A facilitation model for implementing quality improvement practices to enhance outpatient substance use disorder treatment outcomes: a stepped-wedge randomized controlled trial study protocol.

BACKGROUND: The misuse of and addiction to opioids is a national crisis that affects public health as well as social and economic welfare. There is an urgent need for strategies to improve opioid use disorder treatment quality (e.g., 6-month retention). Substance use disorder treatment programs are challenged by limited resources and a workforce that does not have the requisite experience or education in quality improvement methods. The purpose of this study is to test a multicomponent clinic-level intervention designed to aid substance use disorder treatment clinics in implementing quality improvement processes to improve high-priority indicators of treatment quality for opioid use disorder. METHODS: A stepped-wedge randomized controlled trial with 30 outpatient treatment clinics serving approximately 2000 clients with opioid use disorder each year will test whether a clinic-level measurement-driven, quality improvement intervention, called Coaching for Addiction Recovery Enhancement (CARE), improves (a) treatment process quality measures (use of medications for opioid use disorder, in-treatment symptom and therapeutic progress, treatment retention) and (b) recovery outcomes (substance use, health, and healthcare utilization). The CARE intervention will have the following components: (1) staff clinical training and tools, (2) quality improvement and change management training, (3) external facilitation to support implementation and sustainability of quality improvement processes, and (4) an electronic client-reported treatment progress tool to support data-driven decision making and clinic-level quality measurement. The study will utilize multiple sources of data to test study aims, including state administrative data, client-reported survey and treatment progress data, and staff interview and survey data. DISCUSSION: This study will provide the field with a strong test of a multicomponent intervention to improve providers' capacity to make systematic changes tied to quality metrics. The study will also result in training and materials that can be shared widely to increase quality improvement implementation and enhance clinical practice in the substance use disorder treatment system. TRIAL REGISTRATION: Trial # NCT04632238NCT04632238 registered at clinicaltrials.gov on 17 November 2020.

Symptomatology and neurocognition among first-episode psychosis patients with and without cannabis use in the three months prior to first hospitalization.

OBJECTIVE: The nature of associations between recent cannabis use and negative symptoms, positive symptoms, and neurocognitive deficits remains unclear. In a relatively large sample of well-characterized patients with first-episode psychosis, we hypothesized that, compared to first-episode patients without cannabis use in the three months prior to first hospitalization, those having used cannabis would have lesser negative symptoms, greater positive symptoms, and no differences in cognitive functioning. Dose-response relationships were also examined. METHODS: Between 2008 and 2013, 247 first-episode psychosis patients were assessed during their hospitalization at one of six participating inpatient psychiatric units. Measures included the Longitudinal Substance Use Recall for 12 Weeks instrument, the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms, and the MATRICS Consensus Cognitive Battery (MCCB). RESULTS: Anhedonia-asociality was significantly lower among those using cannabis in the past three months (10.7±4.6 v. 12.1±4.4, p=.023). Delusions were more severe among those having used cannabis (19.3±8.4 v. 15.9±9.1, p=.005), as was bizarre behavior (p=.01). There were no significant differences between those using and not using cannabis across nine MCCB measures. Correlations between the "dose" of cannabis and all of these measures were not significant. CONCLUSIONS: Compared to those without cannabis use, those who use cannabis in recent months have lesser anhedonia-asociality, greater delusion and bizarre behavior severity, and no significant differences in neurocognition. Such characterizations could shed light on subgroups of individuals with first-episode psychosis, as well as risk factors for cannabis use in the early course of these disorders.

Screening and Treatment of Tobacco Use Disorder in Mental Health Clinics in New York State: Current Status and Potential Next Steps.

The prevalence of smoking is higher among individuals with serious mental illnesses than the general population. Evidence-based practices exist for tobacco cessation, but little is known about mental health clinics' tobacco cessation treatment practices/protocols. Mental health clinics in New York State were surveyed about their tobacco use treatment protocols and outdoor-smoking policies. One-third of clinics were not providing individual counseling for tobacco use disorder, 39% were not prescribing nicotine replacement therapy, and nearly half reported not prescribing bupropion or varenicline. Even smaller proportions reported implementing other clinical practice guidelines, with only 25.2% providing staff training and 20.3% having a dedicated staff member for coordinating tobacco use disorder treatment. Regarding outdoor smoke-free policies, 38% of clinics reported not allowing any tobacco use anywhere on grounds. Despite some successes, many clinics do not provide evidence-based tobacco use treatments, meaning important opportunities exist for mental health clinics and oversight agencies to standardize practices.

Chronic Disease Screening and Prevention Activities in Mental Health Clinics in New York State: Current Practices and Future Opportunities.

To understand mental health clinics' chronic disease screening and prevention activities, we surveyed mental health clinics in New York State regarding 16 preventive services. Both numerical and qualitative data were collected. Responding clinics (123, 24.7%) were most likely to report having up-to-date screening/management of tobacco use (114, 92.7%) and were most likely to refer out for infectious disease and cancer screening (57.7%-62.6%). Compared to private/non-profit clinics, county- and state-operated clinics were more likely to refer out for infectious disease screening and to ensure up-to-date: lipid disorder screening, abnormal glucose screening, HIV screening, and cancer screenings. Clinics reported a need for: (1) hiring more (dedicated) medical staff; (2) providing staff trainings; (3) educating patients; and (4) integrating with patients' primary care providers. Implementing proven approaches-and developing new ones-for enhanced chronic disease prevention activities through improvements in policy, staffing, and reimbursement is warranted in mental health clinics.

Major Mental Illness as a Risk Factor for Incarceration.

OBJECTIVE: Individuals with serious mental illness are overrepresented in correctional populations. However, little is known about the representation of persons with serious mental illness at earlier stages in the criminal justice process. This research sought to measure the prevalence of arrestees in New York State who were treated for a major mental illness in the year before their arrest and to assess whether these individuals had a disproportionate rate of incarceration. METHODS: Approximately 600,000 individuals arrested in New York State between January 1, 2010, and December 31, 2013, were matched against public mental health records to identify defendants diagnosed as having a major mental illness in the 12 months before their arrest. RESULTS: Between 4% and 6% of the arrestees were diagnosed as having a major mental illness during a mental health service visit in the 12 months prior to their arrest. A major mental illness diagnosis was associated with more than a 50% increase in the odds of a jail sentence for misdemeanor arrestees, after the analyses controlled for the other case characteristics. Conversely, it was unrelated to the likelihood of a prison sentence given a felony arrest, but it did moderate the effect of other case characteristics within the group of arrestees with felonies. CONCLUSIONS: Differential adjudication of misdemeanor arrestees with a major mental illness diagnosis appears to contribute to their overrepresentation within the jail population. The role that poverty and pretrial incarceration may play in this relationship was not explored in this research and should be the subject of future investigation.

Clinical Characteristics of Synthetic Cannabinoid Use in a Large Urban Psychiatric Emergency Setting.

BACKGROUND: Increasing reports of synthetic cannabinoid (SC)-related adverse events have largely comprised case reports and analyses of calls to poison control centers. Existing studies have also mostly involved white male populations. OBJECTIVES: The purpose of this study is to systematically describe clinical characteristics of SC use in a relatively large, diverse, urban sample presenting to a psychiatric emergency setting. METHODS: SC users (n = 110) were identified by reviewing charts (n = 948) from the psychiatric emergency service of a large, urban public hospital in the United States for November 2014, which was randomly selected from the 12 months of that year. Sociodemographic data were collected from administrative databases and clinical data were collected from the electronic medical record. RESULTS: SC users were mostly non-white (90.0%) males (95.5%), who were likely to be police-involved (34.5%) and homeless (84.5%). SC users also had significant and often pre-existing psychiatric and substance use comorbidity, including acute psychotic symptoms (70.0%), more than one comorbid psychiatric diagnosis (31.8%) and primary psychotic disorder diagnosis (40.0%), past psychiatric visits to the hospital (70.9%), comorbid substance use (62.7%), agitation requiring intervention (22.7%), and the need for extended psychiatric observation (15.5%) and inpatient admission (34.5%). Relatively limited medical complications were identified. Conclusions/Importance: In this sample, SC use affected a sociodemographically disadvantaged and mentally ill population, likely exacerbating existing psychiatric problems. This is one of the only studies to systematically examine the clinical effects of SC use in a significant clinical sample, and the first study in an urban, racial/ethnic minority, and vulnerable sample.

Characteristics associated with synthetic cannabinoid use among patients treated in a public psychiatric emergency setting.

BACKGROUND: Growing evidence of adverse outcomes following synthetic cannabinoid use has engendered interest into populations at risk. The existing literature reports that synthetic cannabinoid use is predominant among young, white males. However, reports from local Departments of Health have found contrary evidence, showing that synthetic cannabinoid use is prevalent in populations other than those of young, white men. OBJECTIVES: This study sought to examine sociodemographic characteristics associated with self-reported synthetic cannabinoid use among a clinical psychiatric population within a public hospital in New York City. METHODS: A cross-sectional medical record review was conducted on synthetic cannabinoid users and non-users in an emergency psychiatric setting. A total of 948 patients who presented at the emergency psychiatric setting in 2014 were included in this sample, 110 (11.6%) of whom were synthetic cannabinoid users. Logistic regressions were used to determine the sociodemographic correlates of synthetic cannabinoid use. RESULTS: The most prominent correlate of synthetic cannabinoid use was homelessness/residing in a shelter during time of treatment (AOR = 17.77, 95% CI = 9.74-32.5). Male (AOR = 5.37, 95% CI = 2.04-14.1), non-white (AOR = 2.74, 95% CI = 1.36-5.54), and younger age (AOR = .961, 95% CI = .940-.980) were also significant correlates of synthetic cannabinoid use. CONCLUSION: Synthetic cannabinoid use among the homeless and mentally ill is a growing public health concern, representing a population with unique clinical and social needs. Areas and populations with high rates of homelessness should be targeted for synthetic cannabinoid prevention and treatment efforts, particularly in urban and racial/ethnic minority communities.

Cannabinoids and Schizophrenia: Risks and Therapeutic Potential.

A convergence of evidence shows that use of Cannabis sativa is associated with increased risk of developing psychotic disorders, including schizophrenia, and earlier age at which psychotic symptoms first manifest. Cannabis exposure during adolescence is most strongly associated with the onset of psychosis amongst those who are particularly vulnerable, such as those who have been exposed to child abuse and those with family histories of schizophrenia. Schizophrenia that develops after cannabis use may have a unique clinical phenotype, and several genetic polymorphisms may modulate the relationship between cannabis use and psychosis. The endocannabinoid system has been implicated in psychosis both related and unrelated to cannabis exposure, and studying this system holds potential to increase understanding of the pathophysiology of schizophrenia. Anandamide signaling in the central nervous system may be particularly important. Δ(9)-Tetrahydrocannabinol in cannabis can cause symptoms of schizophrenia when acutely administered, and cannabidiol (CBD), another compound in cannabis, can counter many of these effects. CBD may have therapeutic potential for the treatment of psychosis following cannabis use, as well as schizophrenia, possibly with better tolerability than current antipsychotic treatments. CBD may also have anti-inflammatory and neuroprotective properties. Establishing the role of CBD and other CBD-based compounds in treating psychotic disorders will require further human research.

Depressive symptoms, utilization of mental health care, substance use and sexual risk among young men who have sex with men in EXPLORE: implications for age-specific interventions.

The EXPLORE study evaluated a behavioral intervention to prevent HIV infection among MSM. We examined depressive symptoms, utilization of mental health care, substance use and HIV risk taking behaviors in YMSM aged 16-25 years compared with their older counterparts. YMSM were more likely to report depressive symptoms (OR = 1.55) and less likely to report use of counseling (OR = 0.39) or medication (OR = 0.20) for psychiatric conditions. YMSM were more likely to report heavy alcohol and drug use. YMSM more often reported engaging in unprotected insertive (OR = 1.60) and receptive (OR = 2.07) anal intercourse with presumed HIV-uninfected partners, and unprotected receptive (OR = 1.72) anal intercourse with partners of unknown-HIV status. These findings suggest the need for more appropriate and accessible mental health care and substance use services for YMSM. Additionally, HIV prevention work with this population should provide comprehensive education about HIV testing and risk reduction counseling that focuses on communication about serostatus and safety in sexual situations.

MSM in HIV-prevention trials are sexual partners with each other: An ancillary study to the EXPLORE intervention.

The EXPLORE study evaluated a behavioral intervention to prevent HIV seroconversion among men who have sex with men (MSM). The present ancillary study enrolled 345 EXPLORE participants at one study site (Boston) and assessed high-risk sexual behavior with other EXPLORE participants. It also assessed sexual intentions across other EXPLORE participants, HIV-negative individuals, and unknown HIV serostatus partners. Thirty-one percent reported having sex with another EXPLORE participant: 27% unprotected receptive oral sex with ejaculation (UO), 30% unprotected insertive anal sex (UIA), and 34% reported unprotected receptive anal sex (URA). Significant relationships between intentions to engage in UO, UIA, and URA, and type of partner emerged with intentions to engage in UO, UIA, and URA higher in HIV-negative partners, other EXPLORE participants, and unknown-HIV serostatus partners. Future HIV-prevention studies recruiting MSM at increased sexual risk of HIV infection should address participants potentially becoming sexual partners with each other.