Barriers to Screening for Substance Use in Rural Primary Care

Though addressing substance use is one of the top 10 priorities of Rural Healthy People 2020, a national initiative to identify and promote rural health priorities and effective programs, accessing treatment is particularly challenging in rural regions.

Many patients in rural settings rely on primary care providers (PCPs) for substance use disorder (SUD) treatment and prevention, yet rural primary care clinics are less likely than their urban counterparts to routinely screen patients for substance use.

Rural areas also tend to have fewer providers and health services available compared to urban settings, making it even more challenging for rural patients to access care. Plus, providers in rural settings report they are often short on time and training, and sometimes feel uncomfortable having the necessary conversations with their patients about substance use.

A previous NIDA Clinical Trials Network study (CTN-0062-Ot) looked at whether it was feasible for urban primary care settings to screen patients for substance use using electronic health records to collect the information. This partner study, CTN-0062-Ot-A1, was designed to see whether screening could be implemented in rural practice settings as well.

The first step of the project, reported on in this paper, was to identify current screening practices, barriers, facilitators, and recommendations for the implementation of substance use screening in rural federally qualified health centers (FQHCs).

Focus groups were held with 3 populations at 3 rural FQHCs: primary care providers (PCPs), medical assistants (MAs), and patients. Additionally, individual interviews with 10 PCPs were conducted.

Three primary themes emerged from the focus groups and interviews:

• Identifying the problem: Stakeholders 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, but preferred methods for delivering the screening differed between groups. Patients preferred doing them themselves using tablets, while MAs and PCPs were divided between self-administered and face-to-face approaches.
• Assessing barriers: For patients, barriers to screening centered around a lack of rapport with their providers, contributing to concerns about trust, judgment, and privacy. For PCPs and MAs, barriers included a lack of comfort, training, and preparedness for addressing screening results and offering treatment.

Conclusions: This study offers insights into the acceptability and implementation of substance use screening in a rural FQHC. With rural regions heavily hit by the opioid crisis, identifying and treating substance use issues in rural FQHC patients in a timely manner is critical. The fact that all the stakeholders in this study agreed that screening is important and should be conducted regularly is encouraging. However, reported barriers, particularly those related to trust between patients and providers, warrant further attention. Strengthening patient-provider relationships, increasing provider treatment and in-clinic resources, and educating all stakeholders about privacy concerns may be necessary first steps.

Citation: Saunders EC, et al. Screening for Substance Use in Rural Primary Care: A Qualitative Study of Providers and Patients. Journal of General Internal Medicine 2019 (in press).

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