Jennifer McNeely

Test-retest reliability of a self-administered Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients.

The time required to conduct drug and alcohol screening has been a major barrier to its implementation in mainstream healthcare settings. Because patient self-administered tools are potentially more efficient, we translated the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) into an audio guided computer assisted self interview (ACASI) format. This study reports on the test-retest reliability of the ACASI ASSIST in an adult primary care population. Adult primary care patients completed the ACASI ASSIST, in English or Spanish, twice within a 1-4 week period. Among the 101 participants, there were no significant differences between test administrations in detecting moderate to high risk use for tobacco, alcohol, or any other drug class. Substance risk scores from the two administrations had excellent concordance (90-98%) and high correlation (ICC 0.90-0.97) for tobacco, alcohol, and drugs. The ACASI ASSIST has good test-retest reliability, and warrants additional study to evaluate its validity for detecting unhealthy substance use.

Opioid treatment at release from jail using extended-release naltrexone: A pilot proof-of-concept randomized effectiveness trial

BACKGROUND AND AIMS Relapse to addiction following incarceration is common. We estimated the feasibility and effectiveness of extended-release naltrexone (XR-NTX) as relapse prevention among opioid-dependent male adults leaving a large urban jail. DESIGN Eight-week, proof-of-concept, open-label, non-blinded randomized effectiveness trial. SETTING New York City jails and Bellevue Hospital Center Adult Primary Care clinics, USA. PARTICIPANTS From January 2010 to July 2013, 34 opioid-dependent adult males with no stated interest in agonist treatments (methadone, buprenorphine) received a counseling and referral intervention and were randomized to XR-NTX (n = 17) versus no medication (n = 17) within one week prior to jail release. INTERVENTION XR-NTX (Vivitrol(®) ; Alkermes Inc.), a long-acting injectable mu opioid receptor antagonist. MEASURES The primary intent-to-treat outcome was post-release opioid relapse at week 4, defined as ≥10 days of opioid misuse by self-report and urine toxicologies. Secondary outcomes were proportion of urine samples negative for opioids and rates of opioid abstinence, intravenous drug use (IVDU), cocaine use, community treatment participation, re-incarceration and overdose. FINDINGS Acceptance of XR-NTX was high; 15 of 17 initiated treatment. Rates of the primary outcome of week 4 opioid relapse were lower among XR-NTX participants: 38 versus 88% [P<0.004; odds ratio (OR) = 0.08, 95% confidence interval (CI) = 0.01-0.48]; more XR-NTX urine samples were negative for opioids, 59 versus 29% (P<0.009; OR = 3.5, 95% CI = 1.4-8.5). There were no significant differences in the remaining secondary outcomes, including rates of IVDU, cocaine use, re-incarceration and overdose. CONCLUSION Extended-release naltrexone is associated with significantly lower rates of opioid relapse among men in the United States following release from jail when compared with a no medication treatment-as-usual condition.

Factors Associated with Frequent Utilization of Crisis Substance Use Detoxification Services

ABSTRACT Previous research suggests that some substance users have multiple crisis detoxification visits and never access rehabilitation care. This care-seeking pattern leads to poorer outcomes and higher costs. The authors aimed to identify predictors of repeat detoxification visits by analyzing state-level data routinely collected at the time of substances use services admission. Repeat detoxification clients were more likely to be homeless, city-dwelling fee-for-service Medicaid recipients. Repeat detoxification clients were less likely than those with one admission to enter rehabilitation within 3 days. Treatment providers should aim for rapid transfer to rehabilitation and consider expanding detoxification intake data to improve risk stratification.

A Brief Patient Self-administered Substance Use Screening Tool for Primary Care: Two-site Validation Study of the Substance Use Brief Screen (SUBS)

BACKGROUND Substance use screening is widely encouraged in health care settings, but the lack of a screening approach that fits easily into clinical workflows has restricted its broad implementation. The Substance Use Brief Screen (SUBS) was developed as a brief, self-administered instrument to identify unhealthy use of tobacco, alcohol, illicit drugs, and prescription drugs. We evaluated the validity and test-retest reliability of the SUBS in adult primary care patients. METHODS Adults aged 18-65 years were enrolled from urban safety net primary care clinics to self-administer the SUBS using touch-screen tablet computers for a test-retest reliability study (n = 54) and a 2-site validation study (n = 586). In the test-retest reliability study, the SUBS was administered twice within a 2-week period. In the validation study, the SUBS was compared with reference standard measures, including self-reported measures and oral fluid drug tests. We measured test-retest reliability and diagnostic accuracy of the SUBS for detection of unhealthy use and substance use disorder for tobacco, alcohol, and drugs (illicit and prescription drug misuse). RESULTS Test-retest reliability was good or excellent for each substance class. For detection of unhealthy use, the SUBS had sensitivity and specificity of 97.8% (95% confidence interval [CI], 93.7-99.5) and 95.7% (95% CI, 92.4-97.8), respectively, for tobacco; and 85.2% (95% CI, 79.3-89.9) and 77.0% (95% CI, 72.6-81.1) for alcohol. For unhealthy use of illicit or prescription drugs, sensitivity was 82.5% (95% CI, 75.7-88.0) and specificity 91.1% (95% CI, 87.9-93.6). With respect to identifying a substance use disorder, the SUBS had sensitivity and specificity of 100.0% (95% CI, 92.7-100.0) and 72.1% (95% CI, 67.1-76.8) for tobacco; 93.5% (95% CI, 85.5-97.9) and 64.6% (95% CI, 60.2-68.7) for alcohol; and 85.7% (95% CI, 77.2-92.0) and 82.0% (95% CI, 78.2-85.3) for drugs. Analyses of area under the receiver operating curve (AUC) indicated good discrimination (AUC 0.74-0.97) for all substance classes. Assistance in completing the SUBS was requested by 11% of participants. CONCLUSIONS The SUBS was feasible for self-administration and generated valid results in a diverse primary care patient population. The 4-item SUBS can be recommended for primary care settings that are seeking to implement substance use screening.

Can substance use disorders be managed using the Chronic Care Model? Review and recommendations from a NIDA Consensus Group.

Brain imaging and genetic studies over the past two decades suggest that substance use disorders are best considered chronic illnesses. The passing of the Affordable Care Act in the United States has set the occasion for integrating treatment of substance use disorders into mainstream healthcare; and for using the proactive, team-oriented Chronic Care Model (CCM). This paper systematically examines and compares whether and how well the CCM could be applied to the treatment of substance use disorders, using type 2 diabetes as a comparator. The chronic illness management approach is still new in the field of addiction and research is limited. However comparative findings suggest that most proactive, team treatment-oriented clinical management practices now used in diabetes management are applicable to the substance use disorders; capable of being implemented by primary care teams; and should offer comparable potential benefits in the treatment of substance use disorders. Such care should also improve the quality of care for many illnesses now negatively affected by unaddressed substance abuse.

Extended-release naltrexone plus medical management alcohol treatment in primary care: findings at 15 months

The feasibility of long-term extended-release naltrexone (XR-NTX) alcohol treatment is unknown. Following an initial 12-week, single-arm, observational trial of XR-NTX plus medical management (MM) in primary care, we offered 48 additional weeks of XR-NTX treatment (12 additional monthly injections) in two public primary care clinics as a naturalistic extension study. Of 65 alcohol dependent adults initiating XR-NTX treatment, 40 (62%) completed the initial 12-week XR-NTX observational trial, and 19 (29%) continued treatment for a median of 38 weeks total (range, 16-72 weeks; median 8 total XR-NTX injections). Among active extension phase participants, self-reported rates of drinking days (vs. last 30 days pre-treatment baseline) were low: median 0.2 vs. 6.0 drinks per day; 82 vs. 38% days abstinent; 11 vs. 61% heavy drinking days. Long-term XR-NTX treatment in a primary care MM model was feasible and may promote lasting drinking reductions or alcohol abstinence (clinical trial: NCT00620750).

Validation of an audio computer-assisted self-interview (ACASI) version of the alcohol, smoking and substance involvement screening test (ASSIST) in primary care patients

BACKGROUND AND AIMS To address barriers to implementing the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in medical settings, we adapted the traditional interviewer-administered (IA) ASSIST to an audio-guided computer assisted self-interview (ACASI) format. This study sought to validate the ACASI ASSIST by estimating the concordance, correlation and agreement of scores generated using the ACASI versus the reference standard IA ASSIST. Secondary aims were to assess feasibility and compare ASSIST self-report to drug testing results. DESIGN Participants completed the ACASI and IA ASSIST in a randomly assigned order, followed by drug testing. SETTING Urban safety-net primary care clinic in New York City, USA. PARTICIPANTS A total of 393 adult patients. MEASUREMENTS Scores generated by the ACASI and IA ASSIST; drug testing results from saliva and hair samples. FINDINGS Concordance between the ACASI and IA ASSIST in identifying moderate-high-risk use was 92-99% for each substance class. Correlation was excellent for global scores [intraclass correlation (ICC) = 0.937, confidence interval (CI) = 0.924-0.948] and for substance-specific scores for tobacco (ICC = 0.927, CI = 0.912-0.940), alcohol (ICC = 0.912, CI = 0.893-0.927) and illicit drugs (ICC = 0.854, CI = 0.854-0.900) and good for prescription drugs (ICC = 0.676, CI = 0.613-0.729). Ninety-four per cent of differences in global scores fell within anticipated limits of agreement. Among participants with a positive saliva test, 74% self-reported use on the ACASI ASSIST. The ACASI ASSIST required a median time of 3.7 minutes (range 0.7-15.4), and 21 (5.3%) participants requested assistance. CONCLUSIONS The computer self-administered Alcohol, Smoking and Substance Involvement Screening Test appears to be a valid alternative to the interviewer-administered approach for identifying substance use in primary care patients.

Demographic Trends of Adults in New York City Opioid Treatment Programs—An Aging Population

Background: The population of adults accessing opioid treatment is growing older, but exact estimates vary widely, and little is known about the characteristics of the aging treatment population. Further, there has been little research regarding the epidemiology, healt h status, and functional impairments in this population. Objectives: To determine the utilization of opioid treatment services by older adults in New York City. Methods: This study used administrative data from New York State licensed drug treatment programs to examine overall age trends and characteristics of older adults in opioid treatment programs in New York City from 1996 to 2012. Results: We found significant increases in utilization of opioid treatment programs by older adults in New York City. By 2012, those aged 50–59 made up the largest age group in opioid treatment programs. Among older adults there were notable shifts in demographic background including gender and ethnicity, and an increase in self-reported impairments. Conclusions/Importance: More research is needed to fully understand the specific characteristics and needs of older adults with opioid dependence.

OFFICE-BASED METHADONE PRESCRIBING: ACCEPTANCE BY INNER-CITY PRACTITIONERS IN NEW YORK

In the US, methadone maintenance is restricted by federal and state regulations to large specialized clinics that serve fewer than 20% of the heroin-dependent population. In Europe, Canada, and Australia, primary health care providers already are utilized widely as methadone prescribers. In preparation for a limited study of office-based methadone treatment in New York City, 71 providers from 11 sites were surveyed about their willingness to prescribes methadone in their office-based pratices. Of the 71, 85% had methadone-maintained patients who came to their practice for other care. One-third felt knowledgeable enough to prescribes methadone, and 66% said they would if given proper training and support (88% among AIDS care providers). Half expressed concern that they might be unable to meet the multiple needs of these patients. With additional training and ancillary support, the 47 providers willing to become methadone providers could serve, at 10–20 patients each, 470–940 patients, a population the size of 3–5 average methadone clinics.

Performance of the tobacco, alcohol, prescription medication, and other substance use (TAPS) tool for substance use screening in primary care patients

Tobacco and alcohol use are among the leading causes of preventable death in the United States (1, 2), and illicit substance use is a significant contributor to the HIV and opioid overdose epidemics (3, 4). Health care settings offer an opportunity to identify substance use and related problems, provide timely interventions, and guide patients to treatment. Tobacco screening and treatment are core clinical quality measures for primary care (5), and screening followed by a brief intervention for unhealthy alcohol use is recommended by the U.S. Preventive Services Task Force (69). Although the efficacy of brief interventions in reducing drug use has not been clearly established (1013), screening for substance use in medical settings may be clinically justified by the effects of substance use on the prevention and treatment of other medical conditions (1416), as well as the potential for drugmedication interactions (17, 18) and overdose (19). Primary care settings require a screening and assessment approach that is efficient and accurate, and informs clinical care (2023). Although very brief screening tools have been developed to efficiently identify alcohol and drug use (2427), they do not provide enough information about the specific substances used, or the patients risk level, to guide clinical actions. A structured substance use assessment may provide this information, but current options either are too lengthy (28) or do not provide sufficient detail (29, 30) to meet the needs of medical providers. We developed the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool as a better instrument for substance use screening in primary care settings. This tool consists of a 4-item screen for tobacco, alcohol, illicit drugs, and nonmedical use of prescription medications, followed by a substance-specific assessment of risk level for individuals with positive screening results. The TAPS tool is flexible enough to be administered face to face or self-administered with a tablet computer, so it can accommodate various clinical workflows. This article presents the results from a large multisite study conducted within the National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network to assess the performance of the TAPS tool compared with a reference standard measure in adult primary care patients. Supplement. Study Protocol Methods Participants and Recruitment Participants were recruited from 5 primary care clinics in Baltimore, Maryland; New York, New York; Richmond, Virginia; and 2 sites in Kannapolis, North Carolina. Clinics were selected to provide a geographically diverse sample of urban and suburban participants, in whom substance use patterns would be expected to vary. A sample size of 2000 was set before recruitment began, and sites enrolled competitively from August 2014 to April 2015 until that number was reached. Sample size was determined by using computer simulations to calculate the precision of the estimates of sensitivity and specificity as a function of the number of participants and the prevalence of substance use. We determined that a sample size of 2000 would allow us to estimate sensitivity with a precision (defined as the 95th percentile of the half-width of the 95% CI) of 12.5% for substances with a prevalence of 5% and up to 2.5% for those with a prevalence of 50%. Eligibility Criteria Adults aged 18 years or older who were in a clinic for a medical visit and could provide informed consent were eligible to participate. Persons were excluded if they could not comprehend spoken English, were physically unable to complete the self-administered TAPS tool, or were enrolled in this study previously. Recruitment Research assistants (RAs) consecutively approached each patient in the waiting area. Interested patients were screened for eligibility and provided verbal consent. They were given the option of having the study visit before their appointment if the wait time was longer than 1 hour; otherwise, the study encounter occurred after the medical visit. Study Procedures Study visits were completed in a private room. Participants were assigned a unique identifier and were told that responses were confidential and would not be shared with anyone in the clinic. The electronic data capture system randomly assigned half of the participants to begin with the self-administered TAPS tool and half to begin with the interviewer-administered version. After completing the TAPS tool in the first format (for example, self-administered), the participants completed it in the other version (for example, interviewer-administered). The self-administered version was delivered on a tablet computer (iPad, Apple), which gave participants the option of hearing the questions and response options read verbatim by a recorded female voice. For the interviewer version, the RAs read all the questions and response options aloud to the participants. After both versions were completed, the RA administered a questionnaire about the feasibility and acceptability of the TAPS tool; then, additional substance use measures were collected for comparison purposes. The RAs were not blinded to participant responses on the interviewer-administered TAPS tool when they administered the reference standard measure: the modified World Health Organization World Mental Health Composite International Diagnostic Interview (www.hcp.med.harvard.edu/wmhcidi/index.php) here referred to as CIDI. After completing self-reported assessments, all participants were asked to provide verbal consent to participate in oral fluid testing for drugs. Participants received