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An Electronic Screen for Triaging Adolescent Substance Use by Risk Levels.

Wed, 07/30/2014 - 6:00am

An Electronic Screen for Triaging Adolescent Substance Use by Risk Levels.

JAMA Pediatr. 2014 Jul 28;

Authors: Levy S, Weiss R, Sherritt L, Ziemnik R, Spalding A, Van Hook S, Shrier LA

Abstract
Importance: Screening adolescents for substance use and intervening immediately can reduce the burden of addiction and substance-related morbidity. Several screening tools have been developed to identify problem substance use for adolescents, but none have been calibrated to triage adolescents into clinically relevant risk categories to guide interventions.
Objective: To describe the psychometric properties of an electronic screen and brief assessment tool that triages adolescents into 4 actionable categories regarding their experience with nontobacco substance use.
Design, Setting, and Participants: Adolescent patients (age range, 12-17 years) arriving for routine medical care at 2 outpatient primary care centers and 1 outpatient center for substance use treatment at a pediatric hospital completed an electronic screening tool from June 1, 2012, through March 31, 2013, that consisted of a question on the frequency of using 8 types of drugs in the past year (Screening to Brief Intervention). Additional questions assessed severity of any past-year substance use. Patients completed a structured diagnostic interview (Composite International Diagnostic Interview-Substance Abuse Module), yielding Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) substance use diagnoses.
Main Outcomes and Measures: For the entire screen and the Screening to Brief Intervention, sensitivity and specificity for identifying nontobacco substance use, substance use disorders, severe substance use disorders, and tobacco dependence were calculated using the Composite International Diagnostic Interview-Substance Abuse Module as the criterion standard.
Results: Of 340 patients invited to participate, 216 (63.5%) enrolled in the study. Sensitivity and specificity were 100% and 84% (95% CI, 76%-89%) for identifying nontobacco substance use, 90% (95% CI, 77%-96%) and 94% (95% CI, 89%-96%) for substance use disorders, 100% and 94% (95% CI, 90%-96%) for severe substance use disorders, and 75% (95% CI, 52%-89%) and 98% (95% CI, 95%-100%) for nicotine dependence. No significant differences were found in sensitivity or specificity between the full tool and the Screening to Brief Intervention.
Conclusions and Relevance: A single screening question assessing past-year frequency use for 8 commonly misused categories of substances appears to be a valid method for discriminating among clinically relevant risk categories of adolescent substance use.

PMID: 25070067 [PubMed - as supplied by publisher]

Implementing Adolescent SBIRT Education in a Pediatric Residency Curriculum.

Sat, 07/19/2014 - 6:00am

Implementing Adolescent SBIRT Education in a Pediatric Residency Curriculum.

Subst Abus. 2014 Jul 18;:0

Authors: Schram P, Harris SK, Van Hook S, Forman S, Mezzacappa E, Pavlyuk R, Levy S

Abstract
ABSTRACT Background: Screening, Brief Intervention and Referral to Treatment (SBIRT) is recommended as part of routine health care for adolescents as well as adults. In an effort to promote universal SBIRT, the Substance Abuse and Mental Health Services Administration awarded funding to residency programs to develop and implement SBIRT education and training. Our project focused on creating scientifically-based, developmentally appropriate strategies and teaching materials for the adolescent age range. This manuscript describes curriculum development and implementation and presents evaluation data. Methods: Pediatric and child psychiatry residents were trained. The training consisted of four activities 1) case-based teaching modules, 2) role-play of motivational interviewing and brief interventions, 3) mock interviews with trained adolescents, and 4) supervised "hands-on" screening and brief interventions. Main outcome measures included trainee satisfaction, and SBIRT knowledge, perceived self-efficacy, and self- and observer- report of use of the SBIRT algorithm. Results: Among 150 total participants completing the SBIRT training modules, nearly all (92.3%) were satisfied/very satisfied with the training modules. Knowledge accuracy immediately post-training was high, but declined significantly by the end of the first residency year, with little change across subsequent years of residency. Confidence ratings also declined over time. Use of the SBIRT algorithm during the Adolescent Medicine rotation was high according to trainee self- and faculty observer-report. Conclusions: We found evidence of training satisfaction, increased confidence in talking to adolescents about substance use, and widespread use of recommended practices immediately following training. Use of a highly structured algorithm to guide practice, and simple, highly structured brief interventions was a successful training approach as residents self-reported accurate use of the SBIRT algorithm immediately after training. Knowledge and self-confidence declined over time. It is possible that "booster" sessions and ongoing opportunities to review materials could help residents retain knowledge and skills.

PMID: 25036267 [PubMed - as supplied by publisher]

Screening and brief intervention for alcohol and other abuse.

Wed, 07/16/2014 - 6:00am

Screening and brief intervention for alcohol and other abuse.

Adolesc Med State Art Rev. 2014 Apr;25(1):126-56

Authors: Harris SK, Louis-Jacques J, Knight JR

Abstract
Substance use is the most common health risk behavior among adolescents and is one of the greatest threats to their current and future health. Universal screening of adolescents in general medical settings can be instrumental in identifying substance use early, before further problems develop and when BIs are more likely to be effective. Screening in and of itself may have some therapeutic effect. Brief screening tools feasible for use by busy medical offices to quickly and reliably assess adolescent risk for a substance use disorder now are available. A recent study found that a physician-conducted CRAFFT screen interview required an average of 74 seconds to complete, whereas a computer self-administered version took an average of 49 seconds. The CRAFFT and AUDIT tools currently have the most evidence for validity among adolescents, whereas the validity of other widely used tools such as DAST-10, NIDA-modified ASSIST (Alcohol, Smoking and Substance Involvement Screening Test), and ultra-brief screens (AUDIT-C, single-item screens) has yet to be established for adolescents. Studies are needed to identify effective strategies to promote universal adolescent screening and the use of valid screening tools in general medical settings. One statewide (Massachusetts) study found that although most (86%) primary care physicians seeing adolescents reported screening adolescents for substance use annually, only 1 in 3 reported using a validated tool (the CRAFFT). The remaining physicians reporting using informal screening procedures, their own questionnaire, or the CAGE. Computerization of screening and integration into the electronic health record appear to be promising strategies to promote universal screening and standardized use of valid screening tools. Increasing adolescent screening rates necessitates supporting physicians' ability to respond effectively to the screen results. To that end, recent evidence-informed practice guides from the AAP and NIAAA provide a structured algorithm for specific recommended responses based on level of risk. Adolescents who are at low or moderate risk for a substance use disorder, who constitute most of those seen in general medical settings, may be effectively counseled with a few minutes of brief advice, particularly after being primed with screening, feedback, and education before seeing their physician. High-risk patients (screen-positives) should receive a brief follow-up assessment to determine the appropriate level of care needed and a BI, using MI principles, to enhance motivation for behavioral change and help-seeking. Indications of acute danger or addiction may necessitate breaking confidentiality to protect patient safety and begin RT. Our review shows a small but growing body of research on the effectiveness of opportunistic BIs following screening of adolescents in clinical settings. Studies to date have largely tested brief alcohol-focused MI-based interventions with adolescents in the ED or trauma care settings; however, the number of studies conducted in primary health care settings is increasing. The strongest BI effects found in these studies tend to be related to harm reduction, such as reduction of substance-related driving/riding, alcohol-related injuries, unplanned sex, and other negative consequences of use. Effects on substance use have been more modest and tend to be stronger at shorter (< or = 6 months) rather than longer follow-up (> or = 12 months). However, many of these studies compared BI to active control conditions, which often included elements of BI (eg, assessment, brief advice, informational handouts). Significant reductions in substance use and related harms were also seen in these control groups, likely making detection ofa BI effect more difficult. A few studies have shown initial support for a prevention effect of BI among abstinent adolescents. At the opposite end of the spectrum, little is known about the effects of BI for adolescents with dependence and needing RT because of a lack of studies. Other areas needing additional research are the effect of BI on adolescent drug use, particularly on use of drugs other than cannabis; the mediators and moderators of BI effects; ways to reinforce and sustain effects over time; and how best to increase SBI implementation in general medical settings and to effectively train physicians. The effect of efforts such as the Substance Abuse and Mental Health Services Administration-funded physician residency SBIRT training programs remain to be determined. There has been increasing investigation into the potential of interactive computer technologies to aid SBIRT delivery to adolescents and young adults. A more detailed review of this area of research is beyond the scope of this article, but computer technology is proving to be an acceptable and effective tool in the delivery of BIs to young people, both as physician "extenders" in clinical settings and in the form of stand-alone self-guided programs. Computer technologies likely will play a critical role in promoting the expansion of SBIRT implementation for youth in general medical settings.

PMID: 25022191 [PubMed - in process]

Adolescent substance use: the role of the medical home.

Wed, 07/16/2014 - 6:00am

Adolescent substance use: the role of the medical home.

Adolesc Med State Art Rev. 2014 Apr;25(1):1-14

Authors: Levy S, Williams JF

Abstract
Given the continued high rates of substance use by adolescents and young adults, it should be among the topics addressed at every health care visit in the medical home. Primary care physicians should counsel and refer parents for substance use assessment, counseling, and cessation management when pediatric or adolescent patients are environmentally exposed to substances and substance use. The role of the medical home includes providing parents, children, and adolescents with anticipatory guidance, drug use screening, health advice, brief intervention, and referral for further assessment and treatment when an SUD is suspected. Clinical and technical reports, policy statements, and educational materials provided by national institutes and health professional societies assist those caring for children and adolescents by assuring best practices in detailed guidance and developmentally appropriate strategies related to alcohol, tobacco, and other substance use across the pediatric age range.

PMID: 25022183 [PubMed - in process]

Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice.

Tue, 07/01/2014 - 6:00am
Related Articles

Problem alcohol use among problem drug users: development and content of clinical guidelines for general practice.

Ir J Med Sci. 2014 Mar;183(1):89-101

Authors: Klimas J, Cullen W, Field CA, Problem Alcohol/Drug Use Guideline Development Group

Abstract
BACKGROUND: Problem alcohol use is common and associated with considerable adverse outcomes among patients who attend primary care in Ireland and other European countries for opiate substitution treatment.
AIMS: This paper aims to describe the development and content of clinical guidelines for the management of problem alcohol use among this population.
METHODS: The guidelines were developed in three stages: (1) identification of key stakeholders, (2) development of evidence-based draft guidelines, and (3) determination of a modified 'Delphi-facilitated' consensus among the group members.
RESULTS: The guidelines incorporate advice for physicians on all aspects of care, including (1) definition of problem alcohol use among problem drug users, (2) alcohol screening, (3) brief intervention, and (4) subsequent management of patients with alcohol dependence.
CONCLUSIONS: Primary care has an important role to play in the care of problem alcohol use among problem drug users, especially opiate substitution patients. Further research on strategies to inform the implementation of these guidelines is a priority.

PMID: 23820987 [PubMed - indexed for MEDLINE]

The effects of a brief CBT intervention, delivered by frontline mental health staff, to promote recovery in people with psychosis and comorbid anxiety or depression (the GOALS study): study protocol for a randomized controlled trial.

Sun, 06/29/2014 - 6:00am

The effects of a brief CBT intervention, delivered by frontline mental health staff, to promote recovery in people with psychosis and comorbid anxiety or depression (the GOALS study): study protocol for a randomized controlled trial.

Trials. 2014 Jun 27;15(1):255

Authors: Waller H, Craig T, Landau S, Fornells-Ambrojo M, Hassanali N, Iredale C, Jolley S, McCrone P, Garety P

Abstract
BACKGROUND: NICE guidance states that cognitive behavioural therapy (CBT) should be offered to all patients with psychosis. However, there is a need to improve access to therapeutic interventions. We aim to train frontline mental health staff to deliver brief, structured CBT-based therapies. We have developed and piloted a manualized intervention to support people with psychosis and anxious avoidance or depression to work towards a personal recovery goal.Methods/design: The 'GOALS Study' is a pilot randomized controlled trial comparing usual care plus an 8-week intervention with usual care alone. The key objective is to assess clinical feasibility (recruitment and randomization; compliance with the treatment manual; acceptability and satisfaction; progress towards goals). A secondary objective is a preliminary evaluation of efficacy. Sixty-six participants with a diagnosis of psychosis, plus symptoms of depression or anxiety will be recruited from adult mental health services. Those currently refusing medication, in receipt of CBT, or with a primary diagnosis of an organic mental health problem or substance dependency will be excluded. Following informed consent, randomization will be independent of the trial team, at a 50:50 ratio, at the level of the individual and stratified by main problem focus. Following randomization, participants allocated to the intervention group will begin the 8-week intervention with a local, trained member of staff, supervised by the study coordinator. Outcomes will be assessed blind to treatment condition at 0, 12 and 18 weeks post-randomization. The primary outcome measure for the efficacy analysis will be activity levels at 12 weeks. Secondary outcome measures include mood, psychotic symptoms, quality of life and clinical distress. A health economic analysis comparing service use in each condition will also be performed. Recruitment began in March, 2013 and is ongoing until December, 2014.
DISCUSSION: This is the first trial of the GOALS intervention. The approach is brief and staff can be readily trained in its delivery: there is therefore potential to develop a cost-effective intervention that could be widely disseminated. If the trial proves clinically feasible and demonstrates preliminary evidence of efficacy, a large multi-site trial will be warranted.Trial registration: Current Controlled Trials ISRCTN: 73188383. http://public.ukcrn.org.uk/search/StudyDetail.aspx?StudyID=13538.

PMID: 24973026 [PubMed - as supplied by publisher]

Hair drug testing results and self-reported drug use among primary care patients with moderate-risk illicit drug use.

Tue, 06/17/2014 - 6:00am

Hair drug testing results and self-reported drug use among primary care patients with moderate-risk illicit drug use.

Drug Alcohol Depend. 2014 May 17;

Authors: Gryczynski J, Schwartz RP, Mitchell SG, O'Grady KE, Ondersma SJ

Abstract
BACKGROUND: This study sought to examine the utility of hair testing as a research measure of drug use among individuals with moderate-risk drug use based on the internationally validated Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST).
METHODS: This study is a secondary analysis using baseline data from a randomized trial of brief intervention for drug misuse, in which 360 adults with moderate-risk drug use were recruited from two community clinics in New Mexico, USA. The current study compared self-reported drug use on the ASSIST with laboratory analysis of hair samples using a standard commercially available 5-panel test with assay screening and gas chromatography/mass spectrometry (GC/MS) confirmation. Both self-report and hair testing covered a 3-month period.
RESULTS: Overall concordance between hair testing and self-report was 57.5% (marijuana), 86.5% (cocaine), 85.8% (amphetamines), and 74.3% (opioids). Specificity of hair testing at standard laboratory cut-offs exceeded 90% for all drugs, but sensitivity of hair testing relative to self-report was low, identifying only 52.3% (127/243) of self-disclosed marijuana users, 65.2% (30/46) of cocaine users, 24.2% (8/33) of amphetamine users, and 2.9% (2/68) of opioid users. Among participants who disclosed using marijuana or cocaine in the past 3 months, participants with a negative hair test tended to report lower-frequency use of those drugs (p<.001 for marijuana and cocaine).
CONCLUSIONS: Hair testing can be useful in studies with moderate-risk drug users, but the potential for under-identification of low-frequency use suggests that researchers should consider employing low detection cut-offs and using hair testing in conjunction with self-report.

PMID: 24932945 [PubMed - as supplied by publisher]

Trends in detection rates of risky marijuana use in Colorado health care settings.

Sun, 06/08/2014 - 6:00am
Related Articles

Trends in detection rates of risky marijuana use in Colorado health care settings.

Subst Abus. 2013;34(3):248-55

Authors: Richmond MK, Page K, Rivera LS, Reimann B, Fischer L

Abstract
BACKGROUND: Over the past several years, many states, including Colorado, have approved medical marijuana legislation. There is concern that increased access to and visibility of medical marijuana may lead to harmful use.
METHODS: This study examined changes in patients' marijuana use in 12 health care settings through a statewide screening, brief intervention, and referral to treatment (SBIRT) initiative.
RESULTS: Beginning in 2009, the odds of screening positive for risk-prone marijuana use significantly increased, coinciding with dramatic increases in use of Colorado's medical marijuana program. Young males were most likely to screen positive. Among users, there was a small, statistically significant increase in severity of use over time.
CONCLUSIONS: Findings suggest that health care providers may be serving increasing numbers of patients using marijuana for medical or recreational purposes.

PMID: 23844955 [PubMed - indexed for MEDLINE]

Effectiveness of Nurse-Practitioner-Delivered Brief Motivational Intervention for Young Adult Alcohol and Drug Use in Primary Care in South Africa: A Randomized Clinical Trial.

Fri, 06/06/2014 - 6:00am

Effectiveness of Nurse-Practitioner-Delivered Brief Motivational Intervention for Young Adult Alcohol and Drug Use in Primary Care in South Africa: A Randomized Clinical Trial.

Alcohol Alcohol. 2014 Jun 4;

Authors: Mertens JR, Ward CL, Bresick GF, Broder T, Weisner CM

Abstract
AIMS: To assess the effectiveness of brief motivational intervention for alcohol and drug use in young adult primary care patients in a low-income population and country.
METHODS: A randomized controlled trial in a public-sector clinic in Delft, a township in the Western Cape, South Africa recruited 403 patients who were randomized to either single-session, nurse practitioner-delivered Brief Motivational Intervention plus referral list or usual care plus referral list, and followed up at 3 months.
RESULTS: Although rates of at-risk alcohol use and drug use did not differ by treatment arm at follow-up, patients assigned to the Brief Motivational Intervention had significantly reduced scores on ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) for alcohol-the most prevalent substance.
CONCLUSION: Brief Motivational Intervention may be effective at reducing at-risk alcohol use in the short term among low-income young adult primary care patients; additional research is needed to examine long-term outcomes.

PMID: 24899076 [PubMed - as supplied by publisher]

Effectiveness of brief interventions as part of the Screening, Brief Intervention and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances: a systematic review.

Tue, 06/03/2014 - 6:00am

Effectiveness of brief interventions as part of the Screening, Brief Intervention and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances: a systematic review.

Syst Rev. 2014 May 24;3(1):50

Authors: Young MM, Stevens A, Galipeau J, Pirie T, Garritty C, Singh K, Yazdi F, Golfam M, Pratt M, Turner L, Porath-Waller A, Arratoon C, Haley N, Leslie K, Reardon R, Sproule B, Grimshaw J, Moher D

Abstract
BACKGROUND: The purpose of this systematic review is to assess the effectiveness of brief interventions (BIs) as part of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances.
METHODS: Bibliographic databases (including MEDLINE, Embase, The Cochrane Library, CINAHL, and PsycINFO to April 2012) and gray literature sources were searched. We included randomized controlled trials that opportunistically screened adolescents or adults and then provided a one-to-one, verbal BI to those at risk of substance-use harm. Of interest was the nonmedical use of psychoactive substances (for example, drugs prohibited by international law), excluding alcohol, nicotine, and caffeine. Interventions comprised four or fewer sessions and were compared with no/delayed intervention or provision of information only. Studies were assessed for bias using the Cochrane risk of bias tool. Results were synthesized narratively. Evidence was interpreted according to the GRADE framework.
RESULTS: We identified 8,836 records. Of these, five studies met our inclusion criteria. Two studies compared BI with no BI, and three studies compared BI with information only. Studies varied in characteristics such as substances targeted, screening procedures, and BI administered. Outcomes were mostly reported by a single study, leading to limited or uncertain confidence in effect estimates.
CONCLUSIONS: Insufficient evidence exists as to whether BIs, as part of SBIRT, are effective or ineffective for reducing the use of, or harms associated with nonmedical use of, psychoactive substances when these interventions are administered to nontreatment-seeking, screen-detected populations. Updating this review with emerging evidence will be important.Trial registration: CRD42012002414 http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42012002414.

PMID: 24887418 [PubMed - as supplied by publisher]

Randomized clinical trial of the effects of screening and brief intervention for illicit drug use: the life shift/shift gears study.

Tue, 06/03/2014 - 6:00am

Randomized clinical trial of the effects of screening and brief intervention for illicit drug use: the life shift/shift gears study.

Addict Sci Clin Pract. 2014 May 22;9(1):8

Authors: Woodruff SI, Clapp JD, Eisenberg K, McCabe C, Hohman M, Shillington AM, Sise CB, Castillo EM, Chan TC, Sise MJ, Gareri J

Abstract
BACKGROUND: Although screening, brief intervention, and referral to treatment (SBIRT) has shown promise for alcohol use, relatively little is known about its effectiveness for adult illicit drug use. This randomized controlled trial assessed the effectiveness of the SBIRT approach for outcomes related to drug use among patients visiting trauma and emergency departments (EDs) at two large, urban hospitals.
METHODS: A total of 700 ED patients who admitted using illegal drugs in the past 30 days were recruited, consented, provided baseline measures of substance use and related problems measured with the Addiction Severity Index-Lite (ASI-Lite), and then randomized to the Life Shift SBIRT intervention or to an attention-placebo control group focusing on driving and traffic safety (Shift Gears). Both groups received a level of motivational intervention matched to their condition and risk level by trained paraprofessional health educators. Separate measurement technicians conducted face-to-face follow-ups at 6 months post-intervention and collected hair samples to confirm reports of abstinence from drug use. The primary outcome measure of the study was past 30-day drug abstinence at 6 months post-intervention, as self-reported on the ASI-Lite.
RESULTS: Of 700 participants, 292 (42%) completed follow-up. There were no significant differences in self-reported abstinence (12.5% vs. 12.0% , p = 0.88) for Life Shift and Shift Gears groups, respectively. When results of hair analyses were applied, the abstinence rate was 7 percent for Life Shift and 2 percent for Shift Gears (p = .074). In an analysis in which results were imputed (n = 694), there was no significant difference in the ASI-Lite drug use composite scores (Life Shift +0.005 vs. Shift Gears +0.017, p = 0.12).
CONCLUSIONS: In this randomized controlled trial, there was no evidence of effectiveness of SBIRT on the primary drug use outcome.Trial registration: ClinicalTrials.gov NCT01683227.

PMID: 24886786 [PubMed - as supplied by publisher]

Screening, Brief Intervention, and Referral to Treatment for Older Adults With Substance Misuse.

Sat, 05/17/2014 - 6:00am

Screening, Brief Intervention, and Referral to Treatment for Older Adults With Substance Misuse.

Am J Public Health. 2014 May 15;

Authors: Schonfeld L, Hazlett RW, Hedgecock DK, Duchene DM, Burns LV, Gum AM

Abstract
Objectives. We compared substance use and SBIRT (Screening, Brief Intervention, and Referral to Treatment) services received for older adults screened by the Florida BRITE (BRief Intervention and Treatment of Elders) Project, across 4 categories of service providers. Methods. Staff from 29 agencies screened for substance use risk in 75 sites across 18 Florida counties. Clients at no or low risk received feedback about screening; moderate risk led to brief intervention, moderate or high risk led to brief treatment, and highest severity led to referral to treatment. Six-month follow-ups were conducted with a random sample of clients. Results. Over 5 years (September 15, 2006-September 14, 2011), 85 001 client screenings were recorded. Of these, 8165 clients were at moderate or high risk. Most received brief intervention for alcohol or medication misuse. Differences were observed across 4 categories of agencies. Health educators screening solely within medical sites recorded fewer positive screens than those from mental health, substance abuse, or aging services that screened in a variety of community-based and health care sites. Six-month follow-ups revealed a significant decrease in substance use. Conclusions. The Florida BRITE Project demonstrated that SBIRT can be extended to nonmedical services that serve older adults. (Am J Public Health. Published online ahead of print May 15, 2014: e1-e7. doi:10.2105/AJPH.2013.301859).

PMID: 24832147 [PubMed - as supplied by publisher]

Prevention and Screening, Brief Intervention, and Referral to Treatment for Substance Use in Primary Care.

Sat, 05/17/2014 - 6:00am

Prevention and Screening, Brief Intervention, and Referral to Treatment for Substance Use in Primary Care.

Prim Care. 2014 Jun;41(2):185-213

Authors: Strobbe S

Abstract
Substance use and related disorders are among the leading causes of preventable injury and illness, chronic health conditions, medical complications, disability, increased suffering, and premature death. Primary care clinicians can help patients avoid, reduce, or eliminate high-risk behaviors and negative consequences associated with substance use by integrating prevention and screening, brief intervention, and referral to treatment into their clinical practices. This article provides the necessary information, evidence-based recommendations, and readily available resources to help address substance use and related disorders in primary care, with special emphasis on the use of tobacco, alcohol, cannabis, and nonmedical prescription opioid medications.

PMID: 24830605 [PubMed - as supplied by publisher]

Pilot study of a social network intervention for heroin users in opiate substitution treatment: study protocol for a randomized controlled trial.

Tue, 05/06/2014 - 6:00am
Related Articles

Pilot study of a social network intervention for heroin users in opiate substitution treatment: study protocol for a randomized controlled trial.

Trials. 2013;14:264

Authors: Day E, Copello A, Seddon JL, Christie M, Bamber D, Powell C, George S, Ball A, Frew E, Freemantle N

Abstract
BACKGROUND: Research indicates that 3% of people receiving opiate substitution treatment (OST) in the UK manage to achieve abstinence from all prescribed and illicit drugs within 3 years of commencing treatment, and there is concern that treatment services have become skilled at engaging people but not at helping them to enter a stage of recovery and drug abstinence. The National Treatment Agency for Substance Misuse recommends the involvement of families and wider social networks in supporting drug users' psychological treatment, and this pilot randomized controlled trial aims to evaluate the impact of a social network-focused intervention for patients receiving OST.
METHODS AND DESIGN: In this two-site, early phase, randomized controlled trial, a total of 120 patients receiving OST will be recruited and randomized to receive one of three treatments: 1) Brief Social Behavior and Network Therapy (B-SBNT), 2) Personal Goal Setting (PGS) or 3) treatment as usual. Randomization will take place following baseline assessment. Participants allocated to receive B-SBNT or PGS will continue to receive the same treatment that is routinely provided by drug treatment services, plus four additional sessions of either intervention. Outcomes will be assessed at baseline, 3 and 12 months. The primary outcome will be assessment of illicit heroin use, measured by both urinary analysis and self-report. Secondary outcomes involve assessment of dependence, psychological symptoms, social satisfaction, motivation to change, quality of life and therapeutic engagement. Family members (n = 120) of patients involved in the trial will also be assessed to measure the level of symptoms, coping and the impact of the addiction problem on the family member at baseline, 3 and 12 months.
DISCUSSION: This study will provide experimental data regarding the feasibility and efficacy of implementing a social network intervention within routine drug treatment services in the UK National Health Service. The study will explore the impact of the intervention on both patients receiving drug treatment and their family members.
TRIAL REGISTRATION: Trial Registration Number: ISRCTN22608399. ISRCTN22608399 registration: 27/04/2012. Date of first randomisation: 14/08/2012.

PMID: 23958332 [PubMed - indexed for MEDLINE]

Suicidal ideation and HIV risk behaviors among a cohort of injecting drug users in New Delhi, India.

Sat, 05/03/2014 - 6:00am
Related Articles

Suicidal ideation and HIV risk behaviors among a cohort of injecting drug users in New Delhi, India.

Subst Abuse Treat Prev Policy. 2013;8:2

Authors: Sarin E, Singh B, Samson L, Sweat M

Abstract
BACKGROUND: Data on mental health among injecting drug users in South Asia is scarce yet poor mental health among users has significant implications for the success of HIV prevention and treatment programmes. A cohort of 449 injecting drug users in Delhi was examined on the following issues (1) examine trends in suicidal ideation, suicide plan and suicidal attempts over a 12-month period, (2) examine association between injecting practices (receive and give used syringes) and suicidal ideation over a 12 month study period.
METHODS: An observational study was conducted providing phased interventions with follow up interviews every 3 months to 449 injecting drug users (IDUs), from August 2004 to November 2005. The study was conducted in Yamuna Bazaar, a known hub of drug peddling in Delhi. Interventions included nutrition, basic medical services, needle exchange, health education, HIV voluntary counseling and testing, STI diagnosis and treatment, oral buprenorphine substitution, and detoxification, each introduced sequentially.
RESULTS: Suicidal ideation and suicide attempts, did not significantly change over 12 months of observation, while suicide plans actually increased over the time period. Keeping other factors constant, IDUs with suicidal ideation reported more giving and receiving of used syringes in the recent past. Conclusions: Mental health services are warranted within harm reduction programmes. Special attention must be paid to suicidal IDUs given their higher risk behaviours for acquiring HIV and other blood borne infections. IDU intervention programmes should assess and address suicide risk through brief screening and enhanced counseling.

PMID: 23320480 [PubMed - indexed for MEDLINE]

An Early Evaluation of Implementation of Brief Intervention for Unhealthy Alcohol Use in the U.S. Veterans Health Administration.

Wed, 04/30/2014 - 6:00am

An Early Evaluation of Implementation of Brief Intervention for Unhealthy Alcohol Use in the U.S. Veterans Health Administration.

Addiction. 2014 Apr 29;

Authors: Williams EC, Rubinsky AD, Chavez LJ, Lapham GT, Rittmueller SE, Achtmeyer CE, Bradley KA

Abstract
AIMS: The U.S. Veterans Health Administration (VA) used performance measures and electronic clinical reminders to implement brief intervention for unhealthy alcohol use. We evaluated whether documented brief intervention was associated with subsequent changes in drinking during early implementation.
DESIGN: Observational, retrospective cohort study using secondary clinical and administrative data.
SETTING: 30 VA facilities.
PARTICIPANTS: Outpatients who screened positive for unhealthy alcohol use (AUDIT-C ≥ 5) in the 6 months after the brief intervention performance measure (n=22,214) and had follow-up screening 9-15 months later (n=6,210; 28%).
MEASUREMENTS: Multilevel logistic regression estimated the adjusted prevalence of resolution of unhealthy alcohol use (follow-up AUDIT-C <5 with ≥ 2 point reduction) for patients with and without documented brief intervention (documented advice to reduce or abstain from drinking).
FINDINGS: Among 6,210 patients with follow-up alcohol screening, 1,751 (28%) had brief intervention and 2,922 (47%) resolved unhealthy alcohol use at follow-up. Patients with documented brief intervention were older and more likely to have other substance use disorders, mental health conditions, poor health, and more severe unhealthy alcohol use than those without (p-values <0.05). Adjusted prevalences of resolution were 47% (95% Confidence Interval (CI) 42% - 52%) and 48% (95% CI 42% - 54%) for patients with and without documented brief intervention, respectively (p=0.50).
CONCLUSIONS: During early implementation of brief intervention in the U.S. Veterans Health Administration, documented brief intervention was not associated with subsequent changes in drinking among outpatients with unhealthy alcohol use and repeat alcohol screening.

PMID: 24773590 [PubMed - as supplied by publisher]

Clinical Needs of In-treatment Pregnant Women with Co-occurring Disorders: Implications for Primary Care.

Tue, 04/29/2014 - 6:00am

Clinical Needs of In-treatment Pregnant Women with Co-occurring Disorders: Implications for Primary Care.

Matern Child Health J. 2014 Apr 27;

Authors: Lee King PA, Duan L, Amaro H

Abstract
We investigated social vulnerability and behavioral health clinical profiles (symptom severity) of pregnant women with co-occurring disorders, defined as substance abuse, mental illness, and trauma at treatment entry compared to their nonpregnant counterparts and the role of interpersonal abuse in clinical presentation among pregnant women. Our objective was to provide primary health care providers with insight into the needs of pregnant patients with high behavioral health risks to serve them better during the critical window of opportunity for long-term impact. We conducted cross-sectional secondary analysis of baseline data from women enrolled in treatment programs in the Women, Co-occurring Disorders and Violence Study from nine sites across the United States. We used analysis of variance and Cochran-Mantel-Haenszel statistical analyses to compare means and frequencies of social vulnerability indicators and baseline Addiction Severity Index, Brief Symptom Inventory of mental health, and Posttraumatic Stress Diagnostic Scale scores between 152 pregnant and 2,577 nonpregnant women, and between pregnant women with and without current interpersonal abuse. Compared to nonpregnant women, pregnant women evidenced more social vulnerability but better behavioral health clinical profiles at treatment entry. Current interpersonal abuse was associated with increased mental health and trauma symptomatology but not with alcohol or drug abuse severity among pregnant women. The prenatal period is an important time for screening and intervention for factors such as social vulnerability and co-occurring disorders, known to affect pregnancy and infant outcomes; social and behavioral health services are particularly essential among pregnant women with co-occurring disorders.

PMID: 24770992 [PubMed - as supplied by publisher]

Psychosocial interventions for people with both severe mental illness and substance misuse.

Tue, 04/29/2014 - 6:00am
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Psychosocial interventions for people with both severe mental illness and substance misuse.

Cochrane Database Syst Rev. 2013;10:CD001088

Authors: Hunt GE, Siegfried N, Morley K, Sitharthan T, Cleary M

Abstract
BACKGROUND: Even low levels of substance misuse by people with a severe mental illness can have detrimental effects.
OBJECTIVES: To assess the effects of psychosocial interventions for reduction in substance use in people with a serious mental illness compared with standard care.
SEARCH METHODS: For this update (2013), the Trials Search Co-ordinator of the Cochrane Schizophrenia Group (CSG) searched the CSG Trials Register (July 2012), which is based on regular searches of major medical and scientific databases. The principal authors conducted two further searches (8 October 2012 and 15 January 2013) of the Cochrane Database of Systematic Reviews, MEDLINE and PsycINFO. A separate search for trials of contingency management was completed as this was an additional intervention category for this update.
SELECTION CRITERIA: We included all randomised controlled trials (RCTs) comparing psychosocial interventions for substance misuse with standard care in people with serious mental illness.
DATA COLLECTION AND ANALYSIS: We independently selected studies, extracted data and appraised study quality. For binary outcomes, we calculated standard estimates of relative risk (RR) and their 95% confidence intervals (CI) on an intention-to-treat basis. For continuous outcomes, we calculated the mean difference (MD) between groups. For all meta-analyses we pooled data using a random-effects model. Using the GRADE approach, we identified seven patient-centred outcomes and assessed the quality of evidence for these within each comparison.
MAIN RESULTS: We included 32 trials with a total of 3165 participants. Evaluation of long-term integrated care included four RCTs (n = 735). We found no significant differences on loss to treatment (n = 603, 3 RCTs, RR 1.09 CI 0.82 to 1.45, low quality of evidence), death by 3 years (n = 421, 2 RCTs, RR 1.18 CI 0.39 to 3.57, low quality of evidence), alcohol use (not in remission at 36 months) (n = 143, 1 RCT, RR 1.15 CI 0.84 to 1.56,low quality of evidence), substance use (n = 85, 1 RCT, RR 0.89 CI 0.63 to 1.25, low quality of evidence), global assessment of functioning (n = 171, 1 RCT, MD 0.7 CI 2.07 to 3.47, low quality of evidence), or general life satisfaction (n = 372, 2 RCTs, MD 0.02 higher CI 0.28 to 0.32, moderate quality of evidence).For evaluation of non-integrated intensive case management with usual treatment (4 RCTs, n = 163) we found no statistically significant difference for loss to treatment at 12 months (n = 134, 3 RCTs, RR 1.21 CI 0.73 to 1.99, very low quality of evidence).Motivational interviewing plus cognitive behavioural therapy compared to usual treatment (7 RCTs, total n = 878) did not reveal any advantage for retaining participants at 12 months (n = 327, 1 RCT, RR 0.99 CI 0.62 to 1.59, low quality of evidence) or for death (n = 493, 3 RCTs, RR 0.72 CI 0.22 to 2.41, low quality of evidence), and no benefit for reducing substance use (n = 119, 1 RCT, MD 0.19 CI -0.22 to 0.6, low quality of evidence), relapse (n = 36, 1 RCT, RR 0.5 CI 0.24 to 1.04, very low quality of evidence) or global functioning (n = 445, 4 RCTs, MD 1.24 CI 1.86 to 4.34, very low quality of evidence).Cognitive behavioural therapy alone compared with usual treatment (2 RCTs, n = 152) showed no significant difference for losses from treatment at 3 months (n = 152, 2 RCTs, RR 1.12 CI 0.44 to 2.86, low quality of evidence). No benefits were observed on measures of lessening cannabis use at 6 months (n = 47, 1 RCT, RR 1.30 CI 0.79 to 2.15, very low quality of evidence) or mental state (n = 105, 1 RCT, Brief Psychiatric Rating Scale MD 0.52 CI -0.78 to 1.82, low quality of evidence).We found no advantage for motivational interviewing alone compared with usual treatment (8 RCTs, n = 509) in reducing losses to treatment at 6 months (n = 62, 1 RCT, RR 1.71 CI 0.63 to 4.64, very low quality of evidence), although significantly more participants in the motivational interviewing group reported for their first aftercare appointment (n = 93, 1 RCT, RR 0.69 CI 0.53 to 0.9). Some differences, favouring treatment, were observed in abstaining from alcohol (n = 28, 1 RCT, RR 0.36 CI 0.17 to 0.75, very low quality of evidence) but not other substances (n = 89, 1 RCT, RR -0.07 CI -0.56 to 0.42, very low quality of evidence), and no differences were observed in mental state (n = 30, 1 RCT, MD 0.19 CI -0.59 to 0.21, very low quality of evidence).We found no significant differences for skills training in the numbers lost to treatment by 12 months (n = 94, 2 RCTs, RR 0.70 CI 0.44 to 1.1, very low quality of evidence).We found no differences for contingency management compared with usual treatment (2 RCTs, n = 206) in numbers lost to treatment at 3 months (n = 176, 1 RCT, RR 1.65 CI 1.18 to 2.31, low quality of evidence), number of stimulant positive urine tests at 6 months (n = 176, 1 RCT, RR 0.83 CI 0.65 to 1.06, low quality of evidence) or hospitalisations (n = 176, 1 RCT, RR 0.21 CI 0.05 to 0.93, low quality of evidence).We were unable to summarise all findings due to skewed data or because trials did not measure the outcome of interest. In general, evidence was rated as low or very low due to high or unclear risks of bias because of poor trial methods, or poorly reported methods, and imprecision due to small sample sizes, low event rates and wide confidence intervals.
AUTHORS' CONCLUSIONS: We included 32 RCTs and found no compelling evidence to support any one psychosocial treatment over another for people to remain in treatment or to reduce substance use or improve mental state in people with serious mental illnesses. Furthermore, methodological difficulties exist which hinder pooling and interpreting results. Further high quality trials are required which address these concerns and improve the evidence in this important area.

PMID: 24092525 [PubMed - indexed for MEDLINE]

[A methodology to implement preventive actions against harmful drug use in the context of primary health care in Latin America].

Sat, 04/26/2014 - 6:00am
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[A methodology to implement preventive actions against harmful drug use in the context of primary health care in Latin America].

Rev Panam Salud Publica. 2013 May;33(5):325-31

Authors: Costa PH, Mota DC, Cruvinel E, Paiva FS, Ronzani TM

Abstract
OBJECTIVE: To develop a methodology to implement practices of prevention against the use of alcohol and other drugs in the context of primary health care (PHC) that will contribute to the debate about policies and actions in Latin American countries.
METHODS: This intervention research project was carried out in a small/medium-sized Brazilian city. The development process was assessed through participant observation with the aim of adapting the methodology to local needs and identifying existing weaknesses and strengths with impact on implementation.
RESULTS: A model was developed with six stages: initial contact and planning, diagnosis and mapping, sensitization, training, follow-up, and communication of results to participants. The following weaknesses were identified: limitation of resources (human, financial, infrastructural), limitations in the coverage and comprehensiveness of the assistance network, poor participation from physicians, training based on medicalized care, insufficient participation of health care management, insufficient involvement and participation of civil society, and few opportunities for participation of the population in the planning and execution of public policies. Strengths included the participation of community health agents and nurses in applying, organizing, and planning initiatives, in addition to the organization of educative and preventive actions in schools and communities by health care teams, suggesting that it is possible to implement screening, brief intervention, and referral to treatment (SBIRT) initiatives in the context of PHC in Latin America.
CONCLUSIONS: The methodology developed in this study can be useful for Latin American countries if local needs are taken into consideration. It should be noted, however, that results will only be observed in the mid- to long term, rather than strictly in the short term.

PMID: 23764663 [PubMed - indexed for MEDLINE]

Validity of Brief Screening Instrument for Adolescent Tobacco, Alcohol, and Drug Use.

Wed, 04/23/2014 - 6:00am

Validity of Brief Screening Instrument for Adolescent Tobacco, Alcohol, and Drug Use.

Pediatrics. 2014 Apr 21;

Authors: Kelly SM, Gryczynski J, Mitchell SG, Kirk A, O'Grady KE, Schwartz RP

Abstract
BACKGROUND AND OBJECTIVE: The National Institute on Alcohol Abuse and Alcoholism developed an alcohol screening instrument for youth based on epidemiologic data. This study examines the concurrent validity of this instrument, expanded to include tobacco and drugs, among pediatric patients, as well as the acceptability of its self-administration on an iPad.
METHODS: Five hundred and twenty-five patients (54.5% female; 92.8% African American) aged 12 to 17 completed the Brief Screener for Tobacco, Alcohol, and other Drugs (BSTAD) via interviewer-administration or self-administration using an iPad. Diagnostic and Statistical Manual, Fifth Edition substance use disorders (SUDs) were identified using a modified Composite International Diagnostic Interview-2 Substance Abuse Module. Receiver operating characteristic curves, sensitivities, and specificities were obtained to determine optimal cut points on the BSTAD in relation to SUDs.
RESULTS: One hundred fifty-nine (30.3%) adolescents reported past-year use of ≥1 substances on the BSTAD: 113 (21.5%) used alcohol, 84 (16.0%) used marijuana, and 50 (9.5%) used tobacco. Optimal cut points for past-year frequency of use items on the BSTAD to identify SUDs were ≥6 days of tobacco use (sensitivity = 0.95; specificity = 0.97); ≥2 days of alcohol use (sensitivity = 0.96; specificity = 0.85); and ≥2 days of marijuana use (sensitivity = 0.80; specificity = 0.93). iPad self-administration was preferred over interviewer administration (z = 5.8; P < .001).
CONCLUSIONS: The BSTAD is a promising screening tool for identifying problematic tobacco, alcohol, and marijuana use in pediatric settings. Even low frequency of substance use among adolescents may indicate need for intervention.

PMID: 24753528 [PubMed - as supplied by publisher]

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