Patients' perspectives on care management services for complex substance use disorders.

Although care management approaches have potential to improve clinical outcomes and reduce high health care costs of patients with complex substance use disorders, characterized by high psychosocial, psychological, and/or medical needs and high acute health care utilization, little is known about patients' perspectives or experiences with these interventions. The objectives of this study were to identify barriers and facilitators to patient engagement in care management services for complex substance use disorders from patients' perspectives. This pilot study invited 22 men with complex substance use disorders and high health care utilization who were enrolled in a 1-year open trial of a Care Management Model to complete semi-structured interviews at 1- and 3-months post-baseline. Interviews were recorded, transcribed, and analyzed using template analysis. Five themes related to engagement were identified: barriers to conventional substance use disorder treatment, facilitators of care management services, patient-provider relationship, patient-related factors, and enhancements to a Care Management Model. Results highlighted the importance of the patient-provider relationship, individual visits with providers, flexible and personalized treatment, and a focus on recovery over abstinence in promoting patient engagement in care management services. Results also highlighted a need for increased outreach and assistance with housing and transit to treatment. Patients' perspectives support key elements of the care management services that are designed to facilitate patient engagement and suggest the need for additional outreach and assistance with obtaining shelter and transportation. Additional research is needed to evaluate if care management approaches enhance retention, improve outcomes, and reduce health care utilization of patients with complex and chronic substance use disorders.

Survey of Primary Care and Mental Health Prescribers' Perspectives on Reducing Opioid and Benzodiazepine Co-Prescribing Among Veterans.

Background: Due to the involvement of opioids and benzodiazepines in rising pharmaceutical overdoses, a reduction in coprescribing of these medications is a national priority, particularly among patients with substance use disorders and other high-risk conditions. However, little is known about primary care (PC) and mental health (MH) prescribers' perspectives on these medications and efforts being implemented to reduce coprescribing. Design: An anonymous survey. Setting: One multisite VA health care system. Subjects: Participants were 55 PC and 31 MH prescribers. Methods: Survey development was guided by the Promoting Action on Research Implementation in Health Services (PARIHS) conceptual framework. PC and MH prescribers of opioids or benzodiazepines were invited to complete an anonymous electronic survey. Responses were collapsed to highlight agreement, disagreement, and neutrality and summarized with means and percentages. Results: Over 80% of both prescriber groups reported concern about concurrent use and > 75% strongly agreed with clinical practice guidelines (CPG) that recommend caution in coprescribing among patients with high-risk conditions. More than 40% of both prescriber groups indicated that coprescribing continues because of beliefs that patients appear stable without adverse events and tapering/discontinuation is too difficult. Over 70% of prescribers rated strategies for addressing patients who refuse to discontinue, more time with patients, and identification of high-risk patients as helpful in reducing coprescribing. Conclusion: Despite strong agreement with CPGs, prescribers reported several barriers that contribute to coprescribing of opioids and benzodiazepines and challenge their ability to taper these medications. Multiple interventions are likely needed to reduce opioid and benzodiazepine coprescribing.