). Findings suggest that effective IPV screening and referral programs have been developed, but disparities in IPV screening exist and many programs only screen for IPV victimization. Barriers to the implementation and sustainability of IPV screening programs include lack of ongoing provider training, funding or institutional support, and direct connection to referral services. Further, many IPV screening programs lack assessment of and referral for comorbid psychiatric conditions, including substance use, and tend not to be routinely implemented in SUD clinics. Additional systematic work is needed to develop universal and comprehensive screening and referral programs for substance-related IPV and address issues of long-term sustainability, particularly within SUD treatment settings.

Impact of an intervention to implement provision of opioid use disorder medication among patients with and without co-occurring substance use disorders

IntroductionCo-occurring substance use disorders (SUDs) are common among people with opioid use disorder (OUD) and known to hinder receipt of medications for OUD (MOUD). It is important to understand how MOUD care implemented outside of SUD specialty settings impacts access for patients with co-occurring SUDs. The Veterans Health Administration's (VA) Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative was implemented in primary care, mental health, and pain clinics in 18 VA facilities, and was found to increase MOUD receipt. This study assessed the SCOUTT initiative's impact among patients with and without co-occurring SUDs. MethodsThis study used a controlled interrupted time series design. We extracted electronic health record data for patients with OUD with visits in SCOUTT intervention or matched comparison clinics during the post-implementation year (9/1/2018–8/31/2019). We examined the monthly proportion of patients who received MOUD in SCOUTT intervention or comparison clinics (primary care, mental health, and pain clinics), or in a VA SUD specialty clinic (where patients may have been referred), during the pre- and post-implementation years. Segmented logistic regression models estimated pre-post changes in outcomes (immediate level change from the final month of the pre-implementation period to the first month of the post-implementation period, change in trend/slope) in intervention vs. comparison facilities, adjusting for patient characteristics and pre-implementation trends. We stratified analyses by the presence of co-occurring SUDs. ResultsAmong patients without co-occurring SUDs, the pre-post trend/slope change in MOUD received in SCOUTT intervention or comparison clinics was greater in intervention vs. comparison facilities (adjusted odds ratio [aOR]: 1.06, 95% confidence interval [CI]: 1.02–1.10), and the immediate increase in MOUD received in SUD clinics was greater in intervention vs. comparison facilities (aOR: 1.12, 95% CI: 1.02–1.22). These changes did not significantly differ in intervention vs. comparison facilities among patients with co-occurring SUDs. ConclusionsThe SCOUTT initiative may have increased MOUD receipt primarily among patients without co-occurring SUDs. Focusing on increasing MOUD receipt for patients with co-occurring SUDs may improve the overall effectiveness of MOUD implementation efforts.

Improving HIV and HCV Testing in Substance Use Disorder Programs (SUDs) That Provide Medications for Opiate Use Disorder (MOUD): Role of Addressing Barriers and Implementing Universal and Site-Specific Approaches.

Introduction. National strategies to end the HIV epidemic and eliminate hepatitis c (HCV) through a syndemic approach require improvements in testing for HIV and HCV. Given the intersection of the opioid crisis with HIV and HCV acquisition, substance use disorder (SUD) treatment centers providing medications for opiate use disorder (MOUD) provide a critical opportunity to expand testing. Rates of testing in MOUD clinics have been suboptimal. Method. We employed the Nominal Group Technique (NGT), Ishikawa cause and effect diagrams, and individualized Quality Improvement (QI) efforts at two SUD clinics (SUD A and B) in Connecticut (CT) as part of an HRSA-funded grant focused on improving HCV cure in persons with HIV/HCV coinfection. Baseline and longitudinal data were collected on rates of HIV and HCV testing and positivity as well as linkage to treatment. Results. Between April 1, 2019, and May 31, 2021, for SUD A and B respectively, HIV testing increased from 13% to 90% and 33% to 83%; HCV testing increased from 4% to 90% and 30% to 82%, with few reported cases of HIV/HCV coinfection. HCV testing revealed new and prior diagnoses at both sites, with subsequent referrals for treatment. Qualitative assessments identified best practices which included the institution of formal policies and procedures, streamlining of testing logistics, designation of a site champion, and broadening relevant education to staff and clients. Conclusion. Strategic assessment of barriers and facilitators to HIV and HCV testing at MOUD clinics can lead to improved testing and referral rates that are key to improving the cascade of care for both diseases.

Building medication for opioid use disorder prescriber capacity during the opioid epidemic: Prescriber recruitment trends and methods

IntroductionPhysicians are a critical clinical resource for patient care. Yet physician recruitment has been considerably understudied, particularly in substance use disorder (SUD) settings. This study proposes a conceptual model called the “Physician Recruitment Descriptive Factors Framework” to investigate the role of environmental, organizational, and individual factors in the use of physician recruitment strategies. MethodsThe study setting was 75 sites that provided outpatient SUD treatment services in Florida, Ohio, and Wisconsin from 2016 to 2019. Central to the analysis is the use of five targeted physician recruitment strategies. The study investigated whether financial conditions, location (urban v. non-urban), external implementation coaching, and recruiters’ roles influenced use of the targeted physician recruitment strategies. ResultsDuring the study period, a formal plan to recruit physicians was the most common strategy used (n = 67.6 %). The director or chief executive officer (CEO) was most likely to conduct physician recruitment (n = 58.7 %). During the study, use of four of the five recruitment strategies significantly declined (at p ≤ 0.01), while the perceived need for new prescribing capacity significantly declined (p ≤ 0.01), and prescribers per site increased from 1.54 to 3.21. Sixty-four percent of this increase in prescribers was due to more physician prescribers, while 36 % was due to the onset of the ability of advanced nurse practitioners and physician assistants to prescribe buprenorphine. In year 3 of the study, the strategies most closely aligned with the current number of prescribers were conducting weekly outreach to prescriber candidates (p = .018), having a dedicated prescriber recruiter (p = .011), and having a dedicated budget for prescriber recruiting (p = .002). ConclusionsThe study describes which physician recruitment strategies SUD treatment sites used and how the need to recruit physicians for specialty treatment SUD clinics declined as prescriber capacity increased. The proposed multi-level framework provides the scaffolding for future physician recruitment research and practice.

1.96 Implementation of Measurement-Based Care for Youth in Behavioral Health and Substance Use Clinics: An Examination of Barriers and Facilitators

Research has demonstrated that patient outcomes improve with the use of measurement-based care (MBC). Despite this, there has been limited implementation of MBC in behavioral health and substance use disorder (SUD) clinics. The current study aims to explore barriers and facilitators in the MBC implementation for youth in a child behavioral health clinic and an adolescent SUD clinic. We also aim to examine similarities and differences in barriers and facilitators between these clinics.

Substance Use Disorder Treatment Providers' Knowledge and Opinions Toward Testing and Treatment of Chronic Hepatitis C in Rural North Carolina.

Poor access to care has made western North Carolina vulnerable to an outbreak of hepatitis C viral infection (HCV), particularly among persons who inject drugs (PWID). As substance use disorder (SUD) treatment providers could potentially improve linkage to HCV testing and treatment, we sought to understand SUD providers, clinic and client characteristics; referral patterns; HCV knowledge; willingness to participate in additional trainings; and local linkage-to-care pathways for treatment of substance use and HCV. Online survey data were collected from 78 SUD providers serving PWID in eight western rural North Carolina counties. Providers' attitudes toward working with HCV+ clients were very positive. One-third of providers reported a low fund of knowledge regarding HCV, HCV treatment, and financial assistance opportunities. Non-prescribing providers rarely initiated discussions about HCV testing/treatment, but were receptive to training. Respondents indicated that HCV testing and treatment were best delivered at local health departments or primary care clinics but were open to other venues where PWID access care. The vast majority of prescribing and non-prescribing providers expressed interest in obtaining training in HCV treatments, how to obtain HCV medications and topics on advanced liver disease. Data from prescribing and non-prescribing SUD providers suggest opportunities to develop or expand integrated care models for HCV testing/treatment in PWID in rural Appalachian North Carolina.

Clinician's experiences with involuntary commitment for substance use disorder: A qualitative study of moral distress.

Petitions for involuntary commitment of people living with a substance use disorder (SUD) have almost doubled since 2011 in Massachusetts through the policy Section 35. However, the efficacy of this controversial policy remains unclear, and clinicians differ on whether it ought to be used. This study examines how clinicians decide whether to use Section 35 and their experiences of moral distress, the negative feeling that occurs when a clinician is required to pursue a treatment option against their moral judgement due to institutional constraints, associated with its use. Qualitative semi-structured interviews with clinicians in Massachusetts were conducted between December 2019 and February 2020 and continued until thematic saturation. Thematic and narrative analysis was conducted with recorded and transcribed interviews. Among 21 clinicians, most (77%) experienced some or high moral distress when utilizing Section 35 for involuntary commitment, with clinicians working in emergency departments experiencing less distress than those working in SUD clinics. Clinicians with low moral distress referenced successful patient anecdotes and held an abstinence-based view of SUD, while clinicians with high moral distress were concerned by systemic treatment failures and understood SUD through a nuanced and harm reduction-oriented view. Clinicians across professional settings were concerned by the involvement of law enforcement and criminal justice settings in the Section 35 process. Clinicians employed a variety of strategies to cope with moral distress, including team-based decision-making and viewing the petition as a last resort. Barriers to utilizing Section 35 included restrictive court hours and lack of post-section aftercare services. Widespread distress associated with use of involuntary commitment and inconsistent approaches to its use highlight the need for better care coordination and guidance on best practices for utilization of this policy.

Characterizing autistic traits in treatment-seeking young adults with substance use disorders.

Recent work highlights an increase in the overlap of autism spectrum disorder (ASD) and substance use disorder (SUD). Little is known about the presence of ASD symptoms in SUD-treatment-seeking populations. The informant-rated Social Responsiveness Scale-2 (SRS-2) was completed at intake to an outpatient SUD clinic for youth aged 16-26 (N = 69). Comparisons were made between those with elevated SRS-2 scores on demographic, psychiatric, and substance use variables. Parents of sixty-nine patients with SUD completed the SRS-2. Fourteen (20%) (average age 18.7 ± 2.5) had elevated SRS-2 Total T-scores (≥66) and 55 (average age 18.1 ± 2.8) had non-clinical SRS-2 Total T-scores. There were few differences between groups; however, those with elevated SRS-2 Total T-scores were more likely to have a stimulant use disorder (odds ratio [OR] = 7.59, 95% confidence interval [CI] = 0.77, 101.88; p = 0.05) or an opioid use disorder (OR = 5.02, 95% CI = 0.59, 43.27; p = 0.08) than patients with normal SRS-2 Total T-scores as well as alcohol use in the week prior to intake. A significant proportion of treatment-seeking SUD outpatients suffer from clinically elevated autistic traits. These findings highlight the importance of assessing for autistic traits in SUD treatment settings yet additional research is needed to determine if these findings are specific to the presence of ASD or secondary to sequelae of specific SUD presentations. This study is, to our knowledge, the first to have examined the prevalence, morbidity, or clinical characteristics, associated with ASD symptoms in a SUD-specific population.

Rates and predictors of psychotherapy receipt among U.S. veterans with comorbid posttraumatic stress disorder and substance use disorders

IntroductionVeterans with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) have complex needs and often do not receive adequate mental health treatment. The purpose of this study was to examine rates and predictors of PTSD-only, SUD-only, or PTSD and SUD psychotherapy receipt among newly diagnosed Veterans with PTSD and SUD. Design and settingAn administrative dataset including Veterans Health Administration (VHA) users. ParticipantsThe sample comprised 32,779 United States Veterans with a new PTSD and a new SUD diagnosis in fiscal year 2015. MeasurementMultinomial logistic regression was used to identify predictors of receipt of any and adequate psychotherapy for PTSD, SUD, or PTSD and SUD across settings. Binomial logistic regression was used to identify predictors of PTSD psychotherapy among those who received any psychotherapy. FindingsA total of 13,824 (42.17%) Veterans in this sample received any PTSD- or SUD-related therapy in the year following diagnosis. Low rates of veterans received an adequate dose of PTSD-related psychotherapy (6.58%), SUD-related psychotherapy (7.72%), or both PTSD and SUD-related psychotherapy (<1%) In adjusted models, older age, service-connected disability, and psychiatric comorbidities were associated with decreased odds of treatment. Specific types of SUDs, including alcohol, cocaine, and opioid use disorders, along with receipt of diagnosis in a PTSD or SUD clinic, were associated with increased odds of treatment. ConclusionsLow rates of PTSD and SUD related psychotherapy highlight a need to better engage and retain Veterans with these disorders in care. Predictors of decreased treatment utilization, such as older age, service connection, and bipolar and major depressive disorders, may inform efforts by the VHA to further target and engage Veterans with indicated treatments.

Al-Anon Intensive Referral (AIR): A qualitative formative evaluation for implementation

IntroductionThe Al-Anon mutual-help program helps concerned others (COs; e.g., families, friends) of persons with excessive alcohol use. Despite widespread availability of Al-Anon meetings, participation is limited and little is known about how to best facilitate engagement. Al-Anon Intensive Referral (AIR) was developed to facilitate COs' engagement in Al-Anon and is being tested in a randomized controlled trial (RCT). Toward the end of the recruitment for the RCT, a qualitative formative evaluation was conducted to learn about facilitators, barriers, and recommendations for AIR implementation in substance use disorder (SUD) treatment clinics. MethodsThirty-one directors and staff at ten VA and community SUD clinics were interviewed. Semi-structured interviews were based on the Consolidated Framework for Implementation Research and were thematically analyzed to identify facilitators, barriers, and recommendations for AIR implementation. ResultsPerceived facilitators of AIR implementation included AIR's face validity, adaptability, and alignment with staff values and skills, requiring only minimal training. Several interviewees in community settings thought AIR would fit with their current practices (e.g., family groups), and some clinics reported having sufficient staff available for delivering AIR. Perceived barriers included limited staff time, and VA clinics having limited resources for providing services to COs. Furthermore, many clients have no COs, or COs who are unwilling or unable to engage with them. Recommendations included fitting AIR within existing workflows and focusing on COs with highest readiness to receive support. Interviewees also thought AIR could be adapted to a website format or smartphone app, which may expand its reach while decreasing staff burden and cost; however, it may not be as effective and appealing to some demographic groups (e.g., older COs). ConclusionsAIR has strong potential for implementation in SUD treatment settings, but clinics vary on implementation capacity. Most clinics could implement AIR partially (e.g., case-by-case basis) while clinics with sufficient capacity (e.g., staff time) could implement it more fully. These findings can also inform implementation of other interventions for concerned others.

PTSD improvement and substance use disorder treatment utilization in veterans: Evidence from medical record data

BackgroundClinical trials reveal posttraumatic stress disorder (PTSD) improvement leads to decreased substance use among patients with comorbid substance use disorder (SUD). Using administrative medical record data, we determined whether clinically meaningful PTSD Checklist (PCL) (≥20 points) score decreases were positively associated with SUD treatment utilization. MethodsWe used a retrospective cohort of Veterans Health Affairs (VHA) medical record data (2008–2015). PTSD Checklist (PCL) scores were used to categorize patients into those with a clinically meaningful PTSD improvement (≥20 point decrease) or not (<20 point decrease or increase). PTSD and SUD were measured by ICD-9 codes. Propensity score weighting controlled for confounding in logistic and negative binomial models that estimated the association between clinically meaningful PTSD improvement and use of SUD treatment and number of SUD clinic visits. ResultsThe 699 eligible patients were, on average, 40.4 (±13.2) years old, 66.2% white and 33.1% were married. After controlling for confounding, there was a 56% increased odds of any SUD treatment utilization among those with a PCL decrease ≥20 vs < 20 (OR = 1.56; 95%CI = 1.04−2.33) but there was no association with number of SUD treatment visits. ConclusionsClinically meaningful reductions in PTSD symptoms were associated with any SUD treatment utilization but not amount of utilization. Improvement in PTSD symptoms, independent of the treatment modality, may enable SUD treatment seeking.

Patient-centered care's relationship with substance use disorder treatment utilization

BackgroundCalls for more patient-centered care are growing in the substance use disorder (SUD) treatment field. However, evidence is sparse regarding whether patient-centered care improves access to, or utilization of, effective treatment services. MethodsUsing nationally representative survey data from SUD treatment clinics in the United States, we examine the association between patient-centered clinical care and the utilization of six services: methadone, buprenorphine, behavioral treatment, routine medical care, HIV testing, and suicide prevention counseling. We measured clinics' practice of and emphasis on patient-centered care with two variables: (1) whether the clinic regularly invites patients into clinical decision-making processes, and (2) whether supervisors believe in patient-centered healthcare and shared decision-making practices within their clinics. ResultsIn 2017, only 23% of SUD treatment clinics regularly invited patients into care decision-making meetings when their cases were discussed. A composite variable captured clinical supervisors' own experience with and expectations for patient-clinician interaction within their clinics (Cronbach's alpha = 0.79). Results from regression models that controlled for several organizational and environmental factors show that patient-centered care was independently associated with greater utilization of four of six evidence-based services. ConclusionsA minority of SUD clinics practice patient-centered healthcare in the United States. Given the connection to evidence-based services, increasing participatory mechanisms in SUD treatment service provision can facilitate patients' access to appropriate and evidence-based services.

Routine monitoring of therapeutic alliance to predict treatment engagement in a Veterans Affairs substance use disorders clinic.

Measurement-based care (MBC) can improve mental health treatment outcomes and is a priority within the Department of Veterans Affairs (VA). However, to date, MBC efforts within the VA have focused on assessment of psychological symptoms to the exclusion of psychotherapy process variables such as the therapeutic alliance that may predict treatment response. This quality improvement project involved the implementation of routine monitoring of alliance within a VA substance use disorder (SUD) clinic predominantly serving veterans with serious mental illness. Alliance ratings were provided by 98 veterans following group therapy sessions. Low alliance ratings were used by the clinicians (n = 4) leading the groups (n = 9) as opportunities to discuss veterans' treatment experience and increase engagement. Using multilevel models that accounted for the nested nature of the data and veteran demographics, alliance ratings showed a small increase over time (B = 0.075, p < .001, f2 = 0.033). In addition, maximum alliance rating (i.e., patients' highest rating of alliance across all observations) was significantly but modestly associated with attendance at both MBC group sessions and all SUD-related visits in the 3 months following the initial alliance rating (Bs = 0.96 and 1.79; ps = .006 and .004; f2s = 0.079 and 0.088, respectively). Average alliance rating, however, was not associated with treatment attendance (ps > .050). Findings suggest that assessment of alliance is feasible within a VA SUD clinic and may provide information signaling risk for disengagement that could be used for increasing treatment engagement. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Polysubstance use and association with opioid use disorder treatment in the US Veterans Health Administration.

To understand the role of comorbid substance use disorders (SUDs), or polysubstance use, in the treatment of opioid use disorder (OUD), this study compared patients with OUD only to those with additional SUDs and examined association with OUD treatment receipt. Retrospective national cohort study of Veterans diagnosed with OUD (n=65 741) receiving care from the US Veterans Health Administration (VHA) in fiscal year (FY) 2017. Patient characteristics were compared among those diagnosed with OUD only versus those with one other SUD (OUD+1 SUD) and with multiple SUDs (OUD+≥2 SUDs). The study examined the relationship between comorbid SUDs and receipt of buprenorphine, methadone and SUD outpatient treatment during 1-year follow-up, adjusting for patient demographic characteristics and clinical conditions. Among the 65 741 Veterans with OUD in FY 2017, 41.2% had OUD only, 22.9% had OUD+1 SUD and 35.9% had OUD+≥2 SUDs. Common comorbid SUDs included alcohol use disorder (41.3%), cocaine/stimulant use disorder (30.0%) and cannabis use disorder (22.4%). Adjusting for patient characteristics, patients with OUD+1 SUD [adjusted odds ratio (aOR)=0.87, 95% confidence interval (CI)=0.82-0.93] and patients with OUD+≥2SUDs (aOR=0.65, 95% CI=0.61-0.69) had lower odds of receiving buprenorphine compared with OUD only patients. There were also lower odds of receiving methadone for patients with OUD+1 SUD (aOR=0.91, 95% CI=0.86-0.97)and for those with OUD+≥2SUDs (aOR=0.79, 95% CI=0.74-0.84). Patients with OUD+1 SUD (aOR=1.85, 95% CI=1.77-1.93) and patients with OUD+≥2SUDs (aOR=3.25, 95% CI=3.103.41) were much more likely to have a SUD clinic visit. The majority of Veterans in the US Veterans Health Administration diagnosed with opioid use disorder appeared to have at least one comorbid substance use disorder and many have multiple substance use disorders. Despite the higher likelihood of a substance use disorder clinic visit, having a non-opioid substance use disorder is associated with lower likelihood of buprenorphine treatment, suggesting the importance of addressing polysubstance use within efforts to expand treatment for opioid use disorder.

Menstrual Hygiene Needs Among Women Receiving Substance Use Disorder Treatment [27B

INTRODUCTION: Recent research has highlighted the high unmet menstrual hygiene product needs among low income women. The aim of this study was to evaluate the menstrual hygiene needs of women receiving treatment for substance use disorders (SUD). METHODS: Patients were recruited from an urban, outpatient SUD clinic to complete a voluntary, electronic, cross-sectional survey between July and September 2019. Menstrual hygiene questions were modeled from prior work (Kuhlmann et al., Obstetrics and Gynecology, February 2019) with author permission. Women were classified as having menstrual poverty if they reported needing menstrual hygiene products but not having the money to buy them in the past 12 months. Factors associated with menstrual poverty were assessed using χ2 tests. Exempted by VCU IRB. RESULTS: Eighty-six (94.5% response rate) women completed the survey, of whom 36 (41.9%) had a period in the past 12 months and were included in the study. Almost all (94.4%) were in treatment for opioid use disorder. Mean age was 34.69 (SD 7.433) years. Women were predominantly African American (50%), educated at a high school level (55.6%), unemployed (55.6%), and receiving public assistance (66.7%). Most (n=29; 80.6%) reported menstrual poverty. Menstrual poverty was not associated with heavy menstrual bleeding but was associated with food insecurity (P=.005). Many (n=23; 63.9%) stated they would like to receive hygiene products at the addiction clinic. CONCLUSION: Menstrual hygiene products are a necessity that women receiving addiction treatment lack. In the opioid crisis, providers should be aware of this disparity. Integration of reproductive/sexual health with addiction services should be prioritized.

Smoking cessation group attendance in a substance use disorder clinic: a look at contingency management and other factors to maximize engagement

ABSTRACTContingency management (CM) has emerged as an intervention that can increase smoking quit rates; however, CM has only been tested for reinforcing abstinence for nicotine. This quality improvement project examined the impact of adding CM for attendance to an existing substance use disorder (SUD) clinic group smoking cessation intervention (GSCI), as well as predictors of attendance. After adjustment for covariates, linear regressions compared groups on total and maximum consecutive sessions attended but no differences were observed. Older age, prescriptions for any smoking cessation medication, and longer durations in SUD treatment were associated with greater maximum consecutive sessions attended. Given limited time and resources in busy outpatient SUD clinics, it may be more impactful to focus efforts on engaging patients in the use of cessation medications while offering a group smoking cessation program.

23 Implementation of a Substance Use Disorder Bridge Clinic

Despite the availability of substance use disorder (SUD) treatment programs, many patients have difficulty accessing treatment partly due to long wait times. In order to facilitate timely linkage to treatment, our health system implemented a rapid access, low-barrier SUD clinic with the goal of providing prompt initial treatment (including buprenorphine on-demand) and then transitioning to longitudinal care once possible, regardless of insurance status or current substance use. The clinic, which is located close to the ED inside the hospital, opened in April 2018. The goal of this study is to describe the clinic implementation and outcomes for patients treated in the first year of the clinic. This was a retrospective analysis of patients seen at the clinic between April 2018 and March, 2019. Clinic staff includes a medical provider who can prescribe medication for addiction treatment (MAT), a resource specialist who connects patients to housing, phone service, ID cards and other social services, and recovery coaches, who use their own lived experience to coach other patients through their recovery. The data were obtained at the clinic as part of a quality improvement project to monitor the progress of patients treated in the clinic. IRB approval was obtained to use the dataset for this research. In one year, there were 325 patients referred to the clinic and 242 patients (74.8%) who had at least one visit to the clinic. Top sources of referral were: inpatient wards (n=111, 34.2%), emergency department (n=68, 20.9%), primary care (n=50, 15.4%), or other clinic referral (n=55, 16.9%). The patients were 68.3% (n=222) male, with a mean age of 43.4 (SD 11.9) years. 66% of patients had opioid use disorder, 39% had alcohol use disorder, and 31% had polysubstance use. Of the 242 patients who made it to at least one appointment, 131 patients (54.1%) are still active in the clinic, 85 (35.1%) have been bridged to other facilities and 26 (10.7%) were lost to follow-up. Amongst patients treated for opioid use disorder at the clinic, 142 (93%) were taking buprenorphine, 7 (5%) were taking methadone, and 4 (3%) received extended-release naltrexone. For 98 patients who have data 6 months prior and 6 months post clinic referral, ED visits in our health system decreased by 45% (from 276 before to after 151) and hospital admissions in our health system decreased by 37% (from 153 before to 96 after). Creation of a low-barrier, rapid-access, hospital-based substance use disorder bridge clinic is feasible. Outcomes are promising, with high rates of retention and linkage to treatment, and decreased rate of subsequent ED utilization and hospitalization. Keys to success are a multidisciplinary team, harm reduction model, and support from the health system.

367 Emergency Department Warm Handoff Program: Using Peers to Improve Emergency Department Patient Engagement and Linkages to Community-Based Substance Use Disorder Services

1) To improve emergency department (ED) patient engagement and linkages to substance-use disorder (SUD) services in the community by strengthening existing workflows 2) To move from pilot to program by integrating Certified Recovery Peer Advocates (CRPA) into ED workflow and culture 3) To reduce avoidable ED visits by moving SUD care from the ED into community settings In the initial 6 months of the pilot phase, Certified Addiction Recovery Coaches (CARC) and Certified Recovery Peer Advocates (CRPA) were introduced and integrated in the ED as hospital staff to engage, educate, and advocate for patients and support clinicians in making connections to appropriate SUD services. Using Motivational Interviewing skills and lived experience, peers supported the enhanced workflow by engaging and connecting patients with substance use needs, who typically decline services, to the appropriate level of care. ED clinicians activated peers through in-person requests and by placing orders for peer services through the electronic health record (EHR), which ensured that patients met with the peer before discharge. In addition, peers participated in routine medical rounds to case find and engage individuals coming to the ED with falls, car crashes, and other injuries to determine if SUD was the underlying cause for their ED visit. After a successful pilot period, the implementation team scaled up the intervention to become a program of the hospital ED. The implementation team convened hospital leadership and the hospital’s outpatient SUD clinic to develop a sustainability plan. This plan included guidance on reimbursement for CRPA services, enhanced CRPA responsibilities in the ED at the outpatient clinic, revised ED workflows, and guidelines for continued engagement with the SUD population. Peers, which were previously employed through an outside agency, were hired as hospital staff and re-introduced into the ED with expanded roles and responsibilities to ensure patient engagement and linkages remained person centered and patient driven. In 1 year of program implementation (November 2016 to November 2017, including the pilot phase), there have been 1,049 patient engagements of which 659 were unique patients. 16% of those engagements resulted from case finds. Over 130 handoffs (12.4% of engagements) were made to SUD providers, which is a significantly higher (p-value < 0.0001) than the Substance Abuse and Mental Health Services (SAMHSA) reported national average of people who accepted treatment (1.5%). There was a 27% reduction in avoidable ED visits for people with SUD and other behavioral health diagnoses from November 2016 to August 2017. 3 full-time peers were integrated as hospital employees (2 assigned to the ED, 1 in the outpatient clinic). To move towards integration, peers were granted access to the EHR to support clinicians in coordinating linkages between the ED and the hospital’s outpatient clinic as well as additional community based programs. The WHP was an innovative approach to transform ED workflow and reduce avoidable ED visits using peers. As demonstrated by positive outcomes in patient engagement, linkages to community-based care and ED visits, peers are an essential component to providing patient-driven care for the SUD population. Cross-training peers in best practices for mental health, substance use, HIV, and social determinants of health is an area for further investigation.

Characteristics and clinical treatment of tobacco smokers enrolled in a VA substance use disorders clinic

Individuals with a substance use disorder (SUD) diagnosis are more than twice as likely to smoke cigarettes as the general population. Emerging research has suggested that treating a substance use disorder simultaneously with tobacco use leads to a higher rate of treatment success for both substances. Despite this, substance use treatment protocols tend not to focus on tobacco use; in fact, traditional substance use treatments often discourage patients from attempting to quit smoking. One rationale is that patients may not be motivated to quit smoking. In the current study, data from veterans enrolled in outpatient treatment for a SUD were examined to assess for general characteristics of smokers as compared to non-smokers as well as to examine motivation to quit smoking. Baseline (i.e., pre-treatment) data from 277 Veterans were used. Charts of smokers in the SUD clinic (SUDC) were reviewed to assess how smoking is handled by SUDC providers, and if smokers attempt cessation. Of 277, 163 (59%) SUDC patients reported that they currently smoke cigarettes (M=16.3 cigarettes per day, SD=11.1). Smokers in the clinic reported greater general impairment than nonsmokers on the Short Index of Problems, F(1248)=8.9, p=0.003, as well as greater specific impairment: Physical Problems, F(1258)=13.5, p=0.000; Interpersonal Problems, F(1262)=5.6, p=0.019; Intrapersonal Problems, F(1260)=6.5, p=0.011, and Social Responsibility, F(1262)=14.7, p=0.000. Smokers in the sample were marginally more anxious than their non-smoking counterparts as measured by the GAD-7, F(1254)=4.6, p=0.053, though they were not significantly more depressed (p=0.19). On a 1–10 scale, smokers reported moderate levels of importance (M=5.4, SD=3.1), readiness (M=5.6, SD=3.2), and confidence (M=5.0, SD=3.0) regarding quitting smoking. Review of smokers' medical records reveal that while SUDC providers assess tobacco use at intake (90%) and offer treatment (86.5%), a substantially small portion of smokers attempt cessation (41.1%) while enrolled in SUDC. Moreover, no patients were enrolled in smoking-specific behavioral interventions while in SUDC, though 78 patients did obtain nicotine replacement or another smoking cessation medication (41% were prescribed by a SUDC provider). Contrary to the belief that treatment-seeking substance users are not motivated to quit smoking, these preliminary analyses demonstrate that Veterans were at least contemplating quitting smoking while they were enrolled in substance use treatment. Further, there is evidence that cigarette smokers have greater impairment caused by substance use, suggesting that this subgroup is of particular high need. Specific treatment recommendations are discussed, including how behavioral health providers in SUD clinics may be better able to capitalize on patients' moderate motivation to quit at intake.

Binge-drinking and non-partner aggression are associated with gambling among Veterans with recent substance use in VA outpatient treatment

BackgroundGambling is relatively under-assessed in Veterans Affairs (VA) substance use disorder (SUD) treatment settings, yet shared characteristics with substance addiction suggest the importance of understanding how gambling behaviors present in Veterans seeking SUD care. MethodWe evaluated substance use, mental health, and violence-related correlates of past 30-day gambling among 833 Veterans (93% male, M age 48years, 72% Caucasian) seeking treatment in VA outpatient mental health and SUD clinics who completed screening for a randomized clinical trial. ResultsA total of 288 (35%) Veterans reported past 30-day gambling. Among those who gambled, 79% had cravings/urges to gamble, whereas between 20%–27% of gamblers reported perceived relationship, legal, and daily life problems related to gambling, as well as difficulty controlling gambling. A logistic regression analysis revealed that age, recent binge-drinking, and non-partner physical aggression were associated with recent gambling. ConclusionsGambling was associated with binge-drinking and non-partner physical aggression, supporting potential shared characteristics among these behaviors such as impulsivity and risk-taking, which may complicate SUD treatment engagement and effectiveness. Findings support the need to screen for gambling in the VA, and to adapt treatments to include gambling as a potential behavioral target or relapse trigger, particularly among heavy drinking patients.