Motivational interview improves treatment entry in homeless veterans

Opioid Use Disorder Treatment Linkage at Strategic Touchpoints Using Buprenorphine (OUTLAST-B): Rationale, Design, and Evolution of a Randomized Controlled Trial

Background

Despite the effectiveness and growing availability of treatment for opioid use disorder (OUD) with buprenorphine, many people with OUD do not access treatment services. This article describes the rationale, methodological design, evolution, and progress of an ongoing clinical trial of treatment linkage strategies for people with untreated OUD.

Methods

The study, titled Opioid Use Disorder Treatment Linkage at Strategic Touchpoints using Buprenorphine (OUTLAST-B), uses "strategic touchpoints", initially sexual health clinics and subsequently broadened to other service venues and participant social networks, for recruitment and screening. Adults with untreated OUD (target N = 360) are randomized to one of the three arms: Usual Care (UC, enhanced with overdose education and naloxone distribution), Patient Navigation (PN), or Patient Navigation with an immediate short-term bridge prescription for buprenorphine (PN + BUP). In the PN and PN + BUP arms, the Patient Navigator works with participants for 2 months to facilitate treatment entry and early retention, resolve barriers (e.g., ID cards, transportation), and provide motivational support.

Results

The primary outcome is OUD treatment entry within 30 days of enrollment. Participants are assessed at baseline and followed at 3- and 6-months post-enrollment on measures of healthcare utilization, substance use, and general functioning. Challenges and recruitment adaptations pursuant to the COVID-19 pandemic are discussed.

Conclusions

This study could provide insights on how to reach people with untreated OUD and link them to care through non-traditional routes.

Trial Registration

The study is registered at ClinicalTrials.gov (NCT04991974).

Motivational interviewing for substance use reduction

BACKGROUND

Substance use is a global issue, with around 30 to 35 million individuals estimated to have a substance-use disorder. Motivational interviewing (MI) is a client-centred method that aims to strengthen a person's motivation and commitment to a specific goal by exploring their reasons for change and resolving ambivalence, in an atmosphere of acceptance and compassion. This review updates the 2011 version by Smedslund and colleagues.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance use on the extent of substance use, readiness to change, and retention in treatment.

SEARCH METHODS

We searched 18 electronic databases, six websites, four mailing lists, and the reference lists of included studies and reviews. The last search dates were in February 2021 and November 2022.

SELECTION CRITERIA

We included randomised controlled trials with individuals using drugs, alcohol, or both. Interventions were MI or motivational enhancement therapy (MET), delivered individually and face to face. Eligible control interventions were no intervention, treatment as usual, assessment and feedback, or other active intervention.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane, and assessed the certainty of evidence with GRADE. We conducted meta-analyses for the three outcomes (extent of substance use, readiness to change, retention in treatment) at four time points (post-intervention, short-, medium-, and long-term follow-up).

MAIN RESULTS

We included 93 studies with 22,776 participants. MI was delivered in one to nine sessions. Session durations varied, from as little as 10 minutes to as long as 148 minutes per session, across included studies. Study settings included inpatient and outpatient clinics, universities, army recruitment centres, veterans' health centres, and prisons. We judged 69 studies to be at high risk of bias in at least one domain and 24 studies to be at low or unclear risk. Comparing MI to no intervention revealed a small to moderate effect of MI in substance use post-intervention (standardised mean difference (SMD) 0.48, 95% confidence interval (CI) 0.07 to 0.89; I2 = 75%; 6 studies, 471 participants; low-certainty evidence). The effect was weaker at short-term follow-up (SMD 0.20, 95% CI 0.12 to 0.28; 19 studies, 3351 participants; very low-certainty evidence). This comparison revealed a difference in favour of MI at medium-term follow-up (SMD 0.12, 95% CI 0.05 to 0.20; 16 studies, 3137 participants; low-certainty evidence) and no difference at long-term follow-up (SMD 0.12, 95% CI -0.00 to 0.25; 9 studies, 1525 participants; very low-certainty evidence). There was no difference in readiness to change (SMD 0.05, 95% CI -0.11 to 0.22; 5 studies, 1495 participants; very low-certainty evidence). Retention in treatment was slightly higher with MI (SMD 0.26, 95% CI -0.00 to 0.52; 2 studies, 427 participants; very low-certainty evidence). Comparing MI to treatment as usual revealed a very small negative effect in substance use post-intervention (SMD -0.14, 95% CI -0.27 to -0.02; 5 studies, 976 participants; very low-certainty evidence). There was no difference at short-term follow-up (SMD 0.07, 95% CI -0.03 to 0.17; 14 studies, 3066 participants), a very small benefit of MI at medium-term follow-up (SMD 0.12, 95% CI 0.02 to 0.22; 9 studies, 1624 participants), and no difference at long-term follow-up (SMD 0.06, 95% CI -0.05 to 0.17; 8 studies, 1449 participants), all with low-certainty evidence. There was no difference in readiness to change (SMD 0.06, 95% CI -0.27 to 0.39; 2 studies, 150 participants) and retention in treatment (SMD -0.09, 95% CI -0.34 to 0.16; 5 studies, 1295 participants), both with very low-certainty evidence. Comparing MI to assessment and feedback revealed no difference in substance use at short-term follow-up (SMD 0.09, 95% CI -0.05 to 0.23; 7 studies, 854 participants; low-certainty evidence). A small benefit for MI was shown at medium-term (SMD 0.24, 95% CI 0.08 to 0.40; 6 studies, 688 participants) and long-term follow-up (SMD 0.24, 95% CI 0.07 to 0.41; 3 studies, 448 participants), both with moderate-certainty evidence. None of the studies in this comparison measured substance use at the post-intervention time point, readiness to change, and retention in treatment. Comparing MI to another active intervention revealed no difference in substance use at any follow-up time point, all with low-certainty evidence: post-intervention (SMD 0.07, 95% CI -0.15 to 0.29; 3 studies, 338 participants); short-term (SMD 0.05, 95% CI -0.03 to 0.13; 18 studies, 2795 participants); medium-term (SMD 0.08, 95% CI -0.01 to 0.17; 15 studies, 2352 participants); and long-term follow-up (SMD 0.03, 95% CI -0.07 to 0.13; 10 studies, 1908 participants). There was no difference in readiness to change (SMD 0.15, 95% CI -0.00 to 0.30; 5 studies, 988 participants; low-certainty evidence) and retention in treatment (SMD -0.04, 95% CI -0.23 to 0.14; 12 studies, 1945 participants; moderate-certainty evidence). We downgraded the certainty of evidence due to inconsistency, study limitations, publication bias, and imprecision.

AUTHORS' CONCLUSIONS

Motivational interviewing may reduce substance use compared with no intervention up to a short follow-up period. MI probably reduces substance use slightly compared with assessment and feedback over medium- and long-term periods. MI may make little to no difference to substance use compared to treatment as usual and another active intervention. It is unclear if MI has an effect on readiness to change and retention in treatment. The studies included in this review were heterogeneous in many respects, including the characteristics of participants, substance(s) used, and interventions. Given the widespread use of MI and the many studies examining MI, it is very important that counsellors adhere to and report quality conditions so that only studies in which the intervention implemented was actually MI are included in evidence syntheses and systematic reviews. Overall, we have moderate to no confidence in the evidence, which forces us to be careful about our conclusions. Consequently, future studies are likely to change the findings and conclusions of this review.

Telemedicine as bridge to the offline world for person affected with problematic internet use or internet use disorder and concerned significant others

Introduction

Internet use disorder is a disorder of the digital age and presents a growing problem worldwide. It appears that due to structural and personal barriers, many persons affected (PA) and Concerned Significant Others (CSO) do not reach the health care system so far and thus a chronification of the pathology can proceed.

Methods

A telemedicine counseling service for PA and CSO of PA unwilling to enter treatment with two webcam-based sessions of 60 minutes for each group was created with the aim of reaching out to PA and CSO to provide a low-threshold support and refer the participants to the local health care system. Motivational interviewing for PA and CRAFT (Community Reinforcement and Family Training) for CSO were used as methods. Participants answered questions about their Internet use and sociodemographic data and six months after participation, participants were asked via email if they entered the local health care system. CSO answered the questions for themselves and in a third-party rating for PA unwilling to enter treatment.

Results

107 PA (34 years (SD = 13.64), 86% male) and 38 CSO (53 years (SD = 6.11), 28.9% male) participated in the two telemedicine sessions. After participation, 43.9% of the PA and 42.1% of the CSO reached the health care system. When there was consistency between the location of telemedicine consultation and treatment locally, over 90% of participants arrived (PA: 92.3%, CSO: 100%).

Conclusion

The results from this study reveal that telemedicine services could be a promising approach to address PA and CSO and build a bridge to the local health care system. Future studies should verify if these results can be replicated in randomized controlled trials.

Implementation Potential of Moral Reconation Therapy for Criminal Recidivism in Mental Health Residential Programs

OBJECTIVE

Criminal recidivism is common among patients in mental health residential treatment programs. Moral reconation therapy (MRT) has empirical support for reducing criminal recidivism by modifying antisocial cognitions and behaviors; however, its implementation potential in noncorrectional settings has been rarely studied. This potential was examined in a three-site effectiveness-implementation trial of MRT for justice-involved veterans receiving residential mental health treatment in the U.S. Veterans Health Administration.

METHODS

Semistructured interviews were conducted with 36 veterans who received MRT and 13 residential program staff who were involved in its implementation during the trial. Interviews were guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework and a focus on patient engagement and context. Content analysis was used to identify facilitators of and barriers to MRT implementation in residential mental health treatment.

RESULTS

Participants viewed MRT as unique and complementary to usual residential care, with benefits beyond recidivism reduction. However, time intensity of the MRT curriculum, challenges in adapting its content and format, and long-term costs of maintaining MRT were viewed as barriers to implementation. To facilitate implementation, participants suggested streamlining the MRT curriculum, adding motivational components, and establishing partnerships in- and outside the health care system.

CONCLUSIONS

The findings suggest strategies and modifications to MRT, which, if shown to be effective, may facilitate its wider implementation in mental health residential treatment programs.

Motivational Interviewing-based interventions for reducing substance misuse and increasing treatment engagement, retention, and completion in the homeless populations of high-income countries: An equity-focused systematic review and narrative synthesis

AIM

Rising mortality and disease prevalence in the homeless have been largely attributed to addiction disorders. This review aimed to assess whether Motivational Interviewing (MI) is effective in changing substance misuse behaviours in the homeless, specifically: 1. reducing substance misuse; 2. increasing addiction treatment linkage; and 3. whether MI effectiveness varied according to the different levels of social disadvantage within homeless populations.

METHOD

Electronic databases and other sources were searched (to July 2021) for relevant randomized trials and comparative studies. Risk of bias in included studies was evaluated using the Cochrane Risk of Bias tool. A Narrative Synthesis framework was applied to included studies. Moderator variables subgroup analyses were planned a priori. PROSPERO study protocol registration: CRD42019134312 RESULTS: The searches found 1885 records; after application of inclusion criteria n = 11 studies from 30 articles were included in the review, all from the United States. There was a paucity of research regarding MI effectiveness for substance misuse outcomes in homeless populations, with a focus on short-term rather than long-term impacts. Risk of bias was generally low but was high for detection bias in most studies. MI appeared to be more effective overall amongst adult homeless persons, yielding consistently small effects, and alcohol use behaviours seemed to be more amenable to change as a result of MI/MET (Motivational Enhancement Therapy) interventions than drug use ones. Limited evidence with high risk of bias indicated that social gradient may attenuate MI effectiveness within the young homeless population, with no impact in the most disadvantaged.

CONCLUSIONS

The review's mixed findings discourage the use of MI as a stand-alone substance use intervention in homeless populations. Although the review findings did not identify MI effectiveness for substance use according to the external level of social disadvantage faced by homeless persons, this should be a focus for further research.

A Review of Motivational Interviewing in Cognitive Behavioral Therapy for Obsessive-Compulsive Disorder

Although cognitive behavioral therapy (CBT) is a highly effective treatment for individuals with obsessive-compulsive disorder (OCD), a portion people with OCD do not benefit fully from CBT due to ambivalence about participating in treatment, nonadherence to exposure exercises, and dropout. This paper reviews the promising evidence for motivational interviewing (MI) as a therapeutic approach that is well suited to address these issues and potentially improve treatment outcomes. It will also provide a discussion of MI processes that may enhance CBT for OCD which can foster a collaborative relationship that integrates a patient's own goals and values into exposure planning, helps resolve ambivalence or reluctance to engage in exposure exercises and builds and supports patients' intrinsic motivation to participate in treatment. The review will conclude with a case report describing the use of pre-CBT MI for an individual with OCD.

Prevalence of and Risk Factors Associated With Nonfatal Overdose Among Veterans Who Have Experienced Homelessness

IMPORTANCE

Individuals with a history of homelessness are at increased risk for drug or alcohol overdose, although the proportion who have had recent nonfatal overdose is unknown. Understanding risk factors associated with nonfatal overdose could guide efforts to prevent fatal overdose.

OBJECTIVES

To determine the prevalence of recent overdose and the individual contributions of drugs and alcohol to overdose and to identify characteristics associated with overdose among veterans who have experienced homelessness.

DESIGN, SETTING, AND PARTICIPANTS

This survey study was conducted from November 15, 2017, to October 1, 2018, via mailed surveys with telephone follow-up for nonrespondents. Eligible participants were selected from the records of 26 US Department of Veterans Affairs medical centers and included veterans who had received primary care at 1 of these Veterans Affairs medical centers and had a history of experiencing homelessness according to administrative data. Preliminary analyses were conducted in October 2018, and final analyses were conducted in January 2020.

MAIN OUTCOMES AND MEASURES

Self-report of overdose (such that emergent medical care was obtained) in the previous 3 years and substances used during the most recent overdose. All percentages are weighted according to propensity to respond to the survey, modeled from clinical characteristics obtained in electronic health records.

RESULTS

A total of 5766 veterans completed the survey (completion rate, 40.2%), and data on overdose were available for 5694 veterans. After adjusting for the propensity to respond to the survey, the mean (SD) age was 56.4 (18.3) years; 5100 veterans (91.6%) were men, 2225 veterans (38.1%) were black, and 2345 veterans (40.7%) were white. A total of 379 veterans (7.4%) reported any overdose during the past 3 years; 228 veterans (4.6%) reported overdose involving drugs, including 83 veterans (1.7%) who reported overdose involving opioids. Overdose involving alcohol was reported by 192 veterans (3.7%). In multivariable analyses, white race (odds ratio, 2.44 [95% CI, 2.00-2.98]), self-reporting a drug problem (odds ratio, 1.66 [95% CI, 1.39-1.98]) or alcohol problem (odds ratio, 2.54 [95% CI, 2.16-2.99]), and having witnessed someone else overdose (odds ratio, 2.34 [95% CI, 1.98-2.76]) were associated with increased risk of overdose.

CONCLUSIONS AND RELEVANCE

These findings suggest that nonfatal overdose is relatively common among veterans who have experienced homelessness. While overdose involving alcohol was more common than any specific drug, 1.7% of veterans reported overdose involving opioids. Improving access to addiction treatment for veterans who are experiencing homelessness or who are recently housed, especially for those who have experienced or witnessed overdose, could help to protect this population.

Navigation Services to Avoid Rehospitalization among Medical/Surgical Patients with Comorbid Substance Use Disorder: Rationale and Design of a Randomized Controlled Trial

Substance use disorders (SUDs) are associated with significant morbidity and mortality and contribute to inefficient use of healthcare services. Hospitalized medical/surgical patients with comorbid SUD are at elevated risk of hospital readmission and poor outcomes. Thus, effective interventions are needed to help such patients during hospitalization and post-discharge. This article reports the rationale, methodological design, and progress to date on a randomized trial comparing the effectiveness of Navigation Services to Avoid Rehospitalization (NavSTAR) vs Treatmentas-Usual (TAU) for hospital medical/surgical patients with comorbid SUD (N = 400). Applying Andersen’s theoretical model of health service utilization, NavSTAR employed Patient Navigation and motivational interventions to promote entry into SUD treatment, facilitate adherence to recommendations for medical follow-up and self-care, address basic needs, and prevent the recurrent use of hospital services. As part of the NavSTAR service model, Patient Navigators embedded within the SUD consultation service at a large urban hospital delivered patient-centered, proactive navigation and motivational services initiated during the hospital stay and continued for up to 3 months post-discharge. Participants randomized to TAU received usual care from the hospital and the SUD consultation service, which included referral to SUD treatment but no continued contact post-hospital discharge. Hospital service utilization will be determined via review of electronic health records and the regional Health Information Exchange. Participants were assessed at baseline and again at 3-, 6-, and 12-month follow-up on various measures of healthcare utilization, substance use, and functioning. The primary outcome of interest is time-to-rehospitalization through 12 months. In addition, a range of secondary outcomes spanning the medical and SUD service areas will be assessed. The study will include a health economic evaluation of NavSTAR. If NavSTAR proves to be effective and cost-effective in this high-risk patient group, it would have important implications for addressing the needs of hospital patients with comorbid SUD, designing hospital discharge planning services, informing cost containment initiatives, and improving public health.

Problematic alcohol consumption in homeless Australians: A narrative review of the causes, barriers to receiving help and possible solutions

ISSUE ADDRESSED

Problematic alcohol consumption (PAC) affects one-third of homeless Australians, and it is expected that the rates will increase as the population ages. However, current policy does not recognise the importance of this problem. The aim of this narrative review was to examine the social determinants and other risk factors contributing to PAC in homeless Australians, the barriers to receiving help and possible solutions for the Australian context.

METHODS

PubMed and PsycINFO databases and Australian government websites were examined for the keywords "alcohol" and "homeless," and pertinent articles were selected for inclusion and for citation tracking of further relevant articles.

RESULTS

The causes of PAC in homeless Australians are multifactorial, and multidirectional, and include risk factors such as low socio-economic status, mental illness and having experienced trauma. There is significant stigma associated with both homelessness and PAC, which further isolates this group. Current policies to address PAC in the homeless are inadequate; however, there are a range of possible programs to reduce PAC in this group, and international harm reduction strategies have also shown success in improving outcomes for this group.

CONCLUSION

There are numerous social risk factors that influence the development of PAC in the homeless. The introduction of harm reduction strategies, programs to enhance motivation and personal skills, as well as better mental health treatment, would all fill important gaps in services for homeless Australians with PAC. SO WHAT?: Health professionals can be advised that there are many social determinants that influence PAC in homeless Australians. There are important structural barriers to providing this marginalised group with the services they require; however, there is scope for the introduction of new programs, including harm reduction strategies, to meet the fundamental needs of this group.

Randomized controlled trial of harm reduction treatment for alcohol (HaRT-A) for people experiencing homelessness and alcohol use disorder

BACKGROUND

People experiencing homelessness are disproportionately affected by alcohol use disorder (AUD). Abstinence-based treatment, however, does not optimally engage or treat this population. Thus, harm reduction treatment for alcohol (HaRT-A) was developed together with people with lived experience of homelessness and AUD and community-based agencies that serve them. HaRT-A is a compassionate and pragmatic approach that aims to help people reduce alcohol-related harm and improve quality of life (QoL) without requiring abstinence or use reduction. A three-month, two-arm randomized controlled trial was conducted to test the initial efficacy of HaRT-A compared to a services-as-usual control condition.

METHODS

People experiencing homelessness and AUD (N = 168; 24% women) were recruited in community-based clinical and social services settings. Self-reported alcohol use, alcohol-related harm, motivation, and QoL as well as urinary ethyl glucuronide were assessed over a 3-month follow-up. Participants were randomized to receive HaRT-A or services as usual. Over four sessions, HaRT-A interventionists delivered three components: a) collaborative tracking of participant-preferred alcohol metrics, b) elicitation of harm-reduction and QoL goals, and c) discussion of safer-drinking strategies.

RESULTS

Compared to control participants, HaRT-A participants reported significantly greater increases in confidence to engage in harm reduction and decreases in peak alcohol use, alcohol-related harm, AUD symptoms, and positive urinary ethyl glucuronide tests (ps < .05). Findings were inconclusive regarding group differences on QoL (ps > .12).

CONCLUSION

A low-barrier, low-intensity, patient-driven, harm-reduction approach has at least short-term efficacy in improving AUD outcomes in this population. Future studies are needed to establish its longer-term efficacy.

The Availability and Utility of Services to Address Risk Factors for Recidivism among Justice-Involved Veterans

The availability and utility of services to address recidivism risk factors among justice-involved veterans is unknown. We explored these issues through qualitative interviews with 63 Specialists from the Department of Veterans Affairs' (VA) Veterans Justice Programs. To guide the interviews, we utilized the Risk-Need-Responsivity (RNR) model of offender rehabilitation. Specialists reported that justice-involved veterans generally have access to services to address most RNR-based risk factors (substance abuse; lack of positive school/work involvement; family/marital dysfunction; lack of prosocial activities/interests), but have less access to services targeting risk factors of antisocial tendencies and associates and empirically-based treatments for recidivism in VA. Peer-based services, motivational interviewing/cognitive-behavioral therapy, and Veterans Treatment Courts were perceived as useful to address multiple risk factors. These findings highlight potential gaps in provision of evidence-based care to address recidivism among justice-involved veterans, as well as promising policy-based solutions that may have widespread impact on reducing recidivism in this population.

Personal goals and factors related to QoL in Dutch homeless people: what is the role of goal-related self-efficacy?

Very little is known about the personal goals of homeless people and how these relate to their quality of life (QoL). By using survey data on 407 homeless adults upon entry to the social relief system in 2011, we examined the personal goals of homeless adults and the association between their perceived goal-related self-efficacy and their QoL. A hierarchical regression analysis was used to analyse the association between QoL and goal-related self-efficacy, relative to factors contributing to QoL, such as demographic characteristics, socioeconomic resources, health and service use. Results indicate that the majority of homeless adults had at least one personal goal for the coming 6 months and that most goals concerned housing and daily life (94.3%) and finances (83.6%). The QoL of homeless adults appeared to be lower in comparison with general population samples. General goal-related self-efficacy was positively related to QoL (β = 0.09, P = 0.042), independent of socioeconomic resources (i.e. income and housing), health and service use. The strongest predictors of QoL were psychological distress (β = -0.45, P < 0.001), income (β = 0.14, P = 0.002) and being institutionalised (β = 0.12, P = 0.004). In conclusion, the majority of homeless adults entering the social relief system have personal goals regarding socioeconomic resources and their goal-related self-efficacy is positively related to QoL. It is therefore important to take the personal goals of homeless people as the starting point of integrated service programmes and to promote their goal-related self-efficacy by strength-based interventions.

Efficacy of Group Motivational Interviewing in the Degree of Drug Craving in the Addicts Under the Methadone Maintenance Treatment (MMT) in South East of Iran

BACKGROUND

Craving is one of the important factors having an effective role in the addiction relapse. As an important factor in the therapy failure, this clinical phenomenon has to be diagnosed and treated.

OBJECTIVE

The present research aimed at determining the efficacy of group motivational interviewing in the degree of drug craving in the addicts under the Methadone Maintenance Treatment (MMT).

METHOD

This is a quasi-experimental study carried out on 100 addicted men (aged 18-50 years), who were under the MMT in a drug abstinence clinic affiliated with University of Medical Sciences (Iran) in the second half of 2014. The research sample was selected by the availability criteria based on the inclusion and exclusion criteria, and upon matching, it was divided randomly into two groups of 50 (control and treatment). The treatment group first received 5 sessions of group motivational counseling; then it entered the therapy process. The control group received the usual treatment of the drug abstinence clinic. To assess the drug craving degree (in the pretest, 2, 6 and 12 months after the abstinence), the Visual Cue-induced Craving Task, scored 0 to 100, was used. The data were analyzed by the descriptive statistics through independent t-test, and repeated measures analysis of variance.

RESULTS

The means of craving degrees in the control group, 2, 6 and 12 months after the abstinence (73.28 ± 7.52, 65.83 ± 6.69 and 61.25±5.17, respectively) were significantly (p=0.0001) higher than those in the treatment group (68.94 ± 10.53, 40.48 ± 11.78 and 32.51 ± 9.00). Moreover, the mean of retention in the treatment was 9.24 ± 2.45 months in the treatment group that was significantly (p=0.001) higher than the 4.88 ± 3.65 months of retention in the control group.

CONCLUSION

The research results support the fact that motivational interviewing decreases the degree of drug craving, and increases the probability of the addicts' retention in long-term therapeutic abstinence programs. Therefore, the use of such an approach as a pretreatment and a complementary therapy in changing health behaviors is recommended.

Self-Report After Randomly Assigned Supervision Does not Predict Ability to Practice Motivational Interviewing

The objective of this study was to investigate the relation between self-report and objective assessment of motivational interviewing (MI) skills following training and supervision. After an MI workshop, 96 clinicians from 26 community programs (age 21-68, 65% female, 40.8% Black, 29.6% Caucasian, 24.5% Hispanic, 2.0% Asian, 3.1% other) were randomized to supervision (tele-conferencing or tape-based), or workshop only. At four time points, trainees completed a self-report of MI skill, using items from the MI understanding questionnaire (MIU), and were objectively assessed by raters using the Motivational Interviewing Treatment Integrity (MITI) system. Correlations were calculated between MIU and MITI scores. A generalized linear mixed model was tested on MIU scores, with MITI scores, supervision condition and time as independent variables. MIU scores increased from pre-workshop (mean = 4.74, SD = 1.79) to post-workshop (mean = 6.31, SD = 1.03) (t = 8.69, p < .0001). With supervision, scores continued to increase, from post-workshop to week 8 (mean = 7.07, SD = 0.91, t = 5.60, p < .0001) and from week 8 to week 20 (mean = 7.28, SD = 0.94, t = 2.43, p = .02). However, MIU scores did not significantly correlate with MITI scores, with or without supervision. Self-reported ability increased with supervision, but self-report was not an indicator of objectively measured skill. This suggests that training does not increase correspondence between self-report and objective assessment, so community treatment programs should not rely on clinician self-report to assess the need for ongoing training and supervision and it may be necessary to train clinicians to accurately assess their own skill.

Sex differences in mental health and substance use disorders and treatment entry among justice-involved Veterans in the Veterans Health Administration

BACKGROUND

Over half of veterans in the criminal justice system have mental health or substance use disorders. However, there is a critical lack of information about female veterans in the criminal justice system and how diagnosis prevalence and treatment entry differ by sex.

OBJECTIVES

To document prevalence of mental health and substance use disorder diagnoses and treatment entry rates among female veterans compared with male veterans in the justice system.

RESEARCH DESIGN

Retrospective cohort study using national Veterans Health Administration clinical/administrative data from veterans seen by Veterans Justice Outreach Specialists in fiscal years 2010-2012.

SUBJECTS

A total of 1535 females and 30,478 male veterans were included.

MEASURES

Demographic characteristics (eg, sex, age, residence, homeless status), mental health disorders (eg, depression, post-traumatic stress disorder), substance use disorders (eg, alcohol and opioid use disorders), and treatment entry (eg, outpatient, residential, pharmacotherapy).

RESULTS

Among female veterans, prevalence of mental health and substance use disorders was 88% and 58%, respectively, compared with 76% and 72% among male veterans. Women had higher odds of being diagnosed with a mental health disorder [adjusted odds ratio (AOR)=1.98; 95% confidence interval (CI), 1.68-2.34] and lower odds of being diagnosed with a substance use disorder (AOR=0.50; 95% CI, 0.45-0.56) compared with men. Women had lower odds of entering mental health residential treatment (AOR=0.69; 95% CI, 0.57-0.83).

CONCLUSIONS

Female veterans involved in the justice system have a high burden of mental health disorders (88%) and more than half have substance use disorders (58%). Entry to mental health residential treatment for women is an important quality improvement target.

"A welfare recipient may be drinking, but as long as he does as told--he may drink himself to death": a qualitative analysis of project implementation barriers among Danish job consultants

BACKGROUND

This paper is embedded in a randomised controlled trial (Alcohol and Employment) that investigated whether welfare-to-work schemes combined with alcohol treatment were more effective than welfare-to-work schemes alone for helping unemployed welfare recipients with alcohol problems get back to employment and reduce their alcohol problems. The implementation of Alcohol and Employment turned out to be challenging, and fewer welfare recipients than expected were enrolled. The aim of this paper was to identify and investigate obstacles to the implementation of Alcohol and Employment. Our main objective was to study the job consultants' role in the implementation process as they were key personnel in conducting the trial.

METHODS

The process evaluation was conducted in four Danish municipalities in 2011-2012. Data for identifying factors important for the implementation were collected through observations and focus group interviews with job consultants. Data were analysed thematically and thoroughly discussed among members of the project team; emerging themes were then grouped and read again repeatedly until the themes were consistent.

RESULTS

Three themes emerged as the main factors influencing the degree of implementation of Alcohol and Employment: (1) The job consultants' personal attitudes toward alcohol were an important factor. The job consultants generally did not consider a high alcohol intake to be an impediment to employment, or they thought that alcohol problems were only symptoms of more profound problems. (2) The job consultants' perception of their own roles and responsibilities in relation to the welfare recipients was a barrier: they felt that addressing alcohol problems and at the same time sustaining trust with the welfare recipient was difficult. Also, they did not consider alcohol problems to be their responsibility. (3) Shortage of time and resources among the job consultants was determined to be an influential factor.

CONCLUSIONS

We identified important factors at the individual level among the job consultants who threatened the implementation of Alcohol and Employment. Future studies in similar settings can take advantage of these findings when preparing interventions that are implemented by job consultants or similar professionals.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT01416103.

Dual diagnosis among veterans in the United States

Purpose

– Over the course of their service, veterans are exposed to elevated levels of chronic stress that contribute to a greater prevalence of mental illness than observed in the general population. When mental illness is present, comorbidity is normative. Convergent evidence suggests that co-occurring substance use and mental illness is among the most prevalent forms of comorbidity within veteran samples. The purpose of this paper is to explore issues associated with dual diagnoses among veterans in the USA.

Design/methodology/approach

– Research on dual diagnoses among veterans was reviewed and consolidated for presentation into three substantive content areas consisting of prevalence, associated conditions, and treatment of dual diagnoses.

Findings

– Dually diagnosed veterans represent a group at particularly high risk for myriad adverse biopsychosocial and treatment outcomes, including poor health, suicidality, violence or aggressive behavior, arrest, homelessness, and unemployment. A comprehensive strategy has been implemented within the Veterans Health Administration to address dual diagnosis and related problems. Additional research is required to more readily identify co-occurring substance use and mental illness and to refine integrated intervention approaches to minimize burden while improving treatment outcomes for veterans and their families.

Originality/value

– The current review includes a wide range of research spanning more than two decades and describing dual diagnosis among combat veterans of all modern eras. Areas in need of further research (e.g. dual diagnosis among female veterans; early detection of psychopathology and fully integrated care among returning veterans) are identified and discussed.

Alcohol screening and brief intervention in workplace settings and social services: a comparison of literature

BACKGROUND

The robust evidence base for the effectiveness of alcohol screening and brief interventions (ASBIs) in primary health care (PHC) suggests that a widespread expansion of ASBI in non-medical settings could be beneficial. Social service and criminal justice settings work frequently with persons with alcohol use disorders, and workplace settings can be an appropriate setting for the implementation of alcohol prevention programs, as a considerable part of their social interactions takes place in this context.

METHODS

Update of two systematic reviews on ASBI effectiveness in workplaces, social service, and criminal justice settings. Review to identify implementation barriers and facilitators and future research needs of ASBI in non-medical settings.

RESULTS

We found a limited number of randomized controlled trials in non-medical settings with an equivocal evidence of effectiveness of ASBI. In terms of barriers and facilitators to implementation, the heterogeneity of non-medical settings makes it challenging to draw overarching conclusions. In the workplace, employee concerns with regard to the consequences of self-disclosure appear to be key. For social services, the complexity of certain client needs suggest that a stepped and carefully tailored approach is likely to be required.

DISCUSSION

Compared to PHC, the reviewed settings are far more heterogeneous in terms of client groups, external conditions, and the focus on substance use disorders. Thus, future research should try to systematize these differences, and consider their implications for the deliverability, acceptance, and potential effectiveness of ASBI for different target groups, organizational frameworks, and professionals.

Adherence to behavioral therapy and psychiatry visits in a safety-net setting in Virginia, USA

Little is known about predictors of adherence to outpatient behavioural therapy and psychiatry visits in those who experience homelessness. Yet, consistent receipt of services in the community is critical to preventing use of acute care psychiatric services, which cause a significant cost burden to the mental health system. This retrospective study examined sociodemographic, housing instability and health-related factors associated with adherence to behavioural therapy and psychiatry appointments among 1711 clients served by an urban healthcare for the homeless centre in Virginia, USA. Clients ≥18 years old with a behavioural health condition who had an intake assessment and at least one behavioural therapy or psychiatry appointment scheduled during October 2005-September 2009 were eligible for the study. Of those with scheduled behavioural therapy visits, 27.7% were high adherers and 19.3% did not attend any appointments, whereas of those with scheduled psychiatry visits, 13.6% were high adherers and 22.1% did not attend any appointments. African Americans, when compared with whites, and those with a primary diagnosis of bipolar disorder were less likely to be high adherers to behavioural therapy. Women and being ≥35 years old were associated with a decreased likelihood of failing to attend psychiatry appointments, whereas African Americans, when compared with whites, and those with co-occurring disorders were more likely to not attend any psychiatry appointments. Understanding factors related to adherence to behavioural health services can help homeless care providers tailor strategies for improving visit adherence.

Alcohol use biomarkers predicting cognitive performance: a secondary analysis in veterans with alcohol dependence and posttraumatic stress disorder

OBJECTIVE

We conducted a secondary analysis of baseline data from a recently completed pharmacological pilot clinical trial among 30 veterans with alcohol dependence and posttraumatic stress disorder (PTSD). This trial included baseline measures of alcohol use biomarkers, both indirect (carbohydrate-deficient transferrin, GGT [γ-glutamyltransferase], mean corpuscular volume, AST [aspartate aminotransferase], alanine aminotransferase) and direct (ethyl glucuronide, ethyl sulfate), as well as neurocognitive measures (Trail Making Test parts A and B, Hopkins Verbal Learning Test-Revised, Balloon Analogue Risk Task, Delay Discounting Task).

METHODS

Two regression models were estimated and tested for each neurocognitive measure (dependent measure). The first model included the alcohol use biomarker alone as the predictor. The second model included the alcohol use biomarker along with the following 3 additional predictors: Beck Depression Inventory, Clinician-Administered PTSD Scale, and receiving medications.

RESULTS

In both models, the indirect biomarkers, such as GGT and AST, significantly predicted performance on the Hopkins Verbal Learning Test-Revised %Retention. GGT alone significantly predicted performance on the Trail Making Test part A.

CONCLUSIONS

Indirect alcohol use biomarkers may have a specific role in identifying those veterans with alcohol dependence and PTSD who have impaired cognitive performance. However, direct alcohol use biomarkers may not share such a role.

Social workers and delivery of evidence-based psychosocial treatments for substance use disorders

Social workers encounter individuals with substance use disorders (SUDs) in a variety of settings. With changes in health care policy and a movement toward integration of health and behavioral health services, social workers will play an increased role vis-á-vis SUD. As direct service providers, administrators, care managers, and policy makers, they will select, deliver, or advocate for delivery of evidence-based SUD treatment practices. This article provides an overview of effective psychosocial SUD treatment approaches. In addition to describing the treatments, the article discusses empirical support, populations for whom the treatments are known to be efficacious, and implementation issues.

Patient attitudes towards change in adapted motivational interviewing for substance abuse: a systematic review

Adapted motivational interviewing (AMI) represents a category of effective, directive and client-centered psychosocial treatments for substance abuse. In AMI, patients' attitudes towards change are considered critical elements for treatment outcome as well as therapeutic targets for alteration. Despite being a major focus in AMI, the role of attitudes towards change in AMI's action has yet to be systematically reviewed in substance abuse research. A search of PsycINFO, PUBMED/MEDLINE, and Science Direct databases and a manual search of related article reference lists identified 416 published randomized controlled trials that evaluated AMI's impact on the reduction of alcohol and drug use. Of those, 54 met the initial inclusion criterion by evaluating AMI's impact on attitudes towards change and/or testing hypotheses about attitudes towards change as moderators or mediators of outcome. Finally, 19 studies met the methodological quality inclusion criterion based upon a Newcastle-Ottawa Quality Assessment Scale score ≥ 7. Despite the conceptual importance of attitudes towards change in AMI, the empirical support for their role in AMI is inconclusive. Future research is warranted to investigate both the contextual factors (ie, population studied) as well as deployment characteristics of AMI (ie, counselor characteristics) likely responsible for equivocal findings.