Randomized controlled trial of a brief intervention for problematic prescription drug use in non-treatment-seeking patients

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.

Addressing opioid medication misuse at point of service in community pharmacy: A study protocol for an interdisciplinary behavioral health trial

BACKGROUND

>1 in 3 of the 9 million individuals engaged in opioid medication misuse obtain legitimate opioid prescriptions and fill these in community pharmacies, which are subsequently misused. This study is testing the efficacy of a pharmacist-led intervention-Brief Intervention-Medication Therapy Management (BI-MTM)-compared to standard medication counseling (SMC) to address opioid medication misuse.

METHODS

Design. This study is a single-blinded 2-group parallel randomized trial within 13 community pharmacies that will enroll 350 individuals. Participant Recruitment. Pharmacy staff approach patients and ask about interest in completing a brief confidential screening tool, which includes opioid medication misuse assessment. Interested patients who report misuse are asked to provide informed consent. Enrolled patients are assessed for behavioral and physical health at enrollment, 2-months post-enrollment, and 6-months post-enrollment.

INTERVENTIONS

Following baseline assessment, participants are randomized (1:1 ratio) to: SMC, a medication information/counseling intervention or BI-MTM, an intervention comprised by 4 evidence-based components: medication therapy management, brief intervention, naloxone dispensing, and patient navigation.

ANALYSES

Primary analyses involve estimating 3-level generalized linear mixed models to relate repeated assessments across time of opioid medication misuse (i.e., the Prescription Opioid Misuse Index) to the intervention.

CONCLUSION

Study results will provide the first critical step towards integrating a highly accessible, low-cost approach to managing risks related to opioid use. Community pharmacies provide an incredibly important setting in which patients can receive high quality care to support health behavior change. Successfully completing this project sets the stage for a large-scale effectiveness study. (NCT#: NCT05141266).

Acceptability of a Game-Based Intervention to Prevent Adolescent Prescription Opioid Misuse

Objective: This study assessed the initial acceptability of SafeUse, a game-based opioid misuse prevention intervention for delivery via smartphone among adolescents. Evidence-based educational and refusal skills training materials were adapted, and game design elements were applied to clinically and scientifically informed scenarios in which opioids are typically introduced to adolescents using standard product development methods to create the SafeUse prototype. Materials and Methods: In a mixed-methods study, 14 adolescents were assessed on their knowledge and perceptions of opioids before and following 5-7 days of access to SafeUse. Participants provided feedback in focus groups on the acceptability, relevance, and understandability of SafeUse and made suggestions for its improvement. Feedback was coded and summarized as to playability, acceptability, appropriateness, content development, and knowledge transfer. Pre- and post-access quantitative data were analyzed using Wilcoxon matched pairs signed-rank tests. Results: Overall, participants liked SafeUse, its characters, graphics, and approach, finding it more appealing than lectures/reading materials and appropriate for school settings. They moderately to extremely "liked the game," "would like to play more game modules," "liked playing through the decisions," thought the game was realistic/relevant and fun, and they learned new information about opioids. Participants reported increased confidence to refuse opioids and decreased likelihood of accepting opioids from someone they know. Knowledge about opioids increased (P < 0.006), and adolescent perception that prescription drugs are safer than illegal drugs decreased (P < 0.003) after playing SafeUse. Conclusion: Findings suggest that SafeUse is acceptable and likely educational to adolescents and worthy of further development and research.

Interventions to reduce benzodiazepine and sedative-hypnotic drug use in acute care hospitals: A scoping review

BACKGROUND

Benzodiazepines and sedative-hypnotic drugs (BZD/SHD) are commonly utilized in the acute care setting for insomnia and anxiety and are associated with cognitive impairment, falls, and fractures. Interventions to reduce use of BZD/SHD in hospitals are not well characterized.

OBJECTIVE

The objective was to conduct a scoping review to identify and characterize interventions to reduce the use of BZD/SHD by adults in the acute care setting.

METHODS

English language studies and abstracts that described an intervention to reduce BZD/SHD in adult hospital patients were included. Six databases (PubMed, EMBASE, CINAHL, PsycINFO, Scopus, and Web of Science) were searched up to July 2018 and updated to February 3, 2021. The grey literature (Opengrey, Grey Matters, Google Advanced) was searched up to July 2018. Titles and abstracts were screened and full-text articles were reviewed and charted by three independent reviewers. Stakeholders were consulted to inform the scoping review and collect perspectives on the findings.

RESULTS

There were 13,046 records identified and 43 studies included. The most common study designs were uncontrolled before and after (23/43, 53.5%) and randomized controlled trials (7/43, 16.3%). The majority of studies tested a single intervention (32/43, 74.4%) such as education, deprescribing, relaxation training and sleep protocols. Patients were frequently the target of relaxation training and behavior change interventions; while sleep protocols, multifaceted interventions, education and deprescribing were usually directed at healthcare providers, either alone or in combination with patients. Most studies reported positive results in decreasing BZD/SHD use (27/43, 62.8%).

CONCLUSIONS

The scoping review found a variety of interventions to decrease the utilization of BZD/SHD in hospitals. Multifaceted interventions aimed at patients and healthcare providers that include a combination of education, sleep protocols, and deprescribing may support reductions in BZD/SHD use. Stakeholders also recommended policy and system changes such as computer alerts due to feasibility and workload.

A community pharmacy-led intervention for opioid medication misuse: A small-scale randomized clinical trial

BACKGROUND

Stemming the opioid epidemic requires testing novel interventions. Toward this goal, feasibility and acceptability of a Brief Motivational Intervention-Medication Therapy Management (BMI-MTM) intervention was examined along with its impact on medication misuse and concomitant health conditions.

METHODS

We conducted a two-group randomized trial in 2 community pharmacies. We screened patients for prescription opioid misuse at point-of-service using the Prescription Opioid Misuse Index. Participants were assigned to standard medication counseling (SMC) or SMC + BMI-MTM (referred to as BMI-MTM herein). BMI-MTM consists of a pharmacist-led medication counseling/brief motivational session and 8-weekly patient navigation sessions. Assessments were at baseline, 2-, and 3-months. Primary outcomes included feasibility, acceptability, and mitigation of opioid medication misuse. Secondary outcomes included pain and depression. Outcomes were analyzed with descriptive and multivariable statistics (intent-to-treat [ITT] and adjusted for number of sessions completed [NUMSESS]).

RESULTS

Thirty-two participants provided informed consent (74.4% consent rate; SMC n = 17, BMI-MTM n = 15; 3-month assessment retention ≥93%). Feasibility was demonstrated by all BMI-MTM recipients completing the pharmacist session and an average of 7 navigation sessions. BMI-MTM recipients indicated ≥4.2 (5 maximum) level of satisfaction with the pharmacist-led session, and 92.4% were satisfied with navigation sessions. Compared to SMC at 3-months, BMI-MTM recipients reported greater improvements in misuse (ITT: Adjusted Odds Ratio [AOR] = 0.13; 95% CI = 0.05, 0.35, p < 0.001.

NUMSESS

AOR = 0.05; 95% CI = 0.01, 0.25; p < 0.001), pain (ITT: В = 8.8, 95% CI=-0.95, 18.5, p = 0.08; NUMSESS: В = 14.0, 95% CI = 3.28, 24.8, p = 0.01), and depression (ITT: B= -0.44; 95% CI=-0.65, -0.22; p < 0.001.

NUMSESS

B= -0.64; 95% CI=-0.82, -0.46; p < 0.001).

CONCLUSIONS

BMI-MTM is a feasible misuse intervention associated with superior satisfaction and outcomes than SMC. Future research should test BMI-MTM in a large-scale, fully-powered trial.

Association of Mental Health Disorders With Health Care Utilization and Costs Among Adults With Chronic Disease

IMPORTANCE

A population-based study using validated algorithms to estimate the costs of treating people with chronic disease with and without mental health disorders is needed.

OBJECTIVE

To determine the association of mental health disorders with health care costs among people with chronic diseases.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study in the Canadian province of Alberta collected data from April 1, 2012, to March 31, 2015, among 991 445 adults 18 years and older with a chronic disease (ie, asthma, congestive heart failure, myocardial infarction, diabetes, epilepsy, hypertension, chronic pulmonary disease, or chronic kidney disease). Data analysis was conducted from October 2017 to August 2018.

EXPOSURES

Mental health disorder (ie, depression, schizophrenia, alcohol use disorder, or drug use disorder).

MAIN OUTCOMES AND MEASURES

Resource use, mean total unadjusted and adjusted 3-year health care costs, and mean total unadjusted 3-year costs for hospitalization and emergency department visits for ambulatory care-sensitive conditions.

RESULTS

Among 991 445 participants, 156 296 (15.8%) had a mental health disorder. Those with no mental health disorder were older (mean [SD] age, 58.1 [17.6] years vs 55.4 [17.0] years; P < .001) and less likely to be women (50.4% [95% CI, 50.3%-50.5%] vs 57.7% [95% CI, 57.4%-58.0%]; P < .001) than those with mental health disorders. For those with a mental health disorder, mean total 3-year adjusted costs were $38 250 (95% CI, $36 476-$39 935), and for those without a mental health disorder, mean total 3-year adjusted costs were $22 280 (95% CI, $21 780-$22 760). Having a mental health disorder was associated with significantly higher resource use, including hospitalization and emergency department visit rates, length of stay, and hospitalization for ambulatory care-sensitive conditions. Higher resource use by patients with mental health disorders was not associated with health care presentations owing to chronic diseases compared with patients without a mental health disorder (chronic disease hospitalization rate per 1000 patient days, 0.11 [95% CI, 0.11-0.12] vs 0.06 [95% CI, 0.06-0.06]; P < .001; overall hospitalization rate per 1000 patient days, 0.88 [95% CI, 0.87-0.88] vs 0.43 [95% CI, 0.43-0.43]; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that mental health disorders are associated with substantially higher resource utilization and health care costs among patients with chronic diseases. These findings have clinical and health policy implications.

A systematic review of strategies to improve appropriate use of opioids and to reduce opioid use disorder and deaths from prescription opioids

Background

Abuse of prescription opioids is a serious problem in North America.

Aims

The aim of this study was to conduct a systematic review of peer-reviewed and grey literature to examine existing strategies aimed at improving the appropriate use of prescription opioids and/or reducing the misuse, abuse, and diversion of these drugs.

Methods

The following electronic databases were searched to September 2015 without language restrictions: MEDLINE, EMBASE, PsycINFO, and CINAHL; the grey literature was searched to May 2014. Reference lists of retrieved papers were also searched. Studies were eligible if a strategy was implemented and its impact on at least one of the primary outcomes of interest (appropriate prescription opioid use; misuse, abuse, opioid use disorder, diversion; overdose) was measured. Standardized, prepiloted forms were used for relevance screening, quality appraisal, and data extraction.

Results

A total of 65 studies that assessed 66 distinct strategies were identified. Due to the heterogeneity of the strategies, a qualitative synthesis was conducted. Many studies combined more than one type of strategy and measured various types of outcomes. The strategies with most promising results involved education, clinical practices, collaborations, prescription monitoring programs, public campaigns, opioid substitution programs, and naloxone distribution. We also found strategies that had some unintended consequences after implementation.

Conclusions

Our review identified successful strategies that have been implemented and evaluated in various jurisdictions. There is a need to replicate and disseminate these strategies where the problem of prescription opioid misuse and abuse has taken a toll on society.

A community pharmacy intervention for opioid medication misuse: A pilot randomized clinical trial

OBJECTIVES

Community pharmacy continues to play a crucial role in the national response to the opioid epidemic. The purpose of this article is to describe the protocol for a pilot study that is examining the feasibility and acceptability of the Motivational Intervention-Medication Therapy Management (MI-MTM) model. This study also examines the preliminary clinical effect of MI-MTM for improving opioid medication misuse and patient activation in self-management of health conditions that increase risk for misuse.

DESIGN

MI-MTM is a pharmacy-based integrated care model made up of 4 evidence-based practices: medication therapy management; brief motivational intervention; patient navigation; and naloxone training and referral. To test MI-MTM compared with Standard Medication Counseling (SMC), we are conducting a 2-group randomized single-blinded controlled trial with assessments at 3 time points.

SETTING AND PARTICIPANTS

The study is being conducted within a western Pennsylvania university-based community pharmacy with 46 patients with opioid misuse (MI-MTM = 23; SMC = 23).

MAIN OUTCOME MEASURES

Feasibility will be measured by capturing patient completion rate of MI-MTM sessions. Acceptability will be measured by administering satisfaction surveys regarding pharmacist and patient navigator services. Acceptability will also be captured by conducting intensive qualitative interviews. Preliminary effect of the intervention on misuse will be measured with the use of the Prescription Opioid Misuse Index and the Opioid Compliance Checklist. Activation in self-management will be measured with the use of the Patient Activation Measure.

RESULTS

This project is currently recruiting, and results are to come.

CONCLUSION

This study is the first in the United States to implement an evidence-based integrated behavioral intervention into the community pharmacy setting to address opioid medication misuse among pharmacy patients. The results of this study will provide necessary foundational data that allow further testing of this intervention model in a larger trial.

Stage-Based Mobile Intervention for Substance Use Disorders in Primary Care: Development and Test of Acceptability

Background

In 2016, 21 million Americans aged 12 years and older needed treatment for a substance use disorder (SUD). However, only 10% to 11% of individuals requiring SUD treatment received it. Given their access to patients, primary care providers are in a unique position to perform universal Screening, Brief Intervention, and Referral to Treatment (SBIRT) to identify individuals at risk, fill gaps in services, and make referrals to specialty treatment when indicated. Major barriers to SBIRT include limited time among providers and low motivation to change among many patients.

Objective

The objective of this study was to develop and test the acceptability of a prototype of a mobile-delivered substance use risk intervention (SURI) for primary care patients and a clinical dashboard for providers that can address major barriers to SBIRT for risky drug use. The SURI delivers screening and feedback on SUD risk via mobile tools to patients at home or in the waiting room; for patients at risk, it also delivers a brief intervention based on the transtheoretical model of behavior change (TTM) to facilitate progress through the stages of change for quitting the most problematic drug and for seeking treatment if indicated. The prototype also delivers 30 days of stage-matched text messages and 4 Web-based activities addressing key topics. For providers, the clinical dashboard summarizes the patient’s SUD risk scores and stage of change data, and provides stage-matched scripts to guide in-person sessions.

Methods

A total of 4 providers from 2 federally qualified health centers (FQHCs) were recruited for the pilot test, and they in turn recruited 5 patients with a known SUD. Furthermore, 3 providers delivered dashboard-guided SBIRT sessions and completed a brief acceptability survey. A total of 4 patients completed a Web-based SURI session and in-person SBIRT session, accessed other program components, and completed 3 acceptability surveys over 30 days. Questions in the surveys were adapted from the National Cancer Institute’s Education Materials Review Form. Response options ranged from 1=strongly disagree to 5=strongly agree. The criterion for establishing acceptability was an overall rating of 4.0 or higher across items.

Results

For providers, the overall mean acceptability rating was 4.4 (standard deviation [SD] 0.4). Notably, all providers gave a rating of 5.0 for the item, “The program can give me helpful information about my patient.” For patients, the overall mean acceptability rating was 4.5 (SD 0.3) for the mobile- and provider-delivered SBIRT sessions and 4.0 (SD 0.4) for the text messages and Web-based activities. One highly rated item was “The program could help me make some positive changes” (4.5).

Conclusions

The SURI program and clinical dashboard, developed to reduce barriers to SBIRT in primary care, were well received by providers and patients.

"Codeine Is My Helper": Misuse of and Dependence on Codeine-Containing Medicines in South Africa

Misuse of codeine-containing medicines is an emerging global public health concern. The majority of research has been conducted in developed countries (European Members States, Australia, the United States). This study aimed to gain an understanding of unique individual and collective experiences of trajectories of codeine misuse and dependence in South Africa. In-depth interviews were conducted with a purposive sample of adult codeine misusers and dependents ( n = 25). Narratives were analyzed using the empirical phenomenological psychological five-step method. Nine themes with 63 categories emerged, with two additional high levels of abstraction. Findings are illustrated: participant profile and product preferences, motives for use, transitioning to misuse and dependence, pharmacy purchasing and alternative sourcing routes, effects and withdrawal experiences, help-seeking and treatment experiences, and strategies for prevention. The study underscores the need for continued support for enhanced patient awareness of risk of habit forming use and related health consequences and professional pharmacovigilance.

Over-the-Counter Codeine-from Therapeutic Use to Dependence, and the Grey Areas in Between

Codeine is a widely used analgesic, that is available for sale in pharmacies over the counter (OTC) in a number of countries including the UK, South Africa, Ireland, France and Australia. In these countries with OTC codeine sales there has been emerging concerns about misuse of and dependence on codeine containing combination analgesics, with increasing numbers of people presenting for help with codeine dependence at primary care and addiction treatment services. This has led to many countries reviewing availability of codeine in OTC available preparations, and considering possible measures to reduce harms from misuse of OTC codeine containing combination analgesics.

A randomized study of the use of screening, brief intervention, and referral to treatment (SBIRT) for drug and alcohol use with jail inmates

BACKGROUND

Screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based practice that has been shown to reduce alcohol and drug use in healthcare, educational, and other settings, but research on the effectiveness of SBIRT with populations involved in the criminal justice system is limited. These populations have high rates of substance use but have limited access to interventions.

METHODS

The study randomized 732 jail inmates from a large urban jail to the SBIRT intervention or to the control group. Using the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), the intervention assessed the risk level for drug and alcohol misuse by inmates and provided those who were at low or medium risk with a brief intervention in jail and referred those at high risk to community treatment following release, including the opportunity to participate in a brief treatment (eight sessions) protocol. Using interview and records data from a 12-month follow-up, analyses compared the two groups with respect to the primary study outcomes of reductions in drug and alcohol use and the secondary outcomes of participation in treatment, rearrest, reduction in HIV risk behaviors, and quality of life. In addition, the costs of delivering the SBIRT intervention were calculated.

RESULTS

When baseline differences were controlled, the groups did not differ at follow-up on any of the primary or secondary outcomes.

CONCLUSIONS

Future research should develop and evaluate SBIRT models that are specifically adapted to the characteristics and needs of the jail population. Until more favorable results emerge, attempts to use SBIRT with jail inmates should be implemented with caution, if at all.

TRIAL REGISTRATION NUMBER

NCT01683643.

A pilot randomized clinical trial of an intervention to reduce overdose risk behaviors among emergency department patients at risk for prescription opioid overdose

BACKGROUND AND AIMS

Prescription opioid overdose is a significant public health problem. Interventions to prevent overdose risk behaviors among high-risk patients are lacking. This study examined the impact of a motivational intervention to reduce opioid misuse and overdose risk behaviors.

METHODS

This study was a pilot randomized controlled trial set in a single emergency department (ED) in which, 204 adult, English-speaking patients seeking care who reported prescription opioid misuse during the prior 3 months were recruited. Patients were randomized to either the intervention, a 30-minute motivational interviewing-based session delivered by a therapist plus educational enhanced usual care (EUC), or EUC alone. Participants completed self-reported surveys at baseline and 6 months post-baseline (87% retention rate) to measure the primary outcomes of overdose risk behaviors and the secondary outcome of non-medical opioid use.

FINDINGS

Participants in the intervention condition reported significantly lower levels of overdose risk behaviors (incidence rate ratio [IRR]=0.72, 95% CI: 0.59-0.87; 40.5% reduction in mean vs. 14.7%) and lower levels of non-medical opioid use (IRR=0.81, 95% CI: 0.70-0.92; 50.0% reduction in mean vs. 39.5%) at follow-up compared to the EUC condition.

CONCLUSIONS

This study represents the first clinical trial of a behavioral intervention to reduce overdose risk. Results indicate that this single motivational enhancement session reduced prescription opioid overdose risk behaviors, including opioid misuse, among adult patients in the ED.

Examining multi-session brief intervention for substance use in primary care: research methods of a randomized controlled trial

Background

Brief interventions such as Screening, a single session of Brief Intervention, and Referral to Treatment (SBIRT) have shown mixed effectiveness in primary care. However, there are indications that multi-session brief interventions may demonstrate more consistently positive outcomes, and perhaps a more intensive approach would be of benefit in addressing substance use in primary care. This study compared the effectiveness of SBIRT with a single BI session (BI/RT) to a multi-session brief-treatment intervention (BI/RT+) in primary care. We also developed easy-to-use, evidence-based materials to assist clinicians in delivering these interventions.

Methods/design

This study was conducted in three Federally Qualified Healthcare Centers (FQHCs). A total of 10,935 patients were screened, and 600 individuals were recruited. The sample was primarily Black/African American (82 %) with a mean age of 40. Patients who attended a healthcare appointment were screened for substance use via the AUDIT and DAST. Patients were eligible for the study if they scored 8 or higher on the AUDIT, were using only marijuana and scored 2 or higher on the DAST, or were using other illicit drugs and scored 1 or higher on the DAST. Participants were randomly assigned to receive one-session BI/RT, or two to six sessions of brief intervention that incorporated elements of motivational enhancement therapy and cognitive-behavioral therapy (BI/RT+). Both interventions were delivered by behavioral health consultants at the FQHCs. Participants completed follow-up assessments every 3 months for 1 year. Primary outcome variables included substance use treatment sessions attended and days of substance use. Secondary outcomes included measures of health, employment, legal, and psychiatric functioning and HIV risk behaviors. Additionally, we will conduct an economic evaluation examining cost-effectiveness and will analyze outcomes from a process evaluation examining patient and provider experiences.

Discussion

The ability of brief interventions to impact substance use has great potential, but research findings have been mixed. By conducting a large-scale randomized controlled trial in real-world health centers, this study will answer important questions about the effectiveness of expanded BIs for patients who screen positive for risky substance use in primary care.

Trial registration NCT01751672

Developing a framework of care for opioid medication misuse in community pharmacy

BACKGROUND

Prescription opioid misuse is a major public health concern in the US. Few resources exist to support community pharmacists engaging patients who misuse or are at risk for misuse.

OBJECTIVES

This report describes the results of the execution of the ADAPT-ITT model (a model for modifying evidence-based behavioral interventions to new populations and service settings) to guide the development of a behavioral health framework for opioid medication misuse in the community pharmacy setting.

METHODS

Pharmacy, addiction, intervention, and treatment experts were convened to attend a one-day meeting to review the empirical knowledgebase and discuss adapting the screening, brief intervention, and referral to treatment (SBIRT) protocol for addressing opioid medication misuse in community pharmacy. Qualitative data gathered from the meeting were analyzed by 2 independent coders in a 2-cycle process using objective coding schemes. Percentage of agreement and Cohen's Kappa were calculated to assess coder agreement.

RESULTS

First-cycle coding identified 4 distinct themes, with coder percentage of agreement ranging from 93.5 to 99.6% and with Kappa values between 0.81 and 0.93. Second-cycle coding identified 10 sub-themes, with coder percentage of agreement ranging from 83 to 99.8% and with Kappa values between 0.58 and 0.93. Identified themes and sub-themes encompassed patient identification, intervention, prevention, and referral to treatment.

CONCLUSIONS

Focus of screening efforts in the emerging model should capitalize on pharmacists' knowledge of medication management. Screening likewise should be multidimensional in order to facilitate patient-centered interventions that activate additional disciplines able to interface with patients at risk or involved in medication misuse.

Psychosocial interventions for benzodiazepine harmful use, abuse or dependence

BACKGROUND

Benzodiazepines (BZDs) have a sedative and hypnotic effect upon people. Short term use can be beneficial but long term BZD use is common, with several risks in addition to the potential for dependence in both opiate and non-opiate dependent patients.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions for treating BZD harmful use, abuse or dependence compared to pharmacological interventions, no intervention, placebo or a different psychosocial intervention on reducing the use of BZDs in opiate dependent and non-opiate dependent groups.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL- the Cochrane Library issue 12, 2014) which includes the Cochrane Drugs and Alcohol Group Specialized Register; PubMed (from 1966 to December 2014); EMBASE (from 1988 to December 2014); CINAHL Cumulative Index to Nursing and AlliedHealth Literature (1982 to September 2013); PsychINFO (1872 to December 2014); ERIC (Education Resources Information Centre, (January 1966 to September 2013); All EBM Reviews (1991 to September 2013, Ovid Interface); AMED (Allied & Alternative Medicine) 1985 to September 2013); ASSIA (Applied Social Sciences Index & Abstracts (1960 to September 2013); LILACS (January 1982 to September 2013);Web of Science (1900 to December 2014);Electronic Grey Literature Databases: Dissertation Abstract; Index to Theses.

SELECTION CRITERIA

Randomised controlled trials examining the use of a psychosocial intervention to treat BZDs versus pharmacological interventions,no intervention, placebo or a different psychosocial intervention on reducing the use of BZDs in opiate dependent and non-opiate dependent groups.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures outlined in Cochrane Guidelines.

MAIN RESULTS

Twenty-five studies including 1666 people met the inclusion criteria. The studies tested many different psychosocial interventions including cognitive behavioural therapy (CBT) (some studies with taper, other studies with no taper), motivational interviewing (MI),letters to patients advising them to reduce or quit BZD use, relaxation studies, counselling delivered electronically and advice provided by a general practitioner (GP). Based on the data obtained, we performed two meta-analyses in this Cochrane review: one assessing the effectiveness of CBT plus taper versus taper only (575 participants), and one assessing MI versus treatment as usual (TAU) (80 participants).There was moderate quality of evidence that CBT plus taper was more likely to result in successful discontinuation of BZDs within four weeks post treatment compared to taper only (Risk ratio (RR) 1.40, 95% confidence interval (CI) 1.05 to 1.86; nine trials, 423 participants) and moderate quality of evidence at three month follow-up (RR 1.51, 95% CI 1.15 to 1.98) in favour of CBT (taper)for 575 participants. The effects were less certain at 6, 11, 12, 15 and 24 months follow-up. The effect of CBT on reducing BZDs by> 50% was uncertain for all time points examined due to the low quality evidence. There was very low quality evidence for the effect on drop-outs at any of the time intervals; post-treatment (RR 1.05, 95% CI 0.66 to 1.66), three month follow-up (RR 1.71, 95% CI0.16 to 17.98) and six month follow-up (RR 0.70, 95% CI 0.17 to 2.88).Based on the very low quality of evidence available, the effect of MI versus TAU for all the time intervals is unclear; post treatment(RR 4.43, 95% CI 0.16 to 125.35; two trials, 34 participants), at three month follow-up (RR 3.46, 95% CI 0.53 to 22.45; four trials,80 participants), six month follow-up (RR 0.14, 95% CI 0.01 to 1.89) and 12 month follow-up (RR 1.25, 95% CI 0.63 to 2.47).There was very low quality of evidence to determine the effect of MI on reducing BZDs by > 50% at three month follow-up (RR 1.52,95% CI 0.60 to 3.83) and 12 month follow-up (RR 0.87, 95% CI 0.52 to 1.47). The effects on drop-outs from treatment at any of e time intervals between the two groups were uncertain due to the wide CIs; post-treatment (RR 0.50, 95% CI 0.04 to 7.10), three month follow-up (RR 0.46, 95% CI 0.06 to 3.28), six month follow-up (RR 8.75, 95% CI 0.61 to 124.53) and 12 month follow-up(RR 0.42, 95% CI 0.02 to 7.71).The following interventions reduced BZD use - tailored GP letter versus generic GP letter at 12 month follow-up (RR 1.70, 95%CI 1.07 to 2.70; one trial, 322 participants), standardised interview versus TAU at six month follow-up (RR 13.11, 95% CI 3.25 to 52.83; one trial, 139 participants) and 12 month follow-up (RR 4.97, 95% CI 2.23 to 11.11), and relaxation versus TAU at three month follow-up (RR 2.20, 95% CI 1.23 to 3.94).There was insufficient supporting evidence for the remaining interventions.We performed a 'Risk of bias' assessment on all included studies. We assessed the quality of the evidence as high quality for random sequence generation, attrition bias and reporting bias; moderate quality for allocation concealment, performance bias for objective outcomes, and detection bias for objective outcomes; and low quality for performance bias for subjective outcomes and detection bias for subjective outcomes. Few studies had manualised sessions or independent tests of treatment fidelity; most follow-up periods were less than 12 months.Based on decisions made during the implementation of protocol methods to present a manageable summary of the evidence we did not collect data on quality of life, self-harm or adverse events.

AUTHORS' CONCLUSIONS

CBT plus taper is effective in the short term (three month time period) in reducing BZD use. However, this is not sustained at six months and subsequently. Currently there is insufficient evidence to support the use of MI to reduce BZD use. There is emerging evidence to suggest that a tailored GP letter versus a generic GP letter, a standardised interview versus TAU, and relaxation versus TAU could be effective for BZD reduction. There is currently insufficient evidence for other approaches to reduce BZD use.

“Doctor shopping and pharmacy hopping”: practice innovations relating to codeine

Purpose

– The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.

Design/methodology/approach

– A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.

Findings

– The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.

Practical implications

– Further development of real-time monitoring processes with process evaluation is advised.

Originality/value

– This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.

A randomized trial of computerized vs. in-person brief intervention for illicit drug use in primary care: outcomes through 12 months

This study examined outcomes through 12 months from a randomized trial comparing computerized brief intervention (CBI) vs. in-person brief intervention (IBI) delivered by behavioral health counselors for adult community health center patients with moderate-level drug misuse (N=360). Data were collected at baseline, 3-, 6-, and 12-month follow-up, and included the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) and laboratory analysis of hair samples. Repeated measures analyses examined differential change over time. There were no significant differences in drug-positive hair tests over time or by condition. Global ASSIST scores decreased in both conditions (p<.001), but there were no significant differences between conditions in overall change across 12 months of follow-up (p=.13). CBI produced greater overall reductions in alcohol (p=.04) and cocaine (p=.02) ASSIST scores than IBI, with initial differences dissipating over time. Computerized brief interventions present a viable alternative to traditional in-person brief interventions.

Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial

IMPORTANCE

Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance).

OBJECTIVE

To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points.

INTERVENTIONS

Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433).

MAIN OUTCOMES AND MEASURES

The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior.

RESULTS

Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, β = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, β = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes.

CONCLUSIONS AND RELEVANCE

A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00877331.

Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial

IMPORTANCE

The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy.

OBJECTIVE

To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)-a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)-compared with no brief intervention.

DESIGN, SETTING, AND PARTICIPANTS

This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of ≥4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts.

INTERVENTIONS

Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master's-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources.

MAIN OUTCOMES AND MEASURES

Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization.

RESULTS

At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity.

CONCLUSIONS AND RELEVANCE

Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00876941.

Computerized versus in-person brief intervention for drug misuse: a randomized clinical trial

BACKGROUND AND AIMS

Several studies have found that brief interventions (BIs) for drug misuse have superior effectiveness to no-treatment controls. However, many health centers do not provide BIs for drug use consistently due to insufficient behavioral health staff capacity. Computerized BIs for drug use are a promising approach, but their effectiveness compared with in-person BIs has not been established. This study compared the effectiveness of a computerized brief intervention (CBI) to an in-person brief intervention (IBI) delivered by a behavioral health counselor.

METHODS

Two-arm randomized clinical trial, conducted in two health centers in New Mexico, United States. Participants were 360 adult primary care patients with moderate-risk drug scores on the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) who were randomly assigned on a 1 : 1 basis to a computerized brief intervention (CBI) or to an in-person brief intervention (IBI) delivered by a behavioral health counselor. Assessments were conducted at baseline and 3-month follow-up, and included the ASSIST and drug testing on hair samples.

RESULTS

The IBI and CBI conditions did not differ at 3 months on global ASSIST drug scores [b = -1.79; 95% confidence interval (CI) = -4.37, 0.80] or drug-positive hair tests [odds ratio (OR) = 0.97; 95% CI = 0.47, 2.02]. There was a statistically significant advantage of CBI over IBI in substance-specific ASSIST scores for marijuana (b = -1.73; 95% CI = -2.91, -0.55; Cohen's d = 0.26; P = 0.004) and cocaine (b = -4.48; 95% CI = -8.26, -0.71; Cohen's d = 0.50; P = 0.021) at 3 months.

CONCLUSIONS

Computerized brief intervention can be an effective alternative to in-person brief intervention for addressing moderate drug use in primary care.

Effectiveness of brief interventions as part of the Screening, Brief Intervention and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances: a systematic review

BACKGROUND

The purpose of this systematic review is to assess the effectiveness of brief interventions (BIs) as part of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) model for reducing the nonmedical use of psychoactive substances.

METHODS

Bibliographic databases (including MEDLINE, Embase, The Cochrane Library, CINAHL, and PsycINFO to April 2012) and gray literature sources were searched. We included randomized controlled trials that opportunistically screened adolescents or adults and then provided a one-to-one, verbal BI to those at risk of substance-use harm. Of interest was the nonmedical use of psychoactive substances (for example, drugs prohibited by international law), excluding alcohol, nicotine, and caffeine. Interventions comprised four or fewer sessions and were compared with no/delayed intervention or provision of information only. Studies were assessed for bias using the Cochrane risk of bias tool. Results were synthesized narratively. Evidence was interpreted according to the GRADE framework.

RESULTS

We identified 8,836 records. Of these, five studies met our inclusion criteria. Two studies compared BI with no BI, and three studies compared BI with information only. Studies varied in characteristics such as substances targeted, screening procedures, and BI administered. Outcomes were mostly reported by a single study, leading to limited or uncertain confidence in effect estimates.

CONCLUSIONS

Insufficient evidence exists as to whether BIs, as part of SBIRT, are effective or ineffective for reducing the use of, or harms associated with nonmedical use of, psychoactive substances when these interventions are administered to nontreatment-seeking, screen-detected populations. Updating this review with emerging evidence will be important.

TRIAL REGISTRATION

CRD42012002414.

Pharmacists Who Screen and Discuss Opioid Misuse With Patients

Background:

Prescription opioid (PO) abuse has reached epidemic proportions in the United States, and pharmacies are locations from which these medications are often diverted. This study identifies factors associated with pharmacists who currently screen and discuss PO misuse with patients.

Methods:

A secondary data analysis of a cross-sectional Web-based survey that was sent to pharmacists was conducted. The survey contained items that assessed whether pharmacists currently screened and discussed PO misuse with patients along with pharmacists’ attitudes and beliefs toward providing brief interventions. Multivariable models were developed which identified factors associated with pharmacists’ currently screening and discussing misuse.

Results:

Chain setting pharmacists (odds ratio [OR] = 6.16, 95% confidence interval [CI] = 1.16-32.72) and pharmacists interested in being directly involved in PO screening and brief intervention research projects (OR = 2.06, 95% CI = 1.35-3.15) were most likely to report current screening. Pharmacists who reported currently screening for misuse (OR = 4.27, 95% CI = 2.83-6.45) and who reported wanting to help patients who misuse POs (OR = 3.03, 95% CI = 1.50-6.15) were most likely to currently discuss abuse.

Conclusions:

Investigators implementing pharmacy-based screening and brief intervention studies for POs should take into account practice location and pharmacists’ interest in addressing PO issues.

Screening and brief intervention for unhealthy drug use: little or no efficacy

Unhealthy drug use ranges from use that risks health harms through severe drug use disorders. This narrative review addresses whether screening and brief intervention (SBI), efficacious for risky alcohol use, has efficacy for reducing other drug use and consequences. Brief intervention among those seeking help shows some promise. Screening tools have been validated though most are neither brief nor simple enough for use in general health settings. Several randomized trials have tested the efficacy of brief intervention for unhealthy drug use identified by screening in general health settings (i.e., in people not seeking help for their drug use). Substantial evidence now suggests that efficacy is limited or non-existent. Reasons likely include a range of actual and perceived severity (or lack of severity), concomitant unhealthy alcohol use and comorbid mental health conditions, and the wide range of types of unhealthy drug use (e.g., from marijuana, to prescription drugs, to heroin). Although brief intervention may have some efficacy for unhealthy drug users seeking help, the model of SBI that has effects in primary care settings on risky alcohol use may not be efficacious for other drug use.

Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Motivational Interviewing (MI) is a method for encouraging people to make behavioral changes to improve health outcomes. We used systematic review and meta-analysis to investigate MI's efficacy in medical care settings.

METHODS

Database searches located randomized clinical trials that compared MI to comparison conditions and isolated the unique effect of MI within medical care settings.

RESULTS

Forty-eight studies (9618 participants) were included. The overall effect showed a statistically significant, modest advantage for MI: Odd ratio=1.55 (CI: 1.40-1.71), z=8.67, p<.001. MI showed particular promise in areas such as HIV viral load, dental outcomes, death rate, body weight, alcohol and tobacco use, sedentary behavior, self-monitoring, confidence in change, and approach to treatment. MI was not particularly effective with eating disorder or self-care behaviors or some medical outcomes such as heart rate.

CONCLUSION

MI was robust across moderators such as delivery location and patient characteristics, and appears efficacious when delivered in brief consultations.

PRACTICE IMPLICATIONS

The emerging evidence for MI in medical care settings suggests it provides a moderate advantage over comparison interventions and could be used for a wide range of behavioral issues in health care.

Screening, brief intervention, and referral to treatment (SBIRT) for offenders: protocol for a pragmatic randomized trial

BACKGROUND

Although screening, brief intervention, and referral to treatment (SBIRT) is an evidence-based technique that, in some health-care settings, has been shown to cost-effectively reduce alcohol and drug use, research on the efficacy of SBIRT among criminal offender populations is limited. Such populations have a high prevalence of drug and alcohol use but limited access to intervention, and many are at risk for post-release relapse and recidivism. Thus, there exists a need for treatment options for drug-involved offenders of varying risk levels to reduce risky behaviors or enter treatment.

METHODS/DESIGN

This protocol describes an assessment of SBIRT feasibility and effectiveness in a criminal justice environment. Eight-hundred persons will be recruited from a large metropolitan jail, with the experimental group receiving an intervention depending on risk level and the control group receiving minimal intervention. The intervention will assess the risk level for drug and alcohol misuse by inmates, providing those at low or medium risk a brief intervention in the jail and referring those at high risk to community treatment following release. In addition, a brief treatment (eight-session) option will be available. Using data from a 12-month follow-up interview, the primary study outcomes are a reduction in drug and alcohol use, while secondary outcomes include participation in treatment, rearrest, quality of life, reduction in HIV risk behaviors, and costs of SBIRT.

EXPECTED VALUE

Individual reductions in alcohol and drug use can have significant effects on public health and safety when observed over a large population at risk for substance-use problems. With wider dissemination statewide or nationwide, a relatively low-cost intervention such as SBIRT could offer demonstrated benefits in this population.

TRIAL REGISTRATION

Clinical Trials Government Identifier, NCT01683643.

Reducing the health consequences of opioid addiction in primary care

Addiction to prescription opioids is prevalent in primary care settings. Increasing prescription opioid use is largely responsible for a parallel increase in overdose nationally. Many patients most at risk for addiction and overdose come into regular contact with primary care providers. Lack of routine addiction screening results in missed treatment opportunities in this setting. We reviewed the literature on screening and brief interventions for addictive disorders in primary care settings, focusing on opioid addiction. Screening and brief interventions can improve health outcomes for chronic illnesses including diabetes, hypertension, and asthma. Similarly, through the use of screening and brief interventions, patients with addiction can achieve improved health outcome. A spectrum of low-threshold care options can reduce the negative health consequences among individuals with opioid addiction. Screening in primary care coupled with short interventions, including motivational interviewing, syringe distribution, naloxone prescription for overdose prevention, and buprenorphine treatment are effective ways to manage addiction and its associated risks and improve health outcomes for individuals with opioid addiction.

Brief intervention and social work: a primer for practice and policy

Most individuals in need of help for alcohol use disorders do not receive care. Screening and brief intervention (SBI) is an evidence-based practice for reducing at-risk drinking and alcohol-related risk behaviors. Health care reform sets the stage for a large expansion of SBI to individuals in the United States. Social workers have the opportunity to play an important role in helping establish SBI nationally, but they must become more involved in its delivery, educating new social workers with respect to SBI practice, and taking part in research to expand the field's knowledge of this service.

Feasibility and Acceptability of Screening and Brief Interventions to Address Alcohol and Other Drug Use among Patients Presenting for Emergency Services in Cape Town, South Africa

Despite evidence from high income countries, it is not known whether screening and brief interventions (SBI) for alcohol and other drug (AOD) use are feasible to implement in low and middle income countries. This paper describes the feasibility and acceptability of a peer-led SBI for AOD-using patients presenting with injuries at emergency services in Cape Town, South Africa. Data were extracted from program records on the number of eligible patients screened and the number of program refusals. A questionnaire examined preliminary responses to the intervention for 30 patients who had completed the program and 10 emergency personnel. Peer counselors were also interviewed to identify barriers to implementation. Of the 1458 patients screened, 21% (305) met inclusion criteria, of which 74% (225) were enrolled in the intervention. Of the 30 patients interviewed, most (83%) found the program useful. Emergency personnel were supportive of the program but felt that visibility and reach could improve. Peer counselors identified the need for better integration of the program into emergency services and for additional training and support. In conclusion, with limited additional resources, peer-led SBIs for AOD use are feasible to conduct in South African emergency services and are acceptable to patients and emergency personnel.

Screening and brief intervention for unhealthy drug use in primary care settings: randomized clinical trials are needed

The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not seek help for drug abuse and dependence, and SBI has proven efficacy for unhealthy alcohol use. On the other hand, the diversity of drugs of abuse and the high prevalence of abuse and dependence among those who use them raise concerns that drug SBI may have limited or no efficacy. Federal efforts to disseminate SBI for drug use are underway, and reimbursement codes to compensate clinicians for these activities have been developed. However, the discrepancies between science and policy developments underscore the need for evidence-based research regarding the efficacy of SBI for drug use. This article discusses the rationale for drug SBI and existing research on its potential to improve drug-use outcomes and makes the argument that randomized controlled trials to determine its efficacy are urgently needed to bridge the gap between research, policy, and clinical practice.

Physician detection of unhealthy substance use on inpatient teaching and hospitalist medical services

BACKGROUND

Screening, brief intervention, and referral to treatment for substance use depends on reliable identification. The goal of this study was to determine the rate of detection of unhealthy substance use by physicians on teaching and nonteaching medical services at a community teaching hospital.

METHODS

This cross-sectional study was conducted from February to June 2009. All new medicine admissions to the Teaching Service or the nonteaching Hospitalist Service were assessed for unhealthy substance use using the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) and Drug Abuse Screening Test (DAST). All patients identified with substance use completed the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). Medical record review was also performed to assess physician documentation.

RESULTS

Of 442 eligible patients, 414 consented to participate. Patients on the Teaching Service were more likely to be male, younger, unmarried, non-white, uninsured or receiving publicly funded insurance, and current smokers (p < .01 for all comparisons). Overall, the detection rate for unhealthy substance use was 64.3% (63 of 98 confirmed cases), with service-specific rates of 73.4% for the Teaching Service, compared with 47.1% for the Hospitalist Service (p = .011). ICD-9 coding accounted for 53.1% of identified cases on the Teaching Service and 14.7% of identified cases on the Hospitalist Service (p < .001). Assignment to the Hospitalist Service, being married, and isolated unhealthy drug use were independently associated with decreased physician detection rates.

CONCLUSIONS

Our study suggests that unhealthy substance use is more likely to be detected on a Teaching Service than on a Hospitalist Service.

Study protocol: brief intervention for medication overuse headache--a double-blinded cluster randomised parallel controlled trial in primary care

Background

Chronic headache (headache ≥ 15 days/month for at least 3 months) affects 2–5% of the general population. Medication overuse contributes to the problem. Medication-overuse headache (MOH) can be identified by using the Severity of Dependence Scale (SDS). A “brief intervention” scheme (BI) has previously been used for detoxification from drug and alcohol overuse in other settings. Short, unstructured, individualised simple information may also be enough to detoxify a large portion of those with MOH. We have adapted the structured (BI) scheme to be used for MOH in primary care.

Methods/Design

A double-blinded cluster randomised parallel controlled trial (RCT) of BI vs. business as usual. Intervention will be performed in primary care by GPs trained in BI. Patients with MOH will be identified through a simple screening questionnaire sent to patients on the GPs lists. The BI method involves an approach for identifying patients with high likelihood of MOH using simple questions about headache frequency and the SDS score. Feedback is given to the individual patient on his/her score and consequences this might have regarding the individual risk of medication overuse contributing to their headache. Finally, advice is given regarding measures to be taken, how the patient should proceed and the possible gains for the patient. The participating patients complete a headache diary and receive a clinical interview and neurological examination by a GP experienced in headache diagnostics three months after the intervention. Primary outcomes are number of headache days and number of medication days per month at 3 months. Secondary outcomes include proportions with 25 and 50% improvement at 3 months and maintenance of improvement and quality of life after 12 months.

Discussion

There is a need for evidence-based and cost-effective strategies for treatment of MOH but so far no consensus has been reached regarding an optimal medication withdrawal method. To our knowledge this is the first RCT of structured non-pharmacological MOH treatment in primary care. Results may hold the potential of offering an instrument for treating MOH patients in the general population by GPs.

Trial registration

ClinicalTrials.gov identifier: NCT01314768

Treatment of opioid dependence in the setting of pregnancy

Opioid dependence in the setting of pregnancy provides a distinct set of challenges for providers. Treatment plans must take into consideration psychiatric and medical comorbidities while balancing risks and benefits for the maternal-fetal dyad. Treatment is best offered through a comprehensive treatment program designed to effectively deliver opioid agonist maintenance treatment along with psychosocial and obstetric care. As misuse of prescription analgesics increases in the United States, identification of the problem in pregnancy will become more important because this misuse is expected to lead to an increased prevalence of opioid dependence in pregnancy. Buprenorphine as maintenance treatment of opioid dependence during pregnancy has promise and may offer some benefits, but more research is needed, especially regarding induction of actively addicted women during pregnancy. For the present, methadone maintenance remains the standard of care for agonist treatment of opioid dependence in pregnancy against which other treatments must be compared.

Development and validation of the Decisional Balance Scale for problematic Prescription Drug use (DBS-PD)-20

The purpose of this study was to develop a Decisional Balance Scale (DBS) for Prescription Drugs (PD), the DBS-PD-20, to examine its factorial structure and test its reliability and external validity by comparison across Stages of Change. A sample of 126 general hospital inpatients with either regular use of PD (more than 60 days within the last three months) or abuse of or dependence on PD was recruited in a northern German city. Exploratory principal components analysis revealed a two-factor structure, the Pros and Cons of PD intake, as expected. While the DBS-PD-20 showed good reliability (Cronbach's alpha=0.91 for the Pros and=0.89 for the Cons), external validity could be proven for the Cons (significant increase from precontemplation to contemplation/action), whereas the Pros showed an insignificant increase. Although further validation is needed, the DBS-PD-20 may be helpful for interventions and research.

Motivational interviewing for substance abuse

BACKGROUND

There are 76.3 million people with alcohol use disorders worldwide and 15.3 million with drug use disorders. Motivational interviewing (MI) is a client-centred, semi-directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The intervention is used widely, and therefore it is important to find out whether it helps, harms or is ineffective.

OBJECTIVES

To assess the effectiveness of motivational interviewing for substance abuse on drug use, retention in treatment, readiness to change, and number of repeat convictions.

SEARCH STRATEGY

We searched 18 electronic databases, 5 web sites, 4 mailing lists, and reference lists from included studies and reviews. Search dates were November 30, 2010 for Cochrane Library, Medline, Embase and PsychINFO.

SELECTION CRITERIA

Randomized controlled trials with persons dependent or abusing substance. Interventions were MI or motivational enhancement therapy. The outcomes were extent of substance abuse, retention in treatment, motivation for change, repeat conviction.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed studies for inclusion, and two authors extracted data. Results were categorized into (1) MI versus no-treatment control, (2) MI versus treatment as usual, (3) MI versus assessment and feedback, and (4) MI versus other active treatment. Within each category, we computed meta-analyses separately for post-intervention, short, medium and long follow-ups.

MAIN RESULTS

We included 59 studies with a total of 13,342 participants. Compared to no treatment control MI showed a significant effect on substance use which was strongest at post-intervention SMD 0.79, (95% CI 0.48 to 1.09) and weaker at short SMD 0.17 (95% CI 0.09 to 0.26], and medium follow-up SMD 0.15 (95% CI 0.04 to 0.25]). For long follow-up, the effect was not significant SMD 0.06 (95% CI-0.16 to 0.28). There were no significant differences between MI and treatment as usual for either follow-up post-intervention, short and medium follow up. MI did better than assessment and feedback for medium follow-up SMD 0.38 (95% CI 0.10 to 0.66). For short follow-up, there was no significant effect . For other active intervention there were no significant effects for either follow-up.There was not enough data to conclude about effects of MI on the secondary outcomes.

AUTHORS' CONCLUSIONS

MI can reduce the extent of substance abuse compared to no intervention. The evidence is mostly of low quality, so further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.

Effectiveness of intervention on improvement of drug use among methadone maintained adults

The purpose of this study is to evaluate the effectiveness of three interventions (individual motivational interviewing, group motivational interviewing, or nurse-led hepatitis health promotion) in reducing drug use. A randomized, controlled trial was conducted with 256 methadone maintained moderate-to-heavy alcohol-using adults attending one of five MM outpatient clinics. Drug use in the overall sample was significantly reduced from baseline to 6-month follow-up, as assessed by a 30-day recall (p < 0.0001), with a trend apparent for 6-month recall (p = 0.09). The group and individual programs revealed significant decreases in drug use at the 30-day recall.

Brief intervention in general hospital for problematic prescription drug use: 12-month outcome

BACKGROUND

The problematic use of prescription drugs (PDs) and related disorders are considerably prevalent but evidence concerning brief intervention for problematic PD users is sparse. A previous analysis of the present study on the effectiveness of brief intervention for problematic PD use in a general hospital revealed a significant reduction in PD use after 3 months. The analyses presented herein provides data from the 12-month follow-up.

METHOD

In a randomized controlled trial, 126 proactively recruited general hospital patients were analyzed. The intervention group received two brief Motivational Interviewing (MI) sessions. Two follow-ups (after 3 and 12 months) were conducted. Intervention effects at 12-month follow-up on PD cessation and reduction were analyzed using regression methods and controlling for significant group differences. Subgroups of sedative/hypnotic- and opioid-users were examined.

RESULTS

No significant intervention effects were found in the overall sample. Respecting significant differences between the intervention and control groups, we detected no effects of the intervention for the subgroups of sedative/hypnotic- or opioid-users.

CONCLUSIONS

In contrast to the short-term effects after 3 months, no long-term effects of brief MI sessions on PD use were found. More intensive interventions, booster-sessions or regular aftercare might help in stabilizing intervention effects on PD use among hospital patients. However, studies using larger samples are needed to allow more powerful and specific analyses. Different samples should be examined. Problems concerning the recruitment of study participants in PD research were discussed and should be considered in further studies.