An evidence based alcohol screening, brief intervention and referral to treatment (SBIRT) curriculum for emergency department (ED) providers improves skills and utilization

Physician Reluctance to Intervene in Addiction: A Systematic Review

Importance

The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low.

Objective

To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions.

Data Sources

A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021.

Study Selection

Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included.

Data Extraction and Synthesis

Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons.

Main Outcomes and Measures

The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria.

Results

A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug.

Conclusions and Relevance

In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.

Empirical assessment of wounds among people who use substances

BACKGROUND

Wounds are a significant source of morbidity among people who use substances (PWUS). This project sought to identify the incidence and severity of wounds among PWUS in the South Bronx, a region of New York City with one of the highest morbidities of substance use disorder.

METHODS

This study recruited PWUS within the past 30 days. Research staff were trained to document the presence and severity of wounds. The primary outcome measure was the incidence of wounds. Acceptability of on-the-street wound care was assessed by the number of participants encountered. The association between participant characteristics and wounds was also evaluated.

RESULTS

In total, 586 PWUS were assessed (19.4 % female: 69 % Hispanic; 23 % Black; 5 % White). Heroin (65.7 %) and psychostimulants (58.3 %) were the most commonly used drugs. Approximately 23 % of outreach recipients disclosed a wound. Among those with a wound, 60.9 % reported one wound, 27.8 % had two wounds, and 11.3 % had three or more wounds. Small wounds (approximately the size of a cherry) were the most common (78.6 %). Recent use of stimulants or heroin, along with intravenous use of any substance were significantly associated with having a wound.

CONCLUSIONS

This study found that drug-related wounds were common among PWUS. Toxicology data from other sources indicate that xylazine was present in the NYC market at the time, though its prevalence among the current sample is difficult to determine. The occurrence and severity of substance-related wounds in NYC should continue to be monitored as a function of changes in the xylazine adulteration.

SAEM GRACE: Anti-craving medications for alcohol use disorder treatment in the emergency department: A systematic review of direct evidence

OBJECTIVES

Alcohol-related concerns commonly present to the emergency department (ED), with a subset of individuals experiencing the symptoms of an alcohol use disorder (AUD). As such, examining the efficacy of pharmacological anti-craving treatment for AUD in the ED is of increasing interest. The objective of this systematic review was to evaluate the direct evidence assessing the efficacy of providing anti-craving medications for AUD treatment in the ED.

METHODS

A systematic search was conducted according to the patient-intervention-control-outcome question: (P) adults (≥18 years old) presenting to the ED with an AUD (including suspected AUD); (I) anti-craving medications (i.e., naltrexone, acamprosate, gabapentin); (C) no prescription or placebo; (O) reduction of repeat ED visits, engagement in addiction services, reductions in heavy drinking days, reductions in any drinking and amount consumed (or abstinence), and in relapse. Two reviewers independently assessed articles for inclusion and conducted risk of bias assessments for included studies.

RESULTS

From 143 potentially relevant articles, 6 met inclusion criteria: 3 clinical trials, and 3 case studies. The clinical trials identified evaluated oral versus extended-release naltrexone, monthly extended-release naltrexone injections, and disulfiram. Both oral and extended-release naltrexone resulted in decreased alcohol consumption. Monthly extended-release naltrexone injections resulted in significant improvements in drinking and quality of life. Although out of scope, the disulfiram studies identified did not result in an improvement in drinking in comparison to no medication.

CONCLUSIONS

Overall, there are few studies directly examining the efficacy of anti-craving medications for AUD in the ED, although the limited evidence that exists is supportive of naltrexone pharmacotherapy, particularly extended-release injection formulation. Additional randomized controlled trials are necessary for substantive direct evidence on anti-craving medication initiation in the ED.

Intimate Partner Violence Among Service Members and Veterans: Differences by Sex and Rurality

Among military service members and veterans (SMVs), factors unique to military service may contribute to an elevated risk of experiencing intimate partner violence (IPV) victimization. Although rurality has been established as a risk factor for IPV, differences in IPV victimization by rural- urban dwelling location, SMV status, and sex have not been explored. The purpose of this study was to estimate the rate of IPV victimization in rural and urban areas in the United States by SMV status and sex. We obtained Behavioral Risk Factor Surveillance System data (BRFSS; n = 18,755); fit a mixed-effects, multilevel generalized linear model to the data for IPV victimization; and linked the model to U.S. Census Bureau population count data. We generated predicted estimates of IPV for SMVs and civilians separately by sex in rural and urban areas. The direct IPV victimization prevalence rate for the entire BRFSS sample was 16.90%. Substantial variation in model-based IPV prevalence was observed across subgroups. Female SMVs (rural = 23.54%, 95% confidence interval [CI] [17.33, 30.02]; urban = 23.34%, 95% CI [17.48, 30.17]) had higher IPV victimization rates than female civilians (rural = 14.55%, 95% CI [13.06, 16.37]; urban = 14.50%, 95% CI [13.19, 16.34]), whereas male civilians (rural = 8.06%, 95% CI [7.19, 9.08]; urban = 8.02%, 95% CI [7.27, 9.02]) had higher IPV victimization rates than male SMVs (rural = 7.21%, 95% CI [6.03, 8.47]; urban = 7.17%, 95% CI [6.00, 8.41]). Programming for preventing and assisting in recovering from IPV exposure should target rural-dwelling female SMVs.

Factors Influencing Patient Receptivity to Brief Alcohol Interventions in Primary Care: An Application of Conjoint Analysis

Background: Brief alcohol interventions (BAIs) are an evidence-based practice for addressing hazardous alcohol use in primary care settings. However, numerous barriers to implementation of BAIs in routine practice have been identified, including concerns about patient receptivity to BAIs. Despite this being a commonly identified barrier to BAI implementation, little BAI implementation research has focused on patient receptivity. Objectives: This study aimed to identify the treatment preferences of primary care patients who screened positive for hazardous alcohol use and to evaluate factors that may influence patients' receptivity to BAIs delivered in primary care. We conducted a mailed survey of primary care patients (N = 245) who screened positive for hazardous alcohol use on annual screening measures based on electronic medical record data. Patients completed measures assessing treatment preferences and a conjoint analysis questionnaire designed to evaluate the relative importance of three factors (focus of the BAI, tailoring of the BAI, and familiarity with the provider delivering the BAI) for patient receptivity. Results: Conjoint analysis results revealed that familiarity with provider (with patients preferring BAIs delivered by providers they have previously met) was the most important factor in predicting patients' receptivity to BAIs. Additionally, patients preferred to discuss alcohol use in the context of another concern (focus of the BAI) and preferred personalized information tailored based on their specific health concerns (tailoring of the BAI), although these factors were not statistically significant when accounting for familiarity with provider. Conclusions: Findings of the present study have potential to inform future research on implementation of BAIs.

Promoting alcohol treatment engagement post-hospitalization with brief intervention, medications and CBT4CBT: protocol for a randomized clinical trial in a diverse patient population

BACKGROUND

Alcohol use disorder (AUD) commonly causes hospitalization, particularly for individuals disproportionately impacted by structural racism and other forms of marginalization. The optimal approach for engaging hospitalized patients with AUD in treatment post-hospital discharge is unknown. We describe the rationale, aims, and protocol for Project ENHANCE (ENhancing Hospital-initiated Alcohol TreatmeNt to InCrease Engagement), a clinical trial testing increasingly intensive approaches using a hybrid type 1 effectiveness-implementation approach.

METHODS

We are randomizing English and/or Spanish-speaking individuals with untreated AUD (n = 450) from a large, urban, academic hospital in New Haven, CT to: (1) Brief Negotiation Interview (with referral and telephone booster) alone (BNI), (2) BNI plus facilitated initiation of medications for alcohol use disorder (BNI + MAUD), or (3) BNI + MAUD + initiation of computer-based training for cognitive behavioral therapy (CBT4CBT, BNI + MAUD + CBT4CBT). Interventions are delivered by Health Promotion Advocates. The primary outcome is AUD treatment engagement 34 days post-hospital discharge. Secondary outcomes include AUD treatment engagement 90 days post-discharge and changes in self-reported alcohol use and phosphatidylethanol. Exploratory outcomes include health care utilization. We will explore whether the effectiveness of the interventions on AUD treatment engagement and alcohol use outcomes differ across and within racialized and ethnic groups, consistent with disproportionate impacts of AUD. Lastly, we will conduct an implementation-focused process evaluation, including individual-level collection and statistical comparisons between the three conditions of costs to providers and to patients, cost-effectiveness indices (effectiveness/cost ratios), and cost-benefit indices (benefit/cost ratios, net benefit [benefits minus costs). Graphs of individual- and group-level effectiveness x cost, and benefits x costs, will portray relationships between costs and effectiveness and between costs and benefits for the three conditions, in a manner that community representatives also should be able to understand and use.

CONCLUSIONS

Project ENHANCE is expected to generate novel findings to inform future hospital-based efforts to promote AUD treatment engagement among diverse patient populations, including those most impacted by AUD.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT05338151.

Timing of Mental Health Service Use After a Pediatric Firearm Injury

OBJECTIVES

To examine how timing of the first outpatient mental health (MH) visit after a pediatric firearm injury varies by sociodemographic and clinical characteristics.

METHODS

We retrospectively studied children aged 5 to 17 years with a nonfatal firearm injury from 2010 to 2018 using the IBM Watson MarketScan Medicaid database. Logistic regression estimated the odds of MH service use in the 6 months after injury, adjusted for sociodemographic and clinical characteristics. Cox proportional hazard models, stratified by previous MH service use, evaluated variation in timing of the first outpatient MH visit by sociodemographic and clinical characteristics.

RESULTS

After a firearm injury, 958 of 2613 (36.7%) children used MH services within 6 months; of these, 378 of 958 (39.5%) had no previous MH service use. The adjusted odds of MH service use after injury were higher among children with previous MH service use (adjusted odds ratio, 10.41; 95% confidence interval [CI], 8.45-12.82) and among non-Hispanic white compared with non-Hispanic Black children (adjusted odds ratio, 1.29; 95% CI, 1.02-1.63). The first outpatient MH visit after injury occurred sooner among children with previous MH service use (adjusted hazard ratio, 6.32; 95% CI, 5.45-7.32). For children without previous MH service use, the first MH outpatient visit occurred sooner among children with an MH diagnosis made during the injury encounter (adjusted hazard ratio, 2.72; 95% CI, 2.04-3.65).

CONCLUSIONS

More than 3 in 5 children do not receive MH services after firearm injury. Previous engagement with MH services and new detection of MH diagnoses during firearm injury encounters may facilitate timelier connection to MH services after injury.

Effectiveness of Substance Use Navigation for Emergency Department Patients With Substance Use Disorders: An Implementation Study

STUDY OBJECTIVE

We implemented a whole person care-informed intervention delivered by substance use navigators (SUN) for emergency department (ED) patients with substance use disorders.

METHODS

This was an implementation study of adult patients discharged from 3 public hospital EDs between September 1, 2021 through January 31, 2022 with cocaine, methamphetamine, alcohol, and opioid use-related diagnoses. The primary effectiveness outcome was treatment engagement within 30 days of ED discharge among patients with and without the SUN intervention. We used logistic regression and nearest neighbor propensity score matching without replacement to control for confounding effects.

RESULTS

There were 1,328 patients in the cohort, and 119 (9.0%) received the SUN intervention; 50.4% of patients in the SUN intervention group and 15.9% of patients without the SUN intervention were engaged in outpatient treatment within 30 days of ED discharge (difference in proportions: 34.5%, 95% confidence interval [CI] 25.3% to 43.8%). In the unadjusted analysis, the SUN intervention was associated with higher rates of treatment engagement after ED discharge for patients with alcohol, opioid, and cocaine-related diagnoses; patients with methamphetamine-related diagnoses had low engagement rates with or without the SUN intervention. In addition, the SUN intervention was associated with higher odds of treatment engagement in the multivariable model (aOR 3.7, 95% CI 2.4 to 5.8) and in the propensity score-matched analysis (OR 2.1, 95% CI 1.2 to 3.5).

CONCLUSION

A whole person care-informed intervention delivered by SUNs for ED patients with substance use disorders was strongly associated with higher engagement rates in addiction treatment after discharge.

A mixed methods protocol to implement universal firearm injury risk screening and intervention among youth and adults in emergency departments across a large US health system

BACKGROUND

Firearm injury is a leading cause of preventable death in the USA. Healthcare providers are uniquely poised to focus on firearm safety and injury prevention from an apolitical harm reduction lens; however, few providers and healthcare settings incorporate firearm injury prevention strategies into usual care. We outline the first protocol to determine how to implement universal Firearm Injury and Mortality Prevention (FIMP) strategies that identify and address firearm access and violence risk in healthcare settings as part of routine care using the Consolidated Framework for Implementation Research (CFIR) to inform implementation and evaluation.

METHODS

The components of our FIMP strategy, including universal screening, intervention for patients at risk, and resources, will be developed from existing evidence-based strategies for firearm access and violence risk (intervention characteristics). The implementation process will include components of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for substance use, adapted to FIMP (implementation process). To engage stakeholders, harmonize language, and garner support, an Executive Advisory Board (EAB) will be formed, consisting of the site- and system-level stakeholders (inner setting) and community stakeholders, including influential figures such as local religious and spiritual leaders, individuals with lived experience, and community-based organizations (outer setting). Pre-implementation surveys will identify the characteristics of individuals and guide the development of education prior to implementation. Patient-level screening data will be analyzed to identify the risk factors, implementation will be evaluated using mixed methods, and a limited-efficacy study will evaluate whether strategies were successful in driving behavior change.

DISCUSSION

This study protocol has breakthrough and methodological innovations, by addressing FIMP as part of usual care to directly mitigate firearm injury risk among youth, adults, and household members (e.g., children) and by using rigorous methods to inform healthcare industry implementation of FIMP strategies. The expected outcomes of this study protocol will provide a solid basis for larger-scale dissemination and evaluation of implementation, effectiveness, and usability across broader pediatric and adult healthcare settings. This project will advance the implementation science and have a positive impact on the health of our patients and communities by preventing firearm injury and mortality and shifting the paradigm to view FIMP through a public health lens.

The Status of SBIRT Training in Health Professions Education: A Cross-Discipline Review and Evaluation of SBIRT Curricula and Educational Research

PURPOSE

To assess the quality of curricular research on the Screening Brief Intervention and Referral to Treatment (SBIRT) approach and determine the presence of useful training modalities, particularly motivational interviewing (MI) training, across health care training curricula.

METHOD

The authors conducted a systematic review of published, peer-reviewed studies in PubMed, ERIC, CINAHL, Ovid HealthSTAR, and PsycINFO databases through March 2021 for English-language studies describing SBIRT, a curriculum for health care trainees, and curricular intervention outcomes. After the records were independently assessed, data were extracted and 20% of the studies were double-coded for interrater reliability.

RESULTS

Of 1,856 studies, 95 were included in the review; 22 had overlapping samples and were consolidated into 10 nested studies, leaving 83 total. Interrater reliability ranged from moderate (κ = .74, P < .001) to strong (κ = .91, P < .001) agreement. SBIRT training was delivered to trainees across many professions, including nursing (n = 34, 41%), medical residency (n = 28, 34%), and social work (n = 24, 29%). Nearly every study described SBIRT training methods (n = 80, 96%), and most reported training in MI (n = 54, 65%). On average, studies reported 4.06 (SD = 1.64) different SBIRT training methods and 3.31 (SD = 1.59) MI training methods. Their mean design score was 1.92 (SD = 0.84) and mean measurement score was 1.89 (SD = 1.05). A minority of studies measured SBIRT/MI skill (n = 23, 28%), and 4 studies (5%) set a priori benchmarks for their curricula.

CONCLUSIONS

SBIRT training has been delivered to a wide range of health care trainees and often includes MI. Rigor scores for the studies were generally low due to limited research designs and infrequent use of objective skill measurement. Future work should include predefined training benchmarks and validated skills measurement.

Understanding low treatment seeking rates for alcohol use disorder: A narrative review of the literature and opportunities for improvement

Despite a well-documented global burden of disease attributable to alcohol use disorder (AUD), treatment seeking rates remain low. In this qualitative literature review, we address treatment seeking for AUD from a host of perspectives and summarize the literature on key factors. First, we summarize the rates of alcohol treatment seeking across various epidemiological surveys, spanning decades. Second, we discuss the definition of treatment seeking and 'what' is typically considered formal treatment. Third, we consider timing and discuss 'when' individuals are most likely to seek treatment. Fourth, we review the literature on 'who' is most likely to seek treatment, including demographic and clinical correlates. Fifth, we address the critical question of 'why' so few people receive clinical services for AUD, relative to the number of individuals affected by the disorder, and review barriers to treatment seeking at the treatment- and person-levels of analysis. Finally, we identify opportunities to improve treatment seeking rates by focusing on tangible points of intervention. Specifically, we recommend a host of adaptations to models of care including efforts to make treatment more appealing across stages of AUD severity, accept a range of health-enhancing drinking goals as opposed to an abstinence-only model, educate providers and consumers about evidence-based behavioral and pharmacological treatments, and incentivize the delivery of evidence-based services.

Mid and long-term effects of a SBIRT program for at-risk drinkers attending to an emergency department. Follow-up results from a randomized controlled trial

BACKGROUND AND IMPORTANCE

SBIRT programs (Screening Brief Intervention and Referral to Treatment) for at-risk drinkers in emergency departments (ED) have shown to be effective, particularly at short term. In this article, we report mid and long-term follow-up results of a specialized SBIRT program. A short-term follow-up after 1.5 months showed encouraging results, with more than a 20% greater reduction of at-risk drinking in the intervention group and more than double of successful referrals to specialized treatment.

OBJECTIVE

We aimed to evaluate the mid and long-term efficacy of an SBIRT program conducted by psychiatrist specialists in addictive disorders and motivational interviewing in the ED of a tertiary hospital.

DESIGN, SETTINGS AND PARTICIPANTS

We conducted a secondary analysis of a previously published randomized controlled trial of an SBIRT program conducted by alcohol specialists for at-risk drinkers presenting to the ED, measured with the AUDIT-C scale.

INTERVENTION OR EXPOSURE

Patients were randomized into two groups, with the control group receiving two leaflets: one regarding alcohol use and the other giving information about the study protocol. The intervention group received the same leaflets as well as a brief motivational intervention on alcohol use and, where appropriate, a referral to specialized treatment.

OUTCOMES MEASURE AND ANALYSIS

Long-term assessment primary outcome was the proportion of at-risk alcohol use measured by AUDIT-C scale. The main effectiveness analysis at 18 weeks and 12 months' follow-up was conducted with multilevel logistic regression analyses. Missing values were imputed with the last observation carried forward.

MAIN RESULTS

Of 200 patients included in the study, 133 (66.5%) and 131 (65.5%) completed 18 weeks and 1-year follow-up respectively. Although the proportion of risky drinkers was substantially lower in the intervention group (38.5 vs. 57.4% at 4.5 months and 58.5 vs 68.2% at 1 year), these results did not reach statistical significance (OR = 2.15; CI, 0.87-5.33).

CONCLUSIONS

In this secondary analysis for mid- and long-term effects of a specialized SBIRT program, there was no significant difference in the reduction of risky drinkers at 18 weeks and 1 year. The small size of the studied sample and the low retention rate precluded any significant conclusion, although point estimates suggest a positive effect. Overall, SBIRT programs are an effective tool to reduce alcohol use at short time and to refer patients to specialized treatment; however, its effects seem to decay over time.

Implementing adolescent SBIRT: Findings from the FaCES project

BACKGROUND

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based approach to early intervention of substance misuse. Methods: This mixed-methods evaluation assessed the implementation of an adolescent SBIRT change package across 13 primary care clinics. These clinics participated in an 18-month learning collaborative, during which they received training and technical assistance on SBIRT practices. Results: Six major themes emerged around the implementation of the change package: operational readiness of the sites, training of staff members, factors around the screening process, factors around intervention delivery, the referral process, and the adaptation and utilization of the electronic health record (EHR). Conclusions: Through the guidance of the change package and the associated training and technical assistance, the participating primary care clinics were able to implement SBIRT practices within their existing workflows. There was also an observed reduction in reported substance use among the at-risk adolescents served by these clinics.

Effectiveness of simulation in psychiatry for nursing students, nurses and nurse practitioners: A systematic review and meta-analysis

AIMS

Mental disorders constitute one of the main causes of disease and disability worldwide. While nurses are often at the frontline of mental health care, they have limited access to dedicated psychiatric training opportunities. Simulation training may foster the development of the appropriate competencies required when supporting people with mental disorders. To evaluate the effectiveness of simulation training in psychiatry for nursing students, nurses and nurse practitioners.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Eight electronic databases, trial registries, key journals and reference lists of selected studies were searched from inception to August 20, 2020 without language restriction.

REVIEW METHODS

We included randomized and non-randomized controlled studies and single group pre/post studies. Cochrane Risk of Bias tool 2.0 was used for randomized controlled study appraisal, and the Medical Education Research Study Quality instrument was completed for all other studies. Meta-analysis was restricted to randomized controlled studies. The other studies were synthesized narratively. The main outcomes were based on Kirkpatrick levels.

RESULTS

A total of 118 studies (6738 participants) were found. Interventions included simulated patients (n = 55), role-plays (n = 40), virtual reality (n = 12), manikins (n = 9) and voice simulations (n = 9). Meta-analyses based on 11 randomized controlled studies found a significant large effect size on skills at immediate post-test for simulation compared with active control; and a small and medium effect size on learners' attitudes for simulation compared with inactive control, at immediate post-test and at three-month follow-up respectively. Three quarters of non-randomized controlled studies and pre/post-tests assessing attitudes and skills showed significant differences, and three quarters of participants in randomized controlled studies and pre/post-tests showed significant differences in behaviours. Among the few studies assessing people with mental health outcomes, almost all reported significant differences.

CONCLUSION

These findings support the effectiveness of simulation training in psychiatric nursing throughout professional development grades, despite heterogeneity in methods and simulation interventions.

The effects of screening brief intervention referral to treatment (SBIRT) training on health professional trainees' regard, attitudes, and beliefs toward patients who use substances

BACKGROUND

Screening Brief Intervention Referral to Treatment (SBIRT) was developed as an integrated and comprehensive public health approach that includes early screening and intervention to address substance use in a variety of health care settings. Research suggests that SBIRT is effective in reducing substance use in individuals whose use places them at higher risk for negative health and social consequences. However, less is known about how training in SBIRT modifies attitudes, regard, and beliefs toward people who use substances. Methods: Participants included 461 students from a variety of healthcare related disciplines (physician assistant, nurse practitioner, pharmacy, psychiatry and psychology, and medical students). Participants were evaluated using a pre-post design to assess changes in regard, attitudes, and beliefs by completing the Short Alcohol and Alcohol Problems Perception Questionnaire, the Drug Problem Perception Questionnaire, the Medical Condition Regard Scale, and the Short Understanding of Substance Abuse Scale before and after a 7-hour SBIRT training program. We hypothesized that trainees would have more positive regard, attitudes, and beliefs toward people who use substances following training in SBIRT relative to a baseline assessment and that there would be between program differences. Results: Results were consistent with hypotheses and suggested that trainees had significantly more positive regard and changes in attitudes and beliefs toward working with patients who use substances following training in SBIRT. Results also suggested significant differences by training group at baseline and at 30-day follow up. Conclusions: Overall, the findings suggest that an important additional benefit of SBIRT is the impact it has on mitigating healthcare professional trainees' negative regard and modifying attitudes and beliefs toward those who use substances.

Strategies to promote the implementation of Screening, Brief Intervention, and Referral to Treatment (SBIRT) in healthcare settings: a scoping review

Background

Screening, brief intervention, and referral to treatment (SBIRT), is an approach for the prevention and treatment of substance use disorders, but is often underutilized in healthcare settings. Although the implementation of SBIRT is challenging, the use of multi-faceted and higher intensity strategies are more likely to result in the successful incorporation of SBIRT into practice in primary care settings. SBIRT may be used in different healthcare settings, and the context for implementation and types of strategies used to support implementation may vary by setting. The purpose of this scoping review is to provide an overview regarding the use of strategies to support implementation of SBIRT in all healthcare settings and describe the associated outcomes.

Methods

A scoping review was conducted using CINAHL Complete, HealthBusiness FullTEXT, PsycINFO, PubMed, and Embase to search for articles published in English prior to September 2019. The search returned 462 citations, with 18 articles included in the review. Two independent reviewers extracted data from each article regarding the theory, design, timeline, location, setting, patient population, substance type, provider, sample size and type, implementation strategies, and implementation outcomes. The reviewers entered all extracted data entered into a table and then summarized the results.

Results

Most of the studies were conducted in the United States in primary care or emergency department settings, and the majority of studies focused on SBIRT to address alcohol use in adults. The most commonly used strategies to support implementation included training and educating stakeholders or developing stakeholder interrelationships. In contrast, only a few studies engaged patients or consumers in the implementation process. Efforts to support implementation often resulted in an increase in screening, but the evidence regarding the brief intervention is less clear, and most studies did not assess the reach or adoption of the referral to treatment.

Discussion

In addition to summarizing the strategies used to increase reach and adoption of SBIRT in healthcare settings, this scoping review identified multiple gaps in the literature. Two major gaps include implementation of SBIRT in acute care settings and the application of implementation theories to inform healthcare efforts to enable use of SBIRT.

Brief alcohol interventions in U.S. medical settings: A systematic review of the implementation literature

This systematic review provides a synthesis of the literature on brief alcohol intervention (BAI) implementation in medical settings. We utilized the Proctor et al. (2011) taxonomy of eight implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability) to organize and describe the qualitative and quantitative literature regarding BAI implementation. An electronic search of the PubMed database identified 25 articles that met inclusion criteria. The study team independently assessed all articles for methodological quality, with the majority of studies rated as weak to moderate. Descriptive and narrative review of the included articles identified penetration and acceptability as the two most commonly reported implementation outcomes. Studies rarely reported other outcomes (e.g., fidelity, cost, sustainability, adoption). On average, studies utilized approximately six implementation strategies to facilitate implementation, with education (96%), quality management (64%), and planning (56%) strategies the most frequently reported. Promising evidence exists that patients and providers are accepting of BAI implementation efforts and implementation efforts are helpful in expanding the reach of BAIs. A theory-informed approach to selecting implementation strategies may enhance implementation success in future work. When reporting on implementation, all studies should provide detailed BAI descriptions and strategies to enhance replication efforts. We suggest study designs that balance practical outcomes with methodological rigor to maximize the quality of future studies and better inform implementation efforts.

Substance Use Disorder Detection Rates Among Providers of General Medical Inpatients

BACKGROUND

The prevalence of substance use disorders is higher among medical inpatients than in the general population, placing inpatient providers in a prime position to detect these patients and intervene.

OBJECTIVE

To assess provider detection rates of substance use disorders among medical inpatients and to identify patient characteristics associated with detection.

DESIGN

Data drawn from a cluster randomized controlled trial that tested the effectiveness of three distinct implementation strategies for providers to screen patients for substance use disorders and deliver a brief intervention (Clinical Trials.gov : NCT01825057).

PARTICIPANTS

A total of 1076 patients receiving care from 13 general medical inpatient units in a large teaching hospital participated in this study.

MAIN MEASURES

Data sources included patient self-reported questionnaires, a diagnostic interview for substance use disorders, and patient medical records. Provider detection was determined by diagnoses documented in medical records.

KEY RESULTS

Provider detection rates were highest for nicotine use disorder (72.2%) and lowest for cannabis use disorder (26.4%). Detection of alcohol use disorder was more likely among male compared to female patients (OR (95% CI) = 4.0 (1.9, 4.8)). When compared to White patients, alcohol (OR (95% CI) = 0.4 (0.2, 0.6)) and opioid (OR (95% CI) = 0.2 (0.1, 0.7)) use disorders were less likely to be detected among Black patients, while alcohol (OR (95% CI) = 0.3 (0.0, 2.0)) and cocaine (OR (95% CI) = 0.3 (0.1, 0.9)) use disorders were less likely to be detected among Hispanic patients. Providers were more likely to detect nicotine, alcohol, opioid, and other drug use disorders among patients with higher addiction severity (OR (95% CI) = 1.20 (1.08-1.34), 1.62 (1.48, 1.78), 1.46 (1.07, 1.98), 1.38 (1.00, 1.90), respectively).

CONCLUSIONS

Findings indicate patient characteristics, including gender, race, and addiction severity impact rates of provider detection. Instituting formal screening for all substances may increase provider detection and inform treatment decisions.

Systematic Review of Clinician-Reported Barriers to Provision of Brief Advice for Alcohol Intake in Hospital Inpatient and Emergency Settings

Hospital inpatient and emergency care settings provide frequent opportunities for clinicians to screen and provide brief interventions to patients who engage in the harmful use of alcohol. However, these services are not always provided, with several reasons given in different studies. We aimed to systematically review clinician-reported barriers in the provision of brief alcohol screening, brief advice, and intervention specific to hospital inpatient and emergency department (ED) settings. A systematic literature review was conducted in MEDLINE, PsycINFO, and CINAHL to identify the barriers perceived by healthcare workers in the provision of alcohol screening and brief intervention. These barriers were then categorized according to the capability, opportunity, and motivation (COM-B) model of behavior change theory. Twenty-five articles were included in this study, which involved questionnaires, surveys, interviews, and conference call discussions. The most commonly cited barriers (i.e., greater than half of the studies) were related to capability (lack of knowledge cited in 60% of studies); opportunity (lack of time and resources, 76 and 52% of studies, respectively); and motivation (personal discomfort in 60% of studies). Twenty-two other barriers were reported but with lower frequency. Clinicians cite a multitude of factors that impede their delivery of alcohol screening and brief interventions in the hospital inpatient and ED settings. These barriers were explored further under the framework of the COM-B model, which allows for intervention design. As such, changes can be made at the policy, managerial, and educational levels to address these barriers and help improve the self-efficacy and knowledge of clinicians who counsel patients on alcohol use.

Implementation of screening, brief intervention, and referral to treatment (SBIRT) by nurses on acute care units: A qualitative descriptive study

BACKGROUND

Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidence-based intervention for patients with substance use disorders, but this intervention is under-utilized. Little is known about the implementation of SBIRT in acute care facilities. The purpose of this study is to describe implementation of SBIRT by nurses in acute care hospitals. Methods: A qualitative descriptive design was used for this study. Registered nurses who agreed to participate in the study completed a 1:1 interview using a semi-structured interview guide. Interviews were audio recorded and transcribed and then data were analyzed using qualitative content analysis. Results: When implementing SBIRT in an acute care setting, participants identified several factors that affect implementation. Some nurses felt that it is "one more thing to do" but other nurses feel that it was a "good, simple" screening tool that does not take long to do and can "plant the seeds of change" for patients. Additionally, participants mentioned barriers and facilitators related to the patients' responses to SBIRT and organizational factors. Conclusions: This study identified several barriers and facilitators to SBIRT implementation related to the nurses, patients, and organization. By understanding the factors that influence implementation, healthcare providers can develop strategies to support effective implementation of SBIRT.

Implementation of strength-based case management for opioid-dependent patients presenting in medical emergency departments: rationale and study design of a randomized trial

BACKGROUND

As the USA grapples with an opioid epidemic, medical emergency departments (EDs) have become a critical setting for intervening with opioid-dependent patients. Brief interventions designed to bridge the gap from acute ED care to longer-term treatment have shown limited efficacy for this population. Strength-based case management (SBCM) has shown strong effects on treatment linkage among patients with substance use disorders in other healthcare settings. This study aimed to investigate whether SBCM is an effective model for linking opioid-dependent ED patients with addiction treatment and pharmacotherapy. Here, we describe the implementation and challenges of adapting SBCM for the ED (SBCM-ED). Study rationale, design, and baseline characteristics are also described.

METHODS

This study compared the effects of SBCM-ED to screening, assessment, and referral alone (SAR) on treatment linkage, substance use, and functioning. We recruited participants from a public hospital in NYC. Working alliance between case managers and participants and the feasibility of SBCM implementation were evaluated. Baseline data from the randomized sample were analyzed for group equivalency. Outcomes analyses are forthcoming.

RESULTS

Three hundred adult participants meeting DSM-IV criteria for opioid dependence were randomly assigned to either SBCM, in which they received a maximum of six case management sessions within 90 days of enrollment, or SAR, in which they received a comprehensive referral list and pamphlet outlining drug use consequences. No significant differences were found between groups at baseline on demographic or substance use characteristics. All SAR participants and 92.6% of SBCM-ED participants initiated their assigned intervention. Over half of SBCM-ED first sessions occurred in the ED on the day of enrollment. Case managers developed a strong working alliance with SBCM-ED participants after just one session.

CONCLUSION

Interventions that exceed SBIRT were accepted by an opioid-dependent patient population seen in an urban medical ED. At the time of study funding, this trial was one of the first to focus specifically on this population in this challenging setting. The successful implementation of SBCM demonstrates its adaptability to the ED and may serve as a potential model for EDs seeking to adopt an intervention that overcomes the barrier between the ED encounter and more intensive treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02586896 . Registered on 27 October 2015.

Simulation in psychiatry for medical doctors: A systematic review and meta-analysis

CONTEXT

Most medical doctors are likely to work with patients experiencing mental health conditions. However, educational opportunities for medical doctors to achieve professional development in the field of psychiatry are often limited. Simulation training in psychiatry may be a useful tool to foster this development.

OBJECTIVES

The purpose of this study was to assess the effectiveness of simulation training in psychiatry for medical students, postgraduate trainees and medical doctors.

METHODS

For this systematic review and meta-analysis, we searched eight electronic databases and trial registries up to 31 August 2018. We manually searched key journals and the reference lists of selected studies. We included randomised and non-randomised controlled studies and single group pre- and post-test studies. Our main outcomes were based on Kirkpatrick levels. We included data only from randomised controlled trials (RCTs) using random-effects models.

RESULTS

From 46 571 studies identified, we selected 163 studies and combined 27 RCTs. Interventions included simulation by role-play (n = 69), simulated patients (n = 72), virtual reality (n = 22), manikin (n = 5) and voice simulation (n = 2). Meta-analysis found significant differences at immediate post-tests for simulation compared with active and inactive control groups for attitudes (standardised mean difference [SMD] = 0.52, 95% confidence interval [CI] 0.31-0.73 [I²  = 0.0%] and SMD = 0.28, 95% CI 0.04-0.53 [I²  = 52.0%], respectively), skills (SMD = 1.37, 95% CI 0.56-2.18 [I²  = 93.0%] and SMD = 1.49, 95% CI 0.39-2.58 [I²  = 93.0%], respectively), knowledge (SMD = 1.22, 95% CI 0.57-1.88 [I²  = 0.0%] and SMD = 0.72, 95% CI 0.14-1.30 [I²  = 80.0%], respectively), and behaviours (SMD = 1.07, 95% CI 0.49-1.65 [I²  = 68.0%] and SMD = 0.45, 95% CI 0.11-0.79 [I²  = 41.0%], respectively). Significant differences in terms of patient benefit and doctors' behaviours and skills were found at the 3-month follow-up.

CONCLUSIONS

Despite heterogeneity in methods and simulation interventions, our findings demonstrate the effectiveness of simulation training in psychiatry training.

Feasibility and Acceptability of a Text Message-Based Intervention to Reduce Overuse of Alcohol in Emergency Department Patients: Controlled Proof-of-Concept Trial

Background

Emergency department (ED) patients have high rates of risky alcohol use, and an ED visit offers an opportunity to intervene. ED-based screening, brief intervention, and referral to treatment (SBIRT) reduces alcohol use and health care costs. Mobile health (mHealth) interventions may expand the impact of SBIRTs but are understudied in low-resource ED populations.

Objective

The objective of this study was to assess the feasibility of and patient satisfaction with a text-based mHealth extension of an ED screening program to reduce risky alcohol use in low-income, urban patients.

Methods

Research assistants screened a convenience sample of ED patients in person for risky alcohol use via the Alcohol Use Disorders Identification Test (AUDIT). Patients who reported AUDIT scores ≥8 and <20 were informed of their AUDIT score and risk. RAs invited patients with SMS text message–capable phones to receive mROAD (mobilizing to Reduce Overuse of Alcohol in the ED), an SMS text message–based extension of the ED screening program. mROAD is a 7-day program of twice-daily SMS text messages based on the National Institutes of Health’s Rethinking Drinking campaign. Participants were allocated to a control group (daily sham text messages without specific guidance on behaviors, such as “Thanks for taking part!”) or to the mROAD intervention group. Patients were interviewed at 30 days to assess acceptability, satisfaction, and changes in drinking behavior. Satisfaction was examined descriptively. Pre and post measurements of drinking behaviors and motivation were compared, as were differences in change scores between the intervention arms.

Results

Of 1028 patients screened, 95 (9.2%) exhibited risky alcohol use based on AUDIT, and 23/95 (24%) of those patients did not own an SMS text messaging–capable phone; this left 72/95 (76%) eligible patients. Among eligible participants, 48/72 (67%) agreed to enroll; 31/48 (65%) achieved follow-up (18/24 (75%) in the intervention group and 13/24 (55%) in the control group). Participants who completed follow-up reported high satisfaction. Changes in behavior were similar between the arms. Overall, the number of drinking days reported in the prior 30 days decreased by 5.0 (95% CI 1.7-8.3; P=.004), and the number of heavy drinking days decreased by 4.1 (95% CI 1.0 to 7.15, P=.01). Patients reported an 11-point increase (95% CI 2.6-20, P=.01, 10% overall increase) in motivation to change alcohol use via the Change Questionnaire. The were no statistical differences in drinking days, heavy drinking days, or motivation to change between the arms.

Conclusions

The mROAD trial was feasible. Over three-quarters of ED patients with risky alcohol use owned a text message–capable phone, and two-thirds of these patients were willing to participate; only 1 patient opted out of the intervention. Although 35% of patients were lost to follow-up at 30 days, those patients who did follow up had favorable impressions of the program; more than 90% reported that SMS text messages were a “good way to teach,” and 89% of intervention arm participants enjoyed the program and found that the messages were motivating. Both the mROAD and sham message groups showed promising changes in alcohol use and motivation to change. mROAD is a feasible intervention that may reduce rates of risky alcohol use in ED patients.

Trial Registration

ClinicalTrials.gov NCT02158949; https://clinicaltrials.gov/ct2/show/NCT02158949

Feasibility of a Brief Intervention to Facilitate Advance Care Planning Conversations for Patients with Life-Limiting Illness in the Emergency Department

Background: Advance care planning (ACP) conversations are an important intervention to provide care consistent with patient goals near the end of life. The emergency department (ED) could serve as an important time and location for these conversations. Objectives: To determine the feasibility of an ED-based, brief negotiated interview (BNI) to stimulate ACP conversations among seriously ill older adults. Methods: We conducted a pre/postintervention study in the ED of an urban, tertiary care, academic medical center. From November 2017 to May 2019, we prospectively enrolled adults ≥65 years of age with serious illness. Trained clinicians conducted the intervention. We measured patients' ACP engagement at baseline and follow-up (3 ± 1 weeks) and reviewed electronic medical record documentation of ACP (e.g., medical order for life-sustaining treatment [MOLST]). Results: We enrolled 51 patients (mean age = 71; SD 12), 41% were female, and 51% of patients had metastatic cancer. Median duration of the intervention was 11.8 minutes; few (6%) of the interventions were interrupted. We completed follow-up for 61% of participants. Patients' self-reported ACP engagement increased from 3.0 to 3.7 out of 5 after the intervention (p < 0.01). Electronic documentation of health care proxy forms increased (75%-94%, n = 48) as did MOLST (0%-19%, n = 48) during the six months after the ED visit. Conclusion: A novel, ED-based, BNI intervention to stimulate ACP conversations for seriously ill older adults is feasible and may improve ACP engagement and documentation.

Behavioral Health and Response for COVID-19

Research from financial stress, disasters, pandemics, and other extreme events, suggests that behavioral health will suffer, including anxiety, depression, and posttraumatic stress symptoms. Furthermore, these symptoms are likely to exacerbate alcohol or drug use, especially for those vulnerable to relapse. The nature of coronavirus disease 2019 (COVID-19) and vast reach of the virus, leave many unknows for the repercussions on behavioral health, yet existing research suggests that behavioral health concerns should take a primary role in response to the pandemic. We propose a 4-step services system designed for implementation with a variety of different groups and reserves limited clinical services for the most extreme reactions. While we can expect symptoms to remit overtime, many will also have longer-term or more severe concerns. Behavioral health interventions will likely need to change overtime and different types of interventions should be considered for different target groups, such as for those who recover from COVID-19, health-care professionals, and essential personnel; and the general public either due to loss of loved ones or significant life disruption. The important thing is to have a systematic plan to support behavioral health and to engage citizens in prevention and doing their part in recovery by staying home and protecting others.

Routine alcohol screening in the ED: unscreened patients have an increased risk for hazardous alcohol use

BACKGROUND

Routine screening programmes for hazardous alcohol use in the ED miss large numbers of patients. We investigated whether patient-related or staff-related factors cause screening failures and whether unscreened patients are at increased risk of hazardous alcohol use.

METHODS

This is a secondary analysis of a prospective study. From November 2012 to November 2013, all adult patients visiting a Dutch inner city ED were screened for hazardous alcohol consumption using the Alcohol Use Disorders Identification Test-Consumption. Reasons for failure of screening were categorised as: (A) patient is unable to cooperate (due to illness or pain, decreased consciousness or incomprehension due to intoxication, psychiatric, cognitive or neurological disorder or language barrier), (B) healthcare professional forgot to ask, (C) patient refuses cooperation and (D) screening was recently performed (<6 months ago). Presence of risk factors for hazardous alcohol use was compared between screened and unscreened patients.

RESULTS

Of the 28 019 ED patients, 18 310 (65%) were screened and 9709 (35%) were not. In 7150 patients staff forgot to screen, whereas 2559 patients were not screened due to patient factors (2340 being unable and 219 unwilling). Patients with any of these risk factors were less likely to be screened: male sex, alcohol-related visit, any intoxication, head injury, any kind of wound and major trauma. In multivariate analysis, all these risk factors were independently associated with not being screened. Patients with at least one risk factor for hazardous alcohol use were less likely to be screened. Highest prevalence of risk factors was found in patients unable or unwilling to cooperate.

CONCLUSION

Patients who do not undergo routine screening for alcohol use at triage in the ED have an increased risk for hazardous alcohol use. These data highlight the importance of screening patients, especially those initially unwilling or unable to cooperate, at a later stage.

Outcomes of a novel office-based opioid treatment program in an internal medicine resident continuity practice

BACKGROUND

The integration of opioid use disorder (OUD) care and competencies in graduate medical education training is needed. Previous research shows improvements in knowledge, attitudes, and practices after exposure to OUD care. Few studies report outcomes for patients with OUD in resident physician continuity practices.

METHODS

A novel internal office-based opioid treatment (OBOT) program was initiated in a resident continuity clinic. Surveys of resident and staff knowledge and attitudes of OBOT were administered at baseline and 4 months. A retrospective chart review of the 15-month OBOT clinic obtained patient characteristics and outcomes.

RESULTS

Twelve patients with OUD were seen in the OBOT clinic. Seven patients (58%) were retained in care at the end of the study period for a range of 9-15 months. Eight patients demonstrated a good clinical response. Surveys of residents and staff at 4 months were unchanged from baseline showing persistent lack of comfort in caring for patients with OUD.

CONCLUSIONS

OBOT can be successfully integrated into resident continuity practices with positive patient outcomes. Improvement in resident and staff attitudes toward OBOT were not observed and likely require direct and frequent exposure to OUD care to increase acceptance.

Alcohol Use Disorders in Adolescents

Alcohol use during adolescence is an important and modifiable health risk behavior given the significant acute consequences and long-term impacts on the developing brain. Alcohol is the most common substance used by young adults 12 to 17 years old, with binge drinking, polysubstance use, and co-occurring mental health disorders posing particular concerns in this age group. Physicians can play a crucial role in screening and responding to alcohol use, with targeted brief interventions designed to delay or decrease use.

Implementation of a screening, brief intervention and referral to treatment programme for risky substance use in South African emergency centres: A mixed methods evaluation study

BACKGROUND

Screening, brief intervention, and referral to treatment (SBIRT) for risky substance use is infrequently included in routine healthcare in low-resourced settings. A SBIRT programme, adopted by the Western Cape provincial government within an alcohol harm reduction strategy, employed various implementation strategies executed by a diverse team to translate an evidence-based intervention into services at three demonstration sites before broader programme scale-up. This paper evaluates the implementation of this programme delivered by facility-based counsellors in South African emergency centres.

METHOD

Guided by the Consolidated Framework for Implementation Research, this mixed methods study evaluated the feasibility, acceptability, appropriateness and adoption of this task-shared SBIRT programme. Quantitative data were extracted from routinely collected health information. Qualitative interviews were conducted with 40 stakeholders in the programme's second year.

RESULTS

In the first year, 13 136 patients were screened and 4 847 (37%) patients met criteria for risky substance use. Of these patients, 83% received the intervention, indicating programme feasibility. The programme was adopted into routine services and found to be acceptable and appropriate, particularly by stakeholders familiar with the emergency environment. These stakeholders highlighted the burden of substance-related harm in emergency centres and favourable patient responses to SBIRT. However, some stakeholders expressed scepticism of the behaviour change approach and programme compatibility with emergency centre operations. Furthermore, adoption was both facilitated and hampered by a top-down directive from provincial leadership to implement SBIRT, while rapid implementation limited effective engagement with a diverse stakeholder group.

CONCLUSION

This is one of the first studies to address SBIRT implementation in low-resourced settings. The results show that SBIRT implementation and adoption was largely successful, and provide valuable insights that should be considered prior to implementation scale-up. Recommendations include ensuring ongoing monitoring and evaluation, and early stakeholder engagement to improve implementation readiness and programme compatibility in the emergency setting.

A Web-Based Alcohol Screening and Brief Intervention Training Module Within Physician Assistant Programs in the Midwest to Increase Knowledge, Attitudes, and Confidence: Evaluation Study

BACKGROUND

Preventing and reducing risky alcohol use and its side effects remains a public health priority. Discussing alcohol use with patients can be difficult; dedicated training for health care providers is needed to facilitate these conversations. A Web-based alcohol screening and brief intervention (SBI), comprising didactic and skills application training, was designed for physician assistant students.

OBJECTIVE

This paper details experiences and outcomes in developing an alcohol SBI training curriculum and coordinating virtual encounters with standardized patients. We also explain challenges faced with developing an alcohol SBI training and a Web-based learning management site to fit the needs of 5 different physician assistant programs.

METHODS

Training development comprised 3 phases-precourse, development, and implementation. The precourse phase included developing the initial training curriculum, building a website, and testing with a pilot group. The development phase refined the training curriculum based on user feedback and moved into a three-component module: didactic training module, guided interactive encounter with a simulated patient, and live encounter with a standardized patient. A learning management system website was also created. In the implementation phase, 5 physician assistant schools incorporated the Web-based training into curricula. Each school modified the implementation method to suit their organizational environment. Evaluation methods included pre- and postchange over time on trainee attitudes, knowledge, and skills (confidence) on talking to patients about alcohol use, trainee self-reported proficiency on the standardized patient encounter, standardized patient evaluation of the trainee proficiency during the alcohol use conversation, user evaluation of the type of technology mode for the standardized patient conversation, and overall trainee satisfaction with the Web-based training on alcohol SBI.

RESULTS

Final evaluation outcomes indicated a significant (P<.01) change over time in trainee knowledge and skills (confidence) in the conduct of the alcohol SBI with a standardized patient, regardless of the program implementation method. Trainees were generally satisfied with the Web-based training experience and rated the use of the videoconference medium as most useful when conducting the alcohol SBI conversation with the standardized patient. Training that included a primer on the importance of screening, individual participation in the Web-based didactic alcohol SBI modules, and virtual encounters with standardized patients through a university-based simulation center was the most widely accepted. Successful implementation included program investment and curriculum planning. Implementation barriers involved technical challenges with standardized patient encounters and simulation center logistics, and varying physician assistant school characteristics.

CONCLUSIONS

Development and implementation of Web-based educational modules to educate health care professionals on alcohol SBI is effective, easy to reproduce, and readily accessible. Identifying challenges affecting development, implementation, and utilization of learned techniques in practice, enhances facilitation of learning and training efficacy. As the value of technology-based learning becomes more apparent, reports detailing what has worked versus what has not may help guide the process.

Intervention for alcohol use disorders at an HIV care clinic in Harare: a pilot and feasibility study

BACKGROUND

Alcohol use in HIV infected patients is associated with risky sexual behaviour, poor adherence to Highly Active Antiretroviral Therapy, treatment failure and increased physiologic harm. The objectives of the study were to pilot the outcome assessments to be used in the trial proper, assess the feasibility of delivery of a brief MI/CBT intervention compared to an WHO mhGAP intervention for problematic alcohol use in PLWH in Zimbabwe, and pilot the effectiveness (on alcohol use, functionality and CD4 count) of these interventions at 3 months in a randomised controlled trial design.

METHODS

An intervention for HIV infected patients with problematic alcohol use, developed through adaptation of existing evidence based psychological treatments, was assessed for its feasibility at a tertiary HIV care clinic in Zimbabwe. Registered general nurses, using a manualised protocol, delivered the intervention. Forty patients were recruited and randomised to receive either an MI/CBT intervention or the WHO mhGAP Intervention Guide for AUDs (n = 20 patients per group).

RESULTS

Out of 40 participants enrolled, 31 were successfully followed up for 3 months with a loss to follow-up rate of 23%. There was a statistically significant decrease in AUDIT score over time in both groups (p < 0.001), however no statistically significant group difference with a mean difference of 0.80, standard error of 2.07 and p = 0.70. For the CD4 count, the median and interquartile ranges at baseline for MI/CBT and WHO mhGAP IG groups were 218 (274) and 484 (211.50), respectively. At follow-up, median and interquartile ranges for the CD4 count for MI/CBT and WHO mhGAP IG groups were 390 (280) and 567 (378), respectively, indicative of improvement in immunological parameters in both arms.

CONCLUSION

The findings from this pilot study suggests that a brief MI/CBT delivered by Registered General Nurses for problematic alcohol use is feasible in this population but will require the implementation of additional measures to improve retention. However, mechanisms to improve retention need special attention. Trial registration Pan African Clinical Trial Registry, current PACTR201509001211149.

Elucidating the Effect of a Brief Drinking Intervention Using Neuroimaging: A Preliminary Study

BACKGROUND

Brief interventions have empirical support for acutely reducing alcohol use among non-treatment-seeking heavy drinkers. Neuroimaging techniques allow for the examination of the neurobiological effect of behavioral interventions, probing brain systems putatively involved in clinical response to treatment. Few studies have prospectively evaluated whether psychosocial interventions attenuate neural cue reactivity that in turn reduces drinking in the same population. This study aimed to examine the effect of a brief intervention on drinking outcomes, neural alcohol cue reactivity, and the ability of neural alcohol cue reactivity to prospectively predict drinking outcomes.

METHODS

Non-treatment-seeking heavy drinking participants were randomized to receive a brief interview intervention (n = 22) or an attention-matched control (n = 24). Immediately following the intervention or control, participants underwent a functional magnetic resonance imaging scan comprised of the alcohol taste cues paradigm. Four weeks after the intervention (or control), participants completed a follow-up visit to report on their past-month drinking. Baseline and follow-up percent heavy drinking days (PHDD) were calculated for each participant.

RESULTS

There was no significant effect of the brief intervention on PHDD at follow-up or on modulating neural activation to alcohol relative to water taste cues. There was a significant association between neural response to alcohol taste cues and PHDD across groups (Z > 2.3, p < 0.05), such that individuals who had greater neural reactivity to alcohol taste cues in the precuneus and prefrontal cortex (PFC) had fewer PHDD at follow-up.

CONCLUSIONS

This study did not find an effect of the brief intervention on alcohol use in this sample, and the intervention was not associated with differential neural alcohol cue reactivity. Nevertheless, greater activation of the precuneus and PFC during alcohol cue exposure predicted less alcohol use prospectively suggesting that these neural substrates subserve the effects of alcohol cues on drinking behavior.

Fidelity and Feasibility of a Brief Emergency Department Intervention to Empower Adults With Serious Illness to Initiate Advance Care Planning Conversations

CONTEXT

Emergency department (ED) visits provide opportunities to empower patients to discuss advance care planning with their outpatient clinicians, but systematically developed, feasible interventions do not currently exist. Brief negotiated interview (BNI) interventions, which allow ED clinicians to efficiently motivate patients, have potential to meet this need.

OBJECTIVES

We developed a BNI ED intervention to empower older adults with life-limiting illness to formulate and communicate medical care goals to their primary outpatient clinicians. This study assessed the fidelity and feasibility of this intervention in a high-volume ED.

METHODS

We enrolled adult patients with serious illnesses (advanced cancer, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease on dialysis, predicted survival <12 months) in an urban, tertiary care academic medical center ED. All participants received the BNI intervention. We video-recorded the encounters. Two reviewers assessed the recordings for intervention fidelity based on adherence to the BNI steps (Part I) and communication skills (Part II).

RESULTS

We reviewed 46 video recordings. The mean total adherence score was 21.07/27 (SD 3.68) or 78.04%. The Part I mean adherence score was 12.07/15 (SD 2.07) or 80.47%. The Part II mean adherence score was 9.0/12 (SD 2.51) or 75%. The majority (75.6%) of recordings met the prespecified threshold for high intervention fidelity.

CONCLUSION

ED clinicians can deliver a BNI intervention to increase advance care planning conversations with high fidelity. Future research is needed to study the intervention's efficacy in a wider patient population.

Preparing Mexican-Origin Community Health Advocates (Promotores) to Conduct SBIRT for Problem Drinking in the Emergency Room

Community Health Advocates (CHAs), known as Promotores in Spanish-speaking communities, are an important resource for the mobilization, empowerment, and the delivery of health education messages in Hispanic/Latino communities. This article focuses on understanding cultural, didactic, and logistical aspects of preparing CHAs to become competent to perform a brief intervention and referral to treatment (SBIRT) in the emergency room (ER). The CHAs training emphasizes making connections with Mexican-origin young adults aged 18-30, and capitalizing on a teachable moment to effect change in alcohol consumption and negative outcomes associated with alcohol use. We outline a CHA recruitment, content/methods training, and the analysis of advantages and challenges presented by the delivery of an intervention by CHAs.

Empower Seriously Ill Older Adults to Formulate Their Goals for Medical Care in the Emergency Department

BACKGROUND

Most seriously ill older adults visit the emergency department (ED) near the end of life, yet no feasible method exists to empower them to formulate their care goals in this setting.

OBJECTIVE

To develop an intervention to empower seriously ill older adults to formulate their future care goals in the ED.

DESIGN

Prospective intervention development study.

SETTING

In a single, urban, academic ED, we refined the prototype intervention with ED clinicians and patient advisors. We tested the intervention for its acceptability in English-speaking patients ≥65 years old with serious illness or patients whose treating ED clinician answered "No" to the "surprise question" ("would not be surprised if died in the next 12 months"). We excluded patients with advance directives or whose treating ED clinician determined the patient to be inappropriate.

MEASUREMENTS

Our primary outcome was perceived acceptability of our intervention. Secondary outcomes included perceived main intent and stated attitude toward future care planning.

RESULTS

We refined the intervention with 16 mock clinical encounters of ED clinicians and patient advisors. Then, we administered the refined intervention to 23 patients and conducted semistructured interviews afterward. Mean age of patients was 76 years, 65% were women, and 43% of patients had metastatic cancer. Most participants (n = 17) positively assessed our intervention, identified questions for their doctors, and reflected on how they feel about their future care.

CONCLUSION

An intervention to empower seriously ill older adults to understand the importance of future care planning in the ED was developed, and they found it acceptable.

Evaluation of a Pediatric Resident Skills-Based Screening, Brief Intervention and Referral to Treatment (SBIRT) Curriculum for Substance Use

PURPOSE

To evaluate a screening, brief intervention and referral to treatment curriculum for alcohol and other substance use developed, implemented and integrated into a pediatric residency program.

METHODS

During a 1-month adolescent medicine rotation, pediatric, and medicine/pediatric residents in an urban teaching hospital completed a 2 1/2-hour formal curriculum including a didactic lecture, a 40-minute video describing the Brief Negotiation Interview (BNI), and a skill-based session practicing the BNI and receiving individualized feedback. Access to a website with didactic material was provided. Outcome measures were pre- and post-training knowledge, BNI performance measured with a standardized patient using a validated BNI adherence scale, satisfaction with training, and adoption of BNI into clinical practice.

RESULTS

Of the 106 residents trained, 92(87%) completed both pre- and post-test evaluations. Significant improvements were found in pre- versus post-test scores of knowledge, (20.0 [2.4 SD] vs. 24.1 [3.5 SD], p <.001) and BNI performance comparing pre- and post BNI adherence scale total scores, (5.14 [1.8 S.D.] vs. 11.5 [.96], p<.001). Residents reported high satisfaction with training, [1.4, SD .5, immediately and 1.6, SD .6, 30-days post training)with scores ranging from 1 to 5 with lower score=greater satisfaction. During the 12-month follow-up period, we received 83 responses from residents reporting a total of 129 BNIs in actual clinical settings.

CONCLUSIONS

A screening, brief intervention and referral to treatment curriculum was successfully integrated into an adolescent medicine elective in a pediatric residency program. Residents demonstrated significant improvements in knowledge and skills performing the BNI, with high satisfaction and adoption of the BNI into clinical practice.

Emergency department screening and interventions for substance use disorders

The emergency department (ED) has long been recognized as providing critical access to the health care system for many, yet only in the past few decades has the ED visit been recognized as an opportunity to identify and link patients to care for substance use disorders (SUDs). This review explores the evidence for ED-based screening, psychosocial and pharmacological interventions, and linkage to treatment for the spectrum of SUDs including high risk alcohol use and alcohol, opioid, tobacco and other SUDs. Despite knowledge gaps, methodological challenges and some inconsistency across interventions studied, opportunities for EDs to improve the care of patients across the spectrum of SUDs are robust.

Screening, brief intervention, and referral to treatment for adolescent alcohol use in Canadian pediatric emergency departments: a national survey of pediatric emergency physicians

BACKGROUND

Problematic alcohol use is associated with detrimental cognitive, physiological and social consequences. In the emergency department (ED), Screening, Brief Intervention, and Referral to Treatment (SBIRT) is the recommended approach to identify and treat adolescent alcohol-related concerns, but is underused by physicians.

OBJECTIVE

This study examined pediatric emergency physicians’ perceptions of adolescent drinking and treatment, and their current self-reported SBIRT practices.

METHOD

Physicians in the Pediatric Emergency Research Canada database (n=245) received a 35-item questionnaire that was administered through a web-based platform and paper-based mail-outs. Recruitment followed a modified Dillman four-contact approach.

RESULTS

From October 2016 to January 2017, 166 pediatric emergency physicians (46.4% males; mean age=43.6 years) completed the questionnaire. The response rate was 67.8%. Physicians recognized the need (65%) and responsibility (86%) to address adolescent alcohol problems. However, confidence in knowledge and abilities for SBIRT execution was low. Twenty-five percent of physicians reported never having practiced all, or part of, SBIRT while 1.3% reported consistent SBIRT delivery for adolescents with alcohol-related visits. More alcohol education and counselling experience was associated with higher SBIRT use; however, physicians generally reported to have received minimal alcohol training. SBIRT practices were also associated with physician perceptions of problematic alcohol use and its treatability.

CONCLUSIONS

Pediatric emergency physicians acknowledge the need to address problematic adolescent alcohol use, but routine SBIRT use is lacking. Strategies to educate physicians about SBIRT and enhance perceived self-competency may improve SBIRT use. Effectiveness trials to establish SBIRT impact on patient outcomes are also needed.

Effectiveness of a Specialized Brief Intervention for At-risk Drinkers in an Emergency Department: Short-term Results of a Randomized Controlled Trial

BACKGROUND

Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs have been developed, evaluated, and shown to be effective, particularly in primary care and general practice. Nevertheless, effectiveness of SBIRT in emergency departments (EDs) has not been clearly established.

OBJECTIVE

We aimed to evaluate the feasibility and efficacy of an SBIRT program conducted by highly specialized professionals in the ED of a tertiary hospital.

METHODS

We conducted a randomized controlled trial to study the feasibility and efficacy of an SBIRT program conducted by alcohol specialists for at-risk drinkers presenting to the ED, measured with the three-item version of the Alcohol Use Disorder Identification Test (AUDIT-C). Patients were randomized to two groups, with the control group receiving two leaflets-one regarding alcohol use and the other giving information about the study protocol. The intervention group received the same leaflets as well as a brief motivational intervention on alcohol use and, where appropriate, a referral to specialized treatment. The primary outcomes were the proportion of at-risk alcohol use measured by AUDIT-C scale and the proportion of patients attending specialized treatment at 1.5 months.

RESULTS

Of 3,027 patients presenting to the ED, 2,044 (67%) were potentially eligible to participate, 247 (12%) screened positive for at-risk drinking, and 200 agreed to participate. Seventy-two percent of the participating sample were men, and the mean (±SD) age was 43 (±16.7) years. Follow-up rates were 76.5%. At 1.5 months, the intervention group showed greater reductions in alcohol consumption and fewer patients continuing with at-risk alcohol use (27.8% vs. 48.1%; p = 0.01). The SBIRT program also increased the probability of attending specialized treatment, compared to the control condition (23% vs. 9.8%, p = 0.0119) CONCLUSION: The SBIRT program in the ED was found to be feasible and effective in identifying at-risk drinkers, reducing at-risk alcohol use, and increasing treatment for alcohol problems.

Attitudes, practices, and preparedness to care for patients with substance use disorder: Results from a survey of general internists

BACKGROUND

Previous research demonstrates that most primary care physicians feel unprepared to diagnose and treat substance use disorder (SUD). Confidence in SUD management has been associated with improved clinical practices.

METHODS

A cross-sectional survey of 290 inpatient and outpatient general internists in an academic medical center evaluating attitudes, preparedness, and clinical practice related to SUD.

RESULTS

149 general internists responded, a response rate of 51%. Forty-six percent frequently cared for patients with SUD. Sixteen percent frequently referred patients to treatment and 6% frequently prescribed a medication to treat SUD. Twenty percent felt very prepared to screen for SUD, 9% to provide a brief intervention, 7% to discuss behavioral treatments, and 9% to discuss medication treatments. Thirty-one percent felt that SUD is different from other chronic diseases because they believe using substances is a choice. Fourteen percent felt treatment with opioid agonists was replacing one addiction with another. Twelve percent of hospitalists and 6% of PCPs believe that someone who uses drugs is committing a crime and deserves punishment. Preparedness was significantly associated with evidence-based clinical practice and favorable attitudes. Frequently caring for patients with SUD was significantly associated with preparedness, clinical practice, and favorable attitudes.

CONCLUSIONS

SUD is a treatable and prevalent disease, yet a majority of general internists do not feel very prepared to screen, diagnose, provide a brief intervention, refer to treatment, or discuss treatment options with patients. Very few frequently prescribe medications to treat SUD. Some physicians view substance use as a crime and a choice. Physician preparedness and exposure to SUD is associated with improved clinical practice and favorable attitudes towards SUD. Physicians need education and support to provide better care for patients with SUD.

A feasible model for early intervention for high-risk substance use in the emergency department setting

Objective In response to escalating alcohol and other drug (AOD)-related emergency department (ED) presentations, a tertiary Melbourne hospital embedded experienced AOD clinical nurse consultants in the ED on weekends to trial a model for screening, assessment and brief intervention (BI). The aim of the present study was to evaluate the relative contributions of AOD to ED presentations and to pilot a BI model. Methods Using a customised AOD screening tool and a framework for proactive case finding, screened participants were offered a comprehensive AOD assessment and BI in the ED. Immediate effects of the intervention were evaluated via the engagement of eligible individuals and a self-administered 'intention to change' survey. Results Over the 32-month pilot, 1100 patients completed a comprehensive AOD assessment, and 95% of these patients received a BI. The most commonly misused substances were, in order, alcohol, tobacco, amphetamine-type stimulants, gamma-hydroxybutyrate and cannabis. Thirty-two per cent of patients were found to be at risk of dependence from alcohol and 25% were found to be at risk of dependence from other substances. Forty per cent of the people assessed reported no previous AOD support or intervention. On leaving the ED, 78% of participants reported an intention to contact community support services and 65% stated they would change the way they used AOD in the future. Conclusion This study of a pilot program quantifies the relative contribution of AOD to ED presentations and demonstrates that hospital EDs can implement a feasible, proactive BI model with high participation rates for people presenting with AOD-related health consequences. What is known about the topic? Clinician-led BI for high-risk consumption of alcohol has been demonstrated to be effective in primary care and ED settings. However, hospital EDs are increasingly receiving people with high-risk AOD-related harms. The relative contribution of other drugs in relation to ED presentations has not been widely documented. In addition, the optimal model and effects of AOD screening and BI programs in the Australian ED setting are unknown. What does this paper add? This paper describes a 'real-life' pilot project embedding AOD-specific staff in a metropolitan Melbourne ED at peak times to screen and provide BI to patients presenting with AOD-related risk and/or harms. The study quantifies the relative contribution of other drugs in addition to alcohol to ED presentations and reports on this model's much higher levels of patient engagement in receiving BI than has been reported previously. What are the implications for practitioners? This study demonstrates the relative contribution of drugs, in addition to alcohol, to ED presentations at peak weekend times. Although BI has been well proven, the pilot project evaluated herein has demonstrated that by embedding AOD-specific staff in the ED, much higher rates of patient engagement, screening and BI can be achieved.

A Sequential Implementation Model for Workforce Development: A Case Study of Medical Residency Training for Substance Use Concerns

PROBLEM

In graduate medical education, residency programs are often educationally isolated from each other, with varying needs and patient populations, so strategies are needed when attempting to implement training in evidence-based practices across multiple residencies.

INTERVENTION

Using implementation science as a guide, we adapted a community development model to sequentially implement an evidence-based intervention, Screening, Brief Intervention, and Referral to Treatment (SBIRT) for alcohol and drug use problems, across internal medicine, pediatrics, emergency medicine, psychiatry, and obstetrics and gynecology residency programs.

CONTEXT

A grant-funded "executive" team coordinated the implementation, enrolled a new residency program annually, and served as the consultative team to span the programs. The team was attentive to aligning implementation with the needs of each program. To assist in planning, the team included a program champion 1 year prior to SBIRT implementation to provide the opportunity to develop resources and work with peers. We evaluated this model through an implementation science lens using a case study approach that included interviews and quantitative tabulation of products and resident perceptions.

OUTCOME

We successfully instituted SBIRT training in all 5 residency programs through the use of a supported local champion model. Teams developed 90 curricular products and had 57 presentations and publications. Residents reported satisfaction with the SBIRT activities. Champions reported that SBIRT was a useful approach and that they gained valuable knowledge and relationships from working with the executive team when designing learning materials appropriate for their residency. Champions successfully incorporated SBIRT into routine clinical practice.

LESSONS LEARNED

Having a strong team to support subsequent SBIRT champions was essential for implementation. The champions needed financial support to have the necessary time to implement training. The strategy of building a peer network across programs was critical for sustaining the implementation. Collecting and sharing resources aided the champions in developing their materials.

Patterns of simultaneous and concurrent alcohol and marijuana use among adolescents

BACKGROUND

Alcohol and marijuana are the most commonly used substances among adolescents but little is known about patterns of co-use.

OBJECTIVES

This study examined patterns of concurrent (not overlapping) and simultaneous (overlapping) use of alcohol and marijuana among adolescents.

METHODS

Data from US-national samples of 12th graders (N = 84,805, 48.4% female) who participated in the Monitoring the Future study from 1976 to 2016 and who used alcohol and/or marijuana in the past 12 months were used to identify latent classes of alcohol use, marijuana use, and simultaneous alcohol and marijuana (SAM) use.

RESULTS

A four-class solution indicated four patterns of use among adolescents: (1) Simultaneous alcohol and marijuana (SAM) use with binge drinking and recent marijuana use (SAM-Heavier Use; 11.2%); (2) SAM use without binge drinking and with recent marijuana use (SAM-Lighter Use; 21.6%); (3) Marijuana use and alcohol use but no SAM use (Concurrent Use; 10.7%); and (4) Alcohol use but no marijuana or SAM use (Alcohol-Only Use; 56.4%). Membership in either SAM use class was associated with a higher likelihood of truancy, evenings out, and use of illicit drugs other than marijuana. SAM-Heavier Use, compared to SAM-Lighter Use, class members were more likely to report these behaviors and be male, and less likely to have college plans.

CONCLUSIONS

Among 12th graders who use both alcohol and marijuana, the majority use simultaneously, although not all use heavily. Given the recognized increased public health risks associated with simultaneous use, adolescent prevention programming should include focus on particular risks of simultaneous use.

Examining motor vehicle crash involvement and readiness to change on drinking and driving behaviors among injured emergency department patients

OBJECTIVE

To measure the effect of motor vehicle crash (MVC) involvement and readiness to change drinking and driving behaviors on subsequent driving and drinking behaviors among injured emergency department (ED) patients who use alcohol at harmful levels.

METHODS

This was a secondary analysis of a randomized controlled trial of injured ED patients who screened positive for harmful alcohol use, who at recruitment reported driving in the past 12 months and received at least one of the intended intervention sessions (brief behavioral intervention versus attention placebo control; N = 407). Outcome variables were as follows: (1) change in 6 impaired driving behaviors and (2) report of MVCs and traffic violations in the 12 months following recruitment; predictor variables were as follows: (1) treatment assignment, (2) MVC involvement at recruitment, and (3) baseline readiness to change alcohol use and drinking and driving.

RESULTS

Modeling of change in the 6 impaired driving variables indicated that neither the recruitment visits being MVC related nor baseline readiness to change alcohol use and drinking and driving behaviors predicted greater changes in impaired driving over time. Baseline reports of past moving traffic violations and the ED visit being MVC related predicted a greater likelihood of each behavior at 12 months following study recruitment.

CONCLUSIONS

This study and others have demonstrated that ED patients with harmful alcohol use are willing to engage in behavioral interventions directed at changing risky behaviors. However, this study did not demonstrate that patients considered having the potential to be more engaged with the intervention because their ED visit was MVC related and/or they had expressed intent to change their risky alcohol use and drinking and driving behaviors were more likely to change these risky behaviors.

Development and Evaluation of a Short Adverse Childhood Experiences Measure

INTRODUCTION

Clinicians require tools to rapidly identify individuals with significant childhood adversity as part of routine primary care. The goal of this study was to shorten the 11-item Behavioral Risk Factor Surveillance System Adverse Childhood Experiences (ACEs) measure and evaluate the feasibility and validity of this shortened measure as a screener to identify adults who have experienced significant childhood adversity.

METHODS

Statistical analysis was conducted in 2015. ACE item responses obtained from 2011-2012 Behavioral Risk Factor Surveillance System data were combined to form a sample of 71,413 adults aged ≥18 years. The 11-item Behavioral Risk Factor Surveillance System ACE measure was subsequently reduced to a two-item screener by maintaining the two dimensions of abuse and household stressors and selecting the most prevalent item within each dimension.

RESULTS

The screener included household alcohol and childhood emotional abuse items. Overall, 42% of respondents and at least 75% of the individuals with four or more ACEs endorsed one or both of these experiences. Using the 11-item ACE measure as the standard, a cut off of one or more ACEs yielded a sensitivity of 99%, but specificity was low (66%). Specificity improved to 94% when using a cut off of two ACEs, but sensitivity diminished (70%). There was no substantive difference between the 11-and two-item ACE measures in their strength of association with an array of health outcomes.

CONCLUSIONS

A two-item ACE screener appropriate for rapid identification of adults who have experienced significant childhood adversity was developed.

Staff Views of an Emergency Department Intervention Using Safety Planning and Structured Follow-Up with Suicidal Veterans

The objective of this study is to summarize staff perceptions of the acceptability and utility of the safety planning and structured post-discharge follow-up contact intervention (SPI-SFU), a suicide prevention intervention that was implemented and tested in five Veterans Affairs Medical Center emergency departments (EDs). A purposive sampling approach was used to identify 50 staff member key informants. Interviews were transcribed and coded using thematic analysis. Almost all staff perceived the intervention as helpful in connecting SPI-SFU participants to follow-up services. A slight majority of staff believed SPI-SFU increased Veteran safety. Staff members also benefited from the implementation of SPI-SFU. Their comfort discharging Veterans at some suicide risk increased. SPI-SFU provides an appealing option for improving suicide prevention services in acute care settings.