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Introduction: Hazardous drinking is a public health problem affecting approximately 20 % of the U.S. primary care population. Clinical trials have documented the efficacy and effectiveness of Alcohol Screening and Brief Intervention (ASBI), yet widespread implementation remains elusive, and questions remain regarding optimal implementation and sustainment strategies. Kaiser Permanente Northern California (KPNC) implemented systematic ASBI in adult primary care in mid-2013. We used 8 years of electronic health record (EHR) data, combined with surveys which captured primary care provider perceptions organized into PRISM (Practical, Robust Implementation and Sustainability Model) implementation framework domains (Intervention, External Environment, Implementation Infrastructure, and Recipients), to characterize ASBI implementation and sustainment and test how various factors are associated with ASBI rates., Methods: Using EHR data, we calculated yearly screening rates of adults with a primary care visit, and brief intervention (BI) rates among those with a positive hazardous drinking screen, (exceeding the age and sex-specific daily and weekly low-risk NIH guidelines (≤3 per day and ≤ 7 per week for women and older men; ≤4 per day and ≤ 14 per week for men 18-65)), across KPNC, from 2014 to 2021. We collected web-based survey data, informed by the PRISM domains, from primary care providers (n = 796; 35.5 % RR) to assess perceptions on ASBI implementation and sustainability., Results: Between 1/1/2014 and 12/31/21 there were 5,072,270 completed screenings and 624,167 BIs. After adjusting for patient panel characteristics, we found that facilities with higher Implementation Infrastructure domain scores, indicating more robust implementation capacity, had higher screening and BI rates; facilities with higher Intervention domain scores, indicating positive perceptions of SBIRT evidence, and facilities with higher Recipients domain scores, indicating perceived organizational robustness, clinician culture and management support; and greater perceived patient needs and their likely benefit from SBIRT, had higher BI rates., Conclusions: Results provide information on factors which may facilitate successful ASBI implementation and sustainability and could inform future ASBI implementation efforts in healthcare system settings. In particular, efforts toward bolstering an organization's implementation infrastructure capacity, prior to embarking on implementation of a systematic ASBI program, could potentially help pave the way for successful implementation., Competing Interests: Declaration of competing interest The authors have no financial relationships relevant to this article or potential conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The early COVID-19 pandemic resulted in great psychosocial disruption and stress, raising speculation that psychiatric disorders may worsen. This study aimed to identify patients vulnerable to worsening mental health during the COVID-19 pandemic., Methods: This retrospective observational study used electronic health records from March 9 to May 31 in 2019 (n = 94,720) and 2020 (n = 94,589) in a large, community-based health care system. Percent change analysis compared variables standardized to the average patient population for the respective time periods., Results: Compared to 2019, psychiatric visits increased significantly (P < .0001) in 2020, with the majority being telephone/video-based (+264%). Psychiatric care volume increased overall (7%), with the greatest increases in addiction (+42%), behavioral health in primary care (+17%), and adult psychiatry (+5%) clinics. While patients seeking care with preexisting psychiatric diagnoses were mainly stable (−2%), new patients declined (−42%). Visits for substance use (+51%), adjustment (+15%), anxiety (+12%), bipolar (+9%), and psychotic (+6%) disorder diagnoses, and for patients aged 18–25 years (+4%) and 26–39 years (+4%), increased. Child/adolescent and older adult patient visits decreased (−22.7% and −5.5%, respectively), and fewer patients identifying as White (−3.8%) or male (−5.0) or with depression (−3%) or disorders of childhood (−2%) sought care., Conclusions: The early COVID-19 pandemic was associated with dramatic changes in psychiatric care facilitated by a rapid telehealth care transition. Patient volume, demographic, and diagnostic changes may reflect comfort with telehealth or navigating the psychiatric care system. These data can inform health system resource management and guide future work examining how care delivery changes impact psychiatric care quality and access., (© Copyright 2021 Physicians Postgraduate Press, Inc.)

Background: Substance use disorders (SUDs) and psychiatric disorders are common among people with HIV (PWH) and lead to poor outcomes. Yet these conditions often go unrecognized and untreated in primary care., Methods: The Promoting Access to Care Engagement (PACE) trial currently in process examines the impact of self-administered electronic screening for SUD risk, depression and anxiety in three large Kaiser Permanente Northern California primary care clinics serving over 5000 PWH. Screening uses validated measures (Tobacco, Alcohol, Prescription medication, and other Substance use [TAPS]; and the Adult Outcomes Questionnaire [AOQ], which includes the Patient Health Questionnaire [PHQ-9] and Generalized Anxiety Disorder [GAD-2]) delivered via three modalities (secure messaging, tablets in waiting rooms, and desktop computers in exam rooms). Results are integrated automatically into the electronic health record. Based on screening results and physician referrals, behavioral health specialists embedded in primary care initiate motivational interviewing- and cognitive behavioral therapy-based brief treatment and link patients to addiction and psychiatry clinics as needed. Analyses examine implementation (screening and treatment rates) and effectiveness (SUD, depression and anxiety symptoms; HIV viral control) outcomes using a stepped-wedge design, with a 12-month intervention phase implemented sequentially in the clinics, and a 24-month usual care period prior to implementation in each clinic functioning as sequential observational phases for comparison. We also evaluate screening and treatment costs and implementation barriers and facilitators., Discussion: The study examines innovative, technology-facilitated strategies for improving assessment and treatment in primary care. Results may help to inform substance use, mental health, and HIV services., Trial Registration: NCT03217058., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: In clinical trials alcohol brief intervention (BI) in adult primary care has been efficacious in reducing alcohol consumption, but we know little about its impact on health outcomes. Hypertension is a prevalent and costly chronic condition in the U.S. and worldwide, and alcohol use is a modifiable hypertension risk factor., Objective: To evaluate the effect of receiving BI for unhealthy drinking on blood pressure (BP) control among adult hypertensive patients by analyzing secondary data from a clustered, randomized controlled trial on alcohol screening, brief intervention and referral to treatment (SBIRT) implementation by primary care physicians (PCP intervention arm) and non-physician providers and medical assistants (NPP&MA intervention arm) in a large, integrated health care delivery system., Design: Observational, prospective cohort study., Subjects: 3811 adult hypertensive primary care patients screening positive for past-year heavy drinking at baseline, of which 1422 (37%) had an electronic health record BP measure at baseline and 18-month follow-up., Main Outcome Measures: Change in BP and controlled BP (systolic/diastolic BP <140/90mmHg)., Results: Overall no significant associations were found between alcohol BI and BP change at 18-month follow-up when analyzing the combined sample of subjects in both intervention arms. However, moderation analyses found that receiving BI for positive past-year unhealthy drinking was positively associated with better BP control at 18months in the PCP intervention arm, and for those with lower heavy drinking frequency and poor BP control at the index screening., Conclusions: Our findings suggest that hypertensive patients may benefit from receiving physician brief intervention for unhealthy alcohol use in primary care. Findings also highlight potential population-level benefits of alcohol BI if widely applied, suggesting a need for the development of innovative strategies to facilitate SBIRT delivery in primary care settings., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Unhealthy alcohol use is a major contributor to the global burden of disease and injury. The US Preventive Services Task Force has recommended alcohol screening and intervention in general medical settings since 2004. Yet less than one in six US adults report health care professionals discussing alcohol with them. Little is known about methods for increasing implementation; different staffing models may be related to implementation effectiveness. This implementation trial compared delivery of alcohol screening, brief intervention and referral to specialty treatment (SBIRT) by physicians versus non-physician providers receiving training, technical assistance, and feedback reports., Methods: The study was a cluster randomized implementation trial (ADVISe [Alcohol Drinking as a Vital Sign]). Within a private, integrated health care system, 54 adult primary care clinics were stratified by medical center and randomly assigned in blocked groups of three to SBIRT by physicians (PCP arm) versus non-physician providers and medical assistants (NPP and MA arm), versus usual care (Control arm). NIH-recommended screening questions were added to the electronic health record (EHR) to facilitate SBIRT. We examined screening and brief intervention and referral rates by arm. We also examined patient-, physician-, and system-level factors affecting screening rates and, among those who screened positive, rates of brief intervention and referral to treatment., Results: Screening rates were highest in the NPP and MA arm (51 %); followed by the PCP arm (9 %) and the Control arm (3.5 %). Screening increased over the 12 months after training in the NPP and MA arm but remained stable in the PCP arm. The PCP arm had higher brief intervention and referral rates (44 %) among patients screening positive than either the NPP and MA arm (3.4 %) or the Control arm (2.7 %). Higher ratio of MAs to physicians was related to higher screening rates in the NPP and MA arm and longer appointment times to screening and intervention rates in the PCP arm., Conclusion: Findings suggest that time frames longer than 12 months may be required for full SBIRT implementation. Screening by MAs with intervention and referral by physicians as needed can be a feasible model for increasing the implementation of this critical and under-utilized preventive health service within currently predominant primary care models., Trial Registration: Clinical Trials NCT01135654.

Purpose: To explore whether reducing substance misuse through a brief motivational intervention also reduces aggression and HIV risk behaviours., Methods: Participants were enrolled in a randomized controlled trial in primary care if they screened positive for substance misuse. Substance misuse was assessed using the Alcohol, Smoking and Substance Involvement Screening Test; aggression, using a modified version of the Explicit Aggression Scale; and HIV risk, through a count of common risk behaviours. The intervention was received on the day of the baseline interview, with a 3-month follow-up., Results: Participants who received the intervention were significantly more likely to reduce their alcohol use than those who did not; no effect was identified for other substances. In addition, participants who reduced substance misuse (whether as an effect of the intervention or not) also reduced aggression but not HIV risk behaviours., Conclusions: Reducing substance misuse through any means reduces aggression; other interventions are needed for HIV risk reduction., (© The Author 2015. Medical Council on Alcohol and Oxford University Press. All rights reserved.)

Aims: To assess the effectiveness of brief motivational intervention for alcohol and drug use in young adult primary care patients in a low-income population and country., Methods: A randomized controlled trial in a public-sector clinic in Delft, a township in the Western Cape, South Africa recruited 403 patients who were randomized to either single-session, nurse practitioner-delivered Brief Motivational Intervention plus referral list or usual care plus referral list, and followed up at 3 months., Results: Although rates of at-risk alcohol use and drug use did not differ by treatment arm at follow-up, patients assigned to the Brief Motivational Intervention had significantly reduced scores on ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) for alcohol-the most prevalent substance., Conclusion: Brief Motivational Intervention may be effective at reducing at-risk alcohol use in the short term among low-income young adult primary care patients; additional research is needed to examine long-term outcomes., (© The Author 2014. Medical Council on Alcohol and Oxford University Press. All rights reserved.)

Objectives: How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry., Methods: In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or nonproblematic use, was the outcome measure., Results: A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without., Conclusions: Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.

We assessed the relationship between stress, substance use and sexual risk behaviors in a primary care population in Cape Town, South Africa. A random sample of participants (and over-sampled 18-24-year-olds) from 14 of the 49 clinics in Cape Town's public health sector using stratified random sampling (n = 2,618), was selected. We evaluated current hazardous drug and alcohol use and three domains of stressors (Personal Threats, Lacking Basic Needs, and Interpersonal Problems). Several personal threat stressors and an interpersonal problem stressor were related to sexual risk behaviors. With stressors included in the model, hazardous alcohol use, but not hazardous drug use, was related to higher rates of sexual risk behaviors. Our findings suggest a positive screening for hazardous alcohol use should alert providers about possible sexual risk behaviors and vice versa. Additionally, it is important to address a broad scope of social problems and incorporate stress and substance use in HIV prevention campaigns.

Introduction: Health problems are prevalent in chemical dependency (CD) treatment populations, and often precede reductions in substance use among untreated populations. Few studies have examined whether medical problems predict better long-term outcomes in treated individuals, or how primary care utilization and CD/primary care service integration affects long-term outcomes among those with health problems., Method: In a sample of 598 CD patients in a private health plan, logistic regression models examined whether substance abuse-related medical conditions (SAMCs), integrated medical and CD care, and on-going primary care predicted remission of CD problems at 5 years., Results: Those with SAMCs were no more likely than others to be remitted at 5 years except among young adults and those with medical, but not psychiatric SAMCs. Higher levels of medical problem severity at intake and receiving integrated CD and primary care in the index treatment episode predicted remission in the full sample and among those with SAMCs. Among those with SAMCs, individuals with ongoing medical care - 2-10 primary care visits - in the 5 years following intake were more likely to be remitted at 5 years than those with fewer visits., Conclusions: This study highlights the potentially important role of medical services in the long-term treatment of CD disorders. CD treatment may benefit from a disease management approach similar to that recommended for other chronic medical problems: specialty care when the condition is severe followed by services in primary care when the condition is stabilized.

We aimed to assess prevalence and correlates of hazardous use of tobacco, alcohol and other drugs in a primary care population in Cape Town, South Africa. Stratified random sampling was used to select 14 of the 49 clinics in the public health sector in Cape Town, and every "nth" patient, with those ages 18-25 oversampled (N = 2,618). Data were collected from December 2003 through 2004, using the World Health Organization Alcohol, Smoking, and Substance Involvement Screening Test. Hazardous use of tobacco was most common, followed by alcohol and then other drugs. Hazardous tobacco use was associated with the 18-25 years age group, no religious involvement, high school completion, and higher stress. Hazardous alcohol use was associated with male gender, younger men, no religious involvement, employment, some high school education, and higher stress. Hazardous use of other drugs was associated with Colored (mixed) race (particularly among men), no religious involvement, employment, and stress. For all substances, women, particularly Black women, had the lowest rates of hazardous use. Although the study is cross-sectional, it does identify groups that may be at high risk of substance misuse and for whom intervention is urgent. Because prevalence of substance use is high in this population, routine screening should be introduced in primary care clinics.