Ruth A. Gassman

Alcohol and Other Drug Content in Core Courses: Encouraging Substance Abuse Assessment.

This article measures the efficacy of two approaches to teaching students to assess clients for substance abuse: an alcohol and other drug (AOD) minor program and integration of AOD content into core courses. A quasi-experimental design involved nonrandom assignment to an AOD minors program or to a nonminors curriculum. Both groups reported on their usual AOD assessment and on AOD assessment in their first interview with their most recent client. Self-report outcomes, examined in relation to the number of courses with integrated AOD content taken, suggest that these courses lead to significantly more self-reported assessment for substance abuse.

Are We There Yet? A Review of Screening, Brief Intervention, and Referral to Treatment (SBIRT) Implementation Fidelity Tools and Proficiency Checklists

Abstract Screening and brief intervention (SBI) for alcohol is an evidence-based prevention practice designed to reduce frequency and severity of alcohol misuse. Many studies have validated the effectiveness of SBI for reducing levels of alcohol misuse, especially in primary medical care. Additional research continues to be conducted in terms of the effectiveness of including referral to treatment (SBIRT) and addressing illicit drug use and prescription drug abuse. Importantly, cross-comparison among SBIRT programs is difficult because evaluative processes vary widely between programs, which themselves often are substantively different. In this brief report, we utilized cross-comparison techniques to elucidate similarities and differences among SBIRT fidelity tools and proficiency checklists. In early 2014, researchers completed a systematic review of SBIRT fidelity tools and proficiency checklists published or made available from 2004 through April 2014; in total, eleven instruments were located and assessed. The analytic methodology consisted of creating a matrix with key SBIRT components identified from the literature prior to assessment. Three researchers populated the matrix with the identified fidelity tools and proficiency checklists before assessing each tool for the presence or absence of each component. The level of agreement between the researchers was checked for inter-rater reliability using free-marginal Kappa statistics. The results of the matrix analysis suggested heterogeneity among existing SBIRT fidelity tools and proficiency checklists. Importantly, it was not the case that this lack of concordance reflected poorly on any given fidelity tool. Rather, it emphasized the multi-partite and variable nature of SBIRT programs. It was not evident that a single standardized SBIRT fidelity tool or proficiency checklist could appropriately determine the level of fidelity to SBIRT for all programs. Suggestions for next steps in SBIRT fidelity research are provided based on the output of the comparison matrix.

Risk patterns among college youth: identification and implications for prevention and treatment.

Purpose. This study identified underlying subgroups among college students in terms of lifestyle characteristics and health risk behaviors and then investigated how demographic factors were associated with the underlying risk patterns to bolster health promotion efforts and interventions. Method. College students (N = 996) enrolled at Indiana University during 2009-2010 participated in a multidimensional online survey. Latent class analysis was used to identify underlying risk patterns based on seven lifestyle and health behaviors, including frequent alcohol use, binge drinking, smoking, low physical activity, low vegetable intake, low fruit intake, and poor sleep. Results. Four distinct risk behavior patterns were identified for both males and females including a “healthy” class, “low substance use but poor other health behaviors” class, “high substance use” (males)/“high alcohol use” (females) class, and a risk class characterized by elevated probability of all seven indicators. The highest risk class included 34% of the males and 22% of the females; they tended to be older or in more advanced undergraduate classes. Among males, compared with the “healthy” class, the “high substance use” class was more likely to contain non-Hispanic White students and students in advanced classes. Among females, the “low substance use but poor other health behaviors” class was associated with racial/ethnic minority status and lower levels of parental education. Conclusions. Our data suggest that risky health behaviors may tend to cluster in some students and that health promotion techniques might effectively be targeted to identifiable student subgroups.

Effects and Durability of an SBIRT Training Curriculum for First-Year MSW Students

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based process for identification, prevention, and treatment of alcohol misuse. The purpose of this study was to examine the effects of an alcohol-focused training on first-year MSW students’ (n = 71) knowledge, attitudes, and beliefs about SBIRT. Changes in item means were assessed using repeated-measures analysis of variance (critical α = .002). Data indicated a significant and strong main effect for training; perceived competence improved immediately and remained significantly higher 30 days posttraining. Other improvements included knowing what questions to ask patients, ease making alcohol-related statements, and believing that it is rewarding to work with at-risk patients.

Gender Differences in Risk and Protective Factors for Alcohol Use and Substance Use Problems among Hispanic Adolescents

This study investigates gender differences within the context of risk and protective factors for alcohol use and substance use problems in a sample of 8,992 Hispanic students in grades 6 through 12, who responded to a statewide survey of alcohol and other drug use. The effects of gender, grade, and risk and protective factors on past-month alcohol use, binge drinking, and risk for substance use problems are examined. Results show that outcomes were moderated by gender, such that females had greater predicted probabilities than males for alcohol use, binge drinking, and risk for substance use problems across levels of risk and protective factors. An ecological framework is applied to speculate why Hispanic female adolescents were more vulnerable than their males to problem alcohol use.

Assessing the relationship between medical residents' perceived barriers to SBIRT implementation and their documentation of SBIRT in clinical practice

Of the 17.9 million adult Americans who have an alcohol use disorder, most (89%) are unaware of their condition.1 The Centers for Disease Control and Prevention (CDC) lists more than 30 specific immediate and long-term health risks associated with excessive alcohol use,2 suggesting that identifying and addressing alcohol use is an important component of primary medical care. Screening, brief intervention, and referral to treatment (SBIRT) is an integrated and validated approach to identifying risky or problematic alcohol use and providing services to those who need them.3 In 2009, Indiana University School of Medicine (IUSM) reached a cooperative agreement with the Substance Abuse and Mental Health Services Administration (SAMHSA) to begin training its medical residents in SBIRT. The training curriculum focuses on delivery of SBIRT services using motivational interviewing techniques (MI). In addition to developing this curriculum and integrating it into the first year of medical residency at IUSM, we developed a protocol for implementing SBIRT services at an internal medicine continuity clinic. This clinic is part of a larger safety-net health system in Indianapolis at which some residents are assigned a small panel of patients during their internal medicine residency. At the time of the study, the continuity clinic was classified as a community health centre, though it since has received federally qualified health center (FQHC) designation. Medical conditions presenting in the clinic vary, with a predominance of adult chronic diseases such as hypertension, heart failure, diabetes, and chronic obstructive lung disease. At each visit, all adult patients were screened for alcohol, drug, and tobacco use by a medical assistant (MA) using the AUDIT-C tool and single drug and tobacco screening questions. These data were given to care providers, both medical residents and staff physicians, to enable delivery of targeted SBIRT services. At the conclusion of each clinical encounter, providers were then asked to document the components of SBIRT that they completed by responding to four yes/no statements, such as ‘I referred the patient to a substance abuse counselor.’ However, across 9954 initial physician visits with unique patients that occurred between 1/31/2011 and 6/29/2012 (hereafter ‘the study period’), we observed a high frequency of incomplete SBIRT encounter forms (83.8%), meaning that the physicians generally were not documenting whether they completed SBIRT. While this was seen as a cause for concern, logically, we could not conflate incomplete forms with a failure to provide SBIRT services. We therefore were moved conceptually to separate two distinct behaviours: actually performing SBIRT, and documenting that SBIRT was completed. In order for SBIRT to be an integrated part of primary medical care, all associated processes and results need to be recorded. Since we have access to evaluative data collected during their SBIRT training that assesses residents’ anticipated barriers to utilizing SBIRT and MI in their medical practice, we examined whether medical residents’ self-reported barriers to performing SBIRT or using MI in their clinical practice predicted appropriate SBIRT documentation in their clinical practice.

If you teach it, they will screen: Advanced practice nursing students’ use of screening and brief intervention in the clinical setting

BACKGROUND In the United States, approximately 30% of adults drink at risky levels or meet the criteria for harmful or dependent alcohol use. Screening, brief intervention, and referral to treatment (SBIRT) in primary care settings is indicated. This study assessed whether knowledge, attitudes, and beliefs about SBIRT, evaluated after a three-part, mixed-methods training, predicted whether 21 family nurse practitioner (FNP) students screened for alcohol use during clinical patient encounters. METHOD After training, students completed a survey and documented implementation of SBIRT during their clinical practice-specific management courses. RESULTS FNP students who reported higher levels of perceived competence in their posttraining surveys were more likely to screen for alcohol in the clinical setting. CONCLUSION Screening for alcohol misuse and identifying patients engaged in hazardous drinking meet important nurse practitioner competencies. Further research is needed to explore training programs that specifically emphasize activities to increase perceived competence, knowledge, and comfort regarding SBIRT.

Statewide Administration of the CRAFFT Screening Tool: Highlighting the Spectrum of Substance Use

Background: Adolescent alcohol and drug use in the United States are associated with negative consequences spanning multiple domains. Much of the public health surveillance of these behaviors relies on self-report survey data. These data frequently takes the form of frequency or prevalence data for specific substances, which may not provide a complete picture of use. Objectives: This study analyzes a state-level survey that includes the CRAFFT screening tool. The studys goal is to elucidate the spectrum of substance use severity across a large segment of substance-using adolescents attending schools in the state of Indiana and to assess the contribution of a variety of predictor variables to the variance between users falling into each category of use severity. Methods: Data were collected in 2011 from 168,801 adolescents, of whom 25,204 met the inclusion criteria for this study. The authors utilize multinomial logit analyses to highlight variables, including sociodemographic data, poly-drug use, and risk/protective behavior scales, associated with each category of use. Results: Seriousness of use is not uniform across substance-using adolescents; 49% were categorized as nonproblem users, 33% as problem users, and 18% as dependent users. Risk and protective factors predict adolescents’ severity of substance use, but do not do so uniformly. Poly-drug use is a significant predictor of problem use and dependent use as well. Conclusions: The CRAFFT may provide a more nuanced perspective of adolescent substance use than frequency/prevalence data alone; the authors describe the implications derived from these data and analyses to the adolescent prevention and treatment systems.

Examining Sequences of Adolescent Substance Use Initiation Involving Over-the-Counter (OTC) Drug Abuse

Over-the-counter (OTC) drug abuse among adolescents is an increasingly visible and meaningful trend in the United States, but little research has been done to contextualize OTC drug abuse. This study examined a large sample of 152,678 middle school and high school adolescents in an attempt to understand sequences of OTC drug abuse initiation, and the sociodemographic and risk factor-related precursors thereof. We found that while many adolescents who had ever abused an OTC drug and used one or more “gateway” drugs (alcohol, cigarettes, or marijuana) initiated the use of the gateway drug first, there was also a subset of adolescents whose sequence of initiation began with OTC drug abuse. We also found that different risk factors and sociodemographic characteristics predicted different sequences of use. For example, interaction with antisocial peers predicted initiating gateway drug use prior to OTC drug abuse, but not the reverse sequence. Other predictor variables, including gender, grade, and parental attitudes toward drug abuse also differentiated these sequences; we discuss both the theoretical and practical implications of these findings.

Connecting patients to services: Screening, brief intervention and referral to treatment in primary health care

Screening, brief intervention and referral to treatment (SBIRT) in primary care is a burgeoning environmental treatment strategy for illicit and prescription drug abuse and a variety of other health behaviors. While clinical research on SBIRTs efficacy continues to produce positive results, translational research focusing on the integration of the evidence-based processes into primary care settings has been less prevalent. This paper describes the decisions made in the design of the Indiana SBIRT project and describes several barriers that prevented eligible patients from receiving services provided through SBIRT. It then elaborates on the qualitative mechanisms used to identify solutions to those barriers and provides preliminary quantitative evidence for the effectiveness of the solutions that were implemented. The intention of this translational research is to provide a broad perspective on program improvement so that other SBIRT projects in the United States and internationally might benefit from the lessons learned by Indiana SBIRT.