Mental health and substance use screening in HIV primary care before and during the early COVID-19 pandemic.

BACKGROUND: Mental health and substance use disorders disproportionately affect people with HIV (PWH), and may have been exacerbated during COVID-19. The Promoting Access to Care Engagement (PACE) trial was designed to assess the effectiveness of electronic screening for mental health and substance use in HIV primary care and enrolled PWH from October 2018 to July 2020. Our objective here was to compare screening rates and results for PWH before (October 2018 - February 2020) and early in the COVID-19 pandemic (March-July 2020). METHODS: Adult (≥ 18 years) PWH from 3 large HIV primary care clinics in a US-based integrated healthcare system were offered electronic screening online or via in-clinic tablet computer every 6 months. Screening completion and results (for depression, suicidal ideation, anxiety, and substance use) were analyzed using logistic regression with generalized estimating equations to estimate prevalence ratios (PR) before and after the start of the regional COVID-19 shelter-in-place orders on March 17, 2020. Models adjusted for demographics (age, sex, race/ethnicity), HIV risk factors (men who have sex with men, injection drug use, heterosexual, other), medical center, and modality of screening completion (online or tablet). We conducted qualitative interviews with providers participating in the intervention to evaluate how the pandemic impacted patient care. RESULTS: Of 8,954 eligible visits, 3,904 completed screenings (420 during COVID, 3,484 pre-COVID), with lower overall completion rates during COVID (38% vs. 44%). Patients completing screening during COVID were more likely to be White (63% vs. 55%), male (94% vs. 90%), and MSM (80% vs., 75%). Adjusted PRs comparing COVID and pre-COVID (reference) were 0.70 (95% CI), 0.92 (95% CI), and 0.54 (95% CI) for tobacco use, any substance use, and suicidal ideation, respectively. No significant differences were found by era for depression, anxiety, alcohol, or cannabis use. These results were in contrast to provider-reported impressions of increases in substance use and mental health symptoms. CONCLUSION: Findings suggest PWH had modest declines in screening rates early in the COVID-19 pandemic which may have been affected by the shift to telemedicine. There was no evidence that mental health problems and substance use increased for PWH in primary care. TRIAL REGISTRATION: NCT03217058 (First registration date: 7/13/2017); https://clinicaltrials.gov/ct2/show/NCT03217058.

Effectiveness and cost-effectiveness of sector-independent treatment coordination for people with substance-related disorders following an online assessment (ASSIST): study protocol for a randomized controlled trial.

BACKGROUND: The implementation of person-centred, need-oriented and flexible care for people with substance-related problems is often insufficient, in large part due to the complexity of addiction support services among different providers. A standardized online assessment and subsequent sector-independent treatment coordination could provide individuals with more appropriate services, thereby making better use of individual services and leading to a more effective addiction support system as a whole. The aim of this study is to determine the effectiveness and cost-effectiveness of sector-independent treatment coordination following an online assessment, in comparison with the current standard of care and treatment process in Germany. METHODS: The sample size of this randomized, controlled trial has been set to a total of 400 participants with substance-related problems. Participants living in Stuttgart, Germany, will be randomly allocated to (1) the intervention group with immediate online assessment and subsequent sector-independent treatment coordination (ASSIST) or (2) the waitlist group. Participants in the waitlist group will initially remain in usual care and only be provided with the online assessment 6 months later. Short-term effects (over 2 months) and medium-term effects (over 6 months) of ASSIST will be compared between the intervention and the waitlist groups. The primary outcome is improved treatment satisfaction. Secondary outcomes include improved subjective quality of life and empowerment, reductions in patients' substance use, unmet needs and illness-related clinical and social impairment. Health economic evaluation as well as quantitative and qualitative process evaluations will be conducted. DISCUSSION: The results of this study are expected to provide information on whether sector-independent treatment coordination following an online assessment contributes to improved health care service provision for people with substance-related problems. This randomized controlled trial will help identify facilitators and barriers to the sustainable implementation of a cross-sectoral care concept in substance abuse services. TRIAL REGISTRATION: German Clinical Trial Register DRKS00026996 . Registered on 29 October 2021.

Does the Length of Time to Complete an Online Program Matter?

Health care providers are challenged to meet the simultaneous demands of delivering clinical care and acquiring new information, especially in the context of the coronavirus disease 2019 pandemic, the opioid epidemic, and concurrent escalation in alcohol and other drug use. To address the gap in knowledge related to substance use, screening, brief intervention, and referral to treatment (SBIRT), a self-paced online educational program, was developed and delivered to 169 learners. Posttest knowledge scores increased for all learners and did not differ based on their pace of completion. Results indicated that this module provides a means for busy clinicians to increase their ability to manage substance use, even if their learning occurs in multiple sessions interrupted by other pressing demands. Future iterations of this course could further enhance clinical competency by addition of an online clinical simulation component. [J Contin Educ Nurs. 2021;52(11):505-510.].

Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Primary Care, School-Based Health Clinics, and Mental Health Clinics.

Adolescent cannabis use is a modifiable health behavior with potential adverse developmental, cognitive, psychological, and health effects. Over the last 2 decades, work to promote implementation of screening, brief intervention, and referral to treatment has improved screening, use of validated screening tools, and preventive messaging. Current intervention strategies for cannabis use are associated with modest, short-term effects, and referral to treatment is limited by availability of resources for adolescent substance use. This article provides an update on the evidence base for screening, brief intervention, referral to treatment, and the current state of implementation focused on management of cannabis use disorder.

Coronavirus disease pandemic and adolescent substance use.

PURPOSE OF REVIEW: Substance use is common in adolescence and has distinct developmental, cognitive, and health consequences. Over the last 2 years, the coronavirus disease 2019 pandemic has isolated adolescents, disrupted typical developmental milestones, and caused pervasive stress and anxiety. Healthcare providers can help by recognizing and addressing these effects on adolescent mental health and substance use. This update reviews the immediate effects of the pandemic on adolescent substance use, potential future implications, and opportunities to use new strategies to improve care for adolescents with problematic use. RECENT FINDINGS: Initial findings suggest that fewer teens started using substances during the pandemic. This was likely influenced by stay at home orders that reduced opportunities for social use. However, increased time at home was not beneficial for all adolescents. Furthermore, adolescents who used substances prepandemic, experienced material hardship, or reported higher pandemic-related stress tended to intensify substance use during this time. SUMMARY: The adverse effects of pandemic isolation, anxiety, and developmental disruption will likely have consequences for adolescent substance use for many years to come. To comprehensively address adolescent health, healthcare providers can be sensitive to these realities and use existing screening and brief intervention strategies to address use. Innovative telehealth strategies that allow for the expansion of substance use treatment offer promising opportunities to improve care for adolescents with substance use disorder.

Unpacking the Layers: Dismantling Inequities in Substance Use Services and Outcomes for Racially Minoritized Adolescents.

Minoritized youth have lower prevalence rates of substance use disorders (SUD) compared with White peers, but proportionally those that are diagnosed are less likely to engage in specialized care and there are few culturally responsive treatments or programs available. We examine social determinants of SUD, with emphasis on the impact of trauma, including racial trauma, and include an intersectional approach incorporating race, ethnicity, and gender. This review of the literature highlights evidence-based effective clinical practice as examples for the field in developing therapeutic approaches to SUD for this population.

Impact of Cannabis Use, Substance Use Disorders, and Psychiatric Diagnoses on COVID-19 Outcomes: A Retrospective Cohort Study.

Objective: While psychiatric disorders have been recognized as a risk factor for COVID-19 outcomes, the impact of substance use disorders (SUD) on COVID-19 outcomes has not, to date, been examined in a systematic manner. We examined the association between SUD (cannabis, cocaine, alcohol, opioid, and benzodiazepine) as well as psychiatric diagnoses (schizophrenia, mood disorders, anxiety disorders) and COVID-19 outcomes in a large, retrospective cohort study.Methods: COVID-19-positive patients admitted to a large health care system in the US between January and December 2020 were included in this study. SUD and psychiatric diagnoses were identified from urine toxicology reports and ICD-10 diagnosis codes in the electronic medical record, respectively. Multivariable logistic regression was performed controlling for potential confounders such as age, race, sex, smoking status, and medical comorbidities. COVID-19-relevant outcomes included mortality, need for intensive care unit (ICU) admission, need for ventilatory support, length of hospitalization, and number of hospitalizations.Results: Among COVID-19 patients (N = 6,291), those with SUD were more likely to require ICU admission (adjusted odds ratio [AOR] = 1.46, P = .003) and ventilatory support (AOR = 1.49, P = .01). The association between SUD and ICU admission was driven by alcohol use disorder (AUD), whereas that between SUD and ventilatory support was driven by both AUD and opioid use disorder (OUD). Patients with SUD were more likely to have a longer mean maximum length of hospitalization (11.32 vs 8.62 days, P < .0001) and a greater mean number of hospital admissions in 2020 (2.96 vs 2.33, P < .0001). These associations were significant for cannabis use disorder, AUD, OUD, and benzodiazepine use disorder. The association with greater number of admissions was also significant for cocaine use disorder. Patients with psychiatric diagnoses were also more likely to have a greater maximum length of hospitalization (11.93 vs 8.39 days, P < .0001) and hospital admissions (2.72 vs 2.31, P < .0001). These associations were significant for schizophrenia, mood disorders, and anxiety disorders.Conclusions: COVID-19 patients with SUD had greater likelihood of requiring critical interventions, such as ICU admission and ventilatory support. SUD and psychiatric diagnoses were also associated with a longer duration of hospitalization and greater number of hospital admissions. These findings identify COVID-19 patients with SUD and psychiatric comorbidities as a high-risk group.

Rates, Patterns, and Predictors of Follow-up Care for Adolescents at Risk for Substance Use Disorder in a School-Based Health Center SBIRT Program.

PURPOSE: To examine rates, patterns, and predictors of follow-up care for adolescents screened as being at risk for substance use disorder (SUD) in a school-based health center (SBHC) Screening, Brief Intervention and Referral to Treatment (SBIRT) program. METHODS: Electronic health records were extracted of adolescents who received health care services from one of three high school-based health centers implementing SBIRT. Patterns and predictors of engagement in follow-up care within 8 weeks following the week of a positive SUD risk screen were analyzed using item response theory (IRT) modeling. RESULTS: Out of 1,327 adolescents receiving SBHC services, 81.2% completed a health screening questionnaire. Of screened adolescents, 17.7% were positive for SUD risk. Across the 8-week follow-up period, 65.4% of adolescents at risk for SUD received at least one follow-up visit. IRT modeling indicated that high levels of engagement in follow-up care were characterized by contact with a behavioral health care (BHC) provider. The percentage of adolescents having follow-up contact with a BHC provider increased significantly after the onset of the COVID-19 pandemic. Engagement in follow-up care was predicted by risk for depression, history of suicidal behavior, being female, and previous sexual activity. DISCUSSION: SBHCs provide a favorable setting for screening and detecting adolescents at risk for SUD. Adolescents at risk for SUD should receive follow-up contact with a BHC provider. Enhanced follow-up engagement efforts may be warranted for adolescents at risk for SUD without risk for depression or suicidal history, as well as for females and those with previous sexual activity.

Test-retest reliability of a new assessment to detect detailed temporal patterns of polysubstance use.

OBJECTIVE: While polysubstance use is highly prevalent among people who use drugs, the field lacks a reliable assessment that can detect detailed temporal patterns of polysubstance use. This study assessed the test-retest reliability of the newly developed Polysubstance Use-Temporal Patterns Section (PSU-TPS). METHODS: Participants who used cocaine plus alcohol and/or marijuana at least once in the past 30 days (n = 48) were interviewed at baseline and approximately 7 days later (retest) using the Substance Abuse Module and the PSU-TPS. Reliability of PSU-TPS measures of quantity, frequency, and duration of polysubstance use was examined using intra-class correlation coefficients (ICCs) and kappa tests. RESULTS: Excellent reliability was observed for frequencies of concurrent polysubstance use patterns in the past 30 days (ICC range: 0.90-0.94) and quantity of alcohol use (ICC = 0.83), and fair to good reliability was observed for duration of substance use (ICC range: 0.52-0.73). CONCLUSION: Detailed information regarding cocaine, alcohol, and marijuana polysubstance use in the past 30 days can be reliably measured with the PSU-TPS. Data on the order and timing of polysubstance use at the hourly level will improve our understanding of the implications of sequential and simultaneous use patterns, which can help inform treatment and prevention efforts.

One-year mortality of emergency department patients with substance-induced psychosis.

OBJECTIVES: Psychosis is a well established complication of non-prescription drug use. We sought to measure the 1-year mortality of emergency department patients with substance-induced psychosis (SIP). METHODS: This study was a multi-centre, retrospective electronic medical records review of patients presenting to the ED with substance-induced psychosis (SIP). We interrogated the hospital ED database from Jan 1, 2018 and Jan 1, 2019 to identify consecutive patients. All patients were followed for one year from index visit, and classified as alive/dead at that time. Patients were included in the study if they met the following criteria: 1) ED discharge diagnosis of psychosis NOS and a positive urine drugs of abuse screen (UDAS) or the patient verbally endorsed drug use, or 2) Mental disorder due to drug use and "disorganized thought", "bizarre behavior" or "delusional behavior" documented in the chart and one or more of the following criteria: a) arrival with police, b) mental health certification, c) physical restraints, d) chemical restraints. We excluded patients who were not British Columbia residents, since we were unable to ascertain if they were alive or dead at 1 year from their index ED visit. Primary statistical analysis was logistic regression for risk of death in 1 year, based on plausible risk factors, selected a priori. RESULTS: We identified 813 presentations for SIP (620 unique patients). The median age of the entire cohort was 35 years (IQR 28-44), and 69.5% (n = 565) were male. Thirty five patients (4.3%; 95% CI 3.2-5.9) had died one year after their initial presentation to the ED for SIP. Separate multivariable logistic regression analyses, controlling for age, demonstrated schizophrenia (OR 4.2, 95% CI 1.8-11.1) significantly associated with increased 1-year mortality. CONCLUSIONS: In our study of patients presenting to the ED with SIP, the 1-year mortality was 4.3%. Controlling for age, schizophrenia was a notable risk factor for increased 1-year mortality.

Retrospective analysis of laboratory data from 19,275 hair samples submitted for drug abuse/misuse analysis from February 2019 to June 2021.

Drug abuse/misuse is now a major global problem affecting public health as well as economic and social stability. This study presents a retrospective view of the prevalence of drugs in hair. Reasons for hair testing include the need for law enforcement to test suspicious individuals and the need for employers in specific industries to test their employees. Toxicology analysis results were reviewed for a total of 19,275 hair samples requested for drug abuse/misuse analysis at the Academy of Forensic Science over 29 months from February 2019 to June 2021. Drugs and their metabolites in hair samples were analyzed by liquid chromatography - tandem mass spectrometry. In the study, the 19,275 hair samples were screened for a total of 62 illegal drugs, which were divided into three categories: illegal-drugs (I), medication (II), and new psychoactive substances (III). These three categories contain 11, 29 and 22 drugs respectively. In these hair samples, 4852 (25.2 %) tested positive for one or more drugs. Among them, the positive rate of category I was the highest (48.7 %), followed by category II (28.5 %), and category III (22.7 %). Over all, the positive rate of male users (26.2 %) was higher than that of female users (23.7 %), and most of them were young people (25-44 years old). Illegal-drugs (morphine, etc.) had the highest positive rate. Under the influence of some certain factors, the drug abuse situation will also undergo corresponding changes. The results can provide a scientific knowledge database which can help in the prevention of drug abuse.

COVID-19 hospitalization rates in individuals with substance or alcohol use disorders.

People with Substance or Alcohol Use Disorders (SUDs/AUDs) are likely to be more vulnerable to COVID-19 infection than the general population. We performed a cross-sectional study to compare the hospitalization rate (CHR) for COVID-19 in 2020 in patients diagnosed with SUDs or AUDs in the previous 10 years vs the population without these disorders (NAS). We included individuals who were resident in the Metropolitan Area of Bologna (Northern Italy). People with SUDs or AUDs have a greater probability of being hospitalized for COVID-19 infection compared to the general population NAS, suggesting that they suffer from worse physical symptoms/conditions than the general population. Furthermore, we found higher mortality rates during hospitalization for COVID-19 in patients with AUDs or SUDs than the general population NAS. These findings highlight the importance of a careful monitoring and early intervention measures in these patients.

Golden opportunity for intervention? Identifying vitamin D deficiency in patients with substance use disorders in hospital.

SETTING: Based at a busy city hospital, the alcohol care team is a drug and alcohol specialist service, taking referrals for a wide range of patients with substance use disorders (SUD). OBJECTIVES: Patients with SUD are at high risk of vitamin D deficiency; this relates to frequent fractures and proximal myopathy. The coronavirus pandemic brought vitamin D into focus. Local guidelines advise that patients at high risk of vitamin D deficiency are offered replacement. There were no local data on vitamin D deficiency prevalence or any mention of patients with SUD in local vitamin D guidelines. The main aim of this project was to offer vitamin D checks and replacement to all appropriate patients. RESULTS: We collected data on 207 patients, [pilot study (n=50) and two subsequent samples (n=95 and n=62)]. Our pilot study showed that no patients were offered vitamin D testing or replacement. We then offered vitamin D checks to 95 patients. Most had low vitamin D (30 patients were vitamin D deficient and 26 were vitamin D insufficient). We provided vitamin D replacement and follow-up advice. Quality improvement was demonstrated 6 months later. We collected data on a further 62 patients who were all on our current or recent caseload. Following exclusions, nearly half (48%) of patients had had a vitamin D check. Almost all of these (95%) had low vitamin D (60% being classified as deficient). CONCLUSIONS: Patients had not been offered vitamin D replacement despite often having multiple risk factors for vitamin D deficiency. Vitamin D checks (and subsequent replacement) rose in frequency since the outset of this project. Local guidelines should add SUD as a risk factor for vitamin D deficiency. Hospital admission provides a rich opportunity to offer this simple intervention to patients who are often poorly engaged with community services.

Impact of COVID-19 pandemic on emergency department substance use screens and overdose presentations.

BACKGROUND: The COVID-19 pandemic can exacerbate underlying substance use disorder and has impacted this vulnerable population in a variety of ways. There are limited data regarding how this pandemic has impacted emergency department (ED) patient presentations. METHODS: We extracted data on ED visits from the electronic health record (EHR) of a large healthcare system in the Washington, DC/Baltimore, MD metropolitan area. The dataset includes data from 7 hospitals on ED visits between 11/1/2019-6/30/2020. The health system utilizes a validated screening program for substance use, Screening, Brief Intervention, and Referral to Treatment (SBIRT), for ED patients who are clinically stable and willing to complete screening. We evaluated trends in patients with a positive SBIRT screen and those presenting with a clinical diagnosis of acute alcohol or substance intoxication/overdose before (11/1/19-2/29/2020-pre) and during the first wave of the COVID pandemic (3/1/2020-6/30/2020-post). Data were described using descriptive statistics. Bivariate analyses were conducted using chi-square test and two-sample t-tests. Interrupted time series analysis was used to evaluate the changes in the weekly trends with the start of the pandemic. RESULTS: There were 107,930 screens performed in the EDs during the study period (61,961 pre, 45,969 post). The population was primarily African American (64.7%) and female (57.1%). Positive SBIRT screens increased from 12.5% to 15.8% during COVID (p < 0.001). Alcohol intoxication presentations increased as a proportion of positive screens from 12.6% to 14.4% (p = 0.001). A higher percentage of screened patients reported problem drinking (AUDIT score ≥ 7) during the pandemic (2.4% pre vs 3.2% post, p < 0.001). Substance intoxication/overdoses among all screened increased from 2.1% to 3.1% (p < 0.001) and as a percentage of positive screens during the pandemic (16.8% to 20%, p < 0.001). The proportion of opioid vs. non-opioid overdoses remained unchanged before (67%) and during the pandemic (64%, p = 0.33). DISCUSSION: There was an increase in the proportion of positive SBIRT screens and visits for acute overdoses and intoxication during the first wave of the COVID-19 pandemic. Additional research should focus on mitigation strategies to address substance use during this vulnerable time.

"I'm pretty sure it's either food poisoning or Covid-19": Lived experience versus medical knowledge in diagnosing substance use problems.

People who use drugs, or who have in the past, often report that doctors and/or treatment providers devalue, or are unwilling to believe their claims in regards to substance use issues, in particular the presence and severity of withdrawal. In the case of benzodiazepine withdrawal this can not only lead to significant discomfort, frustration, and trauma for patients, but can lead to serious medical problems. This commentary uses the authors' recent first-person experience with a disbelieving doctor in order to illustrate the lack of value often given to the claims and narratives of people with lived substance use experience. I outline some of the potential problems with this approach, including the effects on patients themselves and the loss of an important source of evidence-based knowledge. It also discusses potential risks associated with the recent increase in benzodiazepine prescription due to Covid-19 and offers suggestions for improving treatment outcomes.

Transdiagnostic vulnerability factors for behavioral health problems during COVID-19.

The novel 2019 SARS-2-CoV causing COVID-19 has had a devastating impact on the entire world. COVID-19 is a broad-based stressor, and research to date has documented increases in mental health problems, including anxiety, depression, and substance use, since the onset of COVID-19. By taking a transdiagnostic approach, scholars can help elucidate mechanisms and vulnerability as well as resiliency related to behavioral health problems in the context of COVID-19. The aim of the current special issue of Cognitive Behaviour Therapy was to showcase ongoing research focused on transdiagnostic factors in the context of COVID-19. The purpose of this issue is to highlight the significance of this work in the pandemic for research and practice; illustrate some of the many domains currently being explored via innovative approaches; and explicate fruitful areas for programmatic study. We hope that readers will recognize the important role of transdiagnostic models and their potential to offset the mental, addictive, and physical health disease burden of COVID-19.

The Opioid Epidemic Within the COVID-19 Pandemic: Drug Testing in 2020.

The convergence of the opioid epidemic and the coronavirus disease 2019 (COVID-19) pandemic has created new health care challenges. The authors analyzed changes in clinical drug testing patterns and results at a national clinical laboratory, comparing data obtained before and during the pandemic. Testing for prescription and illicit drugs declined rapidly during the pandemic, with weekly test volumes falling by approximately 70% from the baseline period to the trough (the week beginning March 29) before rising in subsequent weeks. Among individuals tested, positivity increased by 35% for non-prescribed fentanyl and 44% for heroin during the pandemic. Positivity for non-prescribed fentanyl increased significantly among patients positive for other drugs: by 89% for specimens positive for amphetamines; 48% for benzodiazepines; 34% for cocaine; and 39% for opiates (P < 0.01 for all comparisons). These findings suggest significant increases in dangerous drug combinations. Positivity for non-prescribed use of many other drugs remained consistent or declined for some drugs, relative to pre-pandemic patterns. Models adjusting for potential confounding variables, including medication-assisted treatment and treatment at a substance use disorder facility indicated that the risk for non-prescribed fentanyl positivity rose by more than 50% during the pandemic. In summary, these findings demonstrate decreased drug testing overall, with increased positivity for high-risk drugs and dangerous drug combinations. The convergence of the drug abuse epidemic and COVID-19 pandemic has led to an increased need for health care and public health resources dedicated to supporting vulnerable patients and addressing the underlying causes of these disturbing trends.