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RRP 13-445 – HSR&D Study

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RRP 13-445
Substance Use Disorder Treatment in Integrated Primary Care-Mental Health
Lisa Zubkoff PhD MS BA
White River Junction VA Medical Center, White River Junction, VT
White River Junction, VT
Funding Period: March 2014 - February 2015

BACKGROUND/RATIONALE:
Substance use disorders are a common problem in Veterans and include alcohol and opioid use disorders. Approximately 13% of VA users misuse alcohol. The 5-year prevalence of opioid abuse is 1% among all VA users and 3% among those who are prescribed an opioid. Treatment for substance use disorders can be delivered in a variety of settings, ranging from primary care to specialized substance use disorders clinics.

There are evidence-based interventions for substance use disorders, including screening and brief counseling, medications, and complex psychosocial treatment programs. These interventions can occur in a variety of settings, however, little is known about the use of these treatments in the primary care-mental health integrated setting.

Primary care-mental health integrated clinics are an existing VA service developed to improve primary care patients' access to mental health treatment. Three integrated care service models are endorsed by the VA: 1) Colocated Collaborative Care; 2) Translating Initiatives for Depression into Effective Solutions (TIDES); and 3) Behavioral Health Laboratory (BHL). These models have been developed, researched, and implemented to varying degrees in the VA. Practices for providing treatment for mental health disorders in these models have been well characterized, but there is little known about their treatment of Veterans with substance use disorders.

OBJECTIVE(S):
This project aimed to learn about substance use disorder services currently provided in primary care-mental health integrated clinics including the effect of integrated care service models on treatment offerings. Specifically, this project sought to a) understand the provision of substance use disorder services in primary care mental health integrated clinics; and b) identify barriers and facilitators to providing evidence-based substance use disorders treatment in primary care-mental health integrated clinics.

METHODS:
The project team conducted site visits to six VA medical centers with primary care-mental health integrated (PC-MHI) clinics to understand the operation of integrated care services at each site and to learn how Veterans with substance use disorders receive treatment in these settings, including the types of services offered and how service provision is tracked.

We conducted semi-structured interviews and focus groups with leadership and front-line clinicians to inquire about the operation of the integrated care model, how Veterans with substance use disorders receive services, the types of services offered, how services are tracked, and to identify barriers and facilitators of SUD treatment in the PC-MHI setting. This work was guided by the Consolidated Framework for Implementation Research (CFIR). Interviews were audio recorded and transcribed. Qualitative analysis included coding of a priori and emergent themes.

FINDINGS/RESULTS:
First, there is limited implementation of the pure integrated care models, suggesting there may be limited use for model-specific implementation programs for SUD treatments. Second, the resources and staffing vary considerably between models, suggesting that available resources may necessitate flexible implementation programs that leverage locally available resources. Third, there is considerable variation in the goals and structures of the clinics. Fourth, clinics have very little focus on SUD issues, with most sites concentrating on evaluation and treatment for depression, anxiety, and PTSD. Fifth, PC-MHI staff believe there are few evidence-based treatments for SUDs that are appropriate for the PC-MHI. Overall, this work found that despite efforts to offer SUD treatment in the integrated care setting, staff members do not view providing SUD treatment as their duty.

IMPACT:
This work provides insight into SUD treatment options in the PC-MHI setting, with the goal to improve the quality of substance use disorder services in the VA. The policy implications from this work highlight the need for more training and guidance on substance use disorder services in the PC-MHI setting.

PUBLICATIONS:
None at this time.


DRA: Mental, Cognitive and Behavioral Disorders, Substance Abuse and Addiction
DRE: Treatment - Comparative Effectiveness
Keywords: none
MeSH Terms: none

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