Screening for Substance Use in Rural Primary Care: a Qualitative Study of Providers and Patients

Abstract

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.

“It’s way more than just writing a prescription”: A qualitative study of preferences for integrated versus non-integrated treatment models among individuals with opioid use disorder

“…All interviews were conducted by the first author (ECS), a female health policy and clinical practice doctoral candidate. This interviewer had received doctoral-level training on qualitative interviewing and also had experience conducting interviews about opioid and other substance use in several previous studies [59][60][61]. The interviewer had no relationships with any participants prior to their involvement in the study.…”

“…Participants also expressed doubts about the ability of general medical providers to effectively treat their OUD, noting concerns about training. These concerns are often mirrored by general medical providers, who have widely reported feeling unprepared to treat substance use disorders [60,[91][92][93][94][95]. An opportunity to increase training and education exists, as general medical providers in one survey study strongly believed treatment for OUD could be effective and supported improving education and training [96].…”

Primary healthcare approach to substance abuse management

“…Thus, alcohol and tobacco have been defined as the gateway to substance abuse. 15 The relevant aetiological factors are mainly defined under the following three categories:…”

“…18 Urine testing for substances should not be performed routinely but can be used to support a suspected diagnosis, assess for polysubstance use and monitor treatment response. 15 Some of the commonly used selfreporting screening tools for substance abuse are the following:…”

PCP Opinions of Universal Suicide Risk Screening in Rural Primary Care: Current Challenges and Strategies for Successful Implementation

“…Although PCPs noted the value and potential feasibility of universal screening, they also noted multiple barriers to screening, which supports previous research. [46][47][48][49]51,[64][65][66][67][68][69] Of the barriers noted by PCPs, a lack of mental health and crisis support services and concerns about follow-up with suicidal patients were 2 of the most frequently reported. Key challenges related to rural location included lack of access to psychiatric beds, long waitlists for local outpatient behavioral health, transportation issues, and geographic isolation.…”