Michael A. Cucciare

A Randomized Trial Comparing Two Models of Web-Based Training in Cognitive Behavioral Therapy for Substance Abuse Counselors

This study compared training outcomes obtained by 147 substance abuse counselors who completed eight self-paced online modules on cognitive-behavioral therapy (CBT) and attended a series of four weekly group supervision sessions using Web conferencing software. Participants were randomly assigned to two conditions that systematically varied the degree to which they explicitly promoted adherence to the CBT protocol and the degree of control that they afforded participants over the sequence and relative emphasis of the training curriculum. Outcomes were assessed at baseline and immediately following training. Counselors in both conditions demonstrated similar improvements in CBT knowledge and self-efficacy. Counselors in the low-fidelity condition demonstrated greater improvement on one of three measures of job-related burnout when compared to the high-fidelity condition. The study concludes that it is feasible to implement a technology-based training intervention with a geographically diverse sample of practitioners, that two training conditions applied to these samples of real-world counselors do not produce statistically or clinically significant differences in knowledge or self-efficacy, and that further research is needed to evaluate how a flexible training model may influence clinician behavior and patient outcomes.

Retention in medication-assisted treatment for opiate dependence: A systematic review

ABSTRACT Retention in medication-assisted treatment among opiate-dependent patients is associated with better outcomes. This systematic review (55 articles, 2010–2014) found wide variability in retention rates (i.e., 19%–94% at 3-month, 46%–92% at 4-month, 3%–88% at 6-month, and 37%–91% at 12-month follow-ups in randomized controlled trials), and identified medication and behavioral therapy factors associated with retention. As expected, patients who received naltrexone or buprenorphine had better retention rates than patients who received a placebo or no medication. Consistent with prior research, methadone was associated with better retention than buprenorphine/naloxone. And, heroin-assisted treatment was associated with better retention than methadone among treatment-refractory patients. Only a single study examined retention in medication-assisted treatment for longer than 1 year, and studies of behavioral therapies may have lacked statistical power; thus, studies with longer-term follow-ups and larger samples are needed. Contingency management showed promise to increase retention, but other behavioral therapies to increase retention, such as supervision of medication consumption, or additional counseling, education, or support, failed to find differences between intervention and control conditions. Promising behavioral therapies to increase retention have yet to be identified.

What do patients do with unused opioid medications

Objectives:The volume of opioid medications being prescribed in the United States is increasing rapidly. Problems associated with the misuse of opioid medications are also increasing, in part because of medication diversion from legitimate prescriptions. However, little is known about what patients do with any unused opioid medications. This paper uses a qualitative analysis of patients’ self-report of medication storage and retention habits to begin to address this gap. Methods:We analyzed responses to the Prescription Drug Use Questionnaire in conjunction with other data on prescription opioid use in a sample of 191 Veteran patients (83% of whom had a preexisting factor associated with higher rates of opioid misuse) who received one or more opioid prescriptions in the previous 12 months. Results:Only 6.3% of participants disposed of extra medications and 24.1% reported having no extra opioids. A total of 65.4% of participants reported retaining some or all opioids even if they ceased taking the medication, and some participants accumulated large amounts of medication. A total of 34.0% of participants described engaging in sharing or diversion of opioids at least once, most often receiving them from a family member or a friend. Discussion:A majority of patients retain unused opioids, and medication sharing is common. Interventions to improve monitoring of patient experience with opioid medication, educate patients about the dangers of opioid use by nonprescribed others, and increase information about medication disposal options could decrease the supply of opioid medications available for misuse.

Alcohol and Drug Misuse, Abuse, and Dependence in Women Veterans

We conducted a systematic literature review on substance misuse, abuse, and dependence in women veterans, including National Guard/reserve members. We identified 837 articles published between 1980 and 2013. Of 56 included studies, 32 reported rates of alcohol misuse, binge drinking, or other unhealthy alcohol use not meeting diagnostic criteria for abuse or dependence, and 33 reported rates of drug misuse or diagnosed alcohol or drug use disorders. Rates ranged from 4% to 37% for alcohol misuse and from 7% to 25% for binge drinking; among Veterans Health Administration (VA) health-care system outpatients, rates ranged from 3% to 16% for substance use disorder. Studies comparing women veterans and civilians reported no clear differences in binge or heavy drinking. Substance misuse rates were generally lower among women veterans than men veterans. Substance misuse was associated with higher rates of trauma, psychiatric and medical conditions, and increased mortality and suicide rates. Most studies included only VA patients, and many used only VA medical record data; therefore, the reported substance misuse rates likely do not reflect true prevalence. Rates also varied by assessment method, source of data, and the subgroups studied. Further efforts to develop epidemiologically valid prevalence estimates are needed to capture the true health burden of substance misuse in women veterans, particularly those not using VA care.

Exploring the relationship between physical health, depressive symptoms, and depression diagnoses in Hispanic dementia caregivers

Objectives: The present study examined the relationship between self-reported physical health, depressive symptoms, and the occurrence of depression diagnosis in Hispanic female dementia caregivers. Participants: Participants were 89 Hispanic female dementia caregivers. Design: This study used a cross-sectional design. Baseline depression and physical health data were collected from participants enrolled in the ‘Reducing Stress in Hispanic Anglo Dementia Caregivers’ study sponsored by the National Institute on Aging. Measurements: Physical health was assessed using the Medical Outcome Study Short Form-36 (SF-36), a one-item self-report health rating, body mass index, and the presence or history of self-reported physical illness. Depressive symptoms were assessed using the Center for Epidemiologic Studies–Depression Scale (CES-D). The occurrence of depression diagnosis was assessed using the Clinical Interview for DSM-IV Axis I Disorders (SCID). Analysis: Multiple linear and logistic regression analysis was used to examine the extent to which indices of physical health and depressive symptoms accounted for variance in participants’ depressive symptoms and depressive diagnoses. Results. Self-reported indices of health (e.g., SF-36) accounted for a significant portion of variance in both CES-D scores and SCID diagnoses. Caregivers who reported worsened health tended to report increased symptoms of depression on the CES-D and increased likelihood of an SCID diagnosis of a depressive disorder. Conclusion. Self-reported health indices are helpful in identifying Hispanic dementia caregivers at risk for clinical levels of depression.

Characterizing binge drinking among U.S. military Veterans receiving a brief alcohol intervention

BACKGROUND Brief web-based alcohol interventions (BAIs) are effective for reducing binge drinking in college students and civilian adults, and are increasingly being applied to U.S. military populations. However, little is known about factors associated with binge drinking in Veteran populations and therefore some concern remains on the generalizability of studies supporting BAIs for addressing binge drinking in this population. This study sought to better understand the characteristics (e.g., demographic, coping related mental health factors, prior exposure to traumatic events, and factors assessing motivation to change alcohol use) of a predominantly male sample of binge drinking Veterans receiving a BAI from a VA provider. METHODS A primarily male (93.5%) sample (N=554) of Veterans completed a BAI consisting of brief assessment and personalized feedback. RESULTS We found that Veterans who were younger, used drugs/alcohol to cope with symptoms of PTSD and depression (e.g., nightmares and flashbacks and sleep difficulties), and had experienced sexual assault, had higher self-reported peak blood alcohol concentration and a higher likelihood for a binge drinking episode in the last 90days. CONCLUSIONS BAIs may be a promising approach for addressing binge drinking in Veterans. However, binge drinking among a sample of mostly male Veterans receiving a BAI may be associated with a complex set of factors that are less prevalent in the college student population and thus studies demonstrating the efficacy of BAIs with Veterans are needed.

How Internet Technology Can Improve the Quality of Care for Substance Use Disorders

By allowing for the efficient delivery of instructional content and the secure collection of self-report data regarding substance use and related problems, the Internet has tremendous potential to improve the effectiveness and accessibility of addiction treatment services. This article discusses some of the ways in which Internet technology can facilitate, complement and support the process of traditional clinician-delivered treatment for individuals with substance use disorders. Internet applications are being used to support a range of activities including (a) the assessment and feedback process that constitutes a central feature of brief motivational interventions, (b) the concurrent monitoring of individual level outcomes among patients who are currently enrolled in addiction treatment programs, (c) the continuing care and ongoing recovery of patients who have completed treatment, and (d) the delivery of clinical training in evidence based practices for addiction treatment providers. This emerging body of literature suggests that addiction counselors and program administrators can enhance the quality of clinician-delivered treatment by incorporating internet applications into existing processes of care. Internet applications provide an unparalleled opportunity to engage patients in the treatment process, incorporate real-time data into treatment planning, prevent relapse, and promote evidence-based treatment approaches.

Substance Use Among Women Veterans: Epidemiology to Evidence-Based Treatment

An increasing percentage of women are U.S. Military Veterans. We review the substance misuse rates and comorbidities and the risk factors for and consequences of substance use among women Veterans. Women Veterans may have higher rates of substance misuse and comorbid psychiatric and medical disorders than male Veterans and women who are not Veterans. Studies support the AUDIT-C as a scaled marker of alcohol-related risk among female Veterans, but validated drug screening instruments are needed. We discuss evidence-based approaches in terms of treating women Veterans’ substance misuse in primary and specialty care settings, along with knowledge gaps and potential research priorities to improve care in this special population.

Predicting future healthcare costs: how well does risk‐adjustment work?

PURPOSE Risk-adjustment is designed to predict healthcare costs to align capitated payments with an individuals expected healthcare costs. This can have the consequence of reducing overpayments and incentives to under treat or reject high cost individuals. This paper seeks to review recent studies presenting risk-adjustment models. DESIGN/METHODOLOGY/APPROACH This paper presents a brief discussion of two commonly reported statistics used for evaluating the accuracy of risk adjustment models and concludes with recommendations for increasing the predictive accuracy and usefulness of risk-adjustment models in the context of predicting future healthcare costs. FINDINGS Over the last decade, many advances in risk-adjustment methodology have been made. There has been a focus on the part of researchers to transition away from including only demographic data in their risk-adjustment models to incorporating patient data that are more predictive of healthcare costs. This transition has resulted in more accurate risk-adjustment models and models that can better identify high cost patients with chronic medical conditions. ORIGINALITY/VALUE The paper shows that the transition has resulted in more accurate risk-adjustment models and models that can better identify high cost patients with chronic medical conditions.

Teaching Motivational Interviewing to Primary Care Staff in the Veterans Health Administration

ABSTRACTBACKGROUNDThe Veterans Health Administration (VHA) is implementing the patient-centered medical home (PCMH) model of primary care which emphasizes patient-centered care and the promotion of healthy lifestyle changes. Motivational Interviewing (MI) is effective for promoting various health behaviors, thus a training protocol for primary care staff was implemented in a VHA health care setting.OBJECTIVESWe examined the effect of the training protocol on MI knowledge, confidence in ability to use MI-related skills and apply them to written vignettes, perceived comfort level and skill in lifestyle counseling, and job-related burnout.DESIGNTraining was provided by experts in MI. The training protocol consisted of three sessions—one half day in-person workshop followed by a 60-minute virtual training, followed by a second workshop. Each of the sessions were spaced two weeks apart and introduced trainees to the theory, principles, and skills of using MI in health care settings.PARTICIPANTSAll primary care staff at the Veterans Affairs Palo Alto Health Care System were invited to participate.MEASUREMENTSTrainees completed a short set of questionnaires immediately before and immediately after the training.RESULTSWe found support for our primary hypotheses related to knowledge, confidence, and written responses to the vignettes. Changes in perceived comfort level and skill in lifestyle counseling, and job-related burnout were not observed.CONCLUSIONSTraining primary care staff in MI is likely to become increasingly common as health care systems transition to the PCMH model of care. Therefore, it is important for health care systems to have low-cost methods for evaluating the effectiveness of such trainings. This study is a first step in developing a brief written assessment with the potential of measuring change in a range of behaviors and skills consistent with MI.