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Abstract: Background: The National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) has supported clinical trials of substance use disorder (SUD) interventions for 25 years. This review describes the use of implementation outcomes across CTN trials, characterizes outcomes included, and identifies gaps and potential opportunities to strengthen implementation research within the CTN and the field of SUD treatment. Methods: This systematic review included active or completed studies listed on the CTN Dissemination Library webpage as of August 18, 2021, and approved by the CTN for development by January 1, 2022. Study summaries and protocols were reviewed if they: 1) measured at least one implementation outcome and 2) examined a practice change, intervention, or process. Extracted data elements included trial design characteristics, implementation frameworks, and outcome assessment domains informed by the RE-AIM and Proctor Implementation Outcomes Frameworks. Results: 114 protocols were considered, 42 full-text protocols were screened, and 25 were included for data extraction. Start dates of trials spanned a 20-year period (2004–2024) with latter studies including more implementation outcomes. Fidelity (n = 29) and reach/penetration (n = 26) were the most included implementation outcomes. Equity was not identified in any protocols. Methods of defining, capturing, and evaluating outcomes data varied across trials and outcomes. Conclusions: The inclusion of implementation outcomes increased over time, perhaps reflecting a growing emphasis on implementation research. Incorporating measures of equity could advance knowledge about differential receipt or effectiveness of SUD interventions. Future research should seek to improve the consistency and comprehensiveness in descriptions of implementation science elements. Related protocols: CTN-0016, CTN-0056, CTN-0062-Ot, CTN-0064, CTN-0065, CTN-0069, CTN-0074, CTN-0074-A-1, CTN-0075, CTN-0076-Ot, CTN-0079, CTN-0079-A-1, CTN-0088, CTN-0090, CTN-0091, CTN-0095, CTN-0096, CTN-0097, CTN-0098, CTN-0099, CTN-0102, CTN-0103, CTN-0107, CTN-0116, CTN-0121

Abstract:

The US Preventive Services Task Force (USPSTF) now recommends screening for unhealthy drug use if effective treatment is available (B recommendation), which is an update to its 2008 conclusion of insufficient information. The new recommendation is based on 3 important findings from large bodies of research in adults. First, valid screening tests for drug use are available. Second, treatments for drug use disorders (DUDs) are effective. Third, counseling adult primary care patients whose drug use is identified by screening does not decrease drug use. As a result, in contrast to USPSTF recommendations for unhealthy alcohol use, the USPSTF does not recommend brief preventive counseling in primary care to reduce drug use in patients identified by screening. Instead, the USPSTF recommends screening adults for unhealthy drug use, including nonmedical use of prescription drugs, when accurate diagnosis based on DUD symptoms and treatment of DUDs are available in primary care or by referral. For adolescents, the USPSTF found insufficient evidence to recommend screening for unhealthy drug use (I statement), In this editorial, the authors address several important issues regarding screening adult patients for drug use: (1) the importance of how screening is implemented, (2) the need to screen for cannabis use separately in the majority of states with legal medical or recreational cannabis use, (3) gaps in research on how to manage patients who screen positive for drug use, and (4) innovations that show promise for improving the diagnosis and treatment of DUDs in primary care.

Related protocols: CTN-0065

Abstract:

Cannabis and other drug use is associated with adverse health events, but little is known about the association of routine clinical screening for cannabis or other drug use and acute care utilization. This study evaluated whether self-reported frequency of cannabis or other drug use was associated with subsequent acute care.

This retrospective cohort study used EHR and claims data from 8 sites in Washington State that implemented annual substance use screening. Eligible adult primary care patients (N=47,447) completed screens for cannabis (N=45,647) and/or other drug use, including illegal drug use and prescription medication misuse, (N=45,255) from 3/3/15-10/1/2016. Separate single-item screens assessed frequency of past-year cannabis and other drug use: never, less than monthly, monthly, weekly, daily/almost daily. An indicator of acute care utilization measured any urgent care, emergency department visits, or hospitalizations =19 months after screening. Adjusted Cox proportional hazards models estimated risk of acute care.

Patients were predominantly non-Hispanic white. Those reporting cannabis use less than monthly or daily had greater risk of acute care during follow-up than those reporting no use. Patients reporting other drug use less than monthly, weekly, or daily had greater risk of acute care than those reporting no other drug use.

Conclusions: Population-based screening for cannabis and other drug use in primary care may have utility for understanding risk of subsequent acute care. It is unclear whether findings will generalize to U.S. states with broader racial/ethnic diversity.

Related protocols: CTN-0065

Abstract:

This pilot study (related to CTN-0065) evaluated whether use of evidence-based implementation strategies to integrate care for cannabis and other drug use into primary care (PC) as part of Behavioral Health Integration (BHI) increased diagnosis and treatment of substance use disorders (SUDs).

Patients who visited the three pilot PC sites were eligible. Implementation strategies included practice coaching, electronic health record decision support, and performance feedback (3/2015-4/2016). BHI introduced annual screening for past-year cannabis and other drug use, a Symptom Checklist for DSM-5 SUDs, and shared decision-making about treatment options. Main analyses tested whether the proportions of PC patients diagnosed with, and treated for, new cannabis or other drug use disorders (CUDs and DUDs, respectively), differed significantly pre- and post-implementation.

Of 39,599 eligible patients, 57% and 59% were screened for cannabis and other drug use, respectively. Among PC patients reporting daily cannabis use (2%) or any drug use (1%), 51% and 37%, respectively, completed an SUD Symptom Checklist. The proportion of PC patients with newly diagnosed CUD increased significantly post-implementation (5 v 17 per 10,000 patients, p < 0.0001), but not other DUDs (10 vs 13 per 10,000, p = 0.24). The proportion treated for newly diagnosed CUDs did not increase post-implementation (1 vs 1 per 10,000, p = 0.80), but did for those treated for newly diagnosed other DUDs (1 vs 3 per 10,000, p = 0.038).

Conclusions: This pilot implementation of BHI to increase routine screening and assessment for SUDs was associated with increased new CUD diagnoses and a small increase in treatment of new other DUDs.

Related protocols: CTN-0065

Abstract:

Review of Measurement-based care of using DSM-5 for opioid use disorder: can we make opioid medication treatment more effective by J Mardsen, B Tai, R Ali, L Hu, AJ Rush, N Volkow. Three factors are important to consider when integrating measurement-based care for opioid use disorders into primary care: integration with other behavioral health and substance use disorders care, the availability of a brief, valid measure that is responsive to change, and implementation in a manner that fosters accurate reporting.

Related protocols: CTN-0065

Abstract:

Cannabis is the third most commonly used drug in the USA, after alcohol and tobacco, and the prevalence of cannabis use and cannabis use disorders (CUD) has doubled in the last decade, due in part to increasingly legalized access. Individuals who use cannabis have increased risk of behavioral health conditions, including depression, anxiety, and tobacco, alcohol, and other substance use disorders, but little is known about the association between frequency of cannabis use and behavioral health conditions among primary care patients. This population-based study of primary care patients reports on the prevalence of common behavioral health conditions across cannabis use frequency.

Using electronic health record data collected as part of CTN-0065 in a large health system in Washington State, Kaiser Permanente Washington, cannabis frequency was categories into three levels of past-year use: none, less than daily, and daily. Other behavioral health conditions identified through screening included depression symptoms, unhealthy alcohol use, and any illicit drug and/or medication misuse. Also assessed in the year prior to the screen were EHR-documented tobacco use and composite indicators for both mental health and substance use disorder diagnoses.

Analysis revealed a strong association between the frequency of cannabis use and tobacco use, depression symptoms, and other drug use, as well as diagnosed mental health and substance use disorders. Tobacco and unhealthy alcohol use were most common among young adult patients who reported daily and any past-year cannabis use, respectively. Among patients who used cannabis daily, nearly 50% reported depression symptoms and more than 35% had a past-year mental health disorder diagnosis.

Conclusions: Asking about the frequency of cannabis use as part of routine behavioral health screening primary care, in a state with legalized use, identifies patients at increased risk for substance use and mental health conditions.

Related protocols: CTN-0065

Abstract:

This is the Results Article for CTN-0065.

Over 12% of U.S. adults report past-year cannabis use, and among those who use daily, 25% or more have a cannabis use disorder. Use is increasing as legal access expands, yet cannabis use is not routinely assessed in primary care, and little is known about use among primary care patients and relevant demographic and behavioral health subgroups. This study, from NIDA Clinical Trials Network protocol CTN-0065 (Evaluation of Drug Screening Implementation in Primary Care), describes the prevalence and frequency of past-year cannabis use among primary care patients assessed for use during a primary care visit.

This observational cohort study included adults who made a visit to primary care clinics with annual behavioral health screening, including a single-item question about frequency past-year cannabis use (March 2015-February 2016; n=29,857). Depression, alcohol, and other drug use were also assessed by behavioral health screening. Screening results, tobacco use, and diagnoses for past-year behavioral health conditions (e.g. mental health and substance use disorders) were obtained from EHRs.

Among patients who completed the cannabis use question (n=22,095; 74% of eligible patients), 15.3% (14.8-15.8%) reported any past-year use: 12.2% (11.8-12.6%) less than daily, and 3.1% (2.9-3.3%) daily. Among 2228 patients age 18-29 years, 36% (34-38%) reported any cannabis use and 8.1% (7-9.3%) daily use. Daily cannabis use was common among men age 18-29 years who used tobacco or screened positive for depression: 25.5% (18.8-32.1%) and 31.7% (23.3-50%) respectively.

Conclusions: This study of the prevalence and frequency of cannabis use among primary care patients, in a state with legalized use, found that most primary care patients who completed recommended routine behavioral health screening (e.g., depression and alcohol) also completed a question about past-year cannabis use. In addition, while 15% of all primary care patients reported any past-year cannabis use, the prevalence was much higher in important patient subgroups. Most notably, more than 1 in 4 younger men who used tobacco or screened positive for depression reported high-risk daily cannabis use. Routinely asking about cannabis use could promote recognition of patients who may benefit from primary care discussions about their cannabis use.