Chris Dunn

Brief Intervention for Problem Drug Use in Safety-Net Primary Care Settings: A Randomized Clinical Trial

IMPORTANCE Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance). OBJECTIVE To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual. DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points. INTERVENTIONS Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433). MAIN OUTCOMES AND MEASURES The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior. RESULTS Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, β = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, β = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes. CONCLUSIONS AND RELEVANCE A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00877331.

A Randomized Stepped Care Intervention Trial Targeting Posttraumatic Stress Disorder for Surgically Hospitalized Injury Survivors

Objective: To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury. Background: Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings. Methods: The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at 1, 3, 6, 9, and 12 months after the index injury admission. Results: Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared with controls [group by time effect, CAPS (Clinician-Administered PTSD Scale): F(2, 185) = 5.50, P < 0.01; PCL-C (PTSD Checklist Civilian Version): F(4, 185) = 5.45, P < 0.001]. Clinically and statistically significant PTSD treatment effects were observed at the 6-, 9-, and 12-month postinjury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function [MOS SF-36 PCS (Medical Outcomes Study Short Form 36 Physical Component Summary) main effect: F(1, 172) = 9.87, P < 0.01]. Conclusions: Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at US trauma centers. (Trial Registration: clinicaltrials.gov identifier: NCT00270959)

Agency context and tailored training in technology transfer: A pilot evaluation of motivational interviewing training for community counselors

Few empirical studies are available to guide best practices for transferring evidenced-based treatments to community substance abuse providers. To maximize the learning and maintenance of new clinical skills, this study tested a context-tailored training (CTT) model, which used standardized patient actors in role-plays tailored to agency clinical context, repetitive cycles of practice and feedback, and enhanced organizational support. This study reports the results of a randomized pilot evaluation of CTT for motivational interviewing (MI). Investigators randomly assigned community substance abuse treatment agencies to receive either CTT or a standard 2-day MI workshop. The study also evaluated the effects of counselor-level and organizational-level variables on the learning of MI. No between-condition differences were observed on the acquisition and maintenance of MI skills despite reported higher satisfaction with the more costly context-tailored model. Analyses revealed that those counselors with more formal education and less endorsement of a disease model of addiction made the greatest gains in MI skills, irrespective of training condition. Similarly, agencies whose individual counselors viewed their organization as being more open to change and less supportive of autonomy showed greater average staff gains in MI skills, again, irrespective of training method. Posttraining activities within agencies that supported the ongoing learning and implementation of MI mediated the effects of organizational openness to change. This pilot study suggests that tailored training methods may not produce better outcomes than traditional workshops for the acquisition of evidence-based practice, and that efforts to enhance skill acquisition can be focused on characteristics of learners and ongoing organizational support of learning.

Posttraumatic Distress, Alcohol Disorders, and Recurrent Trauma Across Level 1 Trauma Centers

BACKGROUND Injured survivors of individual and mass trauma receive their initial evaluation in acute care. Few investigations have comprehensively screened for posttraumatic stress disorder (PTSD) symptoms and related comorbidities across sites. METHODS This investigation included 269 randomly selected injury survivors hospitalized at two level 1 trauma centers. All patients were screened for PTSD, depressive, and peritraumatic dissociative symptoms during their surgical inpatient admission. Prior traumatic life events and alcohol abuse/dependence also were assessed. RESULTS In this study, 58% of the patients demonstrated high levels of immediate posttraumatic distress or alcohol abuse/dependence. Regression analyses identified greater prior trauma, female gender, nonwhite ethnicity, and site as significant independent predictors for high levels of posttraumatic distress. CONCLUSIONS High levels of posttraumatic distress, recurrent trauma, and alcohol abuse/dependence were present in more than half of acute care inpatients. Early mental health screening and intervention procedures that target both PTSD and alcohol use should be developed for acute care settings.

Practical guidelines for performing alcohol interventions in trauma centers

Nearly 50% of trauma patients are injured while under the influence of alcohol; however, addressing alcohol problems is not considered a routine component of trauma care. A public health approach to trauma prevention should include attention to underlying risk factors in the same way that advice regarding smoking cessation is offered in adult respiratory medicine clinics, and blood pressure, cholesterol, dietary, and exercise advice is provided in coronary care units. The Department of Health and Human Services, in its recent report to Congress, stated that efforts to reduce death and disability from injuries must be combined with efforts to reduce alcohol abuse, and called for an increase in the use of alcohol interventions in trauma patients. According to the National Academy of Sciences, the responsibility to provide counseling for patients with uncomplicated cases of mild to moderate alcohol abuse lies not with specialized alcohol treatment centers, but with physicians and other health care staff in general hospital settings trained to provide brief interventions. This paper provides practical guidelines for the administration of alcohol interventions that are suitable for trauma center use, and that have documented efficacy in reducing alcohol consumption.

Hazardous drinking by trauma patients during the year after injury

BACKGROUND To improve reinjury prevention strategies targeting hazardous drinking, we determined its predictors and longitudinal course in the year after injury. METHODS This was a prospective study of 101 randomly selected hospitalized trauma patients who before injury represented the full range of substance abuse, from severe to none. We hypothesized that clinical data obtained routinely by trauma centers would predict hazardous drinking during the postinjury year. RESULTS Drug and alcohol use dropped markedly 1 month after injury but returned to preinjury levels by 4 months. Forty-one percent of the sample drank hazardously before injury, and 55% drank hazardously after. From before to after injury, 20% of patients worsened their hazardous drinking status, and only 6% of patients improved it. Three clinical predictors of hazardous drinking during the year were identified: any positive blood alcohol concentration > 0 at admission (odds ratio [OR], 9.18; 95% confidence interval [CI], 2.51-33.56), any days > 0 of using nonprescription drugs of abuse in the month before injury (OR, 6.63; 95% CI, 1.76-25.04), and suffering an intentional injury (OR, 5.1; 95% CI, 1.38-18.77). CONCLUSION Efforts to reduce hazardous drinking after injury should target patients with this risk profile and focus on the 1- to 4-month period after injury hospitalization.

Are medical marijuana users different from recreational users? The view from primary care.

BACKGROUND AND OBJECTIVES Marijuana is currently approved for medical use in 23 states. Both clinicians and the lay public have questioned whether users of marijuana for medical purposes are different from users of marijuana for recreational purposes. This study examined similarities and differences in important clinical characteristics between users of medical marijuana and users of recreational marijuana. METHODS The sample consisted of 868 adult primary care patients in Washington State, who reported use of medical marijuana (n = 131), recreational marijuana (n = 525), or drugs other than marijuana (n = 212). Retention was over 87% at 3-, 6-, 9-, and 12-month assessments. RESULTS The majority of medical, psychiatric, substance use, and service utilization characteristic comparisons were not significant. However, medical marijuana users had significantly more medical problems, a significantly larger proportion reported >15 days medical problems in the past month, and significantly smaller proportions reported no pain and no mobility limitations (p < .001). Medical marijuana users also had significantly lower drug problem severity, lower alcohol problem severity, and significantly larger proportions reported using marijuana alone and concomitant opioid use only (p < .001). There was no significant difference between medical and recreational users in the percentage using marijuana with at least two additional substances (48% vs. 58%, respectively, p = .05). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Although our results suggest that there are few distinct differences between medical and recreational users of marijuana, the differences observed, while mostly very small in effect size (<.2), are consistent with at least some medical users employing marijuana to relieve symptoms and distress associated with medical illness.

Disseminating alcohol screening and brief intervention at trauma centers: a policy-relevant cluster randomized effectiveness trial.

BACKGROUND AND AIMS In 2005 the American College of Surgeons passed a mandate requiring that level I trauma centers have mechanisms to identify and intervene with problem drinkers. The aim of this investigation was to determine if a multi-level trauma center intervention targeting both providers and patients would lead to higher-quality alcohol screening and brief intervention (SBI) when compared with trauma center mandate compliance without implementation enhancements. DESIGN Cluster randomized trial in which intervention site (site n = 10, patient n = 409) providers received 1-day workshop training on evidence-based motivational interviewing (MI) alcohol interventions and four 30-minute feedback and coaching sessions; control sites (site n = 10, patient n = 469) implemented the mandate without study team training enhancements. SETTING Trauma centers in the United States of America. PARTICIPANTS A total of 878 blood alcohol-positive in-patients with and without traumatic brain injury (TBI). MEASUREMENTS MI skills of providers were assessed with fidelity coded standardized patient interviews. All patients were interviewed at baseline and 6- and 12-months post-injury with the Alcohol Use Disorders Identification Test (AUDIT). FINDINGS Intervention site providers consistently demonstrated enhanced MI skills compared with control providers. Intervention patients demonstrated an 8% reduction in AUDIT hazardous drinking relative to controls over the course of the year after injury (relative risk = 0.88, 95%, confidence interval = 0.79, 0.98). Intervention patients were more likely to demonstrate improvements in alcohol use problems in the absence of traumatic brain injury (TBI) (P = 0.002). CONCLUSION Trauma center providers can be trained to deliver higher-quality alcohol screening and brief intervention (SBI) than untrained providers, which is associated with modest reductions in alcohol use problems, particularly among patients without TBI.

What is Seen Through the Looking Glass: The Impact of Training on Practitioner Self-Rating of Motivational Interviewing Skills

Training efforts for evidenced based treatments require evaluation, yet the value of practitioner self-reports of skills acquisition has been questioned. Thus, a key issue concerns how accurately practitioners assess their own clinical skills. In the current study, 23 community practitioners participated in training of Motivational Interviewing (MI), completed standardized patient (SP) interviews before and after training, and provided self-ratings of MI elements after each interview. Interview recordings were later coded independently. Results suggest training contributed to: 1) reasonable agreement between practitioner and independent ratings; and 2) more effective use of MI, despite a tendency for practitioners to underestimate training gains. This micro-analysis of training documents initial skill gains along with increased practitioner self-awareness. Further, it exemplifies how practitioner self-ratings and objective skill assessment methods may be used in tandem to more fully describe practitioner learning.

MOTIVATIONAL INTERVIEWING WITH INJURED ADOLESCENTS IN THE EMERGENCY DEPARTMENT: IN-SESSION PREDICTORS OF CHANGE

This paper reports the process outcomes of a randomized trial of a one-session Motivational Interviewing (MI) intervention(1) conducted with youth (12-20 years) in a hospital emergency department (ED) while undergoing medical care for an injury. The interventions targeted six behaviors placing youths at high risk for injury. Those youth whose counselors perceived their readiness to increase between the start and end of the MI session were 4.5 times more likely to have improved their use of seat belts 6 months later compared with youth who were not perceived to have increased in readiness during the session.