Christine Lloyd-Travaglini

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

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 masters-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.

The relationship between sexual and physical abuse and substance abuse consequences

This study examines the relationship between a history of physical and sexual abuse (PhySexAbuse) and drug and alcohol related consequences. We performed a cross-sectional analysis of data from 359 male and 111 female subjects recruited from an inpatient detoxification unit. The Inventory of Drug Use Consequences (InDUC), measured negative life consequences of substance use. Eighty-one percent of women and 69% of men report past PhySexAbuse, starting at a median age of 13 and 11, respectively. In bivariate and multivariable analyses, PhySexAbuse was significantly associated with more substance abuse consequences (p < 0.001). For men, age < or =17 years at first PhySexAbuse was significantly associated with more substance abuse consequences than an older age at first abuse, or no abuse (p = 0.048). For women, the association of PhySexAbuse with substance use consequences was similar across all ages (p = 0.59). Future research should develop interventions to lessen the substance abuse consequences of physical and sexual abuse.

Impact of health literacy on depressive symptoms and mental health-related: quality of life among adults with addiction.

AbstractBACKGROUND: Health literacy has been linked to health status in a variety of chronic diseases. However, evidence for a relationship between health literacy and mental health outcomes is sparse. OBJECTIVE: We hypothesized that low literacy would be associated with higher addiction severity, higher levels of depressive symptoms, and worse mental health functioning compared with those with higher literacy in adults with alcohol and drug dependence. METHODS: The association of literacy with multiple mental health outcomes was assessed using multivariable analyses. Measurement instruments included the Rapid Estimate of Adult Literacy in Medicine (REALM), the Center for Epidemiologic Studies-Depression (CES-D) scale, the Mental Component Summary scale of the Short Form Health Survey, and the Addiction Severity Index for drug and alcohol addiction. Subjects included 380 adults recruited during detoxification treatment and followed prospectively at 6-month intervals for 2 years. Based on the REALM, subjects were classified as having either low (≤8th grade) or higher (≥9th grade) literacy levels. RESULTS: In longitudinal analyses, low literacy was associated with more depressive symptoms. The adjusted mean difference in CES-D scores between low and high literacy levels was 4 (P <.01). Literacy was not significantly associated with mental health-related quality of life or addiction severity. CONCLUSIONS: In people with alcohol and drug dependence, low literacy is associated with worse depressive symptoms. The mechanisms underlying the relationship between literacy and mental health outcomes should be explored to inform future intervention efforts.

Chronic Care Management for Dependence on Alcohol and Other Drugs The AHEAD Randomized Trial

IMPORTANCE People with substance dependence have health consequences, high health care utilization, and frequent comorbidity but often receive poor-quality care. Chronic care management (CCM) has been proposed as an approach to improve care and outcomes. OBJECTIVE To determine whether CCM for alcohol and other drug dependence improves substance use outcomes compared with usual primary care. DESIGN, SETTING, AND PARTICIPANTS The AHEAD study, a randomized trial conducted among 563 people with alcohol and other drug dependence at a Boston, Massachusetts, hospital-based primary care practice. Participants were recruited from September 2006 to September 2008 from a freestanding residential detoxification unit and referrals from an urban teaching hospital and advertisements; 95% completed 12-month follow-up. INTERVENTIONS Participants were randomized to receive CCM (n=282) or no CCM (n=281). Chronic care management included longitudinal care coordinated with a primary care clinician; motivational enhancement therapy; relapse prevention counseling; and on-site medical, addiction, and psychiatric treatment, social work assistance, and referrals (including mutual help). The no CCM (control) group received a primary care appointment and a list of treatment resources including a telephone number to arrange counseling. MAIN OUTCOMES AND MEASURES The primary outcome was self-reported abstinence from opioids, stimulants, or heavy drinking. Biomarkers were secondary outcomes. RESULTS There was no significant difference in abstinence from opioids, stimulants, or heavy drinking between the CCM (44%) and control (42%) groups (adjusted odds ratio, 0.84; 95% CI, 0.65-1.10; P=.21). No significant differences were found for secondary outcomes of addiction severity, health-related quality of life, or drug problems. No subgroup effects were found except among those with alcohol dependence, in whom CCM was associated with fewer alcohol problems (mean score, 10 vs 13; incidence rate ratio, 0.85; 95% CI, 0.72-1.00; P=.048). CONCLUSIONS AND RELEVANCE Among persons with alcohol and other drug dependence, CCM compared with a primary care appointment but no CCM did not increase self-reported abstinence over 12 months. Whether more intensive or longer-duration CCM is effective requires further investigation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00278447.

Primary Care Patients with Drug Use Report Chronic Pain and Self-Medicate with Alcohol and Other Drugs.

Chronic pain is common among patients with drug use disorders. The prevalence of chronic pain and its consequences in primary care patients who use drugs is unknown. To examine: 1) the prevalence of chronic pain and pain-related dysfunction among primary care patients who screen positive for drug use, and 2) the prevalence of substance use to self-medicate chronic pain in this population. This was a cross-sectional analysis. This study included 589 adult patients who screened positive for any illicit drug use or prescription drug misuse, recruited from an urban, hospital-based primary care practice. Both pain and pain-related dysfunction were assessed by numeric rating scales, and grouped as: (0) none, (1–3) mild, (4–6) moderate, (7–10) severe. Questions were asked about the use of substances to treat pain. Among 589 participants, chronic pain was reported by 87 % (95 % CI: 84–90 %), with 13 % mild, 24 % moderate and 50 % severe. Pain-related dysfunction was reported by 74 % (95 % CI: 70–78 %), with 15 % mild, 23 % moderate, and 36 % severe. Of the 576 that used illicit drugs (i.e., marijuana, cocaine, and/or heroin), 51 % reported using to treat pain (95 % CI: 47–55 % ). Of the 121 with prescription drug misuse, 81 % (95 % CI: 74–88 %) used to treat pain. Of the 265 participants who reported any heavy drinking in the past 3 months, 38 % (95 % CI: 32–44 %) did so to treat pain compared to 79 % (95 % CI: 68–90 %) of the 57 high-risk alcohol users. Chronic pain and pain-related dysfunction were the norm for primary care patients who screened positive for drug use, with nearly one-third reporting both severe pain and severe pain-related dysfunction. Many patients using illicit drugs, misusing prescription drugs and using alcohol reported doing so in order to self-medicate their pain. Pain needs to be addressed when patients are counseled about their substance use.ABSTRACTBACKGROUNDChronic pain is common among patients with drug use disorders. The prevalence of chronic pain and its consequences in primary care patients who use drugs is unknown.OBJECTIVESTo examine: 1) the prevalence of chronic pain and pain-related dysfunction among primary care patients who screen positive for drug use, and 2) the prevalence of substance use to self-medicate chronic pain in this population.DESIGNThis was a cross-sectional analysis.PARTICIPANTSThis study included 589 adult patients who screened positive for any illicit drug use or prescription drug misuse, recruited from an urban, hospital-based primary care practice.MAIN MEASURESBoth pain and pain-related dysfunction were assessed by numeric rating scales, and grouped as: (0) none, (1–3) mild, (4–6) moderate, (7–10) severe. Questions were asked about the use of substances to treat pain.KEY RESULTSAmong 589 participants, chronic pain was reported by 87 % (95 % CI: 84–90 %), with 13 % mild, 24 % moderate and 50 % severe. Pain-related dysfunction was reported by 74 % (95 % CI: 70–78 %), with 15 % mild, 23 % moderate, and 36 % severe. Of the 576 that used illicit drugs (i.e., marijuana, cocaine, and/or heroin), 51 % reported using to treat pain (95 % CI: 47–55 % ). Of the 121 with prescription drug misuse, 81 % (95 % CI: 74–88 %) used to treat pain. Of the 265 participants who reported any heavy drinking in the past 3 months, 38 % (95 % CI: 32–44 %) did so to treat pain compared to 79 % (95 % CI: 68–90 %) of the 57 high-risk alcohol users.CONCLUSIONSChronic pain and pain-related dysfunction were the norm for primary care patients who screened positive for drug use, with nearly one-third reporting both severe pain and severe pain-related dysfunction. Many patients using illicit drugs, misusing prescription drugs and using alcohol reported doing so in order to self-medicate their pain. Pain needs to be addressed when patients are counseled about their substance use.

Professional Satisfaction Experienced When Caring for Substance-abusing Patients

This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients’ family history. Physicians were less likely (P<.05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction. Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician satisfaction may improve care for patients with addictions.

Emergency department and hospital utilization among alcohol and drug-dependent detoxification patients without primary medical care.

Utilization of emergency department (ED) services and hospitalization among a cohort of substance abusers are described based on structured research interviews with 470 adults without primary care admitted to an urban residential detoxification program. Cross-sectional analysis of baseline data of subjects found nearly 19% of subjects went to an ED on 2 or more occasions in the 6 months prior to detoxification and 14% were admitted for an overnight hospitalization. Upon further analysis of past 6-month ED utilization, the following factors were independently associated with increased odds of ED use: White race; at least one month homeless in the past 5 years chronic health condition; injury in past 6 months; and subject perception that their substance abuse interfered with seeking care from a regular doctor. Subjects with cocaine as a primary problem had lower odds of ED utilization than a reference group with alcohol as a primary problem.

Receipt of Addiction Treatment as a Consequence of a Brief Intervention for Drug Use in Primary Care: A Randomized Trial

Background and Aims Screening, brief intervention and ‘referral to treatment’ programs have been promoted widely as US federal policy. Little is known about the efficacy of the RT component (referral to treatment) of brief intervention for motivating patients with unhealthy drug use identified by screening to use addiction treatment. This study aimed to compare receipt of addiction treatment following two types of brief intervention for drug use versus a no‐intervention control group among primary care patients screening positive for drug use. Design Secondary analyses from a single‐site randomized controlled trial. Setting Massachusetts, USA. Participants A total of 528 adults with Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) drug‐specific scores ≥ 4. Interventions Random assignment to: (1) a 10–15‐minute brief negotiated interview (BNI) conducted by health educators (n = 174), (2) a 30–45‐minute adaptation of motivational interviewing by Masters‐level counselors (MOTIV) (n = 177) or (3) no BI (n = 177). All received a list of treatment and mutual help resources; both intervention protocols included dedicated staff for treatment referrals. Measurements Receipt of any addiction treatment within 6 months after study entry, assessed in a state‐wide database and hospital electronic medical record linked to trial data. Findings Among 528 participants, the main drugs used were marijuana (63%), cocaine (19%) and opioids (17%); 46% met past‐year drug dependence criteria (short form Composite International Diagnostic Interview); and 10% of MOTIV, 18% of BNI and 17% of control participants had any addiction treatment receipt within 6 months after study entry. There was no significant difference in addiction treatment receipt for BNI versus control [adjusted odds ratio (AOR) = 1.11; 95% confidence interval (CI) = 0.57, 2.15, Hochberg adjusted P = 0.76]. The MOTIV group had lower odds of linking to treatment (AOR = 0.36, 95% CI = 0.17, 0.78, Hochberg adjusted P = 0.02) compared with the no BI group. Conclusion Brief intervention delivered in primary care for screen‐identified drug use did not increase addiction treatment receipt significantly; a motivational interviewing approach appeared to be counterproductive.

Screening and brief intervention for drug use in primary care: the Assessing Screening Plus brief Intervention’s Resulting Efficacy to stop drug use (ASPIRE) randomized trial

Methods In this randomized trial (the Assessing Screening Plus brief Intervention’s Resulting Efficacy to stop drug use (ASPIRE) study) we tested the efficacy of a brief negotiated interview (BNI), and an adaptation of motivational interviewing (AMI), compared to no BI. Primary care patient participants had Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) drug specific scores of ≥4. Primary outcome at 6 months was number of days use of the drug of most concern (DOMC) in the past 30 days.

Phosphatidylethanol confirmed alcohol use among ART-naïve HIV-infected persons who denied consumption in rural Uganda

ABSTRACT Under-reporting of alcohol use by HIV-infected patients could adversely impact clinical care. This study examined factors associated with under-reporting of alcohol consumption by patients who denied alcohol use in clinical and research settings using an alcohol biomarker. We enrolled ART-naïve, HIV-infected adults at Mbarara Hospital HIV clinic in Uganda. We conducted baseline interviews on alcohol use, demographics, Spirituality and Religiosity Index (SRI), health and functional status; and tested for breath alcohol content and collected blood for phosphatidylethanol (PEth), a sensitive and specific biomarker of alcohol use. We determined PEth status among participants who denied alcohol consumption to clinic counselors (Group 1, n = 104), and those who denied alcohol use on their research interview (Group 2, n = 198). A positive PEth was defined as ≥8 ng/ml. Multiple logistic regression models were used to examine whether testing PEth-positive varied by demographics, literacy, spirituality, socially desirable reporting and physical health status. Results showed that, among the 104 participants in Group 1, 28.8% were PEth-positive. The odds of being PEth-positive were higher for those reporting prior unhealthy drinking (adjusted odds ratio (AOR): 4.7, 95% confidence interval (CI): 1.8, 12.5). No other factors were statistically significant. Among the 198 participants in Group 2, 13.1% were PEth-positive. The odds of being PEth-positive were higher for those reporting past unhealthy drinking (AOR: 4.6, 95% CI: 1.8, 12.2), the Catholics (AOR: 3.8, 95% CI: 1.3, 11.0) compared to Protestants and lower for the literate participants (AOR: 0.3, 95% CI: 0.1, 0.8). We concluded that under-reporting of alcohol use to HIV clinic staff was substantial, but it was lower in a research setting that conducted testing for breath alcohol and PEth. A report of past unhealthy drinking may highlight current alcohol use among deniers. Strategies to improve alcohol self-report are needed within HIV care settings in Uganda.