Of particular interest to the current implementation efforts of the Substance Use Disorders-Quality Improvement Enhancement Research Initiative (SUD-QUERI) is the improvement of services for veterans with posttraumatic stress disorder (PTSD) and substance use disorders (SUD). Persons with PTSD are at elevated risk for development of SUDs, experience more difficulty quitting substance use (e.g., higher relapse rates in treatment), and manifest greater psychological and functional impairment than non-dually diagnosed patients. Given this elevated risk, it is particularly important to recognize and treat SUDs in this population promptly and effectively.
Cannabis is one of the most frequently abused substances in the United States (US), and it was the most prevalent drug of new initiation in the US in 2008. Cannabis Use Disorders (CUD) are associated with negative medical, psychological, social, cognitive, economic, and functional consequences. Evidence-based psychosocial treatments for SUDs, in general, are also evidence-based treatments for CUD, and these treatments are widely available in VA specialty SUD treatment programs. However, there is evidence that patients with CUD are not being recognized and engaging in these beneficial evidence-based treatments.
Although rates of CUD have been rising rapidly within VA over the past 8 years (an increase of 166.7%), diagnosis rates are highly variable (0.30% - 4.33% across VA facilities in 2009) and often lower than would be expected given even the general, rather than clinical, population prevalence of CUDs (1.7% in 2008). Providing evidence based treatment for CUD requires that the patients with CUD are identified and referred to VA specialty treatment. The wide variation in diagnosis and treatment engagement rates across facilities suggests that engaging indicated patients into the existing available evidence-based treatments for CUD is a substantial implementation problem for VA. As such, understanding implementation barriers and supports to SUD treatment among individuals with CUD at greatest risk for relapse (e.g., those with PTSD) is of great importance.
The goal of the proposed project was to explore the rates of CUD diagnoses among individuals with PTSD as well as the rates of SUD treatment engagement among veterans with co-occurring CUD and PTSD. Additionally, in order to determine implementation barriers and supports to existing SUD treatment among those with co-occurring CUD and PTSD, the purpose of this project was to determine how, and to what extent, CUD diagnosis and SUD treatment engagement are affected by system-, patient-, and clinician-level barriers and supports, especially within SUD and PTSD specialty care settings. Here, the proposed project is informed by the PARIHS model, as it specifically focuses on the assessment of evidence and context elements (i.e., pre-implementation research to be used in the design of future implementation studies).
Our study aims were achieved by examining data from the 2010 National Patient Care Database as well as interviewing/surveying key clinical personnel at 12 PTSD treatment clinics (5 with low [25th percentile] rates of CUD diagnoses and 7 with high [75th percentile] rates of CUD diagnoses) and 21 SUD treatment programs (10 with low [25th percentile] rates of treatment engagement and 11 with high [75th percentile] rates of treatment engagement, among individuals with co-occurring CUD and PTSD). A total of 107 treatment providers were interviewed for this study. Participants were clinical service care providers who were interviewed/surveyed about their beliefs, knowledge, attitudes toward, and concerns about cannabis use and its disorders, as well as perceived barriers and supports for CUD treatment.
Quantitative data from the study indicated that diagnosis of CUD has increased significantly in the past decade, with PTSD among one of the most common co-occurring psychological disorders among those with CUD. Though CUD diagnoses have increased, the variability of diagnosis rates between VA hospitals remains high, with little to no agreement with the state-level variability observed in U.S. data.
In terms of qualitative data, across both PTSD and SUD treatment settings, clinicians from clinics with low rates of CUD diagnosis, compared to those with high rates, were more likely to: (1) think Veterans use cannabis because it relieves PTSD symptoms; (2) find the treatment of CUD to be a low priority; (3) rate CUD as a moderate concern; (4) discuss CUD more frequently; (5) state that their facilities were adequate to treat CUD; but (6) state that they had lack of education and support overall; and (7) report their facilities only have outpatient treatment.
In terms of PTSD setting-specific findings, clinicians from those PTSD clinics with low rates of CUD diagnosis, compared to those with high rates, were more likely to: (1) report that their patients were "not open" about their cannabis use; (2) report that patients did not report wanting to stop using cannabis; (3) view CUD as an equal priority compared to other SUDs; (4) report a lack of education and support; and (5) report frequent coordination between PTSD and SUD clinics.
However, clinicians from PTSD clinics with high rates of CUD diagnosis, compared to those with low rates, were more likely to: (1) believe cannabis could have positive effects; (2) reported CUD to be a high priority, including the treatment of CUD to be a clinical need; (3) view their clinic as adequate or with adequate expertise to treat CUD; and (4) view cannabis to be as serious as other drugs.
In terms of SUD setting-specific findings, clinicians from clinics with low rates of CUD diagnosis, compared to those with high rates, were more likely to: (1) say their clinic was small in size; (2) have little concern for CUD; (3) use an informal assessment and treatment approach for CUD; (4) feel that they could treat PTSD and SUD concurrently; (5) report that CUD is infrequently treated or referred; (6) report that patients infrequently present to treatment for CUD, specifically; (7) believe that CUD does not frequently co-occur with other SUDs; and (8) state that their patients were not receptive to treatment.
The knowledge gleaned from the proposed study allows for the development of targeted implementation efforts aimed at increasing the utilization of existing SUD assessments and treatments among those with co-occurring CUD and PTSD, consistent with the goals of the SUD-QUERI.
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