Evidence is necessary to improve our nursing practice. Using the CINAHL database in the Chamberlain Library, search for and locate a scholarly professional nursing journal article that meets these cri

Conceptualizing patient-centered care for

substance use disorder treatment: findings

from a systematic scoping review

Kirsten Marchand 1,2* , Scott Beaumont 1,2, Jordan Westfall 3, Scott MacDonald 4, Scott Harrison 4, David C. Marsh 5,

Martin T. Schechter 1,2 and Eugenia Oviedo-Joekes 1,2

Abstract

Background: Despite ongoing efforts aimed to improve treatment engagement for people with substance-related

disorders, evidence shows modest rates of utilization as well as client-perceived barriers to care. Patient-centered

care (PCC) is one widely recognized approach that has been recommended as an evidence-based practice to

improve the quality of substance use disorder treatment. PCC includes four core principles: a holistic and

individualized focus to care, shared decision-making and enhanced therapeutic alliance.

Aims: This scoping review aimed to explore which PCC principles have been described and how they have defined

and measured among people with substance-related disorders.

Methods: Following the iterative stages of the Arksey and O ’Malley scoping review methodology, empirical (from

Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references were eligible if they

focused on people accessing treatment for substance-related disorders and described PCC. Two reviewers

independently screened the title/abstract and full-texts of references. Descriptive analyses and a directed content

analysis were performed on extracted data.

Findings: One-hundred and forty-nine references met inclusion from the 2951 de-duplicated references screened.

Therapeutic alliance was the most frequent principle of PCC described by references (72%); this was consistently

defined by characteristics of empathy and non-judgment. Shared decision-making was identified in 36% of

references and was primarily defined by client and provider strategies of negotiation in the treatment planning

process. Individualized care was described by 30% of references and included individualized assessment and

treatment delivery efforts. Holistic care was identified in 23% of references; it included an integrated delivery of

substance use, health and psychosocial services via comprehensive care settings or coordination. Substance use

and treatment engagement outcomes were most frequently described, regardless of PCC principle.

Conclusions: This review represents a necessary first step to explore how PCC has been defined and measured for

people accessing substance use disorder treatment. The directed content analysis revealed population and

context-specific evidence regarding the defining charac teristics of PCC-principles that can be used to further

support the implementation of PCC.

Keywords: Patient-centered care, Client-centered care, Subst ance-related disorders, Scoping review, Directed

content analysis

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/ ), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated.

* Correspondence: [email protected] 1School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada2Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul ’s Hospital, 575- 1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada Full list of author information is available at the end of the article

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 https://doi.org/10.1186/s13011-019-0227-0 Background

Substance-related disorders are increasingly considered

multifactorial health conditions that require evidence-

based and public health responses [ 1]. Substantial efforts

have been made to expand the availability of pharmaco-

logical, psychosocial and community-based treatments

[ 2,3]. In addition, practice-based frameworks, such as

trauma-informed and culturally competent, responsive

and appropriate care, have also been developed [ 4–6]. In

spite of these efforts, global estimates suggest that one

out of every six people [ 7] or less [ 2,8] in need of sub-

stance use disorder treatment receives it. This treatment

gap poses a significant public health concern given that

treatment engagement (i.e., retention, adherence) is posi-

tively associated with improvements in substance use,

health and social functioning [ 2,9,10].

To understand this gap, a growing body of research

has focused on treatment process barriers and facilita-

tors from the perspectives of people using substances.

Select recent evidence from across populations and set-

tings reveals similarities in peoples ’experiences. For ex-

ample, structural barriers include the costs and

convenience of treatment [ 11,12], societal stigma [ 11–

13 ] and the attitudes and behaviours of health care pro-

viders [ 12,14]. Research has also shown that people ’s

preferred treatment goals and outcomes are often incon-

gruent with those of the health care system [ 15–17].

Additionally, evidence suggests that people want more

opportunities to be involved in the substance use dis-

order treatment planning process [ 18,19].

This body of research reveals opportunities to improve

the quality of substance use disorder treatment. Exam-

ples of existing frameworks include trauma-informed

and culturally competent, responsive, and appropriate

care. These frameworks emphasize respect for client di-

versity, an empowerment of people using substances and

provider understanding of the varied impact that trauma

and ethnicity/culture have on treatment expectations

and experiences [ 4,5,20]. In addition, there are emer-

ging interests in the design of patient-centered ap-

proaches for substance use disorder treatment (see for

example [ 21–25]). Patient-centered care (PCC) has been

widely recommended to strengthen the quality of health

care [ 4,26,27] as it can be universally applied across

treatments, settings and providers. This framework chal-

lenges traditional approaches to treatment by prioritizing

the unique needs of each client and seeking a greater

balance in power between the client and provider. In the

last two decades, the health and social sciences have

expanded the conceptualization of PCC. Although this

varies slightly between disciplines and settings, the

principles of PCC most frequently include the integra-

tion of a holistic or bio-psycho-social approach; an indi-

vidualized focus on clients ’unique needs, goals and

preferences; shared power and responsibility between

the client and health care provider as with collaborative

care or shared decision-making; and a therapeutic alli-

ance [ 28–31].

Such varying conceptualizations of PCC have posed

challenges to its implementation and measurement of its

outcomes [ 30]. Consequently, an important first step to-

ward designing, implementing and evaluating PCC ap-

proaches in substance use disorder treatment is a broad

exploration of its orientation and conceptualization in

this field. To our knowledge, no such reviews exist, al-

though specific principles of PCC have been empirically

studied (see for example [ 22,24,32]). Therefore, the aim

of the present scoping review was to systematically ex-

plore how the principles of PCC have been defined in

substance use disorder treatment. Specifically, this study

asked:

(1) Which PCC principles have been described in

substance use disorder treatment settings?

(2) How have these PCC principles been

conceptualized?

(3) What outcomes of PCC principles have been

empirically described?

Methods

A scoping review was deemed the most appropriate and

feasible synthesis methodology to capture the breadth of

existing evidence. This review followed the classic Ark-

sey and O ’Malley framework [ 33,34] and best practices

for conducting and reporting scoping reviews [ 35,36]

(Additional file 1). The review ’s protocol was registered

with Open Science Framework ( https://osf.io/5swvd/ ).

Full methodological details are available elsewhere [ 31]

and summarized below.

The search strategy (Additional file 2) was developed

as a broad framing of the population (people with sub-

stance-related disorders), concept (patient-centered

care) and context (health care settings delivering sub-

stance use disorder treatment). It was developed in

English in Medline (Ovid), refined through extensive

consultations with a Health Sciences Librarian and

clinical experts (authors SM and SH) and was peer-

reviewed. The empirical search for primary studies and

previous reviews was conducted in Medline (Ovid),

Embase (Ovid), PsycINFO, CINAHL, and ISI Web of

Science. The search for grey literature reports and clin-

ical practice guidelines was done in British Columbia

Guidelines and Protocols Databases, CPG Infobase, the

Registered Nurses ’Association Clinical Practice Guide-

lines Program, Des Libris, National Guideline Clearing-

house and TRIP.

Two independent reviewers (author KM and SB) se-

lected references through a two-stage screening process.

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 Page 2 of 15 In the first stage, the reviewers screened the de-dupli-

cated titles/abstracts (85% agreement) according to cri-

teria one through three below. In the second stage,

titles/abstracts meeting these initial criteria underwent

full-text review (93% agreement) based on the full list of

eligibility criteria. Empirical and grey literature refer-

ences were eligible, if they:

1. Included people with substance-related disorders,

including tobacco, alcohol, cannabis, stimulants,

opioids or had dual diagnoses.

2. Described patient-centered care (i.e., holistic care,

individualized care, shared decision-making,

therapeutic alliance), trauma-informed care and/or

culturally safe care.

3. Were set in a health care context that delivered

substance use disorder treatment. This included

inpatient (e.g., hospital, residential treatment) or

outpatient (e.g., emergency department, primary

care, community-based program) settings. This

excluded criminal justice settings and self-help

models.

4. Were published between 1 January 1960 and 1 July

2018 in English, French, Spanish, Italian or

Portuguese.

5. Provided an operational or conceptual definition of

the patient-centered care approach.

6. Empirical quantitative references observed at least

one patient outcome (e.g., substance use, health) or

treatment process outcome (e.g., treatment

engagement, treatment satisfaction).

Study screening (including de-duplication) and data

extraction was done in DistillerSR [ 37]. The data chart-

ing form (Additional file 3) was used to capture the

characteristics of each reference and to identify which

principle(s) of PCC were described (objective 1). This

form was piloted with the first five empirical and grey

literature references. Author KM led data extraction and

author SB checked extraction of the PCC principles

(94% agreement).

A descriptive overview (including tabular and graph-

ical summaries) of extracted data was completed. In

addition, a directed content analysis [ 38,39] was per-

formed on the defining characteristics of PCC principles

and their outcomes (objectives 2 and 3). This systematic

method is particularly beneficial when there exists theor-

ies or frameworks (i.e., for patient-centered care) that

can guide coding and analysis and can be used to deter-

mine patterns and relationships between the content

coded [ 38, 39]. For this analysis, a coding guide

(Additional file 4) was developed to identify categories

(e.g., therapeutic alliance), sub-categories (e.g., defining

characteristics, outcomes associated with) and codes for

the defining characteristics (e.g., non-judgment) and

outcomes (e.g., frequency of substance use) of each

PCC-principle. This guide was developed in iterative

stages through consultation with the team ’s knowledge

users and the initial data extraction process; these codes

and categories were then broadly operationalized ac-

cording to existing PCC frameworks. Directed content

analysis also allows new evidence to emerge via open

codes, which are used to label content that is unique to

predetermined codes [ 38,39]. Open coding was used

within each of the broader categories (e.g., therapeutic

alliance/defining characteristics) and also to identify an-

tecedents to PCC.

Author KM led initial coding; after which, the categor-

ies, subcategories, codes and content were reviewed with

the team for trustworthiness and for further analysis

(e.g., integration, collapsing, or expanding categories).

Since the content coded across categories was not mutu-

ally exclusive (i.e., a reference could have more than one

principle of PCC or more than one category of outcomes

coded), data reported are the number of references (i.e.,

sources) coded at each category, instead of the number

of times each reference is coded. The directed content

analysis was carried out in NVivo (version 11 for Mac).

Results

Descriptive results

After de-duplication, 2951 unique references underwent

title/abstract screening. Of these, 395 were assessed dur-

ing the full-text review, with 149 references included

(Fig. 1; Additional files 5and 6for Excluded References

and Detailed Extracted Data). Table 1provides the char-

acteristics of the eligible references. Approximately 50%

of the references were empirical quantitative papers pub-

lished in the last decade, over two-thirds were based in

North America and all but three of the references were

published in English. The targeted population was pri-

marily adults receiving substance use disorder treatment.

Nearly two-thirds of the references were in outpatient

settings and delivered psychosocial treatments. Regard-

ing the principles of PCC, 63 (42.3%) references de-

scribed more than one PCC principle, and therapeutic

alliance was the most frequently described ( n= 107;

71.8%).

Directed content analysis of the defining characteristics

of PCC principles

Tables 2,3,4,5,6and 7summarize the results of the

directed content analysis of defining characteristics for

each PCC principle, and include representative examples

of the content coded. For holistic care (Table 2), the

sub-categories converged in their aim to provide “wrap-

around services that meet clients' needs at a given point

in time ”[44]. For most of these references, this included

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 Page 3 of 15 an integrated delivery ( n= 25) or the coordination ( n=

15) of additional health (e.g., primary care, specialist

care, nutrition, exercise) and psychosocial supports (e.g.,

housing, financial, legal, family) within a substance use

disorder treatment setting. Gender-responsive services

( n= 9) described an integrated approach, wherein

women ’s health, substance use and psychosocial

treatment needs were comprehensively addressed.

Finally, four references described the delivery of sub-

stance use disorder treatment within a primary care or

hospital setting.

Individualized care (Table 3) was defined by health

care providers ’efforts to understand clients ’unique

needs, preferences, and expectations. The first of such

efforts was the use of individualized assessments and

treatment plans, both at entry and throughout treatment

( n= 29). Eight of these references (8/26 = 30.8%) used a

specific tool (e.g., Goals of Treatment Questionnaire

[ 73]) in these assessments. More frequently, a general

process of assessment was described, whereby health

care providers took time to understand the “main prob-

lems to be addressed, what actions and resources were

needed, who is responsible and timeframes for action and

review ”[74]. The second defining sub-category described

efforts to deliver treatment by “fit [ting] services to the

individual, based on an ongoing assessment of that per-

son ’s needs and level of functioning ”[75]( n= 24). This

often included presenting clients with a range of

treatment options that responded to those assessed

needs and preferences. Examples of treatment options

included group or individual counseling, medication op-

tions (when there was more than one), the schedule and

frequency of visits, and location of visits. This was some-

times referred to as “treatment-matching ”(n=9) or “as-

needed dosing ”(n= 3).

Shared decision-making (Table 4) was defined in the

first sub-category by activities or strategies whereby the

client and provider engaged in dialogue to reach a mu-

tual decision on the best course of treatment ( n= 31), in-

cluding choice of the intervention, its frequency,

duration, and follow-up plans. Here, health care pro-

viders elicited clients ’preferences and needs, presented

information on the available treatment options, and then

the client and provider “negotiated dialogues towards a

mutually agreed upon destination ”[95]. In the second

sub-category, decision-making was referred to as an au-

tonomous and client-led approach ( n= 17). Clients were

described as having responsibility and control over their

treatment decisions, including the frequency of counsel-

ing (e.g. [ 20,23]), choice of medications or behavioural

interventions, and transition plans (e.g. [ 76–78]). These

two defining categories were similar in their empowering

view of clients as an “integral partner, rather than pas-

sive or compliant recipient, of a treatment program ”[75].

They diverged in the extent of autonomy that the client

had and in their emphasis on the dialogue process.

Fig. 1 Flow diagram for scoping review process

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 Page 4 of 15 Table 1 Extracted characteristics of eligible publications, including the target population, concept and context

Publication Characteristics Number of references Percentage of total references

( n= 149)

Publication Year:

< 2000 17 11.4

2000 –2004 12 8.1

2005 –2009 44 29.5

2010 –2014 35 23.5

2015-Present 41 27.5

Publication Type:

Empirical Quantitative Study 74 49.7

Empirical Qualitative Study 25 16.8

Empirical Mixed-Methods 3 2.0

Empirical Review 5 3.4

Report 25 16.8

Clinical Practice Guideline 17 11.4

Publication Location:

Africa 1 0.7

Asia 2 1.3

Australia 8 5.4

Europe 37 24.8

North America 100 67.1

South America 1 0.7

Publication Language:

English 146 98.0

French 3 2.0

Population Sampled or Targeted:

Adult clients with substance-related disorders 96 64.4

Youth clients with substance-related disorders 21 14.1

Health care providers delivering substance use disorder treatment 27 18.1

Both clients and health care providers 5 3.4

Primary Substance Used or Targeted:

Alcohol 23 15.4

Cannabis 7 4.7

Opioids 17 11.4

Stimulants 4 2.7

Tobacco 13 8.7

Poly-substance a 6 4.0

Dual diagnosis b 19 12.8

People receiving addiction treatment in general c 60 40.3

Health Care Setting: d

Inpatient 28 18.8

Outpatient 99 66.4

Inpatient & Outpatient 22 14.8

Type of Addiction Treatment: e

Pharmacological 7 4.7

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 Page 5 of 15 Table 1 Extracted characteristics of eligible publications, including the target population, concept and context (Continued)

Publication Characteristics Number of references Percentage of total references

( n= 149)

Psychosocial 99 66.4

Psychosocial & Pharmacological 33 22.1

Not specified 10 6.7

Patient-Centered Care Principles (not mutually exclusive categories):

Holistic care 35 23.5

Individualized care 46 30.9

Shared decision-making 54 36.2

Therapeutic alliance 109 73.1

Trauma-informed care 9 6.0

Culturally-safe care 8 5.4

More than one principle described 63 42.3

All four PCC principles described 7 4.7

aPoly-substance use included references that targeted people using more than one substance category (e.g., alcohol, opioids and stimulants) or peop le using injection drugs (e.g., opioids or stimulants)bDual diagnosis included references that targeted people with diagnoses for substance-related disorders and mental health conditions (e.g., post- traumatic stress disorder and opioid use)cNot a targeted substance category included references that were primarily based on convenience samples of people receiving inpatient or outpatient treatment for substance use. Therefore the samples were a mix of people with problematic licit and illicit substance usedInpatient settings included hospitals or residential addiction-specific treatment centers. Outpatient settings included general primary care o r addiction specific outpatient programs (e.g., opioid agonist treatment clinics)ePharmacological treatment included any medication-based substitute interventions (e.g., methadone maintenance treatment, nicotine replaceme nt therapy). Psychosocial treatment included any behavioural treatments (e.g., cognitive behavioural therapy, contingency management, strengths-based tre atment). When a combination of behavioural and medication-assisted interventions was used, the reference was classified as using a combined approach. For the 10 re ferences where the type of treatment was not specified, 4 references were guidelines written about general approaches for the delivery of addiction treatment , and therefore, could be considered applicable to both psychosocial and pharmacological interventions. The remaining 6 references generally describe d addiction treatment as delivered in residential settings or primary care based settings, without specifying the particular treatments delivered

Table 2 Directed content analysis of the defining characteristics of holistic care

Defining Characteristics a Representative Example of Content Coded

Integrated delivery of physical health, mental health or psychosocial supports within addiction treatment setting ( n= 25) b “Other interventions designed to improve the potential for a successful outcome included educational sessions about the harmful effects of smokingand the benefits of stopping, stress management, the value of developing a support network, improving nutrition and avoiding significant weight gain after stopping smoking, the importance of a safe and regular exerciseprogram, and understanding the potential role of spirituality. ”[40]

Coordination of health or psychosocial services as part of addiction treatment (n = 15) c “ If a woman was involved with many service providers, the ICF [Integrated Care Facilitator], with the woman ’s permission, would maintain contact with those providers to ensure that all providers understood her needs in a similar way and that services were coordinated. ”[41]

Adapting a gender-responsive approach to the delivery of health, substance use, and psychosocial treatment (n = 9) d “ It allows clinicians to treat addiction as the primary problem while also addressing the complexity of issues that women bring to treatment: geneticpredispositions, health consequences, shame, isolation, histories of abuse, or a combination of these. ”[42]

Integrated delivery of addiction treatment as part of a primary care or hospital setting for other health or psychosocial needs (n = 4) e “ NRT [Nicotine Replacement Therapy] was available to participants at no cost during hospitalization.[ …] A variety of group meetings were held according to a preset time schedule which was announced at the unit. The degree towhich patients participated in the meetings differed depending on the length of their hospital stay. ”[43]

aA total of 35 references defined holistic care. Coded categories were not mutually exclusive such that a reference might have defined the principle of patient- centered care at more than one category. Bracketed numbers represent the number of unique references coded at each categorybReferences coded at this category [ 20,25,40–62] cReferences coded at this category [ 41,44,45,47,50,51,56,63–70] dReferences coded at this category [ 41,42,44,45,50,55,65,69,71] eReferences coded at this category [ 43,54,67,70]

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 Page 6 of 15 Therapeutic alliance was defined by relationships that

were non-judgmental, respectful and accepting ( n= 37)

and/or as empathic, understanding, warm and kind ( n=

32). While these defining categories reflected distinct re-

lational qualities, there was substantial overlap between

them ( n= 26 references coded at both), as shown in the

representative examples in Table 3. In addition to these

characteristics, 56 (52.3%) references defined therapeutic

alliance according to empirically-based measures, such

as the widely used Working Alliance Inventory. Among

these references, therapeutic alliance was commonly ex-

plored as a predictor or mediating variable of substance

use and treatment engagement outcomes.

Trauma-informed care was defined according to exist-

ing theoretical and clinical practice frameworks ( n= 6),

such as Seeking Safety ( n= 2) and Harris & Fallot ’s

trauma theory (n = 2). Open coding captured additional

defining features, including understanding the effects of

trauma ( n= 3) and avoiding re-traumatization ( n= 1).

Defining characteristics of culturally-safe care included

open codes for adapting care plans according to cultur-

ally-relevant preferences of clients ( n= 7), inquiring

about the health and healing beliefs of clients (n = 2),

and health care providers ’reflection of their personal be-

liefs and biases (n = 2).

Directed content analysis of outcomes of PCC principles

A total of 103 (69%) references were identified as

describing or exploring at least one of the predeter-

mined categories of outcomes. The sankey diagram

(Fig. 2) displays nodes for each principle of PCC, as

well as the categories and sub-categories of coded

outcomes. The width of each flow represents, among

those references that identified outcomes, the rela-

tive distribution of which PCC principles were stud-

ied or described, and in association with which

outcome categories and sub-categories. As shown in

Fig. 2, therapeutic alliance and shared decision-

making contributed a high er number of references

with identified outcomes. Within each of the PCC

principles, substance use ( n= 52/103; 50.5%) and

treatment engagement outcomes ( n= 50/103; 48.5%)

were the most frequently coded categories, followed

by health and psychosocial outcomes ( n= 40/103;

38.8%), and patient-reported experiences ( n= 17/103;

16.5%). Within each of the broader outcome cat-

egories, the most frequent subcategories included

the number of days of substance use, number of

visits or sessions attended, physical and mental

health symptoms, perceived self-efficacy, and treat-

ment satisfaction.

Table 3 Directed content analysis of the defining characteristics of individualized care

Defining Characteristics a Representative Example of Content Coded

Individualized assessment and treatment planning (n = 29) b “ Needs assessment and treatment planning activities are necessary to match patients to appropriate treatments. [ …] Similarly, care plans must include provisions for monitoring the client ’s progress after the index episode of treatment, given that posttreatment relapse is so common. ”[69]

Delivery of treatment according to patient needs and preferences (n = 24) c “ The participants in this residential program used as much medication as was necessary to suppress nicotine withdrawal symptoms which often was more than what is typically prescribed. ” [ 40]

Treatment adapted to clients ’barriers and assets ( n= 11) d “A typical call included discussion of the reasons the participant sought and discontinued treatment; the participant ’s current intentions regarding alcohol and drug use with a focus on increasing motivation to achieve or maintain abstinence; the participant ’s thoughts about what might be most helpful at this time; and troubleshooting practical barriers to treatment. ”[72]

aA total of 46 references defined individualized care. Coded categories were not mutually exclusive such that a reference might have defined the princ iple of patient-centered care at more than one category. Bracketed numbers represent the number of unique references coded at each categorybReferences coded at this category [ 20,40,42,43,45,47,50,52,64,69,72–89] cReferences coded at this category [ 25,40,43,46,47,50,52–57,63,67,71,75–77,84,87,90–93] dReferences coded at this category [ 20,45,52–54,64,67,72,74,86,88]

Table 4 Directed content analysis of the defining characteristics of shared decision-making

Defining Characteristics a Representative Example of Content Coded

Client and provider dialogue to reach a mutual decision (n = 31) b “ The form of NRT [Nicotine Replacement Therapy] selected is a joint decision made by the client and advisor, and is based on the client ’s individual smoking habits and feelings as well as any contraindications. ”[76]

Autonomous decision-making ( n= 17) c “Participants appreciated the practitioners ’active listening skills. For example, one client noted that her request to not use tablets or patches for smoking cessation was recognised by the practitioners as the topic was not broached again in consultations. ”[94]

aA total of 54 references defined shared decision-making. Coded categories were not mutually exclusive such that a reference might have defined the pr inciple of patient-centered care at more than one category. Bracketed numbers represent the number of unique references coded at each categorybReferences coded at this category [ 20,22,25,40,41,45,47,52,59,61,63,68,69,73–81,84,90,93–99] cReferences coded at this category [ 20,23,45,51,59,61,64,71,72,75–78,80,90,94,98]

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 Page 7 of 15 Directed content analysis of antecedents to PCC

During the directed content analysis, open codes were

used to distinguish antecedents contributing to, or

strengthening the implementation of PCC from those

that were described as outcomes. Since this was not part

of the original review design, these factors were analyzed

inductively and based on their within-category content.

A total of 75 (50.3%) references were coded for describ-

ing such contributors; the emergent categories and sub-

categories are displayed in Table 8. Organizational

values, policies, and procedures ( n= 42; 56.0%) clustered

around six features. These included the skills and train-

ing of providers (e.g., case management, multicultural

competence) and environments that were safe, stable,

and social. Clinical approaches ( n= 49; 65.3%) also

emerged as contributing to therapeutic alliance ( n= 43;

e.g., communication style, building trust), shared deci-

sion-making ( n= 30; e.g., appropriate information shar-

ing; empowering approach), or individualized care ( n=6;

e.g., encouraging client input).

Discussion

To our knowledge, this scoping review is the first to

undertake a systematic synthesis of PCC in substance

use disorder treatment settings. To strengthen the

breadth and specificity of this review, existing frame-

works of PCC from other disciplines were used to guide

the search strategy and data charting methods [ 31], and

the directed content analysis allowed population and

context specific nuances to be identified. The findings

suggested that few references had examined all four

principles of PCC, although 42% described more than

one PCC principle. The most frequent principle identi-

fied was therapeutic alliance and the most frequent out-

comes measured included substance use and treatment

engagement. The findings contribute evidence that can

be used to support a comprehensive and evidence-based

conceptualization of PCC with implications for its im-

plementation and evaluation.

The first objective was to determine which PCC prin-

ciples have been described in substance use disorder

treatment settings, and the results revealed that thera-

peutic alliance was the most frequently described

principle. The first plausible explanation for this is the

longstanding tradition of therapeutic alliance in psycho-

therapeutic research and practice [ 100 ]. In the present

review, two-thirds of the references offered primarily

psychosocial treatments (e.g., cognitive behavioral

therapy) for substance-related disorders. In this discip-

line, therapeutic alliance receives significant attention

given its importance in predicting counseling outcomes

[ 32,100 ]. In the references that described therapeutic al-

liance, over 50% were empirical quantitative papers and

conceptualized therapeutic alliance according to client,

Table 5 Directed content analysis of the defining characteristics of therapeutic alliance

Defining Characteristics a Representative Example of Content Coded

Non-judgmental, respectful and accepting ( n= 37) b “A major theme discussed by patients was the importance of building supportive relationships. Patients expressed a desire to work with staff who possessed qualities such as empathy,understanding, trust, respect and expertise and described feeling accepted in these relationships. Patients who perceived staff to be nonjudgmental in their approach described that this reduced their feelings of shame. ”[51]

Empathy, understanding, warmth, kindness, supportive ( n= 32) c “The nurse engages in caring relationships with patients with the purpose of helping them to handle a complex and intricate health problem in a dignified manner, acknowledging the therapeutic effects offeeling being understood as a patient. ”[43]

aA total of 109 references defined therapeutic alliance. Coded categories were not mutually exclusive such that a reference might have defined the pri nciple of patient-centered care at more than one category. Bracketed numbers represent the number of unique references coded at each categorybReferences coded at this category [ 45,48,51,57,59,61–66,71,76,77,79,83,89,91,93,94,96,99,103 ,104 ,118 –128 ] cReferences coded at this category [ 41,43,45,48,51,57,61,63–66,71,74,89–91,96,103 ,118 –121 ,123 ,125 –132 ]

Table 6 Directed content analysis of the defining characteristics of trauma-informed care

Defining Characteristics a Representative Example of Content Coded

Trauma-informed framework ( n= 6)b “ SAMHSA outlines a “four R ”perspective for the elements that are required to create this shift in organizational culture: (1) realizing the prevalence of trauma, (2) recognizing how trauma affects all individuals involved with the organization (clients, families and team members), (3) responding by putting this knowledge into practice,and (4) actively resisting retraumatization. ”[133 ]

Understanding the effects of trauma ( n=3) c “Taking into account the impact of trauma on the lives, development, and drug use of people. This does not necessarily require disclosure of trauma. ”[59]

Avoiding re-traumatization (n = 1)d “ We should make great efforts to do nothing that could be retraumatizing, such as exercising authority and/or control, asking intrusive questions, being unpredictable, or using shaming language/ techniques. ”[79]

aA total of 9 references defined trauma-informed care. Coded categories were not mutually exclusive such that a reference might have defined the princ iple of patient-centered care at more than one category. Bracketed numbers represent the number of unique references coded at each categorybReferences coded at this category [ 41,42,58,133 –135 ] cReferences coded at this category [ 44,59,79] dReferences coded at this category [ 79]

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 Page 8 of 15 provider, or observer-rated empirical measures, such as

the Working Alliance Inventory (WAI). Thus, this long-

standing tradition to examine the extent of therapeutic

alliance likely contributed to the high number of refer-

ences in the present review that described this PCC-

principle.

Our search also yielded references that delivered add-

itional treatments (e.g., pharmacological treatments

alone or combined with psychosocial) in alternative set-

tings (e.g., residential detoxification programs, harm re-

duction services), which provided an opportunity to

determine that non-judgment, respect, empathy, and un-

derstanding were also common characteristics of thera-

peutic alliance. While respect has been described in

broader conceptual analyses of PCC [ 29,101 ], informa-

tion regarding why these attributes were important

among people with substance use strengthens its

interpretation in this context. Examples of these reasons

included clients ’safety [ 79,102 ]; to gain clients ’trust

[ 45,63,103 ]; and to reduce stigma [ 63,96,104 ]. These

defining attributes are especially salient when consider-

ing that experiences of stigma are common among

people with substance-related disorders [ 105 –107 ] and

have been identified as barriers to treatment [ 12,14].

These relational characteristics also intersected with

shared decision-making, such that the analysis of anteced-

ents to PCC revealed that respectful and understanding

relationships promoted shared decision-making. The re-

ciprocal was also found, whereby collaborative approaches

strengthened therapeutic alliance. These antecedents give

more depth to our finding that the defining characteristics

of shared decision-making denoted an underlying philoso-

phy of respect towards clients as “integral … rather than

passive ”partners in the treatment process. The first defin-

ing characteristic emphasized a joint decision-making

process. This category primarily described a process of

dialogue and discussion that granted clients a more active

role in the decision-making process and facilitated the

health care provider ’s understanding of clients ’needs and

expectations. This view of shared decision-making resem-

bles those of the broader PCC-frameworks that have

conceptualized this principle as “sharing power and

responsibility ”[28],“finding common ground ”[108 ]and

also more recent proposals for the clinical practice of

shared decision-making [ 109 ]. However, the second

defining characteristic emphasized a fully autonomous de-

cision-making process, which is more closely aligned with

other frameworks ’notion of “empowering care ”[29,

110 ]. Those existing frameworks describe autonomy,

self-confidence and self-determination as core charac-

teristics of this principle. While, there is evidence that

increasingly recognizes clients ’preferences to be more

actively involved in substance use disorder treatment

decision-making [ 22], further work might explore the

circumstances under which a deliberative or autono-

mous decision-making process is more suitable from

theclientandhealthcareprovider ’s perspective.

The integration of shared decision-making practices

often presumed an individualized care approach, such

that the process of dialogue involved discussion of cli-

ents ’unique needs, circumstances, traditions and prefer-

ences [ 29]. One study to highlight is that of Joosten et

al. who developed and tested the effectiveness of a

shared decision-making intervention in an inpatient

treatment setting [ 73,80,81]. Their intervention relied

on an individualized assessment of clients ’needs and

goals (via the Camberwell Assessment of Need). The

client and clinician then discussed their independent rank-

ing of the priority of these goals and adapted treatment

accordingly. In this review, individualized care did not

always include shared decision-making however; it was

also described by several treatment matching approaches,

Table 7 Directed content analysis of the defining characteristics of culturally-safe care

Defining Characteristics a Representative Example of Content Coded

Adapting care plans to meet culture-specific preferences (n = 7) “ Akeela House developed a model that incorporated traditional Alaska Native cultural lifestyles into the therapeutic community treatment approach. This was termed a “Spirit Camp Model ”and consisted of four major elements: (1) spirit groups, (2) cultural awareness activities, (3) urban orientation, and (4) individual counseling. To implement these components, additional Alaska Native counselors were hired. ”[136 ]

Inquiring about health and healing practices of the client (n = 2) “ The nurse engages with Charlie to prioritize his needs. He/she discusses his living situation and how he sees the future. The nurse does an assessment in keeping with the principles of cultural safety andcultural competence –he/she begins by asking Charlie if there is anything that he/she should know about him (e.g. beliefs about health and healing practices) to assist with his treatment plan and before making referrals etc. ”[59]

Reflecting on personal beliefs, assumptions and biases (n = 2) “ The concept of cultural safety takes critical inquiry a step further by requiring nurses to reflect on issues of racialization, institutionalized discrimination, culturalism, and health and health-care inequities. ”[59]

aA total of 8 references defined culturally-safe care. Coded categories were not mutually exclusive such that a reference might have defined the princ iple of patient-centered care at more than one category. Bracketed numbers represent the number of unique references coded at each categorybReferences coded at this category [ 6,40,45,47,136 –138 ] cReferences coded at this category [ 59,138 ] dReferences coded at this category [ 45,59]

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 Page 9 of 15 such as as-needed-dosing [ 40,46,90]. Regardless of the

specific design chosen, these findings imply that compre-

hensive assessments and flexibility in service design and

delivery (at a clinical and organizational level) supported

individualized care.

Thus, individualized needs assessment and treatment

delivery overlapped with holistic, trauma-informed and

culturally competent, responsive, and appropriate care

with respect to their common goal to provide compre-

hensive and flexible care, adapted to client-identified

needs and values. Under ideal circumstances, such con-

sideration would be facilitated by an assessment of cli-

ents ’bio-psycho-social needs [ 47], which are often

inextricable from their cultural context and the pervasive

impacts of structural and interpersonal trauma [ 20]. In

the present review, the defining characteristics of these

principles included specific practices adopted by health

care providers (e.g., comprehensive needs assessments,

avoiding re-traumatization). However, the inductive ana-

lysis of antecedents to PCC revealed that both the sys-

tem (e.g., a vision of shared governance; safety and

stability of treatment setting; flexibility of service

provision) and the health care provider (e.g., communi-

cation style) play a conjoint role in the successful imple-

mentation of PCC principles. For instance, a physician ’s

endeavor to adopt shared decision-making practices in

the prescription of opioid substitution treatment will

require a health care system that has implemented

Fig. 2 Directed content analysis of outcomes of patient-centered care principles. a) Among publications reporting outcomes of the patient-

centered care principles, the Sankey diagram presents the general outcome category and sub-category and the relative number of times it was coded within each patientcentered care principle. b) Outcome categories and sub-categories are not mutually exclusive. A publication could havedescribed more than one (e.g., Substance Use and Treatment Engagement). If a publication operationalized more than one principle and/or

outcome, each principle received a link to each general outcome category. Additional space seen in the general outcome category nodes and their flows to sub-outcomes is from publications that studied multiple suboutcomes under one outcome category since each principle did notreceive an additional link to a general outcome category for each sub-outcome studied in that category

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 Page 10 of 15 evidence-based treatment options and policies that sup-

port client-provider collaboration (e.g., flexibility around

dosing schedules, frequency of visits, etc). Thus, a good

starting point for moving PCC into the realm of evi-

dence-based practice in substance use disorder treat-

ment is a consideration of potential barriers to its

implementation from the client, provider and system ’s

perspectives [ 111 ].

While factors supporting PCC have been relatively

consistent across broader concept analyses [ 29,30,112 ],

there has been less agreement on what consequences or

outcomes of PCC can be expected and thus, measured.

Examples of such outcomes have included consultation

processes (e.g., communication skills, quality of care,

treatment satisfaction) [ 29,113 ], health behaviours (e.g.,

service utilization, adherence to treatment plans)

[ 113 ,114 ], health outcomes [ 29] and patient-reported

outcomes [ 112 ]. It has also been proposed that some of

these outcomes are likely more intermediate (i.e., per-

ceived quality of care, satisfaction, consultation process

outcomes), while others more distal (i.e., health behav-

iours and health outcomes) [ 113 ].

In the present review, substance use and treatment en-

gagement outcomes were the most frequently investi-

gated, regardless of PCC principle. This might have been

influenced by the high frequency of references exploring

therapeutic alliance, half of which related the WAI with

the number of days of substance use or number of coun-

seling sessions. However, it might also reflect a common

assumption that the goal of any substance use disorder

treatment is to reduce the severity of use [ 115 ]. A con-

tinued emphasis on substance use outcomes neglects

that the stated goal of PCC is to improve the treatment

process [ 26,27]. It is also not congruent with prior

research demonstrating that clients ’goals extend to

other domains (e.g., health, housing, family relationships)

[ 116 ] and emerging recommendations to integrate pa-

tient-centered or patient-reported measures in substance

use disorder treatment [ 117 ]. Thus, future PCC research

in substance use disorder treatment will be strengthened

through choices of measures that reflect these goals.

This review was a necessary first step towards concep-

tualizing PCC for substance use disorder treatment. Al-

though scoping reviews typically take a broad framing of

the population, concept and context [ 33,34], this

resulted in a high number of false positives and posed

several challenges to the synthesis and to teasing apart

potential differences in treatment type and setting.

While efforts were made to overcome these challenges

(i.e., substantial resources were devoted to reaching ad-

equate inter-rater agreement and carrying out the di-

rected content analysis), there are further limitations to

Table 8 Directed content analysis of antecedents to patient-centered care

Categories (n references coded) Open codes (n references coded)

1. Organizational Values, Policies and Procedures (n = 42) 1.1 Health care provider skills and training (e.g., case management, motivational interviewing, transtheoretical change model) ( n= 18)

1.2 Creating preferred environments that are safe, stable and social (n = 11)

1.3 Inter-professional care teams (n = 9)

1.4 Simplifying the logistics and continuity of access to health care providers ( n=9)

1.5 A system that is rooted in the values of harm reduction and the social determinants of health (n = 6)

1.6 Comprehensive assessment and screening procedures (n = 3)

2. Clinical Approaches that Strengthen Therapeutic Alliance (n = 43) 2.1 Open communication and active listening ( n= 28)

2.2 Investing time to build trust ( n= 20)

2.3 Affirming client ’s ability to succeed in their goals (n = 17)

2.4 Adopting an individualized approach ( n=8)

2.5 Collaborating with clients (n = 7)

2.6 Taking a holistic view ( n=7)

3. Clinical Approaches that Support Shared Decision-making (n = 30) 3.1 Sharing information in a manner appropriate for the client ( n= 21)

3.2 Empowering clients as experts in treatment need and building capacity for self-responsibility ( n= 13)

3.3 Establishing respectful relationship with clients (n = 4)

3.4 Being flexible in approaches offered (n = 2)

4. Clinical Approaches that Support Individualized Care (n = 6) 4.1 Encouraging clients ’input and preferences (n = 3)

4.2 Establishing caring relationship with clients (n = 2)

4.3 Offering a flexible continuum of care (n = 2)

Marchand et al. Substance Abuse Treatment, Prevention, and Policy (2019) 14:37 Page 11 of 15 bear in mind. First, we were unable to carry out a com-

prehensive grey literature search in international search

databases, other than TRIP, and thus, might not have

adequately captured grey literature reports of the imple-

mentation of PCC in settings outside of North America.

In addition, our search strategy was developed in English

and eligibility was limited to references published in

English, French, Spanish, Italian or Portuguese. This

might have influenced the comprehensiveness and inter-

national breadth of the search and thus, inflating the

number of references from North America.

Conclusions

The present scoping review synthesized existing empir-

ical and grey literature as a necessary first step to

explore which PCC principles have been described and

how they have defined and measured for people en-

gaging in substance use disorder treatment. The directed

content analysis revealed population and context-specific

evidence regarding the defining characteristics. These re-

sults can be used to support the implementation and

evaluation of PCC. The results also identify future direc-

tions for research, including potential measures of PCC

and its associated outcomes.

Supplementary informationThe online version of this article ( https://doi.org/10.1186/s13011-019-0227-0 ) contains supplementary material, which is available to authorized users.

Additional file 1. Prisma-ScR checklist. (PDF 82 kb)

Additional file 2. Sample Ovid Medline search terms. (PDF 470 kb)

Additional file 3. Data extraction form. (PDF 287 kb)

Additional file 4. Directed Content Analysis Coding Guide. (PDF 140 kb)

Additional file 5. Excluded references. (PDF 2429 kb)

Additional file 6. Detailed extracted data. (XLSX 33 kb)

Abbreviations PCC: Patient-centered care; WAI: Working alliance inventory

Acknowledgements We would like to acknowledge Ursula Ellis, Health Sciences Librarian (University of British Columbia), who has provided invaluable expertise to thedevelopment and refinement of the search strategy of this scoping review.

Authors ’contributions KM and EOJ led this review, with support from all authors. In particular, SB,SM, and SH were involved in refining the search strategy, including keywords. SM, SH, and JW were involved in establishing eligibility criteria, data charting forms and the directed content analysis coding guide. Allauthors provided feedback on the interpretation of the review ’s findings and approve to the publishing of the manuscript.

Funding Funding for this scoping review has been provided by the Canadian Institutes of Health Research (Operating Grant: Opioid Crisis Knowledge Synthesis OCK-156780).

Availability of data and materials The datasets used and/or analysed during the current study are availablefrom the corresponding author on reasonable request.

Ethics approval and consent to participate Not applicable.

Consent for publication Not applicable.

Competing interests The authors declare they have no competing interests.

Author details1School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada. 2Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul ’s Hospital, 575- 1081 Burrard St, Vancouver, BC V6Z 1Y6, Canada. 3Canadian Association for Safe Supply, 46 East Hastings St, Vancouver, BC V6A 1N1, Canada. 4Providence Health Care, Providence Crosstown Clinic, 84 West Hastings St, Vancouver,BC V6B 1G6, Canada. 5Northern Ontario School of Medicine, 935 Ramsey Lake Road, Sudbury, ON P3E 2C6, Canada.

Received: 26 June 2019 Accepted: 2 September 2019

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