Improving alcohol and substance use care access, outcomes, and equity during the reproductive years: A Type 1 Hybrid Trial in Family Planning Clinics

Rates of risky alcohol and drug use and alcohol and substance use disorders (AUDs/SUDs) are highest among women during their reproductive years compared to other periods of the life course. AUDs and SUDs are associated with significant and lifelong behavioral, mental, physical, and sexual and reproductive health (SRH) consequences for women and disproportionately for racially and ethnically minoritized women and those living in poverty. There is an urgent need for innovative methods to address alcohol and substance use in preventive healthcare settings. Family planning (FP) clinics are a trusted care source and primary point of access for women and serve as a safety net for structurally marginalized groups in the U.S. FP clinics are uniquely well- suited, but entirely understudied, contexts for implementing and scaling integrated alcohol/drug use services. While screening, brief intervention, and referral to treatment (SBIRT) is a widely accepted, evidence-based intervention for alcohol use in primary care and mental health settings, little is known about the facilitators and barriers to the uptake and sustainment of SBIRT in FP clinics. Even less is understood about telemedicine, which has been rapidly rolled out for COVID-19, as a SBIRT delivery platform. Further, virtually no evidence exists on effective organizational level implementation strategies to accelerate SBIRT’s adoption in FP. We propose an explanatory, sequential, mixed methods study to evaluate SBIRT in an expansive FP clinic network of a national SRH organization – a novel and highly impactful setting with a reach of a diverse and largely socially disadvantaged population of reproductive-aged women at greatest risk for AUDs/SUDs. Our integrated study draws upon the evidence-based implementation approach, Implementation and Sustainment Facilitation (ISF), guided by the Consolidated Framework for Implementation Research and Reach, Effectiveness, Adoption, Implementation and Maintenance models. In Aim 1, to identify specific targets for implementation, sustainment, and scale-up of SBIRT, we will conduct administrative surveys with clinic stakeholders (clinic directors, providers, and staff n=153) and key informant interviews with stakeholders and patients (n=40) to investigate organizational practices and perspectives on alcohol- and substance-related services. In Aim 2, we will conduct a dual randomized Type 1 Hybrid Effectiveness-Implementation trial testing SBIRT (in-person and telemedicine) vs. usual care, within a large, high-volume Northeastern affiliate of the national organization. We will randomize 600 patients across 4 clinics, collecting patient level data on alcohol and substance use primary effectiveness outcomes, as well as secondary SRH, mental/physical health, quality of life, and wellbeing outcomes at baseline, 30 days, and 3 months. Aim 3 will explore facilitators and barriers to SBIRT adoption and the ISF implementation strategy via surveys and interviews with clinic directors, providers, and staff (n=20) and patients (n=20) electronic medical records. Results will provide new, timely evidence to inform scale-up of alcohol and substance related services in FP settings nationally.