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BACKGROUND: Substance use frequently goes undetected in primary care. Though barriers to implementing systematic screening for alcohol and drug use have been examined in urban settings, less is known about screening in rural primary care. OBJECTIVE: To identify current screening practices, barriers, facilitators, and recommendations for the implementation of substance use screening in rural federally qualified health centers (FQHCs). DESIGN: As part of a multi-phase study implementing electronic health record-integrated screening, focus groups (n = 60: all stakeholder groups) and individual interviews (n = 10 primary care providers (PCPs)) were conducted. PARTICIPANTS: Three stakeholder groups (PCPs, medical assistants (MAs), and patients) at three rural FQHCs in Maine. APPROACH: Focus groups and interviews were recorded, transcribed, and content analyzed. Themes surrounding current substance use screening practices, barriers to screening, and recommendations for implementation were identified and organized by the Knowledge to Action (KTA) Framework. KEY RESULTS: Identifying the problem: Stakeholders unanimously agreed that screening is important, and that universal screening is preferred to targeted approaches. Adapting to the local context: PCPs and MAs agreed that screening should be done annually. Views were mixed regarding the delivery of screening; patients preferred self-administered, tablet-based screening, while MAs and PCPs were divided between self-administered and face-to-face approaches. Assessing barriers: For patients, barriers to screening centered around a perceived lack of rapport with providers, which contributed to concerns about trust, judgment, and privacy. For PCPs and MAs, barriers included lack of comfort, training, and preparedness to address screening results and offer treatment. CONCLUSIONS: Though stakeholders agree on the importance of implementing universal screening, concerns about the patient-provider relationship, the consequences of disclosure, and privacy appear heightened by the rural context. Findings highlight that strong relationships with providers are critical for patients, while in-clinic resources and training are needed to increase provider comfort and preparedness to address substance use.

Background and Aims Posttraumatic stress disorder (PTSD) is common among people with substance use disorders, and the comorbidity is associated with negative outcomes. We report on a randomized controlled trial comparing the effect of Integrated Cognitive Behavioral Therapy (ICBT) plus standard care, individual addiction counseling plus standard care, and standard care alone on substance use and PTSD symptoms. Design Three-group, multi-site randomized controlled trial. Setting Seven addiction treatment programs in Vermont and New Hampshire, USA. Participants/Cases Recruitment took place between December 2010 and January 2013. In this single-blind study, 221 participants were randomized to one of three conditions: ICBT plus standard care (SC) (n=73); Individual Addiction Counseling (IAC) plus SC (n=75), or SC only (n=73). One hundred seventy-two patients were assessed at 6-month follow-up (58 ICBT; 61 IAC; 53 SC). Intervention and comparators: ICBT is a manual-guided therapy focused on PTSD and substance use symptom reduction with three main components: patient education, mindful relaxation and flexible thinking. IAC is a manual-guided therapy focused exclusively on substance use and recovery with modules organized in a stage-based approach: treatment initiation, early abstinence, maintaining abstinence, and recovery. SC is intensive outpatient program services that include 9–12 hours of face-to-face contact per week over 2–4 days of group and individual therapies plus medication management. Measurements Primary outcomes: PTSD severity and substance use severity at 6-months. Secondary outcomes: Therapy retention. Findings PTSD symptoms reduced in all conditions with no difference between them. In analyses of covariance, ICBT produced more favorable outcomes on toxicology than IAC or SC (comparison with IAC: Parameter estimate: 1.10; CI: 0.17 – 2.04; comparison with SC: Parameter estimate: 1.13; CI: 0.18 – 2.08) and had greater reduction in reported drug use than SC (Parameter estimate: −9.92; CI: −18.14 – −1.70). ICBT patients had better therapy continuation versus IAC (p<.001). There were no unexpected or study related adverse events. Conclusions Integrated cognitive behavioral therapy may improve drug-related outcomes in posttraumatic stress disorder (PTSD) sufferers with substance use disorder more than drug focused counseling but probably not by reducing PTSD symptoms to a greater extent.

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