Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation.
Method
Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes.
Results
There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients.
Conclusions
Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.
CherpitelCJ, YeY.Drug use and problem drinking associated with primary care and emergency room utilization in the US general population: data from the 2005 national alcohol survey. Drug Alcohol Depend. 2008;97(3):226–230.
2.
PilowskyDJ, WuLT.Screening for alcohol and drug use disorders among adults in primary care: A review. Subst Abuse Rehabil. 2012;3(1):25–34.
3.
WuL-T, McNeelyJ, SubramaniamGA, . DSM-5 substance use disorders among adult primary care patients: results from a multisite study. Drug Alcohol Depend. 2017;179:42–46.
4.
PaceCA, UebelackerLA.Addressing unhealthy substance use in primary care. Med Clin North Am. 2018;102(4):567–586.
EdlundMJ, UnutzerJ, WellsKB.Clinician screening and treatment of alcohol, drug, and mental problems in primary care: Results from healthcare for communities. Med Care. 2004;42(12):1158–1166.
8.
D'AmicoEJ, PaddockSM, BurnamA, KungFY.Identification of and guidance for problem drinking by general medical providers: results from a national survey. Med Care. 2005;43(3):229–236.
9.
VennerKL, SánchezV, GarciaJ, . Moving away from the tip of the pyramid: Screening and brief intervention for risky alcohol and opioid use in underserved patients. J Am Board Fam Med. 2018; 31(2) :243–251.
10.
DennyCH, HungerfordDW, McKnight-EilyLR, . Self-reported prevalence of alcohol screening among U.S. adults. Am J Prev Med. 2016;50(3):380–383.
11.
TalenMR, BaumerJG, and MannMM.Screening measures in integrated behavioral health and primary care settings. In TalenMR, ValerasB, eds. Integrated Behavioral Health in Primary Care: Evaluating the Evidence, Identifying the Essentials. New York, NY: Springer Science and Business Media, 2013.
12.
KristensonH, OhlinH, Hultén-NosslinMB, . Identification and intervention of heavy drinking in middle-aged men: results and follow-up of 24–60 months of long-term study with randomized controls. Alcohol Clin Exp Res. 1983;7(2):203–209.
13.
WHO Assist Working Group. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST): development, reliability and feasibility. Addiction. 2002;97(9):1183–1194.
14.
HargravesD, WhiteC, FrederickR, . Implementing SBIRT (Screening, Brief Intervention and Referral to Treatment) in primary care: lessons learned from a multi-practice evaluation portfolio. Public Health Rev. 2017;38:31.
15.
FriedmannPD, McCulloughD, SaitzR.Screening and intervention for illicit drug abuse: a national survey of primary care physicians and psychiatrists. Arch Intern Med. 2001;161(2):248–251.
16.
SterlingS, Kline-SimonAH, WibbelsmanC, WongA, WeisnerC.Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy. Addict Sci Clin Prac. 2012;7:13.
17.
JohnsonM, JacksonR, GuillaumeL, . Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence. J Public Health. 2011;33(3):412–421.
18.
YoastRA, WilfordBB, HayashiSW.Encouraging physicians to screen for and intervene in substance use disorders: obstacles and strategies for change. J Addict Dis. 2008;27(3):77–97.
19.
McCormickKA, CochranNE, BackAL, . How primary care providers talk to patients about alcohol: a qualitative study. J Gen Intern Med. 2006;21(9):966–972.
20.
DucharmeLJ, ChandlerRK, HarrisAH.Implementing effective substance abuse treatments in general medical settings: mapping the research terrain. J Subst Abuse Treat. 2016;60:110–118.
21.
ChanY-F, LuS-E, HoweB, . Screening and follow-up monitoring for substance use in primary care: an exploration of rural-urban variations. J Gen Intern Med. 2016;31(2):215–222.
22.
PalombiLC, St HillCA, LipskyMS, . A scoping review of opioid misuse in the rural United States. Ann Epidemiol. 2018; 28(9) :641–652.
23.
PrunuskeJP, St HillCA, HagerKD, . Opioid prescribing patterns for non-malignant chronic pain for rural versus non-rural US adults: a population-based study using 2010 NAMCS data. BMC Health Serv Res. 2014;14:563.
24.
HingE, HsiaoCJ.State variability in supply of office-based primary care providers: United States. NCHS Data Brief. 2012;2014(151):1–8.
25.
BordersTF, BoothBM.Research on rural residence and access to drug abuse services: where are we and where do we go?J Rural Health. 2007;23(Suppl):79–83.
26.
LenardsonJ, GaleJA.Distribution of substance abuse treatment facilities across the rural-urban continuum. In: Research and Policy Brief. Portland, ME: Maine Rural Health Research Center, Muskie School of Public Health, University of Southern Maine, 2008.
27.
PullenE, OserC.Barriers to substance abuse treatment in rural and urban communities: counselor perspectives. Subst Use Misuse. 2014;49(7):891–901.
28.
BoothBM, KirchnerJ, FortneyJ, . Rural at-risk drinkers: correlates and one-year use of alcoholism treatment services. J Stud Alcohol. 2000;61(2):267–277.
29.
IyiewuarePO, McCulloughC, OberA, . Demographic and mental health characteristics of individuals who present to community health clinics with substance misuse. Health Serv Res Manag Epidemiol. 2017;4:233339281773452.
30.
McNeelyJ, KumarPC, RieckmannT, . Barriers and facilitators affecting the implementation of substance use screening in primary care clinics: a qualitative study of patients, providers, and staff. Addict Sci Clin Pract. 2018;13(1):8.
31.
AdamA, . Electronic self-administered screening for substance use in adult primary care patients: Feasibility and acceptability of the tobacco, alcohol, prescription medication, and other substance use (myTAPS) screening tool. Addict Sci Clin Pract. 2019;14(1):39.
32.
GryczynskiJ, McNeelyJ, WuL-T, . Validation of the TAPS-1: A four-item screening tool to identify unhealthy substance use in primary care. J Gen Intern Med. 2017;32(9):990–996.
33.
McNeelyJ, WuL-T, SubramaniamG, . Performance of the tobacco, alcohol, prescription medication, and other substance use (TAPS) tool for substance use screening in primary care patients. Ann Intern Med. 2016;165(10):690–699.
34.
SchwartzRP, McNeelyJ, WuLT, . Identifying substance misuse in primary care: TAPS Tool compared to the WHO ASSIST. J Subst Abuse Treat. 2017;76:69–76.
35.
SaundersEC, MooreSK, GardnerT, . Screening for substance use in rural primary care: a qualitative study of providers and patients. J Gen Intern Med. 2019;34(12):2824–2832.
36.
WuL-T, McNeelyJ, SubramaniamGA, . Design of the NIDA clinical trials network validation study of tobacco, alcohol, prescription medications, and substance use/misuse (TAPS) tool. Contemp Clin Trials. 2016;50:90–97.
37.
GrahamID, LoganJ, HarrisonMB, . Lost in knowledge translation: time for a map?J Contin Educ Health Prof. 2006;26(1):13–24.
38.
DamschroderLJ.Clarity out of chaos: use of theory in implementation research. Psychiatry Res. 2020;283:112461.
39.
ProctorE, SilmereH, RaghavanR, . Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011;38(2):65–76.
40.
BurnsC.Data: More Opioids Were Handed out per Person in Penobscot County than Anywhere Else in New England. Bangor, ME: Bangor Daily News.
41.
TaylorB, HenshallC, KenyonS, . Can rapid approaches to qualitative analysis deliver timely, valid findings to clinical leaders? A mixed methods study comparing rapid and thematic analysis. BMJ Open. 2018;8(10):e019993.
KeithRE, CrossonJC, O'MalleyAS, . Using the consolidated framework for implementation research (CFIR) to produce actionable findings: a rapid-cycle evaluation approach to improving implementation. Implement Sci. 2017;12(1):15.
44.
Lambert-KerznerAC, AasenDM, OverbeyDM, . Use of the consolidated framework for implementation research to guide dissemination and implementation of new technologies in surgery. J Thorac Dis. 2019;11(Suppl 4):S487–s499.
45.
MattsonM, LipariRN, HaysC, Van HornSL.A day in the life of older adults: Substance use facts. In The CBHSQ Report. Rockville, MD: Substance Abuse and Mental Health Services Administration (SAMHSA), 2017.
46.
SaposnikG, . Cognitive biases associated with medical decisions: a systematic review. BMC Med Infomat Decision Mak. 2016;16(1):138.
47.
MamedeS, van GogT, van den BergeK, . Effect of availability bias and reflective reasoning on diagnostic accuracy among internal medicine residents. JAMA. 2010;304(11):1198–1203.
48.
KeurhorstM, HeinenM, ColomJ, . Strategies in primary healthcare to implement early identification of risky alcohol consumption: Why do they work or not? A qualitative evaluation of the ODHIN study. BMC Fam Pract. 2016;17:70.
49.
MittmanBS.Implementation science in health care. In BrownsonRC, ColditzGA, ProctorEK, eds. Dissemination and Implementation Research in Health: Translating Science to Practice. New York, NY: Oxford University Press, 2012: 70.
50.
ArditiC, Rège-WaltherM, DurieuxP, . Computer-generated reminders delivered on paper to healthcare professionals: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2017;7:CD001175.
51.
ButlerSF, VillapianoA, MalinowA.The effect of computer-mediated administration on self-disclosure of problems on the addiction severity index. J Addict Med. 2009;3(4):194–203.
52.
HarrisSK, KnightJRJr, Van HookS, . Adolescent substance use screening in primary care: validity of computer self-administered versus clinician-administered screening. Substance Abuse. 2016;37(1):197–203.
53.
HankinA, HaleyL, BaugherA, . Kiosk versus in-person screening for alcohol and drug use in the emergency department: patient preferences and disclosure. WestJEM. 2015;16(2):220–228.
54.
MohrDC, BurnsMN, SchuellerSM, . Behavioral intervention technologies: evidence review and recommendations for future research in mental health. Gen Hosp Psychiatry. 2013;35(4):332–338.
55.
AndersonP, LaurantM, KanerE, . Engaging general practitioners in the management of hazardous and harmful alcohol consumption: results of a meta-analysis. J Stud Alcohol. 2004;65(2):191–199.
56.
HymanZ.Brief interventions for high-risk drinkers. J Clin Nurs. 2006;15(11):1383–1396.
57.
GiannettiVJ, SieppertJD, HoloskoMJ.Attitudes and knowledge concerning alcohol abuse: curriculum implications. J Health Soc Policy. 2002;15(1):45–58.
58.
McGillionJ, WanigaratneS, FeinmannC, . GPs’ attitudes towards the treatment of drug misusers. Br J Gen Pract. 2000;50(454):385–386.
59.
GhitzaUE, TaiB.Challenges and opportunities for integrating preventive substance-use-care services in primary care through the Affordable Care Act. J Health Care Poor Underserved. 2014;25(1 Suppl):36–45.
60.
UradaD, . Integration of substance use disorder services with primary care: Health center surveys and qualitative interviews. Subst Abuse Treat Prevent Pol. 2014;9:15.
61.
van BoekelLC, BrouwersEPM, van WeeghelJ, . Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend. 2013;131(1–2):23–35.
62.
LashSJ, TimkoC, CurranGM, . Implementation of evidence-based substance use disorder continuing care interventions. Psychol Addict Behav. 2011;25(2):238–251.
63.
SpandorferJM, IsraelY, TurnerBJ.Primary care physicians’ views on screening and management of alcohol abuse: inconsistencies with national guidelines. J Fam Pract. 1999;48(11):899–902.
64.
PfarrwallerE, MeynardA, ReyreA, . Excessive substance use screening to encourage behaviour change among young people in primary care: pilot study in preparation for a randomized trial. Addict Behav. 2019;98:106049.
PatnodeCD, PerdueLA, RushkinM, . Screening for unhealthy drug use: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2020;323(22):2310–2328.
67.
GlassJE, HamiltonAM, PowellBJ, . Revisiting our review of screening, brief intervention and referral to treatment (SBIRT): meta-analytical results still point to no efficacy in increasing the use of substance use disorder services. Addiction. 2016;111(1):181–183.
68.
KorthuisPT, McCartyD, WeimerM, . Primary care-based models for the treatment of opioid use disorder: a scoping review. Ann Intern Med. 2017;166(4):268–278.
69.
StewartMT, HorganCM, QuinnAE, . The role of health plans in supporting behavioral health integration. Adm Policy Ment Health. 2017;44(6):967–977.
70.
EiblJK, GauthierG, PellegriniD, . The effectiveness of telemedicine-delivered opioid agonist therapy in a supervised clinical setting. Drug Alcohol Depend. 2017;176:133–138.
71.
LinLA, CasteelD, ShigekawaE, . Telemedicine-delivered treatment interventions for substance use disorders: a systematic review. J Subst Abuse Treat. 2019;101:38–49.
72.
CreedonTB, SchraderKE, O'BrienPL, . Rural-nonrural differences in telemedicine use for mental and substance use disorders among Medicaid beneficiaries. PS. 2020;71(8):756–764.
73.
LewisCC, FischerS, WeinerBJ, . Outcomes for implementation science: an enhanced systematic review of instruments using evidence-based rating criteria. Implement Sci. 2015;10:155.
74.
RabinBA, PurcellP, NaveedS, . Advancing the application, quality and harmonization of implementation science measures. Implement Sci. 2012;7:119.
75.
NilsenP, BernhardssonS.Context matters in implementation science: a scoping review of determinant frameworks that describe contextual determinants for implementation outcomes. BMC Health Serv Res. 2019;19(1):189.
76.
ClarkeA.Focus group interviews in health-care research. Profess Nurse. 1999;14(6):395–397.
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
