Intervention attendance among emergency department patients with alcohol- and drug-use disorders

Emergency department visits as a potential opportunity to promote primary care attachment and modify utilization patterns - results of a pilot study in Berlin, Germany

BACKGROUND

Utilization by low acuity patients contributes to emergency department (ED) crowding. Both knowledge deficits about adequate care levels and access barriers in primary care are important promoters of such presentations. Concurrently, not having a general practitioner (GP) increases the likelihood of low-acuity ED utilization. This pilot study thus investigated feasibility, acceptance, and potential effects of an ED-delivered intervention for low-acuity patients with no regular primary care provider, consisting of an educational leaflet on acute care options and an optional GP appointment scheduling service.

METHODS

Low-acuity ED consulters not attached to a GP were given an information leaflet about alternative care offers for acute health problems and offered optional personal appointment scheduling at a local GP practice. Patients were surveyed on demographics, medical characteristics, health care utilization, valuation of the intervention, and reasons for not being attached to a GP and visiting the ED. A follow-up survey was conducted after twelve months. Trends in health and health care utilization were evaluated.

RESULTS

Between December 2020 and April 2022, n = 160 patients were enrolled, n = 114 were followed up. The study population was characterized by young age (mean 30.6 years) and predominantly good general health. Besides good health, personal mobility was a central reason for not being attached to a GP, but general preference for specialists and bad experiences with primary care were also mentioned. Most frequently stated motives for the ED consultation were subjective distress and anxiety, a belief in the superiority of the hospital, and access problems in primary care. The interventional offers were favorably valued, 52.5% (n = 84) accepted the GP appointment scheduling service offer. At follow-up, GP utilization had significantly increased, while there were no significant changes regarding utilization of other providers, including ED. An additional practice survey showed a 63.0% take-up rate for the appointment service.

CONCLUSIONS

With this pilot study, we were able to show that a personalized appointment scheduling service seems to be a promising approach to promote GP attachment and increase primary care utilization in patients without a regular GP in a highly urbanized setting. Further larger-scale studies are needed to investigate potential quantitative effects on ED visits.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS00023480); date 2020/11/27.

Motivational interviewing for substance use reduction

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Factors related to substance use treatment attendance after peer recovery coach intervention in the emergency department

Introduction

Brief intervention with peer recovery coach support has been used to generate referrals to substance use disorder treatment from the emergency department (ED). This retrospective study evaluated factors associated with successful linkage to treatment following brief intervention in the ED.

Methods

Data were extracted from the electronic health record for patients who were referred to substance use treatment from the ED and for whom follow-up data regarding treatment attendance was available (n=666). We examined associations between demographic and insurance variables, substance use, mental health diagnosis, prior abstinence, and stage of change with successful linkage to substance use treatment after ED referral.

Results

The sample was majority male (68%), White (62%), and had a mean age of 43 years (SD=12). Medicaid was the most common insurance (49%) followed by employer/private (34%). Multivariable logistic regression determined patients with Medicaid (OR=2.94, 95% CI:2.09-4.13, p=<.001), those who had a documented alcohol use disorder diagnosis (OR=1.59, 95% CI:1.074-2.342, p=.02), and those in the "Action" stage of change (OR=2.33, 95% CI:1.47-3.69, p=<.001) had greater odds of being successfully linked to treatment.

Conclusions

These results identify characteristics of patients available in the health record to determine who is more likely or less likely to attend substance use treatment following ED referral. Given appropriate screening, this information could be used to direct standard care resources to those with high likelihood of treatment attendance and strengthen follow-up interventions with peer recovery coaches for those with lower likelihood of treatment attendance.

Homelessness and self-rated health: evidence from a national survey of homeless people in Spain

BACKGROUND

Internationally, acute homelessness is commonly associated with complex health and social care needs. While homelessness can be understood as an outcome of structural housing exclusion requiring housing led solutions, the health care issues faced by homeless people equally require attention. A substantive evidence base on the health needs of homeless people exists, but relatively little is known about what influences the self-rated health of homeless people. This article presents new evidence on whether drug use (alcohol consumption, ever having used drugs), health variables (visiting a hospital once in the last year, visiting the doctor in the last month, having a health card, sleeping difficulties, and having a disabling impairment) and sociodemographic characteristics are significantly associated with Self-Rated Health (SRH) among Spanish homeless people.

METHOD

The approach applies secondary analysis to cross-sectional data from a sample of 2437 homeless adults in Spain (83.8% were male). Multinomial logistic regression modelling was used to analyse the relationships between drug use, other health variables and SRH.

RESULTS

Being male, an abstainer, having a health card and being in the youngest age groups were significant factors associated with perceived good health. On the other hand, ever having used drugs, having been a night in hospital, having gone to the doctor in the last month, having sleeping difficulties, having a disabling impairment and being in the older age group were all significant risk factors associated with perceived poor health.

CONCLUSIONS

These results help to improve understanding of the key factors that influence the SRH among homeless people. The findings can contribute to development and delivery of preventive policies, suggesting that interventions to reduce drug consumption and ensure access to a health card/health services, as well as enhancing services for older, female and disabled homeless people are all measures which could improve health and well-being for those who face homelessness. Effective housing interventions (e.g. Housing First or Permanent Supported Housing programmes) are equally important to underpin the effectiveness of measures to improve the self-rated health of homeless people.

Screening and interventions for substance use in primary care

NPs in primary care settings are well positioned to treat substance use disorders (SUDs). SUDs affect patients across the age spectrum and may be diagnosed and treated by NPs using brief interventions and pharmacologic therapies, or patients may be referred to specialty services. This article provides guidelines for screening, brief interventions, and pharmacologic therapies.

The role of substance use and adult sexual assault severity in the course of schizophrenia: An epidemiological catchment study of sexual assault victims

BACKGROUND

Childhood trauma increases the risk of schizophrenia, yet the role of adult sexual assault in the course of schizophrenia is unknown. This study aims to examine the associations between substance use and sexual assault severity characteristics with the course of schizophrenia among adult sexual assault victims using an epidemiologic study design.

METHODS

Sexual assault data on all individuals received from 2000 to 2010 (N = 2147) at the Center for Care of Sexual Assault Victims at Wolfson Medical Center, the largest medical center for sexual assault victims in the country, were merged with the Israel National Psychiatric Case Registry, that consisted of lifetime psychiatric hospitalizations of schizophrenia (birth to 6 years post-assault). The associations between substance use and adult sexual assault severity characteristics with hospitalizations were quantified using recurrent events Cox modeling.

RESULTS

Schizophrenia with sexual assault survivors occurred in 117 persons. Cox modeling showed that recurrent psychiatric hospitalizations were associated with younger age, sexual assault at older age, previous diagnosis of psychosis, and drug use shortly before or during the assault. Other assault characteristics (number of assailants, means of subdual, penetration type, perpetrator violence, physical injury of the victim) and immediacy of seeking help had a null association with the course of psychiatric hospitalization. These results replicated in two sensitivity analyses.

CONCLUSIONS

Substance use among victims of sexual assault was associated with an exacerbated course of schizophrenia, pointing to a possibly modifiable risk factor that should be targeted in prevention, assessment, treatment formulation and implementation.

Use of non-face-to-face modalities for emergency department screening, brief intervention, and referral to treatment (ED-SBIRT) for high-risk alcohol use: A scoping review

Background: The purpose of this review was to examine and chart the "scope" of strategies reported in ED-SBIRT (emergency department-based screening, brief intervention and referral to treatment) studies that employ non-face-to-face (nFtF) modalities for high-risk alcohol use (i.e., risk for alcohol-related injury, medical condition, use disorder) and to identify research gaps in the scientific literature. Methods: The scoping review population included study participants with high-risk alcohol use patterns as well as study participants targeted for primary public health prevention (e.g., adolescent ED patients). Core concepts included SBIRT components among intervention studies that incorporated some form of nFtF modality (e.g., computer-assisted brief intervention). The context encompassed ED-based studies or trauma center studies, regardless of geographic location. After screening a total of 1526 unique references, reviewers independently assessed 58 full-text articles for eligibility. Results: A total of 30 full-text articles were included. Articles covered a period of 14 years (2003-2016) and 19 journal titles. Authors reported the use of a wide range of nFtF modalities across all 3 ED-SBIRT components: "screening" (e.g., computer tablet screening), "brief intervention" (e.g., text message-based brief interventions), and "referral to treatment" (e.g., computer-generated feedback with information about alcohol treatment services). The most frequently used nFtF modality was computerized screening and/or baseline assessment. The main results were mixed with respect to showing evidence of ED-SBIRT intervention effects. Conclusions: There is an opportunity for substance use disorder researchers to explore the specific needs of several populations (e.g., ED patients with co-occurring problems such as substance use disorder and violence victimization) and on several methodological issues (e.g., ED-SBIRT theory of change). Substance use disorder researchers should take the lead on establishing guidelines for the reporting of ED-SBIRT studies-including categorization schemes for various nFtF modalities. This would facilitate both secondary research (e.g., meta-analyses) and primary research design.

Emergency Medicine Research Priorities for Early Intervention for Substance Use Disorders

Introduction

Patients with substance use disorders (SUDs) frequently seek emergency care, and the emergency department (ED) may be their only point of contact with the healthcare system. While the ED visit has been increasingly recognized as providing opportunity for interventions around substance use, many questions remain.

Methods

In December 2016 the Coalition on Psychiatric Emergencies (CPE) convened the first Research Consensus Conference on Acute Mental Illness, which consisted of clinical researchers, clinicians from emergency medicine, emergency psychiatry, emergency psychology, representatives from governmental agencies and patient advocacy groups. Background literature review was conducted prior to the meeting, and questions were iteratively focused, revised, voted on and ranked by perceived importance using nominal group method.

Results

The main goal of the SUD workgroup was to identify research priorities and develop a research agenda to improve the early identification of and management of emergency department (ED) patients with SUDs with the goal of improving outcomes. This article is the product of a breakout session on “Special Populations: Substance Use Disorder.” The workgroup identified with high consensus six research priorities for their importance related to the care of ED patients with SUDs in these overall domains: screening; ED interventions; the role of peer navigators; initiation of SUD management in the ED; specific patient populations that may impact the effectiveness of interventions including sociogenerational and cultural factors; and the management of the acutely intoxicated patient.

Conclusion

Emergency providers are increasingly recognizing the important role of the ED in reducing adverse outcomes associated with untreated SUDs. Additional research is required to close identified knowledge gaps and improve care of ED patients with SUD.

Emergency Department Utilization for Substance Use-Related Disorders and Assessment of Treatment Facilities in New York State, 2011-2013

BACKGROUND

Annually, 1.8 million New York (NY) residents experience substance use disorders (SUDs). Even though emergency departments (EDs) continue to experience high numbers of SUD-related visits, only 15% receive treatment.

OBJECTIVES

This study estimates hospital-based EDs rates for SUDs in the State of New York. Also, the geographic distribution of substance use treatment centers and EDs are mapped to correlate utilization with access to care.

METHODS

The 2011-2013 Healthcare Cost and Utilization Project's NY State Emergency Department Database provided information on utilization of services in EDs, charges, diagnoses, and discharge, as well as patient demographic variables. All patients within NY who had visited the ED for SUDs comprised the study population. Geographic mapping of EDs and substance abuse treatment centers at the county-level is based on data from the National Emergency Department Inventory and National Survey of Substance Abuse Treatment Services, respectively.

RESULTS

A total of 492,419 ED visits for SUDs were reported through 2011-2013. Despite NY's Medicaid expansion in 2012, ED visits increased in 2013. About $856 million was spent in treating SUDs in EDs, with average charge of $1,764 per visit. Conclusions/Importance: Alcohol and drug-induced mental disorders are increasingly prevalent in New York's EDs. There is a need to develop health policies and programs to improve access to care for SUDs in urban states.

A Scoping Review of Emergency Department Discharge Instructions for Children and Adolescents With Mental Disorders

BACKGROUND

Although most young people under the age of 25 years with mental health presentations to the emergency department (ED) are discharged home, several studies suggest discharge instructions are inadequate. We conducted a scoping review to characterize and map the literature, identify research gaps, and prioritize targeted areas for future reviews for ED discharge instructions for young people with mental disorders.

METHODS

Our review was conducted in an iterative approach with 6 stages including identifying the research question, identifying relevant studies, study selection, data extraction, collaring and summarizing, and stakeholder engagement. We characterized the available information on discharge instruction interventions using the Behavior Change Wheel.

RESULTS

Of the 805 potential publications screened, 25 were included for extraction. Nine of the 25 articles focused on suicide or self-harm, 6 were on mental health in general or mixed groups, and 9 focused on alcohol, tobacco, or substance use in general. Five studies included younger children (ie, less than 12 years) but ages ranged significantly among studies. Education and persuasion were intervention functions most commonly reported in publications (n = 13 and n = 12, respectively). From the policy categories, recommendations regarding service provision were most frequently made from four publications. Descriptions of theory were limited in publications.

CONCLUSIONS

The available literature regarding discharge instructions in the ED for youth with mental disorders is focused on certain content areas (eg, self injurious behaviors, substance use) with more work required in chronic mental disorders that make up a significant proportion of ED visits. Research that extends beyond education and with theoretical underpinnings to explain how and why various interventions work would be useful for clinicians, policy-makers, and other researchers.

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.

The role of marijuana use disorder in predicting emergency department and inpatient encounters: A retrospective cohort study

BACKGROUND

Marijuana use disorder (MUD) is the most common illegal drug use disorder and its prevalence is increasing. It is associated with psychiatric and medical problems, but little is known about its impact on emergency department (ED) and inpatient utilization rates.

DESIGN

In a retrospective cohort design, we used electronic health record (EHR) data to identify patients with MUD (n=2752) and demographically matched patients without MUD (n=2752) in 2010. Logistic regressions determined risk of ED and inpatient visits each year from 2010 to 2014 for MUD patients versus controls; mixed-effect growth models examined differences in utilization rates over 5-years. Patient characteristics predicting increased risk of utilization were examined among the MUD sample only.

KEY RESULTS

Rates of ED (OR=0.87, p<0.001) and inpatient (OR=0.76, p<0.001) services use significantly declined over 5 years for all patients. Patients with MUD exhibited a significantly greater decline in ED (OR=0.81, p<0.001) and inpatient (OR=0.64, p<0.001) use relative to controls. However, MUD patients had significantly greater risk of having ED and inpatient visits at each time point (p's<0.001). MUD patients with co-occurring other substance use, medical, and/or psychiatric disorders had a greater risk of having ED or inpatient encounters over 5 years (p's<0.001).

CONCLUSIONS

MUD patients remain at high risk for ED and inpatient visits despite decreasing utilization rates over 5 years. Addressing MUD patients' comorbid conditions in outpatient settings may help reduce inappropriate service use.

Follow-up after acute poisoning by substances of abuse: a prospective observational cohort study

Objective: To chart follow-up of patients after acute poisoning by substances of abuse, register whether patients referred to specialist health services attended, and whether patients contacted a general practitioner (GP) after the poisoning episode.Design: Observational cohort study.Setting: A primary care emergency outpatient clinic in Oslo, Norway.Subjects: Patients ≥12 years treated for acute poisoning by substances of abuse were included consecutively from October 2011 to September 2012.Main outcome measures: Follow-up initiated at discharge, proportion of cases in which referred patients attended within three months, and proportion of cases in which the patient consulted a GP the first month following discharge.Results: There were 2343 episodes of acute poisoning by substances of abuse. In 391 (17%) cases the patient was hospitalised, including 49 (2%) in psychiatric wards. In 235 (10%) cases the patient was referred to specialist health services, in 91 (4%) advised to see their GP, in 82 (3%) to contact social services, in 74 (3%) allotted place in a homeless shelter, and in 93 (4%) other follow-up was initiated. In 1096 (47%) cases, the patient was discharged without follow-up, and in a further 324 (14%), the patient self-discharged. When referred to specialist health services, in 200/235 (85%) cases the patient attended within three months. Among all discharges, in 527/1952 (27%) cases the patient consulted a GP within one month. When advised to see their GP, in 45/91 (49%) cases the patient did.Conclusion: Attendance was high for follow-up initiated after acute poisoning by substances of abuse.KEY POINTSDespite poor long-term prognosis, patients treated for acute poisoning by substances of abuse are frequently not referred to follow-up.Nearly all patients referred to specialist health services attended, indicating the acute poisoning as an opportune moment for intervention.Advising patients to contact their GP was significantly associated with patients consulting the GP, but few patients were so advised.One out of three patients was discharged without follow-up, and there seems to be an unused potential for GP involvement.

Substance misuse brief interventions during psychiatric hospital admissions

Purpose

To provide a summary of the principles, theories and basic components of a recently developed brief integrated motivational intervention (BIMI) for working with individuals experience co-ccurring severe mental health and substance use problems in inpatient settings, including the outcomes of a feasiblity randomised controlled trial (RCT). There are greater financial costs and a negative impact on functioning associated with psychiatric admissions for people who experience co-occurring severe mental heath and substance misuse problems. In addition, their engagement in treatment is often problematic.

Design/methodology/approach

The BIMI described was evaluated via a feasibility RCT that assessed whether the opportunity to discuss use of substances whilst on an inpatient ward represented an opportunity to engage inpatients in thinking about their use and the impact it has on their mental health.

Findings

The BIMI is delivered in short burst sessions of 15-30 minutes over a two-week period adopting a simple 3-step approach that can be delivered by routine ward staff. It incorporates an assessment of substance use, mental health and motivation followed by personalised feedback, a focus on increasing awareness of the impact on mental health and development of goals and a change plan. The intervention has been shown to lead to higher levels of engagement in clients exploration of substance use and the impact on mental health. Findings suggest both staff and inpatients found the intervention feasible and acceptable.

Originality/value

Routine ward staff were trained to deliver a brief intervention to inpatients during an acute hospital admission.

Pilot randomised trial of a brief intervention for comorbid substance misuse in psychiatric in-patient settings

OBJECTIVE

This proof of principle study evaluated the effectiveness and feasibility of a brief motivational intervention, delivered in mental health in-patient settings, to improve engagement in treatment for drug and alcohol misuse.

METHOD

A randomised controlled trial using concealed randomisation, blind, independent assessment of outcome at 3 months. Participants were 59 new adult admissions, to six acute mental health hospital units in one UK mental health service, with schizophrenia related or bipolar disorder diagnoses, users of community mental health services and also misusing alcohol and/or drugs. Participants were randomised to Brief Integrated Motivational Intervention (BIMI) with Treatment As Usual (TAU), or TAU alone. The BIMI took place over a 2-week period and encouraged participants to explore substance use and its impact on mental health.

RESULTS

Fifty-nine in-patients (BIMI n = 30; TAU n = 29) were randomised, the BIMI was associated with a 63% relative odds increase in the primary outcome engagement in treatment [OR 1.63 (95% CI 1.01-2.65; P = 0.047)], at 3 months. Qualitative interviews with staff and participants indicated that the BIMI was both feasible and acceptable.

CONCLUSION

Mental health hospital admissions present an opportunity for brief motivational interventions focussed on substance misuse and can lead to improvements in engagement.

Specialty substance use disorder services following brief alcohol intervention: a meta-analysis of randomized controlled trials

BACKGROUND AND AIMS

Brief alcohol interventions in medical settings are efficacious in improving self-reported alcohol consumption among those with low-severity alcohol problems. Screening, Brief Intervention and Referral to Treatment initiatives presume that brief interventions are efficacious in linking patients to higher levels of care, but pertinent evidence has not been evaluated. We estimated main and subgroup effects of brief alcohol interventions, regardless of their inclusion of a referral-specific component, in increasing the utilization of alcohol-related care.

METHODS

A systematic review of English language papers published in electronic databases to 2013. We included randomized controlled trials (RCTs) of brief alcohol interventions in general health-care settings with adult and adolescent samples. We excluded studies that lacked alcohol services utilization data. Extractions of study characteristics and outcomes were standardized and conducted independently. The primary outcome was post-treatment alcohol services utilization assessed by self-report or administrative data, which we compared across intervention and control groups.

RESULTS

Thirteen RCTs met inclusion criteria and nine were meta-analyzed (n = 993 and n = 937 intervention and control group participants, respectively). In our main analyses the pooled risk ratio (RR) was = 1.08, 95% confidence interval (CI) = 0.92-1.28. Five studies compared referral-specific interventions with a control condition without such interventions (pooled RR = 1.08, 95% CI = 0.81-1.43). Other subgroup analyses of studies with common characteristics (e.g. age, setting, severity, risk of bias) yielded non-statistically significant results.

CONCLUSIONS

There is a lack of evidence that brief alcohol interventions have any efficacy for increasing the receipt of alcohol-related services.

Brief intervention for patients with problematic drug use presenting in emergency departments: a randomized clinical trial

IMPORTANCE

Medical treatment settings such as emergency departments (EDs) present important opportunities to address problematic substance use. Currently, EDs do not typically intervene beyond acute medical stabilization.

OBJECTIVE

To contrast the effects of a brief intervention with telephone boosters (BI-B) with those of screening, assessment, and referral to treatment (SAR) and minimal screening only (MSO) among drug-using ED patients.

DESIGN, SETTING, AND PARTICIPANTS

Between October 2010 and February 2012, 1285 adult ED patients from 6 US academic hospitals, who scored 3 or greater on the 10-item Drug Abuse Screening Test (indicating moderate to severe problems related to drug use) and who were currently using drugs, were randomized to MSO (n = 431), SAR (n = 427), or BI-B (n = 427). Follow-up assessments were conducted at 3, 6, and 12 months by blinded interviewers.

INTERVENTIONS

Following screening, MSO participants received only an informational pamphlet. The SAR participants received assessment plus referral to addiction treatment if indicated, and the BI-B participants received assessment and referral as in SAR, plus a manual-guided counseling session based on motivational interviewing principles and up to 2 "booster" sessions by telephone during the month following the ED visit.

MAIN OUTCOMES AND MEASURES

Outcomes evaluated at follow-up visits included self-reported days using the patient-defined primary problem drug, days using any drug, days of heavy drinking, and drug use based on analysis of hair samples. The primary outcome was self-reported days of use of the patient-defined primary problem drug during the 30-day period preceding the 3-month follow-up.

RESULTS

Follow-up rates were 89%, 86%, and 81% at 3, 6, and 12 months, respectively. For the primary outcome, estimated differences in number of days of use (95% CI) were as follows: MSO vs BI-B, 0.72 (-0.80 to 2.24), P (adjusted) = .57; SAR vs BI-B, 0.70 (-0.83 to 2.23), P (adjusted) = .57; SAR vs MSO, -0.02 (-1.53 to 1.50), P (adjusted) = .98. There were no significant differences between groups in self-reported days using the primary drug, days using any drug, or heavy drinking days at 3, 6, or 12 months. At the 3-month follow-up, participants in the SAR group had a higher rate of hair samples positive for their primary drug of abuse (265 of 280 [95%]) than did participants in the MSO group (253 of 287 [88%]) or the BI-B group (244 of 275 [89%]). Hair analysis differences between groups at other time points were not significant.

CONCLUSIONS AND RELEVANCE

In this sample of drug users seeking emergency medical treatment, a relatively robust brief intervention did not improve substance use outcomes. More work is needed to determine how drug use disorders may be addressed effectively in the ED.

TRIAL REGISTRATION

clinicaltrials.gov Identifier:NCT01207791.

A pilot study to assess the feasibility and impact of a brief motivational intervention on problem drug and alcohol use in adult mental health inpatient units: study protocol for a randomized controlled trial

BACKGROUND

Substance misuse in those with severe mental health problems is common and associated with poor engagement in treatment and treatment outcomes. Up to 44% of those admitted into psychiatric inpatient facilities have coexisting substance-misuse problems. However, this is not routinely addressed as part of their treatment plan. A mental health admission may present a window of opportunity for inpatients to reevaluate the impact of their substance use. This study will aim to evaluate the effectiveness of a targeted brief motivational intervention in improving engagement in treatment and to assess how feasible and acceptable this intervention is to inpatients and staff as a routine intervention.

METHODS/DESIGN

This randomized controlled trial will use concealed randomization; blind, independent assessment of outcome at 3 months; characterization of refusers and dropouts; and be analyzed according to the intention-to-treat principle. After baseline assessments, eligible participants will be randomized either to the Brief Integrated Motivational Intervention plus Treatment As Usual, or Treatment as Usual alone. Eligible participants will be those who are new admissions; >18 years; ICD-10 diagnosis of -schizophrenia or related disorder, bipolar affective disorder, recurrent depressive disorder, and DSM-IV diagnosis of substance abuse or dependence over the last 3 months. The primary outcome is engagement in treatment for substance misuse, and secondary outcomes include readiness to change substance misuse together with a cost-effectiveness analysis. Qualitative interviews with staff and participants will assess the acceptability of the intervention.

DISCUSSION

This pilot randomized trial will provide the first robust evidence base for inpatient care of people with severe mental health problems and co-morbid substance misuse and provide the groundwork for confirmatory trials to evaluate a potentially feasible, cost-effective, and easy-to-implement treatment option that may be readily integrated into standard inpatient and community-based care.

TRIAL REGISTRATION

ISRCTN43548483 Date of ISRCTN assignation: 4/17/2014.

Alcohol, tobacco, and drug use among emergency department patients

BACKGROUND

The prevalence of alcohol, tobacco, and other drug (ATOD) use among emergency department (ED) patients is high and many of these patients have unrecognized and unmet substance use treatment needs. Identification of patients in the ED with problem substance use is not routine at this time.

METHODS

We examined screening data, including standardized measures of ATOD use (HSI, AUDIT-C, DAST-10), from 14,866 ED patients in six hospitals across the United States. We expected younger age, male gender, higher triage acuity, and other substance use severity (ATOD) to be associated both with use versus abstinence and with severity of each substance use type. We used negative binomial hurdle models to examine the association between covariates and (1) substance use versus abstinence (logistic submodel) and with (2) severity among those who used substances (count submodel).

RESULTS

Rates of use and problem use in our sample were similar to or higher than other ED samples. Younger patients and males were more likely to use ATOD, but the association of age and gender with severity varied across substances. Triage level was a poor predictor of substance use severity. Alcohol, tobacco, and drug use were significantly associated with using other substances and severity of other substance use.

CONCLUSION

Better understanding of the demographic correlates of ATOD use and severity and the patterns of comorbidity among classes of substance can inform the design of optimal screening and brief intervention procedures addressing ATOD use among ED patients. Tobacco may be an especially useful predictor.

Characteristics and treatment interests among individuals with substance use disorders and a history of past six-month violence: findings from an emergency department study

The study examined clinical characteristics and treatment interests of individuals identified to have substance use disorders (SUDs) in an urban emergency department (ED) who reported past six-month history of violence or victimization. Specifically, participants were 1441 ED patients enrolled in a randomized controlled trial of interventions designed to link those with SUDs to treatment. To examine factors related to violence type, four groups based on participants' reports of violence toward others were created: no violence (46.8%), partner violence only (17.3%), non-partner violence only (20.2%), and both partner and non-partner violence (15.7%). Four groups based on participants' reports of victimization were also created: no violence (42.1%), victimization from partner only (18.7%), victimization from non-partner only (20.2%), and both partner and non-partner victimization (17.7%). Separate multinomial logistic regression analyses were conducted to examine which variables distinguished the violence and victimization groups from those reporting no violence or victimization. For violence toward others, demographic variables, alcohol and cocaine disorders, and rating treatment for psychological problems were higher for violence groups, with some differences depending on the type of violence. For victimization, demographic variables, having an alcohol disorder, and rating treatment for family/social problems were higher for violence groups, also with some differences depending on the type of violence. Findings from the present study could be useful for designing effective brief interventions and services for ED settings.

Computer-enhanced interventions for drug use and HIV risk in the emergency room: preliminary results on psychological precursors of behavior change

This article describes process data from a randomized controlled trial among 781 adults recruited in the emergency department who reported recent drug use and were randomized to: intervener-delivered brief intervention (IBI) assisted by computer, computerized BI (CBI), or enhanced usual care (EUC). Analyses examined differences between baseline and post-intervention on psychological constructs theoretically related to changes in drug use and HIV risk: importance, readiness, intention, help-seeking, and confidence. Compared to EUC, participants receiving the IBI significantly increased in confidence and intentions; CBI patients increased importance, readiness, confidence, and help-seeking. Both groups increased relative to the EUC in likelihood of condom use with regular partners. Examining BI components suggested that benefits of change and tools for change were associated with changes in psychological constructs. Delivering BIs targeting drug use and HIV risk using computers appears promising for implementation in healthcare settings. This trial is ongoing and future work will report behavioral outcomes.

Prior substance abuse and related treatment history reported by recent victims of sexual assault

To inform intervention approaches, the current study examined prevalence and comorbidity of recent use and history of abuse of alcohol, marijuana, and other illicit drugs as well as history of substance treatment among a sample of female victims of sexual assault seeking post-assault medical care. Demographic variables and prior history of assault were also examined to further identify factors relevant to treatment or prevention approaches. Participants were 255 women and adolescent girls seeking post sexual assault medical services who completed an initial follow-up assessment on average within 3 months post-assault. The majority (72.9%) reported recent substance use prior to assault, approximately 40% reported prior substance abuse history, and 12.2% reported prior substance treatment history. Prior history of assault was associated with recent drug use and history of drug abuse as well as substance treatment. Among those with prior histories of substance abuse and assault, assault preceded substance abuse onset in the majority of cases. Almost all those with prior treatment history reported recent drug or alcohol use. A portion of sexual assault survivors seen for acute medical services may benefit from facilitated referral for substance abuse treatment in addition to counseling at the time of screening. Assessment and intervention approaches should target alcohol, marijuana, and other illicit drug use and abuse. Substance use and associated impairment may serve as a rape tactic by perpetrators of assault. Substance use at the time of assault does not imply blame on the part of assault victims. Previous findings indicate that rape poses high risk of PTSD particularly among women with prior history of assault. Screening and intervention related to substance abuse should be done with recognition of the increased vulnerability it may pose with regard to assault and the high risk of PTSD within this population.

New developments in brief interventions to treat problem drinking in nonspecialty health care settings

The delivery of brief interventions (BIs) in health care settings to reduce problematic alcohol consumption is a key preventive strategy for public health. However, evidence of effectiveness beyond primary care is inconsistent. Patient populations and intervention components are heterogeneous. Also, evidence for successful implementation strategies is limited. In this article, recent literature is reviewed covering BI effectiveness for patient populations and subgroups, and design and implementation of BIs. Support is evident for short-term effectiveness in hospital settings, but long-term effects may be confounded by changes in control groups. Limited evidence suggests effectiveness with young patients not admitted as a consequence of alcohol, dependent patients, and binge drinkers. Influential BI components include high-quality change plans and provider characteristics. Health professionals endorse BI and feel confident in delivering it, but training and support initiatives continue to show no significant effects on uptake, prompting calls for systematic approaches to implementing BI in health care.