Barriers and facilitators affecting the implementation of substance use screening in primary care clinics: a qualitative study of patients, providers, and staff

Jennifer McNeely, Pritika C Kumar, Traci Rieckmann, Erica Sedlander, Sarah Farkas, Christine Chollak, Joseph L Kannry, Aida Vega, Eva A Waite, Lauren A Peccoralo, Richard N Rosenthal, Dennis McCarty, John Rotrosen, Jennifer McNeely, Pritika C Kumar, Traci Rieckmann, Erica Sedlander, Sarah Farkas, Christine Chollak, Joseph L Kannry, Aida Vega, Eva A Waite, Lauren A Peccoralo, Richard N Rosenthal, Dennis McCarty, John Rotrosen

Abstract

Background: Alcohol and drug use are leading causes of morbidity and mortality that frequently go unidentified in medical settings. As part of a multi-phase study to implement electronic health record-integrated substance use screening in primary care clinics, we interviewed key clinical stakeholders to identify current substance use screening practices, barriers to screening, and recommendations for its implementation.

Methods: Focus groups and individual interviews were conducted with 67 stakeholders, including patients, primary care providers (faculty and resident physicians), nurses, and medical assistants, in two urban academic health systems. Themes were identified using an inductive approach, revised through an iterative process, and mapped to the Knowledge to Action (KTA) framework, which guides the implementation of new clinical practices (Graham et al. in J Contin Educ Health Prof 26(1):13-24, 2006).

Results: Factors affecting implementation based on KTA elements were identified from participant narratives. Identifying the problem: Participants consistently agreed that having knowledge of a patient's substance use is important because of its impacts on health and medical care, that substance use is not properly identified in medical settings currently, and that universal screening is the best approach. Assessing barriers: Patients expressed concerns about consequences of disclosing substance use, confidentiality, and the individual's own reluctance to acknowledge a substance use problem. Barriers identified by providers included individual-level factors such as lack of clinical knowledge and training, as well as systems-level factors including time pressure, resources, lack of space, and difficulty accessing addiction treatment. Adapting to the local context: Most patients and providers stated that the primary care provider should play a key role in substance use screening and interventions. Opinions diverged regarding the optimal approach to delivering screening, although most preferred a patient self-administered approach. Many providers reported that taking effective action once unhealthy substance use is identified is crucial.

Conclusions: Participants expressed support for substance use screening as a valuable part of medical care, and identified individual-level as well as systems-level barriers to its implementation. These findings suggest that screening programs should clearly communicate the goals of screening to patients and proactively counteract stigma, address staff concerns regarding time and workflow, and provide education as well as treatment resources to primary care providers.

Keywords: Alcohol abuse; Alcohol screening; Drug abuse; Drug abuse screening; Primary care; Qualitative research; Substance use disorders.

References

    1. Dowell D, et al. Contribution of opioid-involved poisoning to the change in life expectancy in the United States, 2000–2015. JAMA 2017;318(11):1065–7.
    1. Horgan, CM, Skwara KC, Strickler G. Substance abuse: the nation’s number one health problem. Robert Wood Johnson Foundation and Schneider Institute for Health Policy, 2001.
    1. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291(10):1238–1245. doi: 10.1001/jama.291.10.1238.
    1. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270(18):2207–2212. doi: 10.1001/jama.1993.03510180077038.
    1. Substance Abuse and Mental Health Services Administration. NSDUH data review: receipt of services for substance use and mental health issues among adults: results from the 2016 national survey on drug use and health. Rockville: Substance Abuse and Mental Health Services Administration; 2017. . Accessed 6 Feb 2018.
    1. Edlund MJ, Unutzer J, Wells KB. Clinician screening and treatment of alcohol, drug, and mental problems in primary care: results from healthcare for communities. Med Care. 2004;42(12):1158–1166. doi: 10.1097/00005650-200412000-00002.
    1. Rehm J, Anderson P, Manthey J, Shield KD, Struzzo P, Wojnar M, et al. Alcohol use disorders in primary health care: what do we know and where do we go? Alcohol Alcohol. 2016;51(4):422–427. doi: 10.1093/alcalc/agv127.
    1. O’Donnell A, Anderson P, Newbury-Birch D, Schulte B, Schmidt C, Reimer J, et al. The impact of brief alcohol interventions in primary healthcare: a systematic review of reviews. Alcohol Alcohol. 2014;49(1):66–78. doi: 10.1093/alcalc/agt170.
    1. Solberg LI, Maciosek MV, Edwards NM. Primary care intervention to reduce alcohol misuse ranking its health impact and cost effectiveness. Am J Prev Med. 2008;34(2):143–152. doi: 10.1016/j.amepre.2007.09.035.
    1. Whitlock EP, Polen MR, Green CA, Orleans T, Klein J. Behavioral counseling interventions in primary care to reduce risky/harmful alcohol use by adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2004;140(7):557–568. doi: 10.7326/0003-4819-140-7-200404060-00017.
    1. Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, Goodman MJ, Solberg LI. Priorities among effective clinical preventive services: results of a systematic review and analysis. Am J Prev Med. 2006;31(1):52–61. doi: 10.1016/j.amepre.2006.03.012.
    1. Kaner EF, Dickinson HO, Beyer F, Pienaar E, Schlesinger C, Campbell F, et al. The effectiveness of brief alcohol interventions in primary care settings: a systematic review. Drug and Alcohol Review. 2009;28(3):301–323. doi: 10.1111/j.1465-3362.2009.00071.x.
    1. Moyer VA. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013;159(3):210–218.
    1. SBIRT: Screening, Brief Intervention, and Referral to Treatment 2014 [cited 13 Oct 2014]. . Accessed 14 July 2017.
    1. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington; 2016.
    1. Babor TF, McRee BG, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse. Subst Abuse. 2007;28(3):7–30. doi: 10.1300/J465v28n03_03.
    1. Nilsen P. Brief alcohol intervention—where to from here? Challenges remain for research and practice. Addiction (Abingdon, England) 2010;105(6):954–959. doi: 10.1111/j.1360-0443.2009.02779.x.
    1. Nilsen P, Aalto M, Bendtsen P, Seppa K. Effectiveness of strategies to implement brief alcohol intervention in primary healthcare. A systematic review. Scand J Prim Health Care. 2006;24(1):5–15. doi: 10.1080/02813430500475282.
    1. Kaner E. Brief alcohol intervention: time for translational research. Addiction (Abingdon, England) 2010;105(6):960–961. doi: 10.1111/j.1360-0443.2009.02848.x.
    1. Babor TF, Higgins-Biddle JC. Alcohol screening and brief intervention: dissemination strategies for medical practice and public health. Addiction. 2000;95(5):677–686. doi: 10.1046/j.1360-0443.2000.9556773.x.
    1. Rieckmann T, Abraham A, Zwick J, Rasplica C, McCarty D. A longitudinal study of state strategies and policies to accelerate evidence-based practices in the context of systems transformation. Health Serv Res. 2015;50(4):1125–1145. doi: 10.1111/1475-6773.12273.
    1. Garnick DW, Horgan CM, Merrick EL, Hoyt A. Identification and treatment of mental and substance use conditions: health plans strategies. Med Care. 2007;45(11):1060–1067. doi: 10.1097/MLR.0b013e31812e01bb.
    1. Mertens JR, Chi FW, Weisner CM, Satre DD, Ross TB, Allen S, et al. Physician versus non-physician delivery of alcohol screening, brief intervention and referral to treatment in adult primary care: the ADVISe cluster randomized controlled implementation trial. Addict Sci Clin Pract. 2015;10(1):26. doi: 10.1186/s13722-015-0047-0.
    1. Williams EC, Johnson ML, Lapham GT, Caldeiro RM, Chew L, Fletcher GS, et al. Strategies to implement alcohol screening and brief intervention in primary care settings: a structured literature review. Psychol Addict Behav. 2011;25(2):206–214. doi: 10.1037/a0022102.
    1. NIDA CTN Common Data Elements. . Accessed 14 July 2017.
    1. Ghitza UE, Gore-Langton RE, Lindblad R, Shide D, Subramaniam G, Tai B. Common data elements for substance use disorders in electronic health records: the NIDA Clinical Trials Network experience. Addiction. 2013;108(1):3–8. doi: 10.1111/j.1360-0443.2012.03876.x.
    1. Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10:53. doi: 10.1186/s13012-015-0242-0.
    1. Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26(1):13–24. doi: 10.1002/chp.47.
    1. Kastner M, Straus SE. Application of the Knowledge-to-Action and Medical Research Council frameworks in the development of an osteoporosis clinical decision support tool. J Clin Epidemiol. 2012;65(11):1163–1170. doi: 10.1016/j.jclinepi.2012.04.011.
    1. Oregon Health Authority. 2013 Quality Pool Reference Instructions. . Accessed 3 Mar 2017.
    1. Rieckmann T, Renfro S, McCarty D, Baker R, McConnell KJ. Quality metrics and systems transformation: are we advancing alcohol and drug screening in primary care? Health Serv Res. 2017
    1. Medscape. Medscape EHR report 2016. . Accessed 7 July 2017.
    1. Patton MQ. Qualitative research and evaluation methods. 3. Thousand Oaks: Sage; 2002.
    1. Patton MQ. Enhancing the quality and credibility of qualitative analysis. Health Serv Res. 1999;5(34):1189–1208.
    1. Boyatzis RE. Thematic analysis and code development: transforming qualitative information. London: Sage; 1998.
    1. Fleiss JL. Statistical methods for rates and proportions. 2. New York: Wiley; 1981.
    1. Averill JB. Matrix analysis as a complementary analytic strategy in qualitative inquiry. Qual Health Res. 2002;12:855–866. doi: 10.1177/104973230201200611.
    1. Kaner E, Bland M, Cassidy P, Coulton S, Deluca P, Drummond C, et al. Screening and brief interventions for hazardous and harmful alcohol use in primary care: a cluster randomised controlled trial protocol. BMC Public Health. 2009;9:287. doi: 10.1186/1471-2458-9-287.
    1. Hilbink M, Voerman G, van Beurden I, Penninx B, Laurant M. A randomized controlled trial of a tailored primary care program to reverse excessive alcohol consumption. J Am Board Fam Med. 2012;25(5):712–722. doi: 10.3122/jabfm.2012.05.120070.
    1. van Beurden I, Anderson P, Akkermans RP, Grol RP, Wensing M, Laurant MG. Involvement of general practitioners in managing alcohol problems: a randomized controlled trial of a tailored improvement programme. Addiction (Abingdon, England) 2012;107(9):1601–1611. doi: 10.1111/j.1360-0443.2012.03868.x.
    1. Williams EC, Achtmeyer CE, Young JP, Rittmueller SE, Ludman EJ, Lapham GT, et al. Local implementation of alcohol screening and brief intervention at five Veterans Health Administration primary care clinics: perspectives of clinical and administrative staff. J Subst Abuse Treat. 2016;60:27–35. doi: 10.1016/j.jsat.2015.07.011.
    1. Berger D, Bradley KA. Primary care management of alcohol misuse. Med Clin N Am. 2015;99(5):989–1016. doi: 10.1016/j.mcna.2015.05.004.
    1. U.S. Preventive Services Task Force. Screening for Illicit Drug Use: U.S. Preventive Services Task Force Recommendation Statement. 2008. . Accessed 14 July 2017.
    1. Roy-Byrne P, Bumgardner K, Krupski A, Dunn C, Ries R, Donovan D, et al. Brief intervention for problem drug use in safety-net primary care settings a randomized clinical trial. J Am Med Assoc. 2014;312(5):492–501. doi: 10.1001/jama.2014.7860.
    1. Saitz R, Palfai TPA, Cheng DM, Alford DP, Bernstein JA, Lloyd-Travaglini CA, et al. Screening and brief intervention for drug use in primary care the ASPIRE randomized clinical trial. J Am Med Assoc. 2014;312(5):502–513. doi: 10.1001/jama.2014.7862.
    1. Gelberg L, Andersen RM, Afifi AA, Leake BD, Arangua L, Vahidi M, et al. Project QUIT (Quit Using Drugs Intervention Trial): a randomized controlled trial of a primary care-based multi-component brief intervention to reduce risky drug use. Addiction (Abingdon, England) 2015;110(11):1777–1790. doi: 10.1111/add.12993.
    1. Hingson R, Compton WM. Screening and brief intervention and referral to treatment for drug use in primary care: back to the drawing board. JAMA. 2014;312(5):488–489. doi: 10.1001/jama.2014.7863.
    1. Sterling S, Kline-Simon AH, Wibbelsman C, Wong A, Weisner C. Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy. Addict Sci Clin Pract. 2012;7(1):13. doi: 10.1186/1940-0640-7-13.
    1. Friedmann PD, McCullough D, Saitz R. Screening and intervention for illicit drug abuse: a national survey of primary care physicians and psychiatrists. Arch Intern Med. 2001;161(2):248–251. doi: 10.1001/archinte.161.2.248.
    1. Friedmann PD, McCullough D, Chin MH, Saitz R. Screening and intervention for alcohol problems. A national survey of primary care physicians and psychiatrists. J Gen Intern Med. 2000;15(2):84–91. doi: 10.1046/j.1525-1497.2000.03379.x.
    1. McCormick KA, Cochran NE, Back AL, Merrill JO, Williams EC, Bradley KA. How primary care providers talk to patients about alcohol: a qualitative study. J Gen Intern Med. 2006;21(9):966–972. doi: 10.1007/BF02743146.
    1. Spandorfer JM, Israel Y, Turner BJ. Primary care physicians’ views on screening and management of alcohol abuse: inconsistencies with national guidelines. J Fam Pract. 1999;48(11):899–902.
    1. Johnson M, Jackson R, Guillaume L, Meier P, Goyder E. Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health (Oxf). 2011;33(3):412–421. doi: 10.1093/pubmed/fdq095.
    1. Aira M, Kauhanen J, Larivaara P, Rautio P. Factors influencing inquiry about patients’ alcohol consumption by primary health care physicians: qualitative semi-structured interview study. Fam Pract. 2003;20(3):270–275. doi: 10.1093/fampra/cmg307.
    1. Yoast RA, Wilford BB, Hayashi SW. Encouraging physicians to screen for and intervene in substance use disorders: obstacles and strategies for change. J Addict Dis. 2008;27(3):77–97. doi: 10.1080/10550880802122687.
    1. Williams EC, Achtmeyer CE, Young JP, Berger D, Curran G, Bradley KA, et al. Barriers to and facilitators of alcohol use disorder pharmacotherapy in primary care: a qualitative study in five VA clinics. J Gen Intern Med. 2017
    1. Spear SE, Shedlin M, Gilberti B, Fiellin M, McNeely J. Feasibility and acceptability of an audio computer-assisted self-interview version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients. Subst Abuse. 2016;37(2):299–305. doi: 10.1080/08897077.2015.1062460.
    1. Rahm AK, Boggs JM, Martin C, Price DW, Beck A, Backer TE, et al. Facilitators and barriers to implementing Screening, Brief Intervention, and Referral to Treatment (SBIRT) in primary care in integrated health care settings. Subst Abuse. 2015;36(3):281–288. doi: 10.1080/08897077.2014.951140.
    1. Williams EC, Achtmeyer CE, Thomas RM, Grossbard JR, Lapham GT, Chavez LJ, et al. Factors underlying quality problems with alcohol screening prompted by a clinical reminder in primary care: a multi-site qualitative study. J Gen Intern Med. 2015.
    1. Schomerus G, Lucht M, Holzinger A, Matschinger H, Carta MG, Angermeyer MC. The stigma of alcohol dependence compared with other mental disorders: a review of population studies. Alcohol Alcohol. 2011;46(2):105–112. doi: 10.1093/alcalc/agq089.
    1. Brener L, von Hippel W, von Hippel C, Resnick I, Treloar C. Perceptions of discriminatory treatment by staff as predictors of drug treatment completion: utility of a mixed methods approach. Drug Alcohol Rev. 2010;29(5):491–497. doi: 10.1111/j.1465-3362.2010.00173.x.
    1. Luoma JB, Twohig MP, Waltz T, Hayes SC, Roget N, Padilla M, et al. An investigation of stigma in individuals receiving treatment for substance abuse. Addict Behav. 2007;32(7):1331–1346. doi: 10.1016/j.addbeh.2006.09.008.
    1. Anderson P, Laurant M, Kaner E, Wensing M, Grol R. Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta-analysis. J Stud Alcohol. 2004;65(2):191–199. doi: 10.15288/jsa.2004.65.191.

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