Barriers and facilitators affecting the implementation of substance use screening in primary care clinics: a qualitative study of patients, providers, and staff

Abstract

Background Alcohol and drug use are leading causes of morbidity and mortality that frequently go unidentified in medical settings. As part of a multi-phase study to implement electronic health record-integrated substance use screening in primary care clinics, we interviewed key clinical stakeholders to identify current substance use screening practices, barriers to screening, and recommendations for its implementation.MethodsFocus groups and individual interviews were conducted with 67 stakeholders, including patients, primary care providers (faculty and resident physicians), nurses, and medical assistants, in two urban academic health systems. Themes were identified using an inductive approach, revised through an iterative process, and mapped to the Knowledge to Action (KTA) framework, which guides the implementation of new clinical practices (Graham et al. in J Contin Educ Health Prof 26(1):13–24, 2006).ResultsFactors affecting implementation based on KTA elements were identified from participant narratives. Identifying the problem: Participants consistently agreed that having knowledge of a patient’s substance use is important because of its impacts on health and medical care, that substance use is not properly identified in medical settings currently, and that universal screening is the best approach. Assessing barriers: Patients expressed concerns about consequences of disclosing substance use, confidentiality, and the individual’s own reluctance to acknowledge a substance use problem. Barriers identified by providers included individual-level factors such as lack of clinical knowledge and training, as well as systems-level factors including time pressure, resources, lack of space, and difficulty accessing addiction treatment. Adapting to the local context: Most patients and providers stated that the primary care provider should play a key role in substance use screening and interventions. Opinions diverged regarding the optimal approach to delivering screening, although most preferred a patient self-administered approach. Many providers reported that taking effective action once unhealthy substance use is identified is crucial. ConclusionsParticipants expressed support for substance use screening as a valuable part of medical care, and identified individual-level as well as systems-level barriers to its implementation. These findings suggest that screening programs should clearly communicate the goals of screening to patients and proactively counteract stigma, address staff concerns regarding time and workflow, and provide education as well as treatment resources to primary care providers.Electronic supplementary materialThe online version of this article (10.1186/s13722-018-0110-8) contains supplementary material, which is available to authorized users.

Qualitative Assessment of Patients’ Perspectives and Needs from Community Pharmacists in Substance Use Disorder Management

“…Participants reported pharmacists' lack of time as the main reason for not recognizing or accessing pharmacists' extended services. Lack of time was also reported in many other studies (45), among other responses like an educational and policy gap.…”

“…They also expressed their willingness to discuss their SUD when appropriately engaged. The willingness of the study participants to discuss their SUD with community pharmacists may be regarded as contradicting other ndings indicating that patients living with SUD are hesitant to disclose their substance use to health care providers (45). However, participants speci ed that proper communication and gaining trust over a prolonged duration was key to engaging in open discussions regarding SUD.…”

A systematic review of approaches to improve practice, detection and treatment of unhealthy alcohol use in primary health care: a role for continuous quality improvement

“…Programs combining strategies that targeted the clinician, organization and patient were more effective in decreasing alcohol consumption than clinician-only strategies [8]. However, sustained and systematic implementation of evidence-based care for alcohol use in PHC continues to be a problem [6,[9][10][11][12]. Furthermore, there is little evidence of significant effects of implementation strategies on patients' alcohol consumption [8].…”

“…Furthermore, there is little evidence of significant effects of implementation strategies on patients' alcohol consumption [8]. Barriers, such as time pressures, staff retention, lack of training and leadership, as well as the clinicians' perception of alcohol discussions as sensitive, have been identified [6,11,13]. To improve detection and treatment of unhealthy alcohol use, more work is needed to develop and test approaches that are sensitive to facilitators and barriers in an individual PHC setting.…”

Impact of Geographic Access to Primary Care provider on Pediatric Behavioral Health Screening

“…(5)(6)(7)(8)At patient level, lack of awareness, race/ethnicity, socioeconomic status and insurance status have been identi ed as the strong predictors of receiving general health screening services. (9,10) The association of geographic access to primary care providers (PCPs) with pediatric behavior disorder screening is yet to be examined.…”