A single-question screening test for drug use in primary care

Effectiveness of Integrating Suicide Care in Primary Care : Secondary Analysis of a Stepped-Wedge, Cluster Randomized Implementation Trial

BACKGROUND

Primary care encounters are common among patients at risk for suicide.

OBJECTIVE

To evaluate the effectiveness of implementing population-based suicide care (SC) in primary care for suicide attempt prevention.

DESIGN

Secondary analysis of a stepped-wedge, cluster randomized implementation trial. (ClinicalTrials.gov: NCT02675777).

SETTING

19 primary care practices within a large health care system in Washington State, randomly assigned launch dates.

PATIENTS

Adult patients (aged ≥18 years) with primary care visits from January 2015 to July 2018.

INTERVENTION

Practice facilitators, electronic medical record (EMR) clinical decision support, and performance monitoring supported implementation of depression screening, suicide risk assessment, and safety planning.

MEASUREMENTS

Clinical practice and patient measures relied on EMR and insurance claims data to compare usual care (UC) and SC periods. Primary outcomes included documented safety planning after population-based screening and suicide risk assessment and suicide attempts or deaths (with self-harm intent) within 90 days of a visit. Mixed-effects logistic models regressed binary outcome indicators on UC versus SC, adjusted for randomization stratification and calendar time, accounting for repeated outcomes from the same site. Monthly outcome rates (percentage per 10 000 patients) were estimated by applying marginal standardization.

RESULTS

During UC, 255 789 patients made 953 402 primary care visits and 228 255 patients made 615 511 visits during the SC period. The rate of safety planning was higher in the SC group than in the UC group (38.3 vs. 32.8 per 10 000 patients; rate difference, 5.5 [95% CI, 2.3 to 8.7]). Suicide attempts within 90 days were lower in the SC group than in the UC group (4.5 vs. 6.0 per 10 000 patients; rate difference, -1.5 [CI, -2.6 to -0.4]).

LIMITATION

Suicide care was implemented in combination with care for depression and substance use.

CONCLUSION

Implementation of population-based SC concurrent with a substance use program resulted in a 25% reduction in the suicide attempt rate in the 90 days after primary care visits.

PRIMARY FUNDING SOURCE

National Institute of Mental Health.

Prescription Digital Therapeutics for Substance Use Disorder in Primary Care: Mixed Methods Evaluation of a Pilot Implementation Study

BACKGROUND

Delivering prescription digital therapeutics (ie, evidence-based interventions designed to treat, manage, or prevent disorders via websites or smartphone apps) in primary care could increase patient access to substance use disorder (SUD) treatments. However, the optimal approach to implementing prescription digital therapeutics in primary care remains unknown.

OBJECTIVE

This pilot study is a precursor to a larger trial designed to test whether implementation strategies (practice facilitation [PF] and health coaching [HC]) improve the delivery of prescription digital therapeutics for SUDs in primary care. This mixed methods study describes outcomes among patients in the 2 pilot clinics and presents qualitative findings on implementation.

METHODS

From February 10 to August 6, 2021, a total of 3 mental health specialists embedded in 2 primary care practices of the same integrated health system were tasked with offering app-based prescription digital therapeutics to patients with SUD. In the first half of the pilot, implementation activities included training and supportive tools. PF (at 1 clinic) and HC (at 2 clinics) were added in the second half. All study analyses relied on secondary data, including electronic health records and digital therapeutic vendor data. Primary outcomes were the proportion of patients reached by the prescription digital therapeutics and fidelity related to ideal use. We used qualitative methods to assess the adherence to planned activities and the barriers and facilitators to implementing prescription digital therapeutics.

RESULTS

Of all 18 patients prescribed the apps, 10 (56%) downloaded the app and activated their prescription, and 8 (44%) completed at least 1 module of content. Patients who activated the app completed 1 module per week on average. Ideal use (fidelity) was defined as completing 4 modules per week and having a monthly SUD-related visit; 1 (6%) patient met these criteria for 10 weeks (of the 12-week prescription period). A total of 5 (28%) patients had prescriptions while HC was available, 2 (11%) were successfully contacted, and both declined coaching. Clinicians reported competing clinical priorities, technical challenges, and logistically complex workflows in part because the apps required a prescription. Some pilot activities were impacted by staff turnover that coincided with the COVID-19 pandemic. The facilitators to implementation were high engagement and the perception that the apps could meet patient needs.

CONCLUSIONS

The pilot study encountered the barriers to implementing prescription digital therapeutics in a real-world primary care setting, especially staffing shortages, turnover, and competing priorities for clinic teams. The larger randomized trial will clarify the extent to which PF and HC improve the implementation of digital therapeutics.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04907045; https://clinicaltrials.gov/study/NCT04907045.

Assessing Substance Use Disorder Symptoms with a Checklist among Primary Care Patients with Opioid Use Disorder and/or Long-Term Opioid Treatment: An Observational Study

BACKGROUND

Primary care (PC) offers an opportunity to treat opioid use disorders (OUD). The Substance Use Symptom Checklist ("Checklist") can assess DSM-5 substance use disorder (SUD) symptoms in PC.

OBJECTIVE

To test the psychometric properties of the Checklist among PC patients with OUD or long-term opioid therapy (LTOT) in Kaiser Permanente Washington (KPWA).

DESIGN

Observational study using item response theory (IRT) and differential item functioning (DIF) analyses of measurement consistency across age, sex, race and ethnicity, and receipt of treatment.

PATIENTS

Electronic health records (EHR) data were extracted for all adult PC patients visiting KPWA 3/1/15-8/30/2020 who had ≥ 1 Checklist documented and indication of either (a) clinically-recognized OUD (i.e., documented OUD diagnosis and/or OUD medication treatment) or (b) LTOT in the year prior to the checklist.

MAIN MEASURE

The Checklist includes 11 items reflecting DSM-5 criteria for SUD. We described the prevalence of 2 SUD symptoms reported on the Checklist (consistent with mild-severe DSM-5 SUD). Analyses were conducted in the overall sample and in two subsamples (clinically-recognized OUD and LTOT only).

KEY RESULTS

Among 2007 eligible patients, 39.9% endorsed ≥ 2 SUD symptoms (74.3% in the clinically-recognized OUD subsample and 13.1% in LTOT subsample). IRT indicated that a unidimensional model for the 11 checklist items had excellent fit (comparative fit index = 0.998) with high item-level discrimination parameters for the overall sample and both subsamples. DIF across age, race and ethnicity, and treatment was observed for one item each, but had minimal impact on expected number of criteria (0-11) patients endorse.

CONCLUSIONS

The Substance Use Symptom Checklist measured SUD symptoms consistent with DSM-5 conceptualization (scaled, unidimensional) in patients with clinically-recognized OUD and LTOT and had similar measurement properties across demographic subgroups. The Checklist may support symptom assessment in patients with OUD and diagnosis in patients with LTOT.

Positive PTSD Screening and Its Health Correlates in Patients With HIV in Urban Primary Care Settings

Posttraumatic stress disorder (PTSD) is underdiagnosed and undertreated in primary care, especially among African American individuals. The current study assessed documentation rates of PTSD and clinical health correlates among 135 predominantly African American patients with HIV and positive PTSD screens in a primary care unit. The Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) and a retrospective chart review of 135 patients with HIV were conducted. On the PCPTSD-5 (cut point of 3), approximately one half of patients (49.6%; n = 67) had probable PTSD; however, only 11.9% of patients (n = 16) had a chart diagnosis of PTSD. A positive PTSD screen was associated with higher rates of depression and insomnia, but not anxiety, alcohol use, drug use, or pain in patients with HIV. Multi-morbidity of HIV, major depression, and positive PTSD screens was associated with increased risk for asthma, number of medical diagnoses, depression, insomnia, and anxiety. Findings highlight the need for trauma-informed care in primary care settings for people with PTSD and HIV. Larger samples are warranted to further explore health correlates of PTSD. [Journal of Psychosocial Nursing and Mental Health Services, 62(8), 25-36.].

Jail-Based For-Profit Mental Health Providers and Treatment Engagement After Release

OBJECTIVE

This study compared mental health treatment engagement among people with serious mental illness after release from jails that had either a for-profit (N=3 jails) or a nonprofit mental health provider (N=7 jails).

METHODS

Across the 10 jails, data were collected in 2019 for 1,238 individuals with serious mental illness. Data included demographic characteristics (age, race-ethnicity, gender, geography, and jail type) and behavioral health variables (previous mental health treatment, psychotropic medication use, substance use, and receipt of jail-based mental health services). Logistic regression was used to predict treatment engagement during the year after release, stratified by type of jail-based mental health provider, in analyses controlled for demographic and behavioral health variables.

RESULTS

Almost half (46%, N=573) of the individuals had stayed in jails with a for-profit mental health provider; the other half (54%, N=665) had stayed in jails with a nonprofit provider. In the year after release, 37% (N=458) of all individuals engaged in mental health treatment, and 63% (N=780) did not. Those who had stayed in a jail with a for-profit provider were significantly less likely to engage in mental health treatment during the year after release (AOR=0.59, 95% CI=0.42-0.83, p<0.01), compared with those in jails having a nonprofit provider.

CONCLUSIONS

Staying in a jail with a for-profit mental health provider was associated with reduced postrelease engagement with community service providers. Less engagement with services during a pivotal time after release may increase behavioral health crises that erode individuals' well-being and may raise downstream costs due to further criminal legal involvement and emergency care use.

The clinical effectiveness of the Mind/Body Program for Infertility on wellbeing and assisted reproduction outcomes: a randomized controlled trial in search for active ingredients

STUDY QUESTION

Does the Mind/Body Program for Infertility (MBPI) perform better, due to certain distinctive elements, than a partly matched support group in improving the wellbeing and medically assisted reproduction (MAR) outcomes of women with elevated distress levels in a clinical setting?

SUMMARY ANSWER

While robust enhancements occurred in the wellbeing overall, the cognitive behavioural and formalized stress management elements of the MBPI allowed a significantly stronger improvement in trait anxiety, but not in other mental health and MAR outcomes, compared with a support group.

WHAT IS KNOWN ALREADY

Mind-body psychological programmes adjacent to MAR have been found to improve women's mental states and possibly increase chances of pregnancy. However, not enough is known about the programme's effectiveness among patients with elevated distress levels in routine clinical settings, nor is it clear which of its particular ingredients are specifically effective.

STUDY DESIGN, SIZE, DURATION

A pre-post design, single-centre, randomized controlled trial was performed between December 2019 and October 2022 (start and end of recruitment, respectively). The sample size (n = 168) was calculated to detect superiority of the MBPI in improving fertility-related quality of life. Randomization was computer-based, with random numbers concealing identities of patients until after allocation.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The trial was conducted at a large university teaching hospital. A total of 168 patients were randomly assigned to the mind-body (MBPI) group (n = 84) and the fertility support (FS) control group (n = 84). Patients received a 10-week, 135-min/week group intervention, with the FS group following the same format as the MBPI group, but with a less restricted and systematic content, and without the presumed effective factors. The number of patients analysed was n = 74 (MBPI) and n = 68 (FS) for post-intervention psychological outcomes, and n = 54 (MBPI) and n = 56 (FS) for pregnancy outcomes at a 30-month follow-up.

MAIN RESULTS AND THE ROLE OF CHANCE

Significant improvements occurred in both groups in all psychological domains (adjusted P < 0.001), except for treatment-related quality of life. Linear mixed-model regression analysis did not reveal significantly greater pre-post improvements in the MBPI group than in the FS group in fertility-related quality of life (difference in differences (DD) = 4.11 [0.42, 7.80], d = 0.32, adjusted P = 0.124), treatment-related quality of life (DD = -3.08 [-7.72, 1.55], d = -0.20, adjusted P = 0.582), infertility-specific stress (DD = -2.54 [-4.68, 0.41], d = -0.36, adjusted P = 0.105), depression (DD = -1.16 [3.61, 1.29], d = -0.13, adjusted P = 0.708), and general stress (DD = -0.62 [-1.91, 0.68], d = -0.13, adjusted P = 0.708), but it did show a significantly larger improvement in trait anxiety (DD = -3.60 [-6.16, -1.04], d = -0.32, adjusted P = 0.042). Logistic regression showed no group effect on MAR pregnancies, spontaneous pregnancies, or live births.

LIMITATIONS, REASONS FOR CAUTION

The follow-up only covered MAR-related medical outcomes and no psychological variables, and their rates were not equal in the two groups. Biological factors other than age, aetiology, and duration of infertility may have confounded the study results. Loss to follow-up was between 5% and 10%, which may have led to some bias.

WIDER IMPLICATIONS OF THE FINDINGS

The psychologically and medically heterogeneous sample, the normal clinical setting and the low attrition rate all raise the external validity and generalizability of our study. The MBPI works not only in controlled conditions, but also in routine MAR practice, where it can be introduced as a cost-effective, low-intensity psychological intervention, within the framework of stepped care. More studies are needed to further identify its active ingredients.

STUDY FUNDING/COMPETING INTEREST(S)

The authors received no financial support for the research, authorship, and/or publication of this article. The authors have no conflict of interest to disclose.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT04151485.

TRIAL REGISTRATION DATE

5 November 2019.

DATE OF FIRST PATIENT’S ENROLMENT

15 December 2019.

Association of Disability Status and Type With Binge Drinking and Prescription Opioid Misuse Among Adults From a 3-State Sample

BACKGROUND

Research examining at-risk substance use by disability status is limited, with little investigation into differences by disability type. We investigated binge drinking and prescription opioid misuse among adults with and without disabilities, and by type of disability, to inform need for assessment and intervention within these populations.

METHODS

Secondary analyses of adults who completed the disability, alcohol, and prescription opioid misuse items in the 2018 Ohio, Florida, or Nebraska Behavioral Risk Factor Surveillance System surveys (n = 28 341), the only states that included prescription opioid misuse in 2018. Self-reported disability status (yes/no) relied on 6 standardized questions assessing difficulties with: vision, hearing, mobility, cognition, self-care, and independent living (dichotomous, nonmutually exclusive, for each disability). Logistic regression models estimated the association of disability status and type with (1) past 30-day binge drinking and (2) past-year prescription opioid misuse. Additional models were restricted to separate subsamples of adults who: (a) currently drink, (b) received a past-year prescription opioid, and (c) did not receive a past-year prescription opioid.

RESULTS

One-third reported at least one disability, with mobility (19.5%), cognitive (11.5%), and hearing (10.2%) disability being the most common. Disability status was associated with lower odds of binge drinking (adjusted odds ratio [AOR] = 0.74, 95% confidence interval [CI] 0.68-0.80, P ≤ .01). However, among adults who currently drink, people with disabilities had higher odds of binge drinking (AOR = 1.11, 95% CI 1.01-1.22, P ≤ .05]. Disability was associated with higher odds of past-year prescription opioid misuse (AOR = 2.51, 95% CI 2.17-2.91, P ≤ .01).

CONCLUSIONS

Adults with disabilities had higher odds of prescription opioid misuse, and among adults who currently drink, higher odds for binge drinking were observed. The magnitude of the association between disability status and prescription opioid misuse was particularly concerning. Providers should be trained to screen and treat for substance use problems for people with disabilities.

Food Insecurity: Physician Perspectives, Screening and Communication

Introduction

Primary care physicians may perceive food insecurity (FI) as a difficult topic to address in health care encounters, resulting in at-risk patients not being identified. This exploratory study examines physician perspectives on how decisions to screen patients for FI are made, effective FI communication strategies, and barriers to screening.

Methods

Primary care physicians in the statewide, practice-based Iowa Research Network (IRENE) completed a study survey in May 2022 that included structured and open-ended questions regarding their experiences screening for FI. Thematic and descriptive analysis identified common themes in providers' experiences and perspectives.

Results

Although most physicians responding to the survey indicated that they have observed FI in their patient population, 27% have never observed FI in their practice. Physicians varied in their reasons for deciding to screen, with the most reported reason being "when it comes up in conversation." Common screening barriers among respondents included limited appointment time and feeling inadequately prepared to connect patients with resources. Respondents noted that negative experiences with FI screening were rare and noted positive experiences, including gratitude from the patient, and building patient-physician trust. Respondents shared normalizing phrases that helped address the additional obstacle of feeling inadequately prepared to assess FI in a tactful manner.

Conclusions

This study explored physicians' experiences with asking patients about FI and provides insight into FI screening gaps, barriers, and opportunities. Better understanding of physician attitudes and practices may help guide and address barriers to more effective and consistent FI screening.

A systematic review of validity of US survey measures for assessing substance use and substance use disorders

BACKGROUND

The steep rise in substance use and substance use disorder (SUD) shows an urgency to assess its prevalence using valid measures. This systematic review summarizes the validity of measures to assess the prevalence of substance use and SUD in the US estimated in population and sub-population-based surveys.

METHODS

A literature search was performed using nine online databases. Studies were included in the review if they were published in English and tested the validity of substance use and SUD measures among US adults at the general or sub-population level. Independent reviews were conducted by the authors to complete data synthesis and assess the risk of bias.

RESULTS

Overall, 46 studies validating substance use/SUD (n = 46) measures were included in this review, in which 63% were conducted in clinical settings and 89% assessed the validity of SUD measures. Among the studies that assessed SUD screening measures, 78% examined a generic SUD measure, and the rest screened for specific disorders. Almost every study used a different survey measure. Overall, sensitivity and specificity tests were conducted in over a third of the studies for validation, and 10 studies used receiver operating characteristics curve.

CONCLUSION

Findings suggest a lack of standardized methods in surveys measuring and reporting prevalence of substance use/SUD among US adults. It highlights a critical need to develop short measures for assessing SUD that do not require lengthy, time-consuming data collection that would be difficult to incorporate into population-based surveys assessing a multitude of health dimensions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022298280.

Testing a Brief Quitline Intervention for Tobacco Cannabis Co-Users: A Randomized Controlled Pilot Study

Background: Tobacco cannabis co-use is common and becoming more prevalent. Frequent and heavy users of cannabis may struggle to quit smoking. Quitlines offer free cessation treatment in the United States and 25% of quitline callers may also be cannabis users. The present paper describes a randomized pilot study of a tailored intervention for cannabis and cigarette co-users. The intervention combines the quitline smoking cessation treatment with a motivational enhancement therapy-based cannabis intervention. Methods: The randomized pilot study was conducted within four state-funded quitlines with quitline coaches as interventionists. 102 quitline callers who were cannabis and cigarette co-users were randomized to receive treatment as usual (TAU) or the new Quitline Check-Up (QLCU) intervention. Outcomes were collected 90 days post-randomization. Primary outcomes included feasibility and acceptability of delivering the QLCU in the quitline setting. Secondary outcomes included 7-day point prevalence tobacco abstinence, past 30-day cannabis use, and Cannabis Use Disorder Identification Test scores. Results: Study participants were heavy cannabis users, averaging 25 days of use in the past 30; nearly 70% used at a level considered hazardous. Fidelity ratings indicated coaches were successful at delivering the intervention. Treatment engagement was high for both groups (TAU m = 3.4 calls; QLCU m = 3.6 calls) as was treatment satisfaction. Intent-to-treat quit rates (with survey non-responders classified as smokers) were 28.6% for the TAU control group and 24.5% for the QLCU group (P = .45). Discussion: Hazardous cannabis use rates were high in this sample of tobacco cannabis co-users calling quitlines to quit smoking. The intervention for co-users was acceptable and feasible to deliver. No improvements in tobacco cessation outcomes were observed. Pragmatic intervention development within a real-world clinical setting can streamline the intervention development process. More research is needed on tobacco cannabis co-users and who can benefit from a tailored intervention. Registered: ClinicalTrials.gov NCT04737772, February 4, 2021.

Factors associated with meningitis vaccine awareness and engagement among Latino men who have sex with men in South Florida

Awareness and uptake of the meningitis vaccine remains low among marginalized groups, such as Latino men who have sex with men (LMSM), potentially due to structural and psychosocial barriers in accessing preventative healthcare. The current study explored awareness and uptake of meningitis vaccines among a group of LMSM (N = 99) living in South Florida. A three-pronged variable selection approach was utilized prior to conducting regression models (linear and logistic). Overall, 48.5% of the participants reported little to no knowledge about meningitis vaccines, and 20.2% reported being vaccinated. Living with HIV (OR = 10.48) and time since outbreak (OR = 1.03) were significant predictors of meningitis vaccine uptake. No significant correlates of meningitis vaccine awareness were identified. More research is needed to identify other important factors associated with meningitis vaccine awareness and uptake among LMSM, a multiple marginalized group.

[Substance use disorder: Epidemiology, medical consequences and treatment]

Substance use is a common health problem, and substance use disorder, which is its most severe presentation, is associated with multiple medical consequences and a negative impact on individual and on population health. Substance use disorder needs to be addressed as any chronic medical condition; therefore, it has to be detected at the early stages and has to be properly treated to prevent drug-related harm. Internists should be able to recognize and treat intoxication and abstinence. Internists should also be able to refer the patient to state of the art long term treatment, aimed to detoxification and treatment induction to promote abstinence and prevent relapse. In this narrative review we will discuss substance use epidemiology, its main medical consequences and its treatment, with a focus on alcohol, opiates, cocaine and other stimulants, cannabis and benzodiazepines.

Test-retest reliability of DSM-5 substance use symptom checklists used in primary care and mental health care settings

INTRODUCTION

Substance use disorders (SUDs) are underdiagnosed in healthcare settings. The Substance Use Symptom Checklist (SUSC) is a practical, patient-report questionnaire that has been used to assess SUD symptoms based on Diagnostic and Statistical Manual of Mental Disorders-5th edition (DSM-5) criteria. This study evaluates the test-retest reliability of SUSCs completed in primary and mental health care settings.

METHODS

We identified 1194 patients who completed two SUSCs 1-21 days apart as part of routine care after reporting daily cannabis use and/or any past-year other drug use on behavioral health screens. Test-retest reliability of SUSC scores was evaluated within the full sample, subsamples who completed both checklists in primary care (n=451) or mental health clinics (n=512) where SUSC implementation differed, and subgroups defined by sex, insurance status, age, and substance use reported on behavioral health screens.

RESULTS

In the full sample, test-retest reliability was high for indices reflecting the number of SUD symptoms endorsed (ICC=0.75, 95% CI:0.72-0.77) and DSM-5 SUD severity (kappa=0.72, 95% CI:0.69-0.75). These reliability estimates were higher in primary care (ICC=0.81, 95% CI:0.77-0.84; kappa=0.79, 95% CI:0.75-0.82, respectively) than in mental health clinics (ICC=0.74, 95% CI:0.70-0.78; kappa=0.73, 95% CI:0.68-0.77). Reliability differed by age and substance use reported on behavioral health screens, but not by sex or insurance status.

CONCLUSIONS

The SUSC has good-to-excellent test-retest reliability when completed as part of routine primary or mental health care. Symptom checklists can reliably measure symptoms consistent with DSM-5 SUD criteria, which may aid SUD-related care in primary care and mental health settings.

The Association Between Self-Reported Anxiety and Retention in Opioid Agonist Therapy: Findings From a Canadian Pragmatic Trial

BACKGROUND

Prescription-type opioid use disorder (POUD) is often accompanied by comorbid anxiety, yet the impact of anxiety on retention in opioid agonist therapy (OAT) is unclear. Therefore, this study investigated whether baseline anxiety severity affects retention in OAT and whether this effect differs by OAT type (methadone maintenance therapy (MMT) vs. buprenorphine/naloxone (BNX)).

METHODS

This secondary analysis used data from a pan-Canadian randomized trial comparing flexible take-home dosing BNX and standard supervised MMT for 24 weeks. The study included 268 adults with POUD. Baseline anxiety was assessed using the Beck Anxiety Inventory (BAI), with BAI ≥ 16 indicating moderate-to-severe anxiety. The primary outcomes were retention in assigned and any OAT at week 24. In addition, the impact of anxiety severity on retention was examined, and assigned OAT was considered an effect modifier.

RESULTS

Of the participants, 176 (65%) reported moderate-to-severe baseline anxiety. In adjusted analyses, there was no significant difference in retention between those with BAI ≥ 16 and those with BAI < 16 assigned (29% vs. 28%; odds ratio (OR) = 2.03, 95% confidence interval (CI) = 0.94-4.40; P = 0.07) or any OAT (35% vs. 34%; OR = 1.57, 95% CI = 0.77-3.21; P = 0.21). In addition, there was no significant effect modification by OAT type for retention in assigned (P = 0.41) or any OAT (P = 0.71). In adjusted analyses, greater retention in treatment was associated with BNX (vs. MMT), male gender identity (vs. female, transgender, or other), enrolment in the Quebec study site (vs. other sites), and absence of a positive urine drug screen for stimulants at baseline.

CONCLUSIONS

Baseline anxiety severity did not significantly impact retention in OAT for adults with POUD, and there was no significant effect modification by OAT type. However, the overall retention rates were low, highlighting the need to develop new strategies to minimize the risk of attrition from treatment.

CLINICAL TRIAL REGISTRATION

This study was registered in ClinicalTrials.gov (NCT03033732).

Gambling Harm Experienced by Children Exposed to Parental Gambling: An Online Survey of Australians

Although child wellbeing is known to be negatively affected by gambling, relatively little is known about the specific harms experienced by children exposed to parental gambling problems. The current study aimed to better understand gambling harm directly attributed to regular parental gambling in key areas of child wellbeing: financial, psychological, interpersonal wellbeing and intergenerational transmission of problem gambling. Using data from a national survey of Australian adults exposed to parental gambling under the age of 18 (n = 211), the results show that parental gambling was related significant levels of financial harm, abuse, neglect as well as relational and psychological problems as a direct result of parental gambling. The likelihood of experiencing gambling harms was positively associated with parental problem gambling severity. Harmful impacts of parental gambling as a child were also associated with a range of psychological problems in adulthood including depression, anxiety, Post-Traumatic Stress Disorder and intimate partner violence victimisation. Parental problem gambling severity was negatively associated with own lifetime gambling problems, suggesting a specific pattern of intergenerational transmission of problem gambling in children of regular, or heavy, gamblers. This research highlights the need for more supports for families with children in which at least one parent gambles regularly.

General somatic health and lifestyle habits in individuals with obsessive- compulsive disorder: an international survey

BACKGROUND

Obsessive-compulsive disorder (OCD) has been associated with a broad range of health-related issues. Unhealthy lifestyle habits such as physical inactivity, an unhealthy diet, smoking, and alcohol consumption are hypothesized to contribute to this association. However, the lifestyle habits of individuals with OCD have been scarcely investigated. In this international survey, we explored the physical health and lifestyle habits of adults with a self-reported diagnosis of OCD.

METHODS

An online global survey available in seven languages was disseminated through interest organizations and social media between July 2021 and March 2022. The survey included questions relating to socio-demographic variables and clinical characteristics (including OCD symptom severity - as measured with the 12-item self-report scale Obsessive-Compulsive Inventory [OCI-12] - and psychotropic medication), physical health, and lifestyle habits. Frequencies and percentages, or means and standard deviations, as appropriate, were calculated. Subgroup analyses by OCD symptom severity, gender, and age group were performed.

RESULTS

A total of 496 individuals with OCD completed the survey and were included in the analyses (mean age = 36.0 years, SD = 12.5, range 18-79; 78.8% women). Most participants were from Europe (n = 245, 49.4%) and North America (n = 187, 37.7%). OCD symptom severity scores were on the moderate range (OCI-12 mean score = 21.2, SD = 9.1). A majority (n = 354, 71.4%) reported having comorbid somatic health issues, mainly allergies, gastrointestinal conditions, and cardiometabolic conditions. Nearly half of the sample (n = 236, 47.6%) reported a body mass index ≥ 25, corresponding to at least overweight. A significant proportion of the participants reported low physical activity (n = 271, 55.0%), unhealthy dietary habits (n = 182, 36.7%), risk consumption of alcohol (n = 111, 22.3%), and non-restorative sleep (n = 268, 54.0%). Subgroup analyses showed overall similar results across groups, with some exceptions.

CONCLUSIONS

In this sample, individuals with OCD self-reported a range of health-related issues and a number of unhealthy lifestyle behaviors, most prominently a lack of physical activity. Interventions aimed at modifying unhealthy lifestyles to prevent or improve health conditions beyond the psychiatric symptoms should be considered.

Age, Motion, Medical, and Psychiatric Associations With Incidental Findings in Brain MRI

Importance

Few investigations have evaluated rates of brain-based magnetic resonance imaging (MRI) incidental findings (IFs) in large lifespan samples, their stability over time, or their associations with health outcomes.

Objectives

To examine rates of brain-based IFs across the lifespan, their persistence, and their associations with phenotypic indicators of behavior, cognition, and health; to compare quantified motion with radiologist-reported motion and evaluate its associations with IF rates; and to explore IF consistency across multiple visits.

Design, Setting, and Participants

This cross-sectional study included participants from the Nathan Kline Institute-Rockland Sample (NKI-RS), a lifespan community-ascertained sample, and the Healthy Brain Network (HBN), a cross-sectional community self-referred pediatric sample focused on mental health and learning disorders. The NKI-RS enrolled participants (ages 6-85 years) between March 2012 and March 2020 and had longitudinal participants followed up for as long as 4 years. The HBN enrolled participants (ages 5-21 years) between August 2015 and October 2021. Clinical neuroradiology MRI reports were coded for radiologist-reported motion as well as presence, type, and clinical urgency (category 1, no abnormal findings; 2, no referral recommended; 3, consider referral; and 4, immediate referral) of IFs. MRI reports were coded from June to October 2021. Data were analyzed from November 2021 to February 2023.

Main Outcomes and Measures

Rates and type of IFs by demographic characteristics, health phenotyping, and motion artifacts; longitudinal stability of IFs; and Euler number in projecting radiologist-reported motion.

Results

A total of 1300 NKI-RS participants (781 [60.1%] female; mean [SD] age, 38.9 [21.8] years) and 2772 HBN participants (976 [35.2%] female; mean [SD] age, 10.0 [3.5] years) had health phenotyping and neuroradiology-reviewed MRI scans. IFs were common, with 284 of 2956 children (9.6%) and 608 of 1107 adults (54.9%) having IFs, but rarely of clinical concern (category 1: NKI-RS, 619 [47.6%]; HBN, 2561 [92.4%]; category 2: NKI-RS, 647 [49.8%]; HBN, 178 [6.4%]; category 3: NKI-RS, 79 [6.1%]; HBN, 30 [1.1%]; category 4: NKI-RS: 12 [0.9%]; HBN, 6 [0.2%]). Overall, 46 children (1.6%) and 79 adults (7.1%) required referral for their IFs. IF frequency increased with age. Elevated blood pressure and BMI were associated with increased T2 hyperintensities and age-related cortical atrophy. Radiologist-reported motion aligned with Euler-quantified motion, but neither were associated with IF rates.

Conclusions and Relevance

In this cross-sectional study, IFs were common, particularly with increasing age, although rarely clinically significant. While T2 hyperintensity and age-related cortical atrophy were associated with BMI and blood pressure, IFs were not associated with other behavioral, cognitive, and health phenotyping. Motion may not limit clinical IF detection.

Substance Use Disorder

Substance use disorders (SUDs) present a challenge in the emergency department (ED) setting. This article provides an overview of SUDs, their clinical assessment, legal considerations in drug testing, diagnosis, and treatment approaches. SUDs are prevalent and coexist with mental health disorders, necessitating comprehensive evaluation and management. Clinical assessment involves screening tools, substance use history, and identification of comorbidities. Diagnosis relies on a thorough evaluation of substance abuse patterns and associated medical conditions. Treatment approaches encompass a multidisciplinary approach, incorporating counseling, medications, and social support. Effective management of SUDs in the ED requires a comprehensive understanding of these complex disorders.

Severe COVID anxiety among adults in the United Kingdom: cohort study and nested feasibility trial

BACKGROUND

People with severe COVID anxiety have poor mental health and impaired functioning, but the course of severe COVID anxiety is unknown and the quality of evidence on the acceptability and impact of psychological interventions is low.

METHODS

A quantitative cohort study with a nested feasibility trial. Potential participants aged 18 and over, living in the UK with severe COVID anxiety, were recruited online and from primary care services. We examined levels of COVID anxiety in the six months after recruitment, and factors that influenced this, using linear regression. Those scoring above 20 on the short Health Anxiety Inventory were invited to participate in a feasibility trial of remotely delivered Cognitive Behavioural Therapy for Health Anxiety (CBT-HA). Exclusion criteria were recent COVID-19, current self-isolation, or current receipt of psychological treatment. Key outcomes for the feasibility trial were the level of uptake of CBT-HA and the rate of follow-up.

RESULTS

204 (70.2%) of 285 people who took part in the cohort study completed the six month follow-up, for whom levels of COVID anxiety fell from 12.4 at baseline to 6.8 at six months (difference = -5.5, 95% CI = -6.0 to -4.9). Reductions in COVID anxiety were lower among older people, those living with a vulnerable person, those with lower baseline COVID anxiety, and those with higher levels of generalised anxiety and health anxiety at baseline. 36 (90%) of 40 participants enrolled in the nested feasibility trial were followed up at six months. 17 (80.9%) of 21 people in the active arm of the trial received four or more sessions of CBT-HA. We found improved mental health and social functioning among those in the active, but not the control arm of the trial (Mean difference in total score on the Work and Social Adjustment Scale between baseline and follow up, was 9.7 (95% CI = 5.8-13.6) among those in the active, and 1.0 (95% C.I. = -4.6 to 6.6) among those in the control arm of the trial.

CONCLUSIONS

While the mental health of people with severe COVID anxiety appears to improve over time, many continue to experience high levels of anxiety and poor social functioning. Health anxiety is highly prevalent among people with severe COVID anxiety and may provide a target for psychological treatment.

TRIAL REGISTRATION

Retrospectively registered at ISRCTN14973494 on 09/09/2021.

Screening Incarcerated Women for Opioid Use Disorder

The overall aim of the present study is to examine the utility of the DSM OUD Checklist and the NM-ASSIST screening tools to identify symptoms consistent with OUD among incarcerated women in county jails. This study contributes to the existing literature because research on screening and assessment approaches for incarcerated women has been limited. The focus of the current study is to describe the screening procedures and study recruitment for a larger parent study focused on increasing treatment linkages. Study findings indicate a positive correlation between indicators of OUD using the two screening tools, as well as a high degree of correlation between street opioid misuse and other high-risk drug indicators (overdose and injection practices). These findings underscore the importance of outreach, screening, and intervention in real-world settings, including jails, in order to increase access to OUD treatment among this vulnerable sample of women.

Measuring Electronically Shared Rape Myths: Scale Creation and Correlates

Increased access to information online (e.g., social media) provides opportunities for exposure to rape myths (i.e., false beliefs about incidents of sexual assault). Social media, in particular, may serve a critical role in shaping rape culture. Thus, it is important to identify ways to assess online exposure to rape myths, especially given the influence online exposure may have on offline behaviors. Data were analyzed from 2,609 18-25-year-old participants (mean age = 20.9 years; 46.1% male; 71.6% White) recruited in 2017 through social media to complete an online survey on experiences and perceptions of sexual violence. We used exploratory and confirmatory factor analyses (EFA, CFA) to evaluate the relatedness of nine items adapted to reflect rape myths posted by friends on social media. We split the sample into training (50%) and testing (50%) sets for the EFA and CFA, respectively, then evaluated the correlation between experiences of sexual violence, substance use, and social media use and exposure to online rape myths. Eigenvalues (1-factor: 5.509; 2-factor: 0.803; 3-factor: 0.704; 4-factor: 0.482), factor loadings, fit statistics (RMSEA: 0.03; CFI: 0.99; TLI: 0.99; SRMR: 0.057), interpretability, and existing theory supported a 1-factor solution, which was supported by CFA fit statistics (RMSEA: 0.021; CFI: 0.99; TLI: 0.99; SRMR: 0.038). Cronbach's alpha of the nine items was .77. Greater exposure to online rape myths was associated with greater likelihood of attempted rape perpetration (β = .052, SE = .016, p < .005), rape victimization (β = .045, SE = .009, p < .005), use of illicit drugs (β = .021, SE = 0.008, p < .05), being male (β = .017, SE = .008, p < .05), and being younger (β = -.008, SE = .002, p < .005). Our findings support assessing exposure to online rape myths, which may be important for informing sexual violence prevention and intervention efforts.

Validation of a brief screener for broad-spectrum mental and substance-use disorders in South Africa

In low-resource settings, valid mental health screening tools for non-specialists can be used to identify patients with psychiatric disorders in need of critical mental health care. The Mental Wellness Tool-13 (mwTool-13) is a 13-item screener for identifying adults at risk for common mental disorders (CMDs) alcohol-use disorders (AUDs), substance-use disorders (SUD), severe mental disorders (SMDs), and suicide risk (SR). The mwTool-13 is administered in two steps, specifically, only those who endorse any of the initial three questions receive the remaining ten questions. We evaluated the performance of mwTool-13 in South Africa against a diagnostic gold standard. We recruited a targeted, gender-balanced sample of adults, aged ≥18 years at primary and tertiary healthcare facilities in Eastern Cape Province. Of the 1885 participants, the prevalence of CMD, AUD, SMD, SR, and SUD was 24.4%, 9.5%, 8.1%, 6.0%, and 1.6%, respectively. The mwTool-13 yielded high sensitivities for CMD, SMD, and SR, but sub-optimal sensitivities for AUD and SUD (56.7% and 64.5%, respectively). Including a single AUD question in the initial question set improved the tool's performance in identifying AUD and SUD (sensitivity > 70%), while maintaining brevity, face-validity, and simplicity in the South African setting.

Early Insights into Implementation of Universal Screening, Brief Intervention, and Referral to Treatment for Perinatal Substance Use

OBJECTIVES

Perinatal substance use is a growing concern across the United States. Universal screening, brief intervention, and referral to treatment (SBIRT) is one systems-level approach to addressing perinatal substance use. The objective of this study is to assess early efforts to implement SBIRT in an outpatient obstetric clinic.

METHODS

The research team implemented universal screening with the 5 P's screening tool. Providers then engaged patients in a brief intervention and referred to a care manager who then worked with patients via tele-health to connect patients with needed services. Feasibility was measured through the collection of aggregate data describing frequency of universal screening and referral to treatment. The implementation team met bi-weekly to reflect on implementation barriers and facilitators.

RESULTS

In the first year of implementation, 48.5% of patients receiving care in the clinic completed the 5 P's screener at least once during the perinatal period. Screening occurred in a little over a quarter (26.5%) of eligible visits. Of the 463 patients that completed the 5 P's at least once during the perinatal period, 195 (42%) unique patients screened positive (answered yes to at least one question).

CONCLUSIONS FOR PRACTICE

Early implementation efforts suggest this approach is feasible in this obstetric setting. Similar implementation studies should consider implementing universal screening for substance use and perinatal mood and anxiety disorders simultaneously; guide efforts using an implementation framework; invest resources in more intensive training and ongoing coaching for providers; and adopt strategies to track frequency and fidelity of brief intervention.

Personality characteristics, not clinical symptoms, are associated with anhedonia in a community sample: A preliminary investigation

Anhedonia is a salient transdiagnostic psychiatric symptom associated with increased illness severity and chronicity. Anhedonia is also present to varying degrees in non-clinical cohorts. Here, we sought to examine factors influencing expression of anhedonia. Participants (N = 335) were recruited through the Nathan Kline Institute-Rockland Sample, an initiative to deeply phenotype a large community sample across the lifespan. Utilizing a data-driven approach, we evaluated associations between anhedonia severity, indexed by Snaith-Hamilton Pleasure Scale (SHAPS), and 20 physical, developmental, and clinical measures, including Structured Clinical Interview for DSM-IV, Beck Depression Inventory, State-Trait Anxiety Inventory, NEO Five-Factor Inventory-3 (NEO-FFI-3), BMI, Hemoglobin A1C, and demography. Using a bootstrapped AIC-based backward selection algorithm, seven variables were retained in the final model: NEO-FFI-3 agreeableness, extraversion, and openness to experience; BMI; sex; ethnicity; and race. Though median SHAPS scores were greater in participants with psychiatric diagnoses (18.5) than those without (17.0) (U = 12238.5, z = 2.473, p = 0.013), diagnosis and symptom measures were not retained as significant predictors in the final robust linear model. Participants scoring higher on agreeableness, extraversion, and openness to experience reported significantly lower anhedonia. These results demonstrate personality as a mild-to-moderate but significant driver of differences in experiencing pleasure in a community sample.

Perioperative Concerns in the Patient with History of Alcohol Use

Alcohol use is common in patients presenting for surgery and can result in significant physiologic changes and postoperative complications. Anesthesia providers must be aware of the potential risks associated with alcohol consumption and take steps to minimize them. Perioperative management includes assessing patients for alcohol use, providing alcohol cessation interventions, adjusting the anesthetic plan according to the patient's alcohol use history, providing appropriate pain management strategies, and closely monitoring patients during and after surgery for signs of alcohol withdrawal.

Aligning public health and public safety: Probation as a touchpoint to identify and link patients with opioid use disorder to opioid agonist treatment

BACKGROUND

People in criminal justice settings (CJS) have high rates of opioid use disorder (OUD) and HIV. Probation is part of the CJS and congregates many individuals with high rates of mental health and substance use disorders relative to the general population; nevertheless, probation remains a major improvement to incarceration. As a steppingstone to full decarceration efforts, community supervision settings like probation can be leveraged as "touchpoints" to identify and link people with OUD (and other co-morbid conditions) to treatment and reduce criminal activity.

METHODOLOGY

To determine the feasibility of a modified screening, brief intervention and referral to treatment (SBIRT) strategy to link probationers to opioid agonist therapies (OAT) in the newly created probation system in Ukraine, we conducted a single-arm SBIRT intervention in eight probation centers in four Ukrainian administrative regions. For those screening positive for OUD, interest in OAT was assessed before and after a brief intervention. Those interested in OAT were referred to community OAT services. Participants with OUD also underwent HIV testing.

PRINCIPAL FINDINGS

Of the 1,298 consecutive individuals screened, 208 (16.0%) met criteria for opioid dependence. Of these, 122 (58.7%) enrolled in brief intervention, of which 54 (44.3%) had HIV and 14 (25.9%) of these were newly diagnosed. After the brief intervention, interest in starting OAT increased significantly from a median of 7.0 to 8.0 (P = <0.001) using a 10-point scale. Thirty (N = 30; 24.6%) of the enrolled participants initiated OAT and 21 of these (70%) were retained in treatment for 6 months.

SIGNIFICANCE

The prevalence of OUD (and HIV) is high among people in probation in Ukraine. SBIRT can identify a large number of people eligible for OAT, many of whom were willing to initiate and remain on OAT. Integrating SBIRT into probation can potentially assist with OAT scale-up and help address HIV prevention efforts.

Pain, mental health and healthcare utilization: Impact of the COVID-19 pandemic on youth with chronic pain, parents and siblings

BACKGROUND

Paediatric chronic pain was a public health emergency before the novel coronavirus (COVID-19) pandemic, and this problem is predicted to escalate. Pain tends to occur intergenerationally in families, and youth with chronic pain and their parents have high rates of mental health issues, which can further exacerbate pain. Siblings of youth with chronic pain have been largely overlooked in research, as well as the impact of the pandemic on posttraumatic stress disorder (PTSD) symptoms and healthcare utilization.

METHODS

This cross-sectional study examined pain, mental health and healthcare utilization in three groups: youth with chronic pain (n = 357), parents of youth with chronic pain (n = 233) and siblings of youth with chronic pain (n = 156) during the COVID-19 pandemic in Canada.

RESULTS

More so than with pain symptoms, the results revealed high levels of mental health symptoms (i.e. anxiety, depressive, and PTSD), particularly in individuals more personally impacted by the pandemic. The largest effect was seen on PTSD symptoms for all groups. For parents with chronic pain, greater personal COVID-19 impact was related to worse pain interference. Reported rates of healthcare utilization were strikingly high, with youth with chronic pain, parents (reporting on behalf of their children with chronic pain), and siblings of youth with chronic pain reporting that most consultations were due to pain.

CONCLUSIONS

Longitudinal research assessing these outcomes across continued waves of the pandemic is needed to ensure timely, tailored and equitable access to pain and mental health assessment and treatment.

SIGNIFICANCE

This study examined pain, mental health, substance use and healthcare utilization in youth with chronic pain, siblings and parents during the COVID-19 pandemic. Greater personal impact of the pandemic was not largely associated with poorer pain outcomes; however, it was associated with mental health, with the largest effect on PTSD symptoms. The high rates and significant association of COVID-19 impact with PTSD symptoms underscore the importance of including PTSD assessment as part of routine screening practices in pain clinics.

A randomized controlled trial of recovery management checkups for primary care patients: Twelve-month results

BACKGROUND

Primary care settings like federally qualified health centers (FQHC) are optimal locations to identify individuals with substance use disorders (SUD) and link them to SUD treatment, yet successful linkage has proven difficult. Recovery management checkups for primary care (RMC-PC) is a promising method for increasing linkage to care, engagement in treatment, and reducing substance use.

METHODS

Participants (n = 266) who received screening, brief intervention, and referral to treatment (SBIRT) at four FQHC sites and needed SUD treatment were randomized to receive SBIRT only or SBIRT+RMC-PC. All participants received SBIRT prior to randomization as part of usual care while those in the experimental group also received quarterly checkups. All participants completed research interviews at enrollment and 3, 6, 9, and 12 months post-enrollment. The primary outcome was whether participants received any days of SUD treatment. Key secondary outcomes were days of SUD treatment (total and by SUD level of care), days of alcohol or drug abstinence, and a reduction in days of specific substance use, all based on self-report.

RESULTS

Relative to participants receiving SBIRT only, participants assigned to SBIRT+RMC-PC were significantly more likely to have received any SUD treatment over 12 months (adjusted odds ratio [AOR] = 3.85) and more days of SUD treatment over 12 months (Cohen's effect size d = +0.41). The SBIRT+RMC-PC group also reported significantly more days of abstinence over 12 months (d = +0.30), fewer days of alcohol use (d = -0.20) and cannabis use (d = -0.20), and lower combined substance use frequency (d = -0.25). Days of treatment were found to positively mediate the direct effect of SBIRT+RMC-PC on days of abstinence.

CONCLUSION

This study provides further evidence of the effectiveness of the "referral to treatment" component of SBIRT when combined with RMC for patients in primary care settings, including those with drug use problems. Moreover, results demonstrate the value of repeated checkups on longer-term treatment and substance use outcomes.

Association between cannabis use disorder symptom severity and probability of clinically-documented diagnosis and treatment in a primary care sample

BACKGROUND

Brief cannabis screening followed by standardized assessment of symptoms may support diagnosis and treatment of cannabis use disorder (CUD). This study tested whether the probability of a medical provider diagnosing and treating CUD increased with the number of substance use disorder (SUD) symptoms documented in patients' EHRs.

METHODS

This observational study used EHR and claims data from an integrated healthcare system. Adult patients were included who reported daily cannabis use and completed the Substance Use Symptom Checklist, a scaled measure of DSM-5 SUD symptoms (0-11), during routine care 3/1/2015-3/1/2021. Logistic regression estimated associations between SUD symptom counts and: 1) CUD diagnosis; 2) CUD treatment initiation; and 3) CUD treatment engagement, defined based on Healthcare Effectiveness Data and Information Set (HEDIS) ICD-codes and timelines. We tested moderation across age, gender, race, and ethnicity.

RESULTS

Patients (N=13,947) were predominantly middle-age, male, White, and non-Hispanic. Among patients reporting daily cannabis use without other drug use (N=12,568), the probability of CUD diagnosis, treatment initiation, and engagement increased with each 1-unit increase in Symptom Checklist score (p's<0.001). However, probabilities of diagnosis, treatment, and engagement were low, even among those reporting ≥2 symptoms consistent with SUD: 14.0% diagnosed (95% CI: 11.7-21.6), 16.6% initiated treatment among diagnosed (11.7-21.6), and 24.3% engaged in treatment among initiated (15.8-32.7). Only gender moderated associations between Symptom Checklist and diagnosis (p=0.047) and treatment initiation (p=0.012). Findings were similar for patients reporting daily cannabis use with other drug use (N=1379).

CONCLUSION

Despite documented symptoms, CUD was underdiagnosed and undertreated in medical settings.

The development and initial feasibility testing of D-HOMES: a behavioral activation-based intervention for diabetes medication adherence and psychological wellness among people experiencing homelessness

Introduction

Compared to stably housed peers, people experiencing homelessness (PEH) have lower rates of ideal glycemic control, and experience premature morbidity and mortality. High rates of behavioral health comorbidities and trauma add to access barriers driving poor outcomes. Limited evidence guides behavioral approaches to support the needs of PEH with diabetes. Lay coaching models can improve care for low-resource populations with diabetes, yet we found no evidence of programs specifically tailored to the needs of PEH.

Methods

We used a multistep, iterative process following the ORBIT model to develop the Diabetes Homeless Medication Support (D-HOMES) program, a new lifestyle intervention for PEH with type 2 diabetes. We built a community-engaged research team who participated in all of the following steps of treatment development: (1) initial treatment conceptualization drawing from evidence-based programs, (2) qualitative interviews with affected people and multi-disciplinary housing and healthcare providers, and (3) an open trial of D-HOMES to evaluate acceptability (Client Satisfaction Questionnaire, exit interview) and treatment engagement (completion rate of up to 10 offered coaching sessions).

Results

In step (1), the D-HOMES treatment manual drew from existing behavioral activation and lay health coach programs for diabetes as well as clinical resources from Health Care for the Homeless. Step (2) qualitative interviews (n = 26 patients, n = 21 providers) shaped counseling approaches, language and choices regarding interventionists, tools, and resources. PTSD symptoms were reported in 69% of patients. Step (3) trial participants (N = 10) overall found the program acceptable, however, we saw better program satisfaction and treatment engagement among more stably housed people. We developed adapted treatment materials for the target population and refined recruitment/retention strategies and trial procedures sensitive to prevalent discrimination and racism to better retain people of color and those with less stable housing.

Discussion

The research team has used these findings to inform an NIH-funded randomized control pilot trial. We found synergy between community-engaged research and the ORBIT model of behavioral treatment development to develop a new intervention designed for PEH with type 2 diabetes and address health equity gaps in people who have experienced trauma. We conclude that more work and different approaches are needed to address the needs of participants with the least stable housing.

Substance Use and Mental Health Screening Within an Emergency Department-Based HIV Screening Program: Outcomes From 1 Year of Implementation

INTRODUCTION

The emergency department (ED) may be an optimal setting to screen for substance use disorders (SUDs) and co-occurring psychiatric disorders (CODs). We report on the frequency of problematic substance use and comorbid elevated mental health symptoms detected during a 1-year implementation period of an ED-based SUD/COD screening approach within an established ED HIV screening program.

METHODS

Patients (N = 1,924) were approached by dedicated HIV screening staff in an urban, Midwestern ED. Patients first completed measures assessing problematic alcohol (Alcohol Use Disorder Identification Test-Concise [AUDIT-C]) and substance use across 10 categories of substances (National Institute on Drug Abuse-Modified Alcohol, Smoking, and Substance Involvement Screening Test [NIDA-Modified ASSIST]). Patients with positive alcohol and/or substance use screens completed measures assessing symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), and post-traumatic stress disorder (PTSD) (PTSD Checklist-Civilian [PCL-C]).

RESULTS

Patients were predominantly male (60.3%) with a mean age of 38.1 years (SD = 13.0); most identified as White (50.8%) or Black (44.8%). A majority (58.5%) had a positive screen for problematic alcohol and/or other substance use. Of those with a positive substance use screen (n = 1,126), 47.0% had a positive screen on one or more of the mental health measures with 32.1% endorsing elevated depressive symptoms, 29.6% endorsing elevated PTSD-related symptoms, and 28.5% endorsing elevated anxiety symptoms.

CONCLUSIONS

Among those receiving ED HIV screening, a majority endorsed problematic alcohol and/or other substance use and co-occurring elevated mental health symptoms. Substance use and mental health screening programs that can be integrated within other ED preventive services may enhance the identification of individuals in need of further assessment, referral, or linkage to substance use treatment services.

Project lifeline: implementing SBIRT in rural pharmacies to address opioid overdoses and substance use disorder

Background: There is emerging recognition of the unique benefits of implementing screening, brief intervention, and referral to treatment (SBIRT) in pharmacy settings to identify patients who can benefit from services and connecting them to those services.Objectives: This study describes Project Lifeline - a multipronged public health initiative to provide educational and technical support to rural community pharmacies implementing SBIRT for substance use disorder (SUD) and providing harm reduction support.Methods: Eight community pharmacies were recruited. Patients receiving a Schedule II prescription were invited to engage in SBIRT and offered naloxone. Patient screening data and key informant interviews with pharmacy staff on implementation strategy were analyzed.Results: Between 2018-2020, 4,601 adult patients were offered screens and 3,407 screens were completed on 2,881 unique adult patients (51.3% female; <0.01% nonbinary; 95.7% White). Of these unique screens, 107 patients were indicated for brief intervention, 31 accepted the brief intervention; and 12 were given a referral to SUD treatment. Patients who declined SBIRT or who did not want to reduce their use were offered access to naloxone (n = 372). Key informant interviews highlighted the importance of person-centered staff education, role-playing, anti-stigma training, and integrating activities into existing patient-care processes.Conclusion: While ongoing research is needed to characterize the full impact of Project Lifeline on patient outcomes, the reported findings help reinforce the benefits of multipronged public health initiatives that include community pharmacists to address the SUD crisis.

Assessing Rural-Urban Differences in Screening for Mental Health Needs Among Individuals in County Jails

Rural jails are increasingly contributing to the overall jail population and little is known about how they differ from non-rural jails. This study compares demographic, behavioral health and criminal/legal histories of 3,797 individuals who booked into three rural jails and seven non-rural jails. In addition, the study assessed how jails identify mental illness, which was compared to an objective screening instrument (Kessler-6). Individuals in rural jails were more likely to be white, female, have a history of mental health services, misuse substances, and to recidivate. After controlling for these differences, they had 1.5 times greater odds of having a mental illness but lower odds of being identified by the jails. Individuals in rural jails have more behavioral health needs and other criminogenic risk factor and their needs are less likely to be identified by jail staff, which may result in poor connection to diversion or treatment opportunities.

Protocol for a bandit-based response adaptive trial to evaluate the effectiveness of brief self-guided digital interventions for reducing psychological distress in university students: the Vibe Up study

INTRODUCTION

Meta-analytical evidence confirms a range of interventions, including mindfulness, physical activity and sleep hygiene, can reduce psychological distress in university students. However, it is unclear which intervention is most effective. Artificial intelligence (AI)-driven adaptive trials may be an efficient method to determine what works best and for whom. The primary purpose of the study is to rank the effectiveness of mindfulness, physical activity, sleep hygiene and an active control on reducing distress, using a multiarm contextual bandit-based AI-adaptive trial method. Furthermore, the study will explore which interventions have the largest effect for students with different levels of baseline distress severity.

METHODS AND ANALYSIS

The Vibe Up study is a pragmatically oriented, decentralised AI-adaptive group sequential randomised controlled trial comparing the effectiveness of one of three brief, 2-week digital self-guided interventions (mindfulness, physical activity or sleep hygiene) or active control (ecological momentary assessment) in reducing self-reported psychological distress in Australian university students. The adaptive trial methodology involves up to 12 sequential mini-trials that allow for the optimisation of allocation ratios. The primary outcome is change in psychological distress (Depression, Anxiety and Stress Scale, 21-item version, DASS-21 total score) from preintervention to postintervention. Secondary outcomes include change in physical activity, sleep quality and mindfulness from preintervention to postintervention. Planned contrasts will compare the four groups (ie, the three intervention and control) using self-reported psychological distress at prespecified time points for interim analyses. The study aims to determine the best performing intervention, as well as ranking of other interventions.

ETHICS AND DISSEMINATION

Ethical approval was sought and obtained from the UNSW Sydney Human Research Ethics Committee (HREC A, HC200466). A trial protocol adhering to the requirements of the Guideline for Good Clinical Practice was prepared for and approved by the Sponsor, UNSW Sydney (Protocol number: HC200466_CTP).

TRIAL REGISTRATION NUMBER

ACTRN12621001223820.

Using recovery management checkups for primary care to improve linkage to alcohol and other drug use treatment: a randomized controlled trial three month findings

BACKGROUND AND AIMS

Recovery management checkups (RMC) have established efficacy for linking patients to substance use disorder (SUD) treatment. This study tested whether using RMC in combination with screening, brief intervention, and referral to treatment (SBIRT), versus SBIRT alone, can improve linkage of primary care patients referred to SUD treatment.

DESIGN

A randomized controlled trial of SBIRT as usual (n = 132) versus SBIRT plus recovery management checkups for primary care (RMC-PC) (n = 134) with follow-up assessments at 3 months post-baseline.

SETTING

Four federally qualified health centers in the United States serving low-income populations.

PARTICIPANTS

Primary care patients (n = 266, 64% male, 80% Black, mean age, 48.3 [range, 19-53]) who were referred to SUD treatment after SBIRT.

INTERVENTIONS

SBIRT alone (control condition) compared with SBIRT + RMC-PC (experimental condition).

MEASUREMENT

The primary outcome was any days of SUD treatment in the past 3 months. Key secondary outcomes were days of SUD treatment overall and by level of care, days of alcohol and other drug (AOD) abstinence, and days of using specific substances, all based on self-report.

FINDINGS

At 3-month follow-up, those assigned to SBIRT + RMC-PC (n = 134) had higher odds of receiving any SUD treatment (46% vs 20%; adjusted odds ratio = 4.50 [2.49, 8.48]) compared with SBIRT only, including higher rates of entering residential and intensive outpatient treatment. They also reported more days of treatment (14.45, vs 7.13; d = +0.26), more days abstinent (41.3 vs 31.9; d = +0.22), and fewer days of using alcohol (27.14, vs 36.31; d = -0.25) and cannabis (19.49, vs 28.6; d = -0.20).

CONCLUSIONS

Recovery management checkups in combination with screening, brief intervention, and referral to treatment are an effective strategy for improving linkage of primary care patients in need to substance use disorder treatment over 3 months.

The association of severe COVID anxiety with poor social functioning, quality of life, and protective behaviours among adults in United Kingdom: a cross-sectional study

BACKGROUND

Anxiety about COVID-19 is common. For most people this is an appropriate response to the loss of livelihoods and loved-ones, disruptions to social networks, and uncertainty about the future. However, for others these anxieties relate to contracting the virus itself, a phenomenon termed COVID anxiety. Little is known about the characteristics of people with severe COVID anxiety or the impact it has on their daily lives.

METHODS

We conducted a two-phase cross-sectional survey of people aged 18 or over who were living in United Kingdom, self-identified as anxious about COVID-19, and had a score of ≥9 on the Coronavirus Anxiety Scale. We recruited participants nationally through online adverts and locally via primary care services in London. Data on demographic and clinical factors were used in multiple regression modelling to examine the greatest contributors to functional impairment, poor health-related quality of life and protective behaviours in this sample of individuals with severe COVID anxiety.

RESULTS

We recruited 306 people with severe COVID anxiety between January and September 2021. Most were female (n = 246, 81.2%); they had a median age of 41 (range = 18-83). The majority of participants also had generalised anxiety (n = 270, 91.5%), depression (n = 247, 85.5%), and a quarter (n = 79, 26.3%) reported a physical health condition which put them at increased risk of hospitalisation with COVID-19. Half had severe social dysfunction (n = 151, 52.4%). One in ten reported never leaving their home, one in three washed all items brought into their house, one in five washed their hands constantly, and one in five of those with children reported not sending them to school because of fears of COVID-19. Increasing co-morbid depressive symptoms best explained functional impairment and poor quality of life after controlling for other factors.

CONCLUSIONS

This study highlights the high degree of co-occuring mental health problems, and the extent of functional impairment and poor health-related quality of life among people with severe COVID anxiety. Further research is needed to establish the course of severe COVID anxiety as the pandemic progresses, and steps that can be taken to support people who experience this distress.

The Electronic Mental Wellness Tool as a Self-Administered Brief Screening Instrument for Mental Disorders in the General Spanish Population during the Post-COVID-19 Era

(1) Background: In the "post-COVID-19 era", there is a need to focus on properly assessing and addressing the extent of its well-established mental health collateral damage. The "Electronic Mental Wellness Tool" (E-mwTool) is a 13-item validated stepped-care or stratified management instrument that aims at the high-sensitivity captures of individuals with mental health disorders to determine the need for mental health care. This study validated the E-mwTool in a Spanish-speaking population. (2) Methods: It is a cross-sectional validation study using the Mini International Neuropsychiatric Interview as a criterion standard in a sample of 433 participants. (3) Results: About 72% of the sample had a psychiatric disorder, and 67% had a common mental disorder. Severe mental disorders, alcohol use disorders, substance use disorders, and suicide risk had a much lower prevalence rate (6.7%, 6.2%, 3.2%, and 6.2%, respectively). The first three items performed excellently in identifying any mental health disorder with 0.97 sensitivity. Ten additional items classified participants with common mental disorders, severe mental disorders, substance use disorders, and suicide risk. (4) Conclusions: The E-mwTool had high sensitivity in identifying common mental disorders, alcohol and substance use disorders, and suicidal risk. However, the tool's sensitivity in detecting low-prevalence disorders in the sample was low. This Spanish version may be useful to detect patients at risk of mental health burden at the front line of primary and secondary care in facilitating help-seeking and referral by their physicians.

Provider-supported self-management cognitive behavioral therapy for insomnia (Tele-Self CBTi): Protocol for a randomized controlled trial

BACKGROUND

Cognitive Behavioral Therapy for Insomnia (CBTi) is recommended as first-line treatment for insomnia, yet patient access to CBTi is limited. Self-help CBTi could increase patient access. Self-help CBTI with provider sup]port is more effective and is preferred by patients. Self-help CBTi has not been evaluated in veterans; a population with greater medical and mental health morbidity and more severe sleep difficulties than non-veterans. Moreover, those with mental health conditions have been largely excluded from prior CBTi self-help trials. Stablishing the efficacy of provider-supported Self-help CBTi is an important first step for expanding veteran access to CBTi.

METHODS

In a 2-armed randomized controlled trial, a provider-supported self-help CBTi (Tele-Self CBTi) is compared to Health Education for improving insomnia severity (primary outcome) among treatment-seeking veterans with insomnia disorder. Tele-Self CBTi is comprised of two treatment components: self-help CBTi via a professionally designed manual developed using an iterative process of expert review and patient input; and 6 telephone-based support sessions lasting >20 min. Outcomes are assessed at baseline, 8 weeks, and 6 months after baseline. The primary outcome, insomnia severity, is measured using the Insomnia Severity Index. Secondary outcomes include self-reported and actigraphy-assessed sleep, fatigue, depression symptoms, and sleep-related quality of life.

CONCLUSION

Innovative approaches are essential to improving overall health among veterans; a population with highly prevalent insomnia disorder. If effective, Tele-Self CBTi may bridge the gap between unavailable resources and high demand for CBTi and serve as the entry level intervention in a stepped model of care.

CLINICAL TRIALS

GOV IDENTIFIER

NCT03727438.

Digital Health and Community Health Worker Support for Diabetes Management: a Randomized Controlled Trial

OBJECTIVE

The aim of this study was to evaluate the effectiveness of a digital health intervention plus community health worker (CHW) support on self-monitoring of blood glucose and glycosylated hemoglobin (HbA1c) among adult Medicaid beneficiaries with diabetes.

DESIGN

Randomized controlled trial.

SETTING

Urban outpatient clinic.

PARTICIPANTS

Adult Medicaid beneficiaries living with diabetes and treated with insulin and who had a HbA1c ≥ 9%.

INTERVENTION

Participants were randomly assigned to one of three arms. Participants in the usual-care arm received a wireless glucometer if needed. Those in the digital arm received a lottery incentive for daily glucose monitoring. Those in the hybrid arm received the lottery plus support from a CHW if they had low adherence or high blood glucose levels.

MAIN MEASURES

The primary outcome was the difference in adherence to daily glucose self-monitoring at 3 months between the hybrid and usual-care arms. The secondary outcome was difference in HbA1c from baseline at 6 months.

KEY RESULTS

A total of 150 participants were enrolled in the study. A total of 102 participants (68%) completed the study. At 3 months, glucose self-monitoring rates in the hybrid versus usual-care arms were 0.72 vs 0.65, p = 0.23. At 6 months, change in HbA1c in the hybrid versus usual-care arms was - 0.74% vs - 0.49%, p = 0.69.

CONCLUSION

There were no statistically significant differences between the hybrid and usual care in glucose self-monitoring adherence or improvements in HbA1C.

TRIAL REGISTRATION

This trial is registered with clinicaltrials.gov identifier: NCT03939793.

Implementing a Substance Use Screening Protocol in Rural Federally Qualified Health Centers

INTRODUCTION

In 2018, nearly 20% of Americans aged 12 years and older reported using illicit substances, with higher rates in rural areas. Federally Qualified Health Centers (FQHCs) provide health care to one in five rural Americans. However, estimates suggest that only 13.6% of patients in rural FQHCs receive substance use (SU) screening compared with 42.6% of patients in urban FQHCs.

AIMS

This quality improvement (QI) project aimed to improve patient quality and safety and meet Health Resources and Services Administration reporting requirements. These aims were achieved through the design and implementation of a new SU screening protocol in four FQHCs in rural Indiana.

METHOD

Deming's plan-do-study-act model was used to implement QI interventions to increase SU screening rates. A new SU screening tool, the National Institute on Drug Abuse -Modified Alcohol, Smoking, and Substance Involvement Screening Testwas implemented, and staff were trained on its use. the screening, brief intervention, and referral to treatment model was used as a guiding framework. Outcome measures included a comparison of SU screening rates from the first quarter of 2019 to the first quarter of 2020, as well a pretest-posttest designed to measure staff knowledge and attitudes regarding SU.

RESULTS

Baseline SU screening rate in 2019 was 0.87%. This increased to 24.8% by March 2020. Additionally, posttest results demonstrated improvement from staff on all indices, and an approval rating of 77% of the new SU screening practices.

CONCLUSIONS

This project demonstrated that a low-cost QI intervention can increase SU screening rates in rural FQHCs, as well as improve staff knowledge and attitudes regarding SU.

Associations Between Different Types of Housing Insecurity and Future Emergency Department Use Among a Cohort of Emergency Department Patients

Housing insecurity can take multiple forms, such as unaffordability, crowding, forced moves, multiple moves, and homelessness. Existing research has linked homelessness to increased emergency department (ED) use, but gaps remain in understanding the relationship between different types of housing insecurity and ED use. In this study, we examined the association between different types of housing insecurity, including detailed measures of homelessness, and future ED use among a cohort of patients initially seen in an urban safety-net hospital ED in the United States between November 2016 and January 2018. We found that homelessness was associated with a higher mean number of ED visits in the year post-baseline. Other measures of housing insecurity (unaffordability, crowding, forced moves, and multiple moves) were not associated with greater ED use in the year post-baseline in multivariable models. We also found that only specific types of homelessness, primarily unsheltered homelessness, were associated with increased ED use.

Low-Burden Universal Substance Use Screening in a Primary Care Clinic to Lower Implementation Barriers

Universal substance use screening in primary care can proactively identify patients for intervention, though implementation is challenging. This project developed a strategy for universal low time- and labor-cost screening, brief intervention, and referral for treatment (SBIRT) in an HIV primary care clinic at an academic medical center in the Southeastern USA. Screening was implemented using a tablet computer that calculated results in real time and suggested motivational language for provider response. A brief intervention (BNI) was conducted by a trained professional as needed, preventing the need for all clinic providers to be competent in motivational interviewing (MI). More than 1868 patients were screened in 12 months, with an MI intervention conducted for 101 patients with higher risk use. Forty-four patients were referred for in-clinic treatment, compared to nine in the previous year. Computer-based, self-administered screening with real-time linkage to a BNI can allow recommended screening with low provider burden.

Providing substance use disorder treatment in correctional settings: knowledge gaps and proposed research priorities-overview and commentary

This manuscript is the product of the authors' discussions, literature overview, and consultation with experts in the field, and identifies important gaps in the evidence base for substance use disorder (SUD) treatment effectiveness within criminal justice (CJ) settings. Lacking from the extant literature are longitudinal investigations of treatment related outcomes during and after incarceration. Such studies could provide rich contextual data about treatment delivery and effectiveness across the CJ continuum, and would provide important insight into individual characteristics (e.g., motivation, treatment modality preferences, treatment completion rates, etc.) as well as institutional and environmental factors (e.g., appropriate staffing, space limitations for individual treatment sessions, distribution of medications, etc.). We also identified the importance of reproducibility within CJ research, and the unfortunate reality of too many single studies conducted in single (or relatively few) correctional facilities. Some of this has been because the studies designed to produce that evidence are not prioritized for funding, which has continually placed researchers in a position where we cannot make firm conclusions or recommendations based on available evidence. The importance of replicating the foundational studies in this field cannot be overstated. We hope this article spurs other researchers to join in the healthy process of questioning the existing state of the CJ-based SUD treatment research, what should be re-examined, and how we can lay a stronger foundation for the future.

ED-Home: Pilot feasibility study of a targeted homelessness prevention intervention for emergency department patients with drug or unhealthy alcohol use

BACKGROUND

Housing insecurity is prevalent among emergency department (ED) patients. Despite a surge of interest in screening for patients' social needs including housing insecurity, little research has examined ED social needs interventions. We worked together with government and community partners to develop and pilot test a homelessness prevention intervention targeted to ED patients with drug or unhealthy alcohol use.

METHODS

We approached randomly sampled patients at an urban public hospital ED, May to August 2019. Adult patients were eligible if they were medically stable, not incarcerated, spoke English, had unhealthy alcohol or any drug use, and were not currently homeless but screened positive for risk of future homelessness using a previously developed risk screening tool. Participants received a three-part intervention: (1) brief counseling and referral to treatment for substance use delivered through a preexisting ED program; (2) referral to Homebase, an evidence-based community homelessness prevention program; and (3) up to three troubleshooting phone calls by study staff. Participants completed surveys at baseline and 6 months.

RESULTS

Of 2183 patients screened, 51 were eligible and 40 (78.4%) participated; one later withdrew, leaving 39 participants. Participants were diverse in age, gender, race, and ethnicity. Of the 32 participants reached at 6 months, most said it was very or extremely helpful to talk to someone about their housing situation (n = 23, 71.9%) at the baseline ED visit. Thirteen (40.6%) said their housing situation had improved in the past 6 months and 16 (50.0%) said it had not changed. Twenty participants (62.5%) had made contact with a Homebase office. Participants shared ideas of how to improve the intervention.

CONCLUSIONS

This pilot intervention was feasible and well received by participants though it required a large amount of screening to identify potentially eligible patients. Our findings will inform a larger future trial and may be informative for others seeking to develop similar interventions.

CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1-49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1-3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient's circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

Models for Implementing Emergency Department-Initiated Buprenorphine With Referral for Ongoing Medication Treatment at Emergency Department Discharge in Diverse Academic Centers

There has been a substantial rise in the number of publications and training opportunities on the care and treatment of emergency department (ED) patients with opioid use disorder over the past several years. The American College of Emergency Physicians recently published recommendations for providing buprenorphine to patients with opioid use disorder, but barriers to implementing this clinical practice remain. We describe the models for implementing ED-initiated buprenorphine at 4 diverse urban, academic medical centers across the country as part of a federally funded effort termed "Project ED Health." These 4 sites successfully implemented unique ED-initiated buprenorphine programs as part of a comparison of implementation facilitation to traditional educational dissemination on the uptake of ED-initiated buprenorphine. Each site describes the elements central to the ED process, including screening, treatment initiation, referral, and follow-up, while harnessing organizational characteristics, including ED culture. Finally, we discuss common facilitators to program success, including information technology and electronic medical record integration, hospital-level support, strong connections with outpatient partners, and quality improvement processes.

Development and Validation of an Arabic Version of the Drug Abuse Screening Test-10 (DAST-10) among Saudi Drug Abusers

The Drug Abuse Screening Test-10 (DAST-10) is a valid and reliable screening tool for drug use-related problems, however there is no Arabic version. To our knowledge, this is the first study to develop and validate an Arabic DAST-10 version. Saudi young adults participated in the study as two groups; drug users (n=360) recruited from Alamal Complex for Mental Health, Jeddah, and drug non-users (n=100). Three measures were used: (1) Demographic and drug use description questionnaire, (2) Arabic DAST-10 version, and (3) Urine analysis for drug use. The developed Arabic DAST-10 version demonstrated adequate internal consistency. High correlations were shown between its scores and the two standard measures (urine analysis and self-reporting question) indicating good criterion validity. Sensitivity and specificity values were between 91.5 - 99.7% and 57 - 92.5% with different DAST-10 cutoff values. An optimal performance at a cutoff score of 3 or more was most likely to significantly identify drug users. Discriminant analysis showed that more than 90% of cases were correctly classified. Distribution of participants in categories of DAST-10 scores according to degree of problems was reasonable. It is concluded that the developed Arabic DAST-10 version is a reliable and valid screening tool for drug use-related problems in Arabic speakers.

Validity of the Single-Item Screen-Cannabis (SIS-C) for Cannabis Use Disorder Screening in Routine Care

Importance

Cannabis use is prevalent and increasing, and frequent use intensifies the risk of cannabis use disorder (CUD). CUD is underrecognized in medical settings, but a validated single-item cannabis screen could increase recognition.

Objective

To evaluate the Single-Item Screen-Cannabis (SIS-C), administered and documented in routine primary care, compared with a confidential reference standard measure of CUD.

Design, Setting, and Participants

This diagnostic study included a sample of adult patients who completed routine cannabis screening between January 28 and September 12, 2019, and were randomly selected for a confidential survey about cannabis use. Random sampling was stratified by frequency of past-year use and race and ethnicity. The study was conducted at an integrated health system in Washington state, where adult cannabis use is legal. Data were analyzed from May 2021 to March 2022.

Exposures

The SIS-C asks about frequency of past-year cannabis use with responses (none, less than monthly, monthly, weekly, daily or almost daily) documented in patients' medical records.

Main Outcomes and Measures

The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM) for past-year CUD was completed on a confidential survey and considered the reference standard. The SIS-C was compared with 2 or more criteria on the CIDI-SAM, consistent with CUD. All analyses were weighted, accounting for survey design and nonresponse, to obtain estimates representative of the health system primary care population.

Results

Of 5000 sampled adult patients, 1688 responded to the cannabis survey (34% response rate). Patients were predominantly middle-aged (weighted mean [SD] age, 50.7 [18.1]), female or women (weighted proportion [SE], 55.9% [4.1]), non-Hispanic (weighted proportion [SE], 96.7% [1.0]), and White (weighted proportion [SE], 74.2% [3.7]). Approximately 6.6% of patients met criteria for past-year CUD. The SIS-C had an area under receiver operating characteristic curve of 0.89 (95% CI, 0.78-0.96) for identifying CUD. A threshold of less than monthly cannabis use balanced sensitivity (0.88) and specificity (0.83) for detecting CUD. In populations with a 6% prevalence of CUD, predictive values of a positive screen ranged from 17% to 34%, while predictive values of a negative screen ranged from 97% to 100%.

Conclusions and Relevance

In this diagnostic study, the SIS-C had excellent performance characteristics in routine care as a screen for CUD. While high negative predictive values suggest that the SIS-C accurately identifies patients without CUD, low positive predictive values indicate a need for further diagnostic assessment following positive results when screening for CUD in primary care.

Severe COVID-19 anxiety among adults in the UK: protocol for a cohort study and nested feasibility trial of modified cognitive-behavioural therapy for health anxiety

INTRODUCTION

Some people are so anxious about COVID-19 that it impairs their functioning. However, little is known about the course of severe COVID-19 anxiety or what can be done to help people who experience it.

METHODS AND ANALYSIS

Cohort study with a nested feasibility trial with follow-up at 3 and 6 months. We recruited 306 people who were aged 18 and over, lived in the UK and had severe COVID-19 anxiety (indicated by a score of 9 or more on the Coronavirus Anxiety Scale (CAS)). To take part in the nested feasibility trial, participants also had to have a score of 20 or more on the Short Health Anxiety Inventory. We excluded people from the trial if they had had COVID-19 within the previous 4 weeks, if they were currently self-isolating or if they were already receiving psychological treatment.We publicised the study nationally through adverts, social media and posts on message boards. We also recruited participants via clinicians working in primary and secondary care NHS services in London. All those in the active arm will be offered 5-10 sessions of remotely delivered modified cognitive-behavioural therapy for health anxiety (CBT-HA). We will examine the proportion of participants who remain above threshold on the CAS at 3 and 6 months and factors that influence levels of COVID-19 anxiety over 6 months using mixed effects logistic regression. The key feasibility metrics for the nested trial are the level of uptake of CBT-HA and the rate of follow-up.

ETHICS AND DISSEMINATION

Approved by Leicester Central Research Ethics Committee (reference: 20/EM/0238). The results of the study will be published in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

ISRCTN14973494.