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From policy to practice: implementing frontline community health services for substance dependence¿study protocol.

Thu, 08/21/2014 - 6:00am

From policy to practice: implementing frontline community health services for substance dependence¿study protocol.

Implement Sci. 2014 Aug 20;9(1):108

Authors: Gill KJ, Campbell E, Gauthier G, Xenocostas S, Charney D, Macaulay AC

Abstract
BackgroundSubstance abuse is a worldwide public health concern. Extensive scientific research has shown that screening and brief interventions for substance use disorders administered in primary care provide substantial benefit at relatively low cost. Frontline health clinicians are well placed to detect and treat patients with substance use disorders. Despite effectiveness shown in research, there are many factors that impact the implementation of these practices in real-world clinical practice. Recently, the Ministry of Health and Social Services in Quebec, Canada, issued two policy documents aimed at introducing screening and early intervention for substance abuse into frontline healthcare clinics in Quebec. The current research protocol was developed in order to study the process of implementation of evidence-based addiction treatment practices at three primary care clinics in Montreal (Phase 1). In addition, the research protocol was designed to examine the efficacy of overall policy implementation, including barriers and facilitators to addictions program development throughout Quebec (Phase 2).Methods/DesignPhase 1 will provide an in-depth case study of knowledge translation and implementation. The study protocol will utilize an integrated knowledge translation strategy to build collaborative mechanisms for knowledge exchange between researchers, addiction specialists, and frontline practitioners (guided by the principles of participatory-action research), and directly examine the process of knowledge uptake and barriers to transfer using both qualitative and quantitative methodologies. Evaluation will involve multiple measures, time points and domains; program uptake and effectiveness will be determined by changes in healthcare service delivery, sustainability and outcomes. In Phase 2, qualitative methods will be utilized to examine the contextual facilitators and barriers that frontline organizations face in implementing services for substance dependence. Phase 2 will provide the first study exploring the wide-scale implementation of frontline services for substance dependence in the province of Quebec and yield needed information about how to effectively implement mandated policies into clinical practice and impact public health.DiscussionFindings from this research program will contribute to the understanding of factors associated with implementation of frontline services for substance dependence and help to inform future policy and organizational support for the implementation evidence-based practices.

PMID: 25138688 [PubMed - as supplied by publisher]

Addiction Disorders.

Wed, 08/20/2014 - 6:00am

Addiction Disorders.

Med Clin North Am. 2014 Sep;98(5):1097-1122

Authors: Merrill JO, Duncan MH

Abstract
Substance use disorders are common in primary care settings, but detection, assessment, and management are seldom undertaken. Substantial evidence supports alcohol screening and brief intervention for risky drinking, and pharmacotherapy is effective for alcohol use disorders. Substance use disorders can complicate the management of chronic noncancer pain, making routine monitoring and assessment for substance use disorders an important aspect of long-term opioid prescribing. Patients with opioid use disorders can be effectively treated with methadone in opioid treatment programs or with buprenorphine in the primary care setting.

PMID: 25134875 [PubMed - as supplied by publisher]

Facilitators and Barriers to Implementing SBIRT in Primary Care in Integrated Health Care Settings.

Sat, 08/16/2014 - 6:00am

Facilitators and Barriers to Implementing SBIRT in Primary Care in Integrated Health Care Settings.

Subst Abus. 2014 Aug 15;:0

Authors: Rahm AK, Boggs JM, Martin C, Price DW, Beck A, Backer TE, Dearing JW

Abstract
ABSTRACT Background: Substance abuse in the United States is a serious public health concern impacting morbidity and mortality. However, systematic screening and intervention has not been widely adopted into routine practice by health care organizations and routine screening and intervention is not currently in place for primary care at Kaiser Permanente Colorado. Therefore, a formative evaluation was conducted to explore and enhance implementation of the Substance Abuse and Mental Health Services Administration (SAMHSA) Screening, Brief Intervention, and Referral to Treatment (SBIRT) approach in the organization. Methods: Key clinical stakeholders, including internal and family medicine physicians, primary care nurses, mental health therapists, chemical dependency clinicians, and clinic-based psychologists provided feedback. Two focus groups were also conducted with patient stakeholders; one in English and one in Spanish. Results: All clinical stakeholders promoted clinic-based psychologists to conduct brief intervention and determine referral to treatment as the optimal implementation program. Inclusion of the patient perspective also highlighted the importance of considering this perspective in implementation. Both patient groups were generally supportive of SBIRT, especially the educational value of screening questions defining healthy drinking limits, however, English-speaking patients noted privacy concerns and Spanish-speaking patients noted frequently being asked about drug or alcohol use. Organizationally, systems exist to facilitate drug and alcohol use screening, intervention, and referral to treatment. However, physician time, alignment with other priorities, and lack of consistent communication were noted potential barriers to SBIRT implementation. Conclusions: Clinicians expressed concerns about competing priorities and the need for organizational leadership involvement for successful SBIRT implementation. A unique suggestion for successful implementation is to utilize existing primary care clinic-based psychologists to conduct brief intervention and facilitate referral to treatment. Patient stakeholders supported universal screening but cultural differences in opinions and current experience were noted, indicating the importance of including this perspective when evaluating implementation potential.

PMID: 25127073 [PubMed - as supplied by publisher]

Brief Intervention to Increase Emergency Department Uptake of Combined Rapid Human Immunodeficiency Virus and Hepatitis C Screening Among a Drug Misusing Population.

Sat, 08/16/2014 - 6:00am

Brief Intervention to Increase Emergency Department Uptake of Combined Rapid Human Immunodeficiency Virus and Hepatitis C Screening Among a Drug Misusing Population.

Acad Emerg Med. 2014 Jul;21(7):752-767

Authors: Merchant RC, Baird JR, Liu T, Taylor LE, Montague BT, Nirenberg TD

Abstract
OBJECTIVES: In this study, Increasing Viral Testing in the Emergency Department (InVITED), the authors investigated if a brief intervention about human immunodeficiency virus (HIV) and hepatitis C virus (HCV) risk-taking behaviors and drug use and misuse in addition to a self-administered risk assessment, compared to a self-administered risk assessment alone, increased uptake of combined screening for HIV and HCV, self-perception of HIV/HCV risk, and impacted beliefs and opinions on HIV/HCV screening.
METHODS: InVITED was a randomized, controlled trial conducted at two urban emergency departments (EDs) from February 2011 to March 2012. ED patients who self-reported drug use within the past 3 months were invited to enroll. Drug misuse severity and need for a brief or more intensive intervention was assessed using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Participants were randomly assigned to one of two study arms: a self-administered HIV/HCV risk assessment alone (control arm) or the assessment plus a brief intervention about their drug misuse and screening for HIV/HCV (intervention arm). Beliefs on the value of combined HIV/HCV screening, self-perception of HIV/HCV risk, and opinions on HIV/HCV screening in the ED were measured in both study arms before the HIV/HCV risk assessment (pre), after the assessment in the control arm, and after the brief intervention in the intervention arm (post). Participants in both study arms were offered free combined rapid HIV/HCV screening. Uptake of screening was compared by study arm. Multivariable logistic regression models were used to evaluate factors related to uptake of screening.
RESULTS: Of the 395 participants in the study, the median age was 28 years (interquartile range [IQR] = 23 to 38 years), 44.8% were female, 82.3% had ever been tested for HIV, and 67.3% had ever been tested for HCV. Uptake of combined rapid HIV/HCV screening was nearly identical by study arm (64.5% vs. 65.2%; Δ = -0.7%; 95% confidence interval [CI] = -10.1% to 8.7%). Of the 256 screened, none had reactive HIV antibody tests, but seven (2.7%) had reactive HCV antibody tests. Multivariable logistic regression analysis results indicated that uptake of screening was not related to study arm assignment, total ASSIST drug scores, need for an intervention for drug misuse, or HIV/HCV sexual risk assessment scores. However, uptake of screening was greater among participants who indicated placing a higher value on combined rapid HIV/HCV screening for themselves and all ED patients and those with higher levels of perceived HIV/HCV risk. Uptake of combined rapid HIV/HCV screening was not related to changes in beliefs regarding the value of combined HIV/HCV screening or self-perceived HIV/HCV risk (post- vs. pre-risk assessment with or without a brief intervention). Opinions regarding the ED as a venue for combined rapid HIV/HCV screening were not related to uptake of screening.
CONCLUSIONS: Uptake of combined rapid HIV/HCV screening is high and considered valuable among drug using and misusing ED patients with little concern about the ED as a screening venue. The brief intervention investigated in this study does not appear to change beliefs regarding screening, self-perceived risk, or uptake of screening for HIV/HCV in this population. Initial beliefs regarding the value of screening and self-perceived risk for these infections predict uptake of screening.

PMID: 25125271 [PubMed - as supplied by publisher]

Adolescent Substance Involvement Use and Abuse.

Sat, 08/16/2014 - 6:00am

Adolescent Substance Involvement Use and Abuse.

Prim Care. 2014 Sep;41(3):567-585

Authors: Monasterio EB

Abstract
Substance use in adolescence is common, but not all use indicates a substance use disorder. The primary care provider has an essential role in screening for substance involvement, assessing the level of substance use and its impact on function, and engaging in a brief intervention to encourage and support behavioral change related to substance use. This article summarizes the literature on adolescent vulnerability to substance use disorders and their impact on adolescent health and well-being. Practical concrete suggestions for approaches to screening, brief interventions, and referral to treatment provide a stepwise approach to adolescent substance use assessment and intervention.

PMID: 25124207 [PubMed - as supplied by publisher]

Web-based training for primary care providers on screening, brief intervention, and referral to treatment (SBIRT) for alcohol, tobacco, and other drugs.

Fri, 08/15/2014 - 6:00am

Web-based training for primary care providers on screening, brief intervention, and referral to treatment (SBIRT) for alcohol, tobacco, and other drugs.

J Subst Abuse Treat. 2014 Jul 12;

Authors: Stoner SA, Mikko AT, Carpenter KM

Abstract
This project evaluated a Web-based multimedia training for primary care providers in screening, brief intervention, and referral to treatment (SBIRT) for unhealthy use of alcohol, tobacco, and other drugs. Physicians (n=37), physician assistants (n=35), and nurse practitioners (n=20) were recruited nationally by email and randomly assigned to online access to either the multimedia training or comparable reading materials. At baseline, compared to non-physicians, physicians reported lower self-efficacy for counseling patients regarding substance use and doing so less frequently. All provider types in both conditions showed significant increases in SBIRT-related knowledge, self-efficacy, and clinical practices. Although the multimedia training was not superior to the reading materials with regard to these outcomes, the multimedia training was more likely to be completed and rated more favorably. Findings indicate that SBIRT training does not have to be elaborate to be effective. However, multimedia training may be more appealing to the target audiences.

PMID: 25115136 [PubMed - as supplied by publisher]

Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial.

Thu, 08/07/2014 - 6:00am

Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial.

JAMA. 2014 Aug 6;312(5):502-13

Authors: Saitz R, Palfai TP, Cheng DM, Alford DP, Bernstein JA, Lloyd-Travaglini CA, Meli SM, Chaisson CE, Samet JH

Abstract
IMPORTANCE: The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy.
OBJECTIVE: To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)-a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)-compared with no brief intervention.
DESIGN, SETTING, AND PARTICIPANTS: This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of ≥4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts.
INTERVENTIONS: Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master's-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources.
MAIN OUTCOMES AND MEASURES: Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization.
RESULTS: At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity.
CONCLUSIONS AND RELEVANCE: Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention.
TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00876941.

PMID: 25096690 [PubMed - in process]

A pilot study to assess the feasibility and impact of a brief motivational intervention on problem drug and alcohol use in adult mental health inpatient units: study protocol for a randomized controlled trial.

Sun, 08/03/2014 - 6:00am

A pilot study to assess the feasibility and impact of a brief motivational intervention on problem drug and alcohol use in adult mental health inpatient units: study protocol for a randomized controlled trial.

Trials. 2014 Aug 1;15(1):308

Authors: Graham HL, Birchwood M, Griffith E, Freemantle N, McCrone P, Stefanidou CA, Walsh K, Clarke L, Rana A, Copello A

Abstract
BACKGROUND: Substance misuse in those with severe mental health problems is common and associated with poor engagement in treatment and treatment outcomes. Up to 44% of those admitted into psychiatric inpatient facilities have coexisting substance-misuse problems. However, this is not routinely addressed as part of their treatment plan. A mental health admission may present a window of opportunity for inpatients to reevaluate the impact of their substance use. This study will aim to evaluate the effectiveness of a targeted brief motivational intervention in improving engagement in treatment and to assess how feasible and acceptable this intervention is to inpatients and staff as a routine intervention.Methods/design: This randomized controlled trial will use concealed randomization; blind, independent assessment of outcome at 3 months; characterization of refusers and dropouts; and be analyzed according to the intention-to-treat principle. After baseline assessments, eligible participants will be randomized either to the Brief Integrated Motivational Intervention plus Treatment As Usual, or Treatment as Usual alone. Eligible participants will be those who are new admissions; >18 years; ICD-10 diagnosis of -schizophrenia or related disorder, bipolar affective disorder, recurrent depressive disorder, and DSM-IV diagnosis of substance abuse or dependence over the last 3 months. The primary outcome is engagement in treatment for substance misuse, and secondary outcomes include readiness to change substance misuse together with a cost-effectiveness analysis. Qualitative interviews with staff and participants will assess the acceptability of the intervention.
DISCUSSION: This pilot randomized trial will provide the first robust evidence base for inpatient care of people with severe mental health problems and co-morbid substance misuse and provide the groundwork for confirmatory trials to evaluate a potentially feasible, cost-effective, and easy-to-implement treatment option that may be readily integrated into standard inpatient and community-based care.Trial registration: ISRCTN43548483 Date of ISRCTN assignation: 4/17/2014.

PMID: 25085539 [PubMed - as supplied by publisher]

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]

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