A randomized controlled trial testing the efficacy of a brief cannabis universal prevention program among adolescents in primary care

Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Primary Care, School-Based Health Clinics, and Mental Health Clinics

Adolescent cannabis use is a modifiable health behavior with potential adverse developmental, cognitive, psychological, and health effects. Over the last 2 decades, work to promote implementation of screening, brief intervention, and referral to treatment has improved screening, use of validated screening tools, and preventive messaging. Current intervention strategies for cannabis use are associated with modest, short-term effects, and referral to treatment is limited by availability of resources for adolescent substance use. This article provides an update on the evidence base for screening, brief intervention, referral to treatment, and the current state of implementation focused on management of cannabis use disorder.

Brief Interventions for Cannabis Using Adolescents

This article discusses the application of brief interventions to address adolescents with a cannabis use problem. Topics include a general model of brief interventions, the outcome literature, existing brief interventions that focus on youth cannabis use, adjustments to a brief intervention when addressing cannabis, referral to treatment issues, personalizing a brief intervention, the need to address coexisting problems, and future directions.

Leveraging the Full Continuum of Care to Prevent Opioid Use Disorder

Substance use disorder prevention programs are most effective when matched appropriately to the baseline risk of the population. Individuals who misuse opioids often have unique risk profiles different from those who use other substances such as alcohol or cannabis. However, most substance use prevention programs are geared toward universal audiences, neglecting key inflection points along the continuum of care. The HEAL Prevention Cooperative (HPC) is a unique cohort of research projects that represents a continuum of care, from community-level universal prevention to indicated prevention among older adolescents and young adults who are currently misusing opioids or other substances. This paper describes the theoretical basis for addressing opioid misuse and opioid use disorder across the prevention continuum, using examples from research projects in the HPC.

Using session recordings to understand the content of community-based treatment for childhood anxiety disorders and response to technology-based training

OBJECTIVE

The goal of the current study is to advance efforts to increase the quality of care for childhood anxiety disorder (CADs) through (1) detailing the content of community-based treatment sessions, (2) exploring the validity of therapist surveys, (3) examining the influence of setting differences, and (4) testing the effects of a technology-based training on use of nonexposure strategies.

METHODS

Thirteen therapists were randomly assigned to technology-based training in the use of exposure therapy or treatment as usual (TAU) for CADs. Therapeutic techniques were coded from 125 community-based treatment sessions.

RESULTS

Consistent with survey responses community therapists spent the majority of session time reviewing symptoms (34% of session time), implementing nonexposure cognitive behavioral therapy (CBT; 36%), and rarely engaged in exposure (3%). An integrated behavioral health setting was associated with greater endorsement of exposure on survey, p < 0.05, although this difference was not significant in session recordings, p = 0.14. Multilevel models indicated that technology-based training that has been shown to increase exposure, also decreased use of nonexposure CBT techniques (2% vs. 29%, p < 0.001).

CONCLUSION

The study supports the validity of survey-based findings that community-based care for CADs consists of non-exposure CBT techniques. Efforts should be invested in dissemination of within-session exposure.

Accelerating Solutions for the Overdose Crisis: an Effectiveness-Implementation Hybrid Protocol for the HEAL Prevention Cooperative

Given increasing opioid overdose mortality rates in the USA over the past 20 years, accelerating the implementation of prevention interventions found to be effective is critical. The Helping End Addiction Long-Term (HEAL) Prevention Cooperative (HPC) is a consortium of research projects funded to implement and test interventions designed to prevent the onset or escalation of opioid misuse among youth and young adults. The HPC offers a unique opportunity to synthesize and share lessons learned from participating research projects' varied implementation experiences, which can facilitate quicker integration of effective prevention interventions into practice. This protocol paper describes our hybrid approach to collecting and analyzing information about the implementation experiences of nine of the HPC research projects while they maintain their focus on assessing the effectiveness and cost-effectiveness of prevention interventions. To better understand implementation within this context, we will address five research questions: (1) What were the context and approach for implementing the prevention interventions, and how was the overall implementation experience? (2) How representative of the target population are the participants who were enrolled and retained in the research projects' effectiveness trials? (3) For what purposes and how were stakeholders engaged by the research projects? (4) What are the adaptable components of the prevention interventions? And finally, (5) how might implementation of the prevention interventions vary for non-trial implementation? This work will result in intervention-specific and general practical dissemination resources that can help potential adopters and deliverers of opioid misuse prevention make adoption decisions and prepare for successful implementation.

Substance Use Disorders and Role of Complementary and Integrative Medicine/Functional Medicine

Substance use disorders are a growing concern for all ages, including adolescents. Even though there is an increase in recreational substance use and a wider variety of drugs is available to this young population, treatment options remain scarce. Most medications have limited evidence in this population. Few specialists treat individuals struggling with addiction along with mental health disorders. As the evidence grows, these treatments are usually included in complementary and integrative medicine. This article discusses available evidence for many complementary and integrative treatment approaches while briefly describing existing psychotherapeutic and psychotropic medications.

Study design to evaluate a web-intervention to prevent alcohol and cannabis-impaired driving and use among adolescents in driver education

BACKGROUND

Alcohol and cannabis are the most commonly used substances among adolescents in the U.S. The consequences related to using both substances together are significantly higher relative to use of either substance alone. Teens' propensity to engage in risky driving behaviors (e.g., speeding, rapid lane changes, and texting) and their relative inexperience with the timing and duration of cannabis' effects puts them at heightened risk for experiencing harms related to driving under the influence. Use of alcohol and cannabis peak at age 16, the legal age teens may apply for a provisional driver's license in some states. Targeting novice teen drivers prior to licensure is thus an ideal time for prevention efforts focused on reducing alcohol and/or cannabis initiation, use, and impaired driving.

METHODS

The current study proposes to evaluate the efficacy of webCHAT among 15.5 to 17-year-old adolescents (n = 150) recruited at driver education programs. WebCHAT is a single session online intervention that aims to prevent alcohol and cannabis use and risky driving behaviors. We will recruit adolescents enrolled in driver education programs, and stratify based on whether they used cannabis and/or alcohol in the past 3 months (60% screening negative and 40% screening positive). All participants will receive usual driver education and half will also receive webCHAT. We will test whether webCHAT in addition to usual driver education reduces alcohol and/or cannabis initiation or use and reduces risky driving attitudes and behaviors (intent to drive after drinking/using, riding as a passenger with someone who drank/used) compared to teens in usual driver education over a 6-month period. We will also explore whether variables such as beliefs and perceived norms serve as explanatory mechanisms for our outcomes.

DISCUSSION

The study has the potential to promote public welfare by decreasing adolescent initiation and use of cannabis and alcohol and reducing risky driving behaviors that can have substantial monetary, personal, and social costs. The study recruits adolescents who are at risk for substance use as well as those who are not and it is delivered remotely during a teachable moment when adolescents receive driver education. Trial registration This study was registered with ClinicalTrials.gov on July 13, 2021 (NCT04959461). https://clinicaltrials.gov/ct2/show/NCT04959461.

Sustainability of Adolescent Screening and Brief Intervention Services in Primary Care After Removal of Implementation Supports

OBJECTIVE

Although many health care organizations have sought to increase the integration of substance use services into clinical practice, such practice changes can prove difficult to sustain.

METHOD

Seven primary care clinics participated in an implementation study of screening and brief intervention (BI) services for adolescent patients (ages 12-17). All sites delivered screening and brief advice (BA) for low-risk use using a uniform protocol. Clinics were randomized to deliver BI using generalist (provider-delivered) or specialist (behavioral health clinician-delivered) models. Implementation was facilitated by multiple supporting activities (e.g., trainings, local "champion," electronic health record [EHR] integration of screening and documentation, individualized feedback, project-specific materials, etc.). Data on the penetration of screening, BA, and BI delivery (N = 14,486 adolescent patient visits) were abstracted from the EHR for the 20-month implementation phase and a 12-month sustainability phase (during which implementation supports were removed).

RESULTS

Penetration of screening continued to slowly increase across the implementation-to-sustainability phases (62% vs. 70%; p = .04). Although uptake during implementation was low for BA (29%) and BI (22%), there was no significant decrease in service provision during the sustainability phase. Although overall delivery of BI was significantly higher in generalist compared with specialist sites (p < .001), sustainability did not differ by generalist versus specialist conditions. There were considerable differences in penetration across clinic sites.

CONCLUSIONS

Clinics sustained a high level of substance use screening. Uptake of intervention services was low but did not decrease further following the cessation of implementation supports. This study illustrates the challenges of successfully implementing and sustaining substance use services in adolescent primary care.

Substance Use Screening, Brief Intervention, and Referral to Treatment in Pediatric Primary Care, School-Based Health Clinics, and Mental Health Clinics

Adolescent cannabis use is a modifiable health behavior with potential adverse developmental, cognitive, psychological, and health effects. Over the last 2 decades, work to promote implementation of screening, brief intervention, and referral to treatment has improved screening, use of validated screening tools, and preventive messaging. Current intervention strategies for cannabis use are associated with modest, short-term effects, and referral to treatment is limited by availability of resources for adolescent substance use. This article provides an update on the evidence base for screening, brief intervention, referral to treatment, and the current state of implementation focused on management of cannabis use disorder.

Brief Interventions for Cannabis Using Adolescents

This article discusses the application of brief interventions to address adolescents with a cannabis use problem. Topics include a general model of brief interventions, the outcome literature, existing brief interventions that focus on youth cannabis use, adjustments to a brief intervention when addressing cannabis, referral to treatment issues, personalizing a brief intervention, the need to address coexisting problems, and future directions.

Longer-Term Efficacy of a Digital Life-Skills Training for Substance Use Prevention

INTRODUCTION

The main objective of this study was to test the longer-term and differential efficacy of a mobile phone‒based life-skills training program designed to prevent substance use among adolescents.

STUDY DESIGN

A 2-arm, parallel-group, cluster RCT with assessments at baseline and follow-up after 6 and 18 months was conducted. The efficacy of the intervention was compared with that of an assessment-only control condition.

SETTING/PARTICIPANTS

A total of 1,473 students with a mean age of 15.4 years were recruited in 2019/2020 within 89 Swiss secondary and upper secondary school classes.

INTERVENTION

The automated intervention program included online feedback and individually tailored text messages provided over 22 weeks. The contents were based on social cognitive theory and addressed self-management, social, and substance use resistance skills.

MAIN OUTCOME MEASURES

Primary outcomes included 30-day prevalence rates for problem drinking and tobacco use.

RESULTS

The 18-month follow-up assessments were completed by 1,232 study (83.6%) participants. Those in the intervention group reported lower tobacco-smoking prevalence than the controls (OR=0.67; 95% CI=0.47, 0.96), but no significant difference in problem drinking (OR=0.84; 95% CI=0.61, 1.17) was observed. Among secondary outcomes, the intervention was effective at reducing cannabis-smoking prevalence (OR=0.55; 95% CI=0.39, 0.76) and cannabis use days (Cohen's d= -0.19; 95% CI= -0.29, -0.09), whereas no effects were observed for quantity of alcohol use, quantity of cigarettes smoked, well-being, or social skills. No significant moderators of the primary outcomes were observed.

CONCLUSIONS

An automated mobile phone‒based life-skills training program produced longer-term effectiveness in preventing tobacco smoking and cannabis use, whereas no effects were observed for problem drinking. These results suggest that digitally delivered life-skills training programs are similarly effective and are an easy-to-implement alternative to training conducted within a school curriculum.

TRIAL REGISTRATION

This study is registered at ISRCTN41347061 (registration date: 21/07/2018).

Young Adult Substance Use and Healthcare Use Associated With Screening, Brief Intervention and Referral to Treatment in Pediatric Primary Care

PURPOSE

Screening, brief intervention, and referral to treatment (SBIRT) may impact future comorbidity and healthcare utilization among adolescents screening positive for substance use or mood problems.

METHODS

In a randomized trial sample, we compared an SBIRT group to usual care for substance use, mental health, medical diagnoses, and healthcare utilization over 7 years postscreening.

RESULTS

In logistic regression models adjusting for patient characteristics, the SBIRT group had lower odds of any substance (Odds Ratio[OR] = 0.80, 95% Confidence Interval [CI] = 0.66-.98), alcohol (OR = 0.69, 95% CI = 0.51-0.94), any drug (OR = 0.73, 95% CI = 0.54-0.98), marijuana (OR = 0.70, 95% CI = 0.50-0.98), and tobacco (OR = 0.83, 95% CI = 0.69-1.00) diagnoses, and lower odds of any inpatient hospitalizations (OR = 0.59, 95% CI = 0.41-0.85) compared with usual care. Negative binomial models examining number of visits among adolescents with at least one visit of that type found that those in the SBIRT group had fewer primary care (incidence rate ratio[iRR] = 0.90, p < .05) and psychiatry (iRR = 0.64, p < .01) and more addiction medicine (iRR = 1.52, p < .01) visits over 7 years compared with usual care. In posthoc analyses, we found that among Hispanic patients, those in the SBIRT group had lower odds of any substance, any drug and marijuana use disorder diagnoses compared with usual care, and among Black/African American patients, those in the SBIRT group had lower odds of alcohol use disorder diagnoses compared with usual care.

DISCUSSION

Beneficial effects of adolescent SBIRT on substance use and healthcare utilization may persist into young adulthood.

Digital Health Promotion and Prevention in Settings: Scoping Review

BACKGROUND

Digital technologies are increasingly integrating into people's daily living environments such as schools, sport clubs, and health care facilities. These settings play a crucial role for health promotion and prevention because they affect the health of their members, as the World Health Organization has declared. Implementing digital health promotion and prevention in settings offers the opportunity to reach specific target groups, lower the costs of implementation, and improve the health of the population. Currently, there is a lack of scientific evidence that reviews the research on digital health promotion and prevention in settings.

OBJECTIVE

This scoping review aims to provide an overview of research targeting digital health promotion and primary prevention in settings. It assesses the range of scientific literature regarding outcomes such as applied technology, targeted setting, and area of health promotion or prevention, as well as identifies research gaps.

METHODS

The scoping review was conducted following the Levac, Colquhoun, and O'Brien framework. We searched scientific databases and gray literature for articles on digital setting-based health promotion and prevention published from 2010 to January 2020. We included empirical and nonempirical publications in English or German and excluded secondary or tertiary prevention and health promotion at the workplace.

RESULTS

From 8888 records, the search resulted in 200 (2.25%) included publications. We identified a huge diversity of literature regarding digital setting-based health promotion and prevention. The variety of technology types extends from computer- and web-based programs to mobile devices (eg, smartphone apps) and telemonitoring devices (sensors). We found analog, digital, and blended settings in which digital health promotion and prevention takes place. The most frequent analog settings were schools (39/200, 19.5%) and neighborhoods or communities (24/200, 12%). Social media apps were also included because in some studies they were defined as a (digital) setting. They accounted for 31.5% (63/200) of the identified settings. The most commonly focused areas of health promotion and prevention were physical activity (81/200, 40.5%), nutrition (45/200, 22.5%), and sexual health (34/200, 17%). Most of the interventions combined several health promotion or prevention methods, including environmental change; providing information, social support, training, or incentives; and monitoring. Finally, we found that the articles mostly reported on behavioral rather than structural health promotion and prevention.

CONCLUSIONS

The research field of digital health promotion and prevention in settings is heterogeneous. At the same time, we identified research gaps regarding the absence of valid definitions of relevant terms (eg, digital settings) and the lack of literature on structural health promotion and prevention in settings. Therefore, it remains unclear how digital technologies can contribute to structural (or organizational) changes in settings. More research is needed to successfully implement digital technologies to achieve health promotion and prevention in settings.

Optimizing scalable, technology-supported behavioral interventions to prevent opioid misuse among adolescents and young adults in the emergency department: A randomized controlled trial protocol

Preventing opioid misuse and opioid use disorder is critical among at-risk adolescents and young adults (AYAs). An Emergency Department (ED) visit provides an opportunity for delivering interventions during a rapidly changing opioid landscape. This paper describes pilot data and the protocol for a 2 × 2 factorial randomized controlled trial testing efficacy of early interventions to reduce escalation of opioid (prescription or illicit) misuse among at-risk AYAs. Interventions are delivered using technology by health coaches. AYAs ages 16-30 in the ED screening positive for prescription opioid use (+ ≥ 1 risk factor) or opioid misuse will be stratified by risk severity, sex, and age group. Participants will be randomly assigned to a condition at intake, either a live video health coach-delivered single session or a control condition of an enhanced usual care (EUC) community resource brochure. They are also randomly assigned to one of two post-intake conditions: health coach-delivered portal-like messaging via web portal over 30 days or EUC delivered at 30 days post-intake. Thus, the trial has four groups: health coach-delivered session+portal, health coach-delivered session+EUC, EUC + portal, and EUC + EUC. Outcomes will be measured at 3-, 6-, and 12-months. The primary outcome is opioid misuse based on a modified Alcohol Smoking and Substance Involvement Screening Test. Secondary outcomes include other opioid outcomes (e.g., days of opioid misuse, overdose risk behaviors), other substance misuse and consequences, and impaired driving. This study is innovative by testing the efficacy of feasible and scalable technology-enabled interventions to reduce and prevent opioid misuse and opioid use disorder. Trial Registration:ClinicalTrials.gov University of Michigan HUM00177625 NCT Registration: NCT04550715.

Brief interventions to prevent excessive alcohol use in adolescents at low-risk presenting to Emergency Departments: Three-arm, randomised trial of effectiveness and cost-effectiveness

BACKGROUND

Alcohol consumption and related harm increase rapidly from the age of 12 years. We evaluated whether alcohol screening and brief intervention is effective and cost-effective in delaying hazardous or harmful drinking amongst low-risk or abstaining adolescents attending Emergency Departments (EDs).

METHODS

This ten-centre, three-arm, parallel-group, single-blind, pragmatic, individually randomised trial screened ED attenders aged between 14 and 17 years for alcohol consumption. We sampled at random one third of those scoring at most 2 on AUDIT-C who had access to the internet and, if aged under 16, were Gillick competent or had informed consent from parent or guardian. We randomised them between: screening only (control intervention); one session of face-to-face Personalised Feedback and Brief Advice (PFBA); and PFBA plus an electronic brief intervention (eBI) on smartphone or web. We conducted follow-up after six and 12 months. The principal outcomes were alcohol consumed over the 3 months before 12-month follow up, measured by AUDIT-C; and quality-adjusted life-years.

FINDINGS

Between October 2014 and May 2015, we approached 5,016 eligible patients of whom 3,326 consented to be screened and participate in the trial; 2,571 of these were low-risk drinkers or abstainers, consuming an average 0.14 units per week. We randomised: 304 to screening only; 285 to PFBA; and 294 to PFBA and eBI. We found no significant difference between groups, notably in weekly alcohol consumption: those receiving screening only drank 0.10 units (95% confidence interval 0.05 to 0.18); PFBA 0.12 (0.06 to 0.21); PFBA and eBI 0.10 (0.05 to 0.19).

INTERPRETATION

While drinking levels remained low in this population, this trial found no evidence that PFBA with or without eBI was more effective than screening alone in reducing or delaying alcohol consumption.

Práticas de Atenção Primária à Saúde na área de drogas: revisão integrativa

RESUMO O objetivo deste estudo foi o de identificar e analisar as práticas voltadas ao consumo prejudicial de drogas na Atenção Primária à Saúde. Trata-se de Revisão integrativa que buscou estudos nas fontes Medline e Lilacs utilizando os termos ‘Atenção Primária à Saúde’ e ‘Redução do Dano’. Como resultado, incluiram-se 52 estudos, analisados de acordo com os arcabouços teóricos que orientam as práticas em saúde. Tais estudos foram sintetizados em três categorias empíricas: comportamento de risco, que incluiu intervenção breve, programas para prevenir e diminuir o uso de drogas, entre outros; fatores determinantes, que incluiu visitas domiciliares, práticas grupais e organizacionais; e necessidades em saúde, que incluiu práticas educativas emancipatórias. Conclui-se que, majoritariamente, os estudos abordam o uso de drogas pela categoria risco, com proposição de práticas para adaptação social. As intervenções relativas aos determinantes promovem a saúde, propondo melhorias em ambientes de vida e trabalho. Práticas críticas às relações sociais estabelecidas pelo complexo das drogas são minoritárias e envolvem complexidade operacional.

Diploma in primary care psychiatry: Do primary care doctors need training in cannabis use disorder module?

Background:

Cannabis is one of the most used illicit substances in India but is under-recognized and under-represented in clinical settings of India, especially at primary care. Patients usually do not seek treatment primarily for cannabis use, but it is identified on pro-active questioning by doctors. The aim is to study the clinical profiles of patients with cannabis use disorders (CUD) at primary care and to derive learning points from collaborative consultations to devise an optional module for CUD primarily for primary care doctors (PCDs).

Methods:

File review of general patients with cannabis use, identified by PCDs during collaborative video consultation module of Diploma in Primary Care Psychiatry, was performed, and their profile and management difficulties were assessed.

Result:

Twelve patients with a mean age of 31.25 ± 12.04 years were identified by PCDs over a year. All were males with psychosis being the most common comorbidity. None of the patients presented primarily for cannabis use disorder.

Conclusion:

Identifying cannabis use among patients visiting PCDs becomes all the more important as the use of cannabis is not usually revealed spontaneously unless specifically probed. This warrants establishing guidelines for CUD specifically for use of PCDs for identifying and managing CUD.

Evaluating the Effectiveness of a Web-Based Program (POP4Teens) to Prevent Prescription Opioid Misuse Among Adolescents: Randomized Controlled Trial

Background

Prescription opioid (PO) use is common among adolescents in the United States. Despite recent declines from unprecedented peaks in adolescent PO use (eg, in 2012-2013), there is seemingly paradoxical evidence that PO-related consequences (eg, opioid use disorder and overdoses) are increasing. These trends and their possible consequences emphasize the importance of prevention efforts targeting PO misuse. To our knowledge, we have developed the first interactive web-based program (POP4Teens [P4T]) focused specifically on the prevention of PO misuse among adolescents.

Objective

This study aimed to evaluate the effectiveness of P4T, a web-based program designed to prevent adolescent PO misuse, in comparison with JustThinkTwice (JTT), an active control website, on PO-related attitudes, knowledge, risk perception, and intentions to use.

Methods

We conducted a web-based randomized controlled trial in 2018. A total of 406 adolescents (aged 12-17 years) were randomly assigned to either P4T or JTT. The outcome variables were attitudes, knowledge, and risk perceptions associated with PO misuse, intentions to use POs, and program feedback. Data were collected at baseline and at 1, 3, and 6 months.

Results

Both programs resulted in significant and sustained improvements in intention to use POs, increased perceived risk, impacted expectancies consistent with prevention, and improved PO refusal skills. P4T produced significantly greater increases in PO-related knowledge than JTT did, and it was reportedly easier to use and more liked. Baseline scores for youth reporting past-year medical use of POs, friends who engage in nonmedical use of POs, and/or poor mental health underscored their at-risk status compared with youth from the other groups.

Conclusions

P4T positively impacted all study variables that are known to prevent PO misuse among teens. Moreover, its web-based nature simplifies the dissemination and implementation of this novel tool designed to help meet the challenges of the evolving national opioid crisis.

Trial Registration

ClinicalTrials.gov NCT02737696; https://clinicaltrials.gov/ct2/show/NCT02737696

Motivational Interviewing for Cannabis Use Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Cannabis is one of the most used drugs worldwide. There is no gold standard treatment for cannabis use disorder (CUD). Motivational interviewing (MI) has shown efficacy in some substance use disorders. Therefore, a systematic review was conducted to assess the effectiveness of MI in CUD.

METHODS

Randomized controlled trials or open-label studies published until September 2019 from 3 different databases (Pubmed, Scopus, and PsycINFO) were included, following the PRISMA guidelines and a predetermined set of criteria for article selection. Meta-analyses were conducted. The end point was determined as month 3, and 4 outcomes were analysed (abstinence rates, reduction in frequency of use, reduction in quantity of use, and reduction in cannabis use disorder symptoms) in 2 populations (adolescents and adults).

RESULTS

Forty studies were identified, of which 24 were performed in adults and 16 in adolescents. MI showed efficacy in achieving abstinence in both adults (odds ratio [OR] = 3.84, 95% confidence interval [CI] 2.40-6.16, p < 0.0001) and adolescents (OR = 2.02, 95% CI 1.42-2.89, p < 0.0001). MI showed efficacy in reducing frequency and quantity of use in adults but not in adolescents. Those adults who were in the MI group consumed less joints per day than those in the control group (mean difference = -0.69 joints per day, 95% CI -0.84 to -0.53, p < 0.001), and they consumed on less days per month (mean difference = -3.9 days per month, 95% CI -7.47 to -0.34, p = 0.0317) than those in the control group.

CONCLUSIONS

MI is an effective intervention to reduce cannabis use and achieve abstinence, especially among adults and patients with no prior history of psychotic disorder. Further investigation is needed to assess the effect on CUD symptoms. MI should be included in guidelines for treating cannabis use disorder as one of the essential psychological interventions.

Suspected Nonfatal Drug-Related Overdoses Among Youth in the US: 2016-2019

BACKGROUND AND OBJECTIVES

During the current drug overdose crisis, the United States is experiencing a significant number of overdose deaths, hospitalizations, and emergency department visits. Given the vulnerability of young persons to substance use, it is important to assess how this crisis affects the nation's youth. In this study, we investigate trends in suspected nonfatal drug-related overdoses (all-drugs, opioids, heroin, and stimulants) among youth using syndromic surveillance data from 2016 to 2019.

METHODS

A retrospective analysis of emergency department syndromic surveillance data were used to detect quarterly trends in suspected drug overdoses from April 2016 through September 2019 among youth aged 0 to 10, 11 to 14, and 15 to 24 years. Syndrome definitions were developed using chief complaint free-text and discharge diagnosis codes to identify overdoses involving all-drugs, opioids, heroin, and stimulants. Pearson χ² tests detected quarter-to-quarter changes, and joinpoint regression analysis assessed trends over time.

RESULTS

On average, there was a 2.0% increase for youth aged 0 to 10 years and a 2.3% increase for youth aged 11 to 14 years for suspected all-drug overdoses. Suspected heroin overdoses decreased by an average of 3.3% per quarter for youth aged 15 to 24 years. Among all age groups, suspected stimulant overdoses increased across the study period, 3.3% for 0 to 10-year-olds, 4.0% for 11- to 14-year-olds, and 2.3% for 15- to 24-year-olds.

CONCLUSIONS

Suspected stimulant-involved drug overdoses appear to be rising among youth. These findings could inform targeted interventions, such as stimulant-focused prevention, and comprehensive approaches, including school-based prevention and other strategies to lower morbidity and mortality.

Interventions for cannabis use disorder

How to treat adults and adolescents with a Cannabis Use Disorder is a burgeoning research area. This article reviews the empirical literature pertaining to several psychosocial approaches (cognitive-behavior therapy, motivational enhancement, and contingency management), all of which are associated with favorable outcomes. We also review the emerging research on the use of pharmacotherapy, brief interventions and technology-delivered interventions, and conclude with an overview of future research needs.

Interventions to Prevent Illicit and Nonmedical Drug Use in Children, Adolescents, and Young Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Illicit and nonmedical (use in ways other than instructed) drug use is common in adolescents and young adults and increases the risk of harmful outcomes such as injuries, violence, and poorer academic performance.

OBJECTIVE

To review the benefits and harms of interventions to prevent illicit and nonmedical drug use in children, adolescents, and young adults to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMED, PsycINFO, and the Cochrane Central Register of Controlled Trials (January 1, 2013, to January 31, 2019 [children and adolescents]; January 1, 1992, to January 31, 2019 [young adults <25 years]); surveillance through March 20, 2020.

STUDY SELECTION

Clinical trials of behavioral counseling interventions to prevent initiation of illicit and nonmedical drug use among young people.

DATA EXTRACTION AND SYNTHESIS

Critical appraisal was completed independently by 2 investigators. Data were extracted by 1 reviewer and checked by a second. Random-effects meta-analysis was used to estimate the effect sizes associated with the interventions.

MAIN OUTCOMES AND MEASURES

Number of times illicit drugs were used; any illicit drug or any cannabis use.

RESULTS

Twenty-nine trials (N = 18 353) met inclusion criteria. Health, social, or legal outcomes such as mental health symptoms, family functioning, consequences of drug use, and arrests were reported in 19 trials and most showed no group differences. The effects on illicit drug use in 26 trials among nonpregnant youth (n = 17 811) were highly variable; the pooled result did not show a clinically important or statistically significant association with illicit drug use (standardized mean difference, -0.08 [95% CI, -0.16 to 0.001]; 24 effects [from 23 studies]; n = 12 801; I2 = 57.0%). The percentage of participants using illicit drugs ranged from 2.3% to 38.6% in the control groups and 2.4% to 33.7% in the intervention groups at 3 to 32 months' follow-up. The median absolute risk difference between groups was -2.8%, favoring the intervention group (range, -11.5% to 14.8%). The remaining 3 trials provided a perinatal home-visiting intervention to pregnant Native American youth. One trial (n=322) found a reduction in illicit drug use at 38 months (eg, cannabis use in the previous month, 10.7% in the intervention group and 15.6% in the control group) but not at earlier follow-up assessments. Across all 29 trials, only 1 trial reported on harms and found no statistically significant group differences.

CONCLUSIONS AND RELEVANCE

The evidence for behavioral counseling interventions to prevent initiation of illicit and nonmedical drug use among adolescents and young adults was inconsistent and imprecise, with some interventions associated with reduction in use and others associated with no benefit or increased use. Health, social, and legal outcomes were sparsely reported, and few showed improvements.

Primary Care-Based Interventions to Prevent Illicit Drug Use in Children, Adolescents, and Young Adults: US Preventive Services Task Force Recommendation Statement

IMPORTANCE

In 2017, an estimated 7.9% of persons aged 12 to 17 years reported illicit drug use in the past month, and an estimated 50% of adolescents in the US had used an illicit drug by the time they graduated from high school. Young adults aged 18 to 25 years have a higher rate of current illicit drug use, with an estimated 23.2% currently using illicit drugs. Illicit drug use is associated with many negative health, social, and economic consequences and is a significant contributor to 3 of the leading causes of death among young persons (aged 10-24 years): unintentional injuries including motor vehicle crashes, suicide, and homicide.

OBJECTIVE

To update its 2014 recommendation, the USPSTF commissioned a review of the evidence on the potential benefits and harms of interventions to prevent illicit drug use in children, adolescents, and young adults.

POPULATION

This recommendation applies to children (11 years and younger), adolescents (aged 12-17 years), and young adults (aged 18-25 years), including pregnant persons.

EVIDENCE ASSESSMENT

Because of limited and inadequate evidence, the USPSTF concludes that the benefits and harms of primary care-based interventions to prevent illicit drug use in children, adolescents, and young adults are uncertain and that the evidence is insufficient to assess the balance of benefits and harms. More research is needed.

RECOMMENDATION

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care-based behavioral counseling interventions to prevent illicit drug use, including nonmedical use of prescription drugs, in children, adolescents, and young adults. (I statement).

Social Media Interventions for Risky Drinking Among Adolescents and Emerging Adults: Protocol for a Randomized Controlled Trial

BACKGROUND

Despite intervention efforts to date, the prevalence of risky drinking among adolescents and emerging adults remains high, increasing the risk for health consequences and the development of alcohol use disorders. Peer influences are particularly salient among this age group, including via social media. Thus, the development of efficacious early interventions for youth, delivered with a broad reach via trained peers on social media, could have an important role in addressing risky drinking and concomitant drug use.

OBJECTIVE

This paper describes the protocol of a randomized controlled trial (RCT) testing the efficacy of a social media intervention among adolescents and emerging adults who meet the criteria for risky drinking (using the Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]), delivered with and without financial incentives for participation, compared with an attention placebo control condition (ie, entertaining social media content), on alcohol consumption and consequences.

METHODS

This RCT involved recruiting 955 youths (aged 16-24 years) via advertisements on Facebook and Instagram to self-administer a brief web-based screening survey. Those screening positive for past 3-month risky drinking (AUDIT-C positive: ages 16-17 years: ≥3 females and ≥4 males; and ages 18-24 years: ≥4 females and ≥5 males) were eligible for the RCT. After providing consent (a waiver of parental consent was obtained for minors), participants completed a web-based baseline survey and several verification procedures, including a selfie photo matched to Facebook profile photos. Participants were then randomized to join invitation-only secret Facebook groups, which were not searchable or viewable by parents, friends, or anyone not recruited by the study. The 3 conditions were social media intervention with incentives, social media intervention without incentives (SMI), and attention placebo control. Each condition lasted 8 weeks and consisted of bachelor's-level and master's-level therapist electronic coaches posting relevant content and responding to participants' posts in a manner consistent with Motivational Interviewing. Participants in the control condition and SMI condition did not receive payments but were blind to condition assignment between these 2 conditions. Follow-ups are ongoing and occur at 3, 6, and 12 months poststart of the groups.

RESULTS

We enrolled 955 participants over 10 waves of recruitment who screened positive for risky drinking into the RCT.

CONCLUSIONS

The findings of this study will provide the critical next step in delivering early alcohol interventions to the youth, capitalizing on social media platforms, which could have significant public health impact by altering alcohol use trajectories of adolescents and emerging adults engaged in risky drinking.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02809586; https://clinicaltrials.gov/ct2/show/NCT02809586.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/16688.

Prescription opioid misuse among adolescents and emerging adults in the United States: A scoping review

The U.S. opioid epidemic is a critical public health problem. As substance use and misuse typically begin in adolescence and emerging adulthood, there is a critical need for prevention efforts for this key developmental period to disrupt opioid misuse trajectories, reducing morbidity and mortality [e.g., overdose, development of opioid use disorders (OUD)]. This article describes the current state of research focusing on prescription opioid misuse (POM) among adolescents and emerging adults (A/EAs) in the U.S. Given the rapidly changing nature of the opioid epidemic, we applied PRISMA Scoping Review (PRISMA-ScR) guidelines to identify empirical articles published in the past 5 years (January 2013-September 2018) from nine databases examining POM among A/EAs (ages 10-25) in the U.S. Seventy-six articles met our inclusion criteria focusing on POM in the following areas: cross-sectional surveys (n = 60), longitudinal cohort studies (n = 5), objective, non-self-reported data sources (n = 9), and interventions (n = 2). Final charted data elements were organized by methodology and sample, with results tables describing design, sample, interventions (where applicable), outcomes, and limitations. Most studies focused on the epidemiology of POM and risk/protective factors, including demographic (e.g., sex, race), individual (e.g., substance use, mental health), and social (e.g., peer substance use) factors. Despite annual national surveys conducted, longitudinal studies examining markers of initiation and escalation of prescription opioid misuse (e.g., repeated overdoses, time to misuse) are lacking. Importantly, few evidence-based prevention or early intervention programs were identified. Future research should examine longitudinal trajectories of POM, as well as adaptation and implementation of promising prevention approaches.

Understanding Which Teenagers Benefit Most From a Brief Primary Care Substance Use Intervention

BACKGROUND AND OBJECTIVES

The primary care (PC) setting provides an opportunity to address adolescent alcohol and marijuana use. We examined moderators of effectiveness for a PC brief motivational intervention on adolescents' alcohol and marijuana use and consequences 1 year later.

METHODS

We conducted a randomized controlled trial in 4 PC clinics from April 2013 to November 2015 and followed adolescents using Web-based surveys. We examined whether demographic factors and severity of use moderated 12-month outcomes. Adolescents aged 12 through 18 were screened by using the National Institute on Alcohol Abuse and Alcoholism Screening Guide. Those identified as at risk were randomly assigned to the intervention (CHAT) or to usual care (UC).

RESULTS

The sample (n = 294) was 58% female, 66% Hispanic, 17% African American, 12% white, and 5% multiethnic or of other race with an average age of 16 years. After controlling for baseline values of outcomes, teens in CHAT who reported more negative consequences from drinking or had an alcohol use disorder at baseline reported less alcohol use, heavy drinking, and consequences 1 year later compared with teens in UC. Similarly, teens in CHAT with more negative consequences from marijuana use at baseline reported less marijuana use 1 year later compared with teens in UC; however, teens in CHAT who reported fewer marijuana consequences at baseline reported greater marijuana use 1 year later compared with teens in UC.

CONCLUSIONS

A brief intervention can be efficacious over the long-term for adolescents who report problems from alcohol and marijuana use. Findings emphasize the importance of both screening and intervention in at-risk adolescents in PC.

Web-Based Prescription Opioid Abuse Prevention for Adolescents: Program Development and Formative Evaluation

Background

The unprecedented number of youths engaged in nonmedical use of prescription opioids (POs), as well as the myriad negative consequences of such misuse, emphasizes the importance of prevention efforts targeting this public health crisis. Although there are several science-based, interactive drug abuse prevention programs focused on preventing the use of nonprescription drugs in youths, to our knowledge, there are no science-based interactive programs that focus on the prevention of PO abuse among adolescents.

Objective

The aim of this study was to develop and conduct a formative evaluation of a science-based interactive Web-based program focused on the prevention of PO abuse among adolescents aged 12 to 17 years (Pop4Teens). This study was conducted to prepare for a randomized controlled trial designed to evaluate the effectiveness of Pop4Teens compared with an active control website, JustThinkTwice.com (Drug Enforcement Administration), in impacting knowledge and attitudes about POs and perceptions of risk associated with the abuse of POs, as well as intentions to use and actual use of POs.

Methods

We conducted 6 focus groups with 30 youths (a mean of 5 per group: the eligibility being aged 12-19 years) along a continuum of exposure to POs (in treatment for opioid use disorder, in general treatment for other substance use disorder, prescribed an opioid, and opioid-naïve) and writing sessions with 30 youths in treatment for opioid use disorder (12-19 years) to inform the development of the Web-based prevention tool. Feasibility and acceptability of a prototype of the Web-based intervention were then assessed through individual feedback sessions with 57 youths (drawn from the same populations as the focus groups).

Results

We successfully completed the development of a Web-based PO abuse prevention program (Pop4Teens). Analyses of focus group transcripts informed the development of the program (eg, quiz content/format, script writing, and story editing). Selected writing session narratives anchored the planned scientific content by lending credibility and informing the development of compelling storylines intended to motivate the youth to engage with the program. Feedback session data indicated that the Web-based tool could be potentially useful and acceptable. In addition, feedback session participants demonstrated significant increases in their knowledge of key topics related to the prevention of PO abuse after the exposure to sections of the Web-based program.

Conclusions

The opioid crisis is predicted to get worse before it gets better. An effective response will likely require a multipronged strategy inclusive of effective evidence-based prevention programs acceptable to, and accessible by, a majority of youths.

Short- and long-term effects of digital prevention and treatment interventions for cannabis use reduction: A systematic review and meta-analysis

BACKGROUND

Frequent Cannabis use has been linked to a variety of negative mental, physical, and social consequences. We assessed the effects of digital prevention and treatment interventions on Cannabis use reduction in comparison with control conditions.

METHODS

Systematic review with two separate meta-analyses. Thirty randomized controlled trials met the inclusion criteria for the review, and 21 were included in the meta-analyses. Primary outcome was self-reported Cannabis use at post-treatment and follow-up. Hedges's g was calculated for all comparisons with non-active control. Risk of bias was examined with the Cochrane risk-of-bias tool.

RESULTS

The systematic review included 10 prevention interventions targeting 8138 participants (aged 12 to 20) and 20 treatment interventions targeting 5195 Cannabis users (aged 16 to 40). The meta-analyses showed significantly reduced Cannabis use at post-treatment in the prevention interventions (6 studies, N = 2564, g = 0.33; 95% CI 0.13 to 0.54, p =  0.001) and in the treatment interventions (17 comparisons, N = 3813, g = 0.12; 95% CI 0.02 to 0.22, p =  0.02) as compared with controls. The effects of prevention interventions were maintained at follow-ups of up to 12 months (5 comparisons, N = 2445, g = 0.22; 95% CI 0.12 to 0.33, p <  0.001) but were no longer statistically significant for treatment interventions.

CONCLUSIONS

Digital prevention and treatment interventions showed small, significant reduction effects on Cannabis use in diverse target populations at post-treatment compared to controls. For prevention interventions, the post-treatment effects were maintained at follow-up up to 12 months later.

Technology-Based Alcohol Interventions in Primary Care: Systematic Review

Background

Primary care settings are uniquely positioned to reach individuals at risk of alcohol use disorder through technology-delivered behavioral health interventions. Despite emerging effectiveness data, few efforts have been made to summarize the collective findings from these delivery approaches.

Objective

The aim of this study was to review recent literature on the use of technology to deliver, enhance, or support the implementation of alcohol-related interventions in primary care. We focused on addressing questions related to (1) categorization or target of the intervention, (2) descriptive characteristics and context of delivery, (3) reported efficacy, and (4) factors influencing efficacy.

Methods

We conducted a comprehensive search and systematic review of completed studies at the intersection of primary care, technology, and alcohol-related problems published from January 2000 to December 2018 within EBSCO databases, ProQuest Dissertations, and Cochrane Reviews. Of 2307 initial records, 42 were included and coded independently by 2 investigators.

Results

Compared with the years of 2000 to 2009, published studies on technology-based alcohol interventions in primary care nearly tripled during the years of 2010 to 2018. Of the 42 included studies, 28 (64%) were randomized controlled trials. Furthermore, studies were rated on risk of bias and found to be predominantly low risk (n=18), followed by moderate risk (n=16), and high risk (n=8). Of the 24 studies with primary or secondary efficacy outcomes related to drinking and drinking-related harms, 17 (71%) reported reduced drinking or harm in all primary and secondary efficacy outcomes. Furthermore, of the 31 studies with direct comparisons with treatment as usual (TAU), 13 (42%) reported that at least half of the primary and secondary efficacy outcomes of the technology-based interventions were superior to TAU. High efficacy was associated with provider involvement and the reported use of an implementation strategy to deliver the technology-based intervention.

Conclusions

Our systematic review has highlighted a pattern of growth in the number of studies evaluating technology-based alcohol interventions in primary care. Although these interventions appear to be largely beneficial in primary care, outcomes may be enhanced by provider involvement and implementation strategy use. This review enables better understanding of the typologies and efficacy of these interventions and informs recommendations for those developing and implementing technology-based alcohol interventions in primary care settings.

Exploring the components of an efficacious computer brief intervention for reducing marijuana use among adults in the emergency department

OBJECTIVE

To examine the efficacious components of a computer-delivered brief intervention (CBI) for reducing marijuana use among adults presenting to a low-income urban emergency department (ED), which a prior report found to decrease marijuana use at a 6-month follow-up.

METHOD

Participants were 237 ED patients reporting recent drug use (46% male; 54% African-American; mean age, 30.7) who were randomized to receive a CBI consisting of an interactive program guided by a virtual health counselor. The primary outcome was past 30-day marijuana use at 6-month follow-up assessed using the Timeline Follow-Back (TLFB). Intervention components related to change in marijuana use at 6 month follow-up examined in the current study included participant responses to items within five CBI domains that were rooted in motivational interviewing: goals for change, strengths, evoking-change (concerns about use and benefits of change), challenges, and tools for change.

RESULTS

The evoking-change domain was related to significant reductions in marijuana use at 6 months (B = -2.91, SE = 1.10, p < .01). Within this domain, items focused on concerns about family and friends were related to reductions in marijuana use of up to 5.5 fewer days of marijuana use in the past month (B = -5.49, SE = 1.63, p < .01).

CONCLUSIONS

An ED-based brief intervention, delivered by computer, was effective in reducing marijuana use. Intervention components focused on perceived concerns about use and benefits of change in relation to family and friends were critical domains within a CBI associated with reductions in marijuana use at 6-month follow-up.

Consumer Health Information Technology in the Prevention of Substance Abuse: Scoping Review

BACKGROUND

Addiction is one of the most rapidly growing epidemics that currently plagues nations around the world. In the United States, it has cost the government more than US $700 billion a year in terms of health care and other associated costs and is also associated with serious social, physical, and mental consequences. Increasing efforts have been made to tackle this issue at different levels, from primary prevention to rehabilitation across the globe. With the use of digital technology rapidly increasing, an effort to leverage the consumer health information technologies (CHITs) to combat the rising substance abuse epidemic has been underway. CHITs are identified as patient-focused technological platforms aimed to improve patient engagement in health care and aid them in navigating the complex health care system.

OBJECTIVE

This review aimed to provide a holistic and overarching view of the breadth of research on primary prevention of substance abuse using CHIT conducted over nearly past five decades. It also aimed to map out the changing landscape of CHIT over this period.

METHODS

We conducted a scoping review using the Arksey and O'Malley's modified methodological framework. We searched 4 electronic databases (PubMed, Cochrane, Scopus, and EMBASE). Papers were included if the studies addressed the use of CHIT for primary prevention of substance abuse and were published in English between 1809 and 2018. Studies that did not focus solely on primary prevention or assessed additional comorbid conditions were eliminated.

RESULTS

Forty-two papers that met our inclusion criteria were included in the review. These studies were published between 1970 and 2018 and were not restricted by geography, age, race, or sex. The review mapped studies using the most commonly used CHIT platforms for substance abuse prevention from mass media in the 1970s to mobile and social media in 2018. Moreover, 191 studies that were exclusively focused on alcohol prevention were excluded and will be addressed in a separate paper. The studies included had diverse research designs although the majority were randomized controlled trials (RCT) or review papers. Many of the RCTs used interventions based on different behavioral theories such as family interactions, social cognitive theories, and harm-minimization framework.

CONCLUSIONS

This review found CHIT platforms to be efficacious and cost-effective in the real-world settings. We also observed a gradual shift in the types and use of CHIT platforms over the past few decades and mapped out their progression. In addition, the review detected a shift in consumer preferences and behaviors from face-to-face interactions to technology-based platforms. However, the studies included in this review only focused on the aspect of primary prevention. Future reviews could assess the effectiveness of platforms for secondary prevention and for prevention of substance abuse among comorbid populations.

Psychosocial Correlates of Marijuana Use among Pregnant and Nonpregnant Adolescent Girls

STUDY OBJECTIVE

Pregnant and nonpregnant populations in the United States report marijuana as the most commonly used illicit drug. Patterns of marijuana use and psychosocial correlates are unclear among non-treatment-seeking teenage girls. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: The objective of this study was to use cross-sectional data to examine the psychosocial correlates of recent marijuana use among a sample of 646 pregnant and nonpregnant adolescent girls presenting to urban primary care clinics (mean age = 15.6 years, SD = 1.9 years; 65% African American; 8.8% pregnant).

RESULTS

In Poisson regression analysis, frequency of marijuana use was significantly associated with greater likelihood of pregnancy (incident rate ratio [IRR], 1.30; 95% CI, 1.03-1.65), alcohol use (IRR, 1.11; 95% CI, 10.08-1.14), condomless sex (IRR, 1.95; 95% CI, 1.61-2.37), parents' drug use (IRR, 1.04; 95% CI, 1.02-1.05), and negative peer influences (IRR, 1.12; 95% CI, 1.10-1.16).

CONCLUSION

Marijuana use among adolescent girls in this sample was associated with a number of risk behaviors as well as parental and peer influences. Culturally sensitive screening and intervention approaches for marijuana use among adolescent girls should address multiple individual, relationship, and community factors, to prevent unwanted pregnancy as well as to reduce marijuana use during this vulnerable time.

On the use of digital technologies to reduce the public health impacts of cannabis legalization in Canada

The imminent legalization of recreational cannabis represents a considerable public health challenge that requires proactive measures to ensure a responsible transition. The federal government recognizes the need for strict regulation to reduce cannabis-related health harms, notably among the youth. Additionally, the government plans to oversee a national public awareness campaign as part of a harm-reduction strategy. In light of the public health risks of cannabis legalization, this paper proposes the implementation of increasingly popular, evidence-based, preventive, and therapeutic digital interventions to minimize the harms of this policy among adolescents and young adults. These E-health interventions facilitate healthcare delivery, improve patient care, and overcome stigmatization, especially in the context of substance abuse. Therefore, we argue that a continuum of digital tools, including prevention programs, educational material, and therapeutic interventions aimed at reducing risky consumption of cannabis, should be embraced as part of a comprehensive public health strategy by the federal government in anticipation of legalization later this year.

Impact of cannabis legalization on treatment and research priorities for cannabis use disorder

An increasing proportion of the world has legalized cannabis for medicinal or recreational use. The legalization trend appears to be continuing. These changes in the legislative landscape may have important health, treatment, and research implications. This review discusses public health outcomes that may be impacted by increases in cannabis availability and use. It additionally considers potential research and treatment priorities in the face of widespread cannabis legalization.

Effect of Middle School Interventions on Alcohol Misuse and Abuse in Mexican American High School Adolescents: Five-Year Follow-up of a Randomized Clinical Trial

IMPORTANCE

Substance abuse preventive interventions frequently target middle school students and demonstrate efficacy to prevent early onset and use of alcohol and illicit drugs. However, evidence of sustained results to prevent later patterns of alcohol misuse and more serious alcohol abuse disorders has been lacking, particularly for US Latino populations.

OBJECTIVE

To test whether a universal middle school prevention program can reduce the frequency of alcohol misuse and rates of alcohol use disorder 5 years after implementation with a Mexican American sample.

DESIGN, SETTING, AND PARTICIPANTS

A previous randomized clinical trial was conducted with 516 Mexican American 7th graders and at least 1 parent who identified as having Mexican origin. Three annual cohorts of families were recruited from rosters of 4 middle schools and randomized to the 9-session Bridges/Puentes family-focused group intervention or a workshop control condition. Recruitment, screening, pretest, and randomization occurred in the same academic year for each cohort: 2003-2004, 2004-2005, and 2005-2006. Data acquisition for the follow-up assessments of late-adolescent alcohol misuse and abuse, which were not included in the initial randomized clinical trial, was conducted from September 2009 to September 2014; analysis was conducted between August 2016 and July 2017. In this assessment, 420 children (81.4%) of the sample were included, when the majority were in their final year of high school.

INTERVENTIONS

The 9-session Bridges/Puentes intervention integrated youth, parent, and family intervention sessions that were delivered in the spring semester at each school, with separate groups for English-dominant vs Spanish-dominant families. The control workshop was offered during the same semester at each school, also in English and Spanish.

MAIN OUTCOMES AND MEASURES

Primary outcomes were diagnostic assessment of lifetime alcohol use disorder in the 12th grade, 5 years after the intervention, based on the Diagnostic Interview Schedule for Children and past-year frequency of alcohol use, binge drinking, and drunkenness based on the 2001 Youth Risk Behavior Survey.

RESULTS

Of the 420 participants, 215 (51.2%) were girls (mean [SD] age, 17.9 [0.62] years). The intervention reduced the likelihood of having an alcohol use disorder (β = -.93; SE, 0.47; P = .047; odds ratio, 0.39). Intervention associations with past-year alcohol use frequency, binge drinking, and drunkenness were moderated by baseline substance use. The intervention reduced the frequency of alcohol use (β = -.51; SE, 0.24; P = .04; Cohen d = 0.43) and drunkenness (β = -.51; SE, 0.26; P = .049; Cohen d = 0.41) among youth who reported any previous substance use at baseline (T1 initiators) but not among those who had not initiated any substance use (T1 abstainers) at baseline. For past-year binge drinking, the intervention finding did not reach statistical significance among T1 initiators (β = -.40; SE, 0.23; P = .09) or T1 abstainers (β = .23; SE, 0.14; P = .11).

CONCLUSIONS AND RELEVANCE

Study results support an association between a universal middle school intervention and alcohol misuse and alcohol use disorders among Mexican American high school students and implementation of universal middle school interventions to reach Latino communities.

Intervention to Increase HIV Testing Among Substance-Using Young Men Who Have Sex With Men: Protocol for a Randomized Controlled Trial

BACKGROUND

Young men who have sex with men (YMSM) and transgender people in the Detroit Metro Area are the only risk group for whom the incidence of HIV and sexually transmitted infections (STI) has increased since 2000, with HIV incidence nearly doubling among youth. Substance use (including alcohol), which is relatively frequent among YMSM and transgender people, creates barriers to the optimal delivery of HIV prevention and care services. Standard HIV counseling, testing, and referral (CTR) is limited in providing strategies to identify and address substance use. Hence, in its current form, CTR may not be serving the prevention needs of substance-using YMSM and transgender people. Brief counseling interventions, grounded in principles of motivational interviewing, may offer a mechanism to meet the HIV prevention and care needs of substance-using YMSM and transgender people.

OBJECTIVE

This prospective, 4-arm, factorial randomized controlled trial aims to examine the efficacy of an motivational interviewing-based substance use brief intervention (SUBI) on participants' substance use and engagement in HIV prevention.

METHODS

The research implements a prospective randomized controlled trial (Project Swerve) of 600 YMSM and transgender people recruited both online and in person. Eligibility criteria include participants who (1) are between the ages of 15 to 29 years, (2) live in the Detroit Metro Area, (3) self-identify as a man or transgender man or woman, (4) have had sexual contact with a man in the 6 months before enrollment, (5) self-report binge drinking or any substance use in the 3 months before enrollment, and (6) self-report an unknown or negative HIV status upon enrollment. Participants are randomized to receive, 3-months apart starting at baseline, 2 individual sessions. Sessions are CTR-only, SUBI-only, CTR followed by SUBI, or SUBI followed by CTR.

RESULTS

Project Swerve was launched in April 2017 and enrollment is ongoing.

CONCLUSIONS

Incorporating a SUBI that utilizes the principles of motivational interviewing into HIV CTR provides an opportunity to tailor counseling services for YMSM and transgender people to address additional client barriers to HIV and STI testing.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02945436; http://clinicaltrials.gov/ct2/show/NCT02945436 (Archived by WebCite at http://www.webcitation.org/6yFyOK57w).

Pediatrician and Behavioral Clinician-Delivered Screening, Brief Intervention and Referral to Treatment: Substance Use and Depression Outcomes

PURPOSE

Early intervention for adolescent substance use and mental health problems may mitigate potential harm. We examined patient outcomes from a pragmatic trial of two modalities of delivering screening, brief intervention, and referral to treatment (SBIRT) and usual care (UC) in pediatric primary care.

METHODS

All clinic pediatricians (n = 52) were randomized to three arms: (1) pediatrician-only, in which pediatricians were trained to deliver SBIRT; (2) embedded behavioral clinician (BC), in which pediatricians were trained to refer eligible adolescents to a BC who administered SBIRT; and (3) UC. Using electronic health record data, changes in past year substance use and depression symptoms between the index visit and next screening visit were examined across treatment arms.

RESULTS

Among patients who endorsed substance use and/or depression symptoms or were eligible for further assessments, brief interventions, and referrals based on clinician assessment at the index visit, 648 patients (mean age = 15.2 [standard deviation = 1.2]) were rescreened at a follow-up visit between 6 months and 2 years later. Among all patients, self-reported substance use rates did not differ over time or across arms, and depression symptoms increased over time. The embedded BC arm had lower odds of having depression symptoms at follow-up than the physician-only arm, and lower odds than the UC arm although not significant; we found no differences between the pediatrician-only and UC arms.

CONCLUSIONS

The increase in depression symptoms over time highlights this population's vulnerability and the importance of developing appropriate interventions. An embedded BC in pediatric primary care trained in SBIRT may benefit patients with depression symptoms.

The efficacy of computerized interventions to reduce cannabis use: A systematic review and meta-analysis

BACKGROUND AND AIMS

Cannabis is the most widely consumed illicit drug. Although it is too early to confirm the impact of legalization, the use of cannabis appears to be on the rise in some countries due to its authorization for medical/recreational purposes. Among different types of therapeutic approaches to reduce cannabis use, computerized interventions are becoming a new treatment option. To assess their efficacy, a systematic review and meta-analysis was conducted.

METHODS

A systematic review and meta-analysis was performed employing randomized controlled clinical trials indexed in MEDLINE and PsycINFO. The principal outcome measure was cannabis use, and the secondary one was the use of other substances during interventions. A subgroup analysis was conducted by length of follow-up, number of sessions, age group, type of analysis, and type of control condition.

RESULTS

The meta-analysis included nine studies with 2963 participants. Computerized interventions resulted in significant reductions in the use of cannabis (standardized mean difference [SMD]: -0.19; 95% CI: -0.26, -0.11) and other substances (SMD: -0.27; 95% CI: -0.46, -0.08).

CONCLUSIONS

Computerized interventions examined in the present study reduced the frequency of cannabis and other substance use. Limitations included the recalculation of dichotomous and continuous data as SMD and the lower number of studies included in the secondary outcome. Computerized interventions could be a viable option to reduce cannabis use.

Specialty addiction and psychiatry treatment initiation and engagement: Results from an SBIRT randomized trial in pediatrics

OBJECTIVE

Many adolescents needing specialty addiction or psychiatry treatment never access care. We examined initiation and engagement with addiction and/or psychiatry treatment among adolescents referred to treatment from a trial comparing two different modalities of delivering Screening, Brief Intervention and Referral to Treatment (SBIRT) to Usual Care in pediatric primary care. We hypothesized that both intervention arms would have higher initiation and engagement rates than usual care.

METHODS

We randomized all pediatricians (n=52) in a pediatric primary care clinic to three arms: 1) pediatrician-only arm, in which pediatricians were trained to deliver SBIRT for substance use and/or mental health problems; 2) embedded-behavioral health clinician (embedded-BHC arm), in which pediatricians referred adolescents who endorsed substance use and/or mental health problems to a BHC; and 3) Usual Care (UC). We used electronic health record (EHR) data to examine specialty addiction and psychiatry treatment initiation and engagement rates after referral.

RESULTS

Among patients who screened positive for substance use and/or mental health problems and were referred to specialty addiction and/or psychiatry (n=333), those in the embedded-BHC arm had almost four times higher odds of initiating treatment than those in the pediatrician-only arm, OR=3.99, 95% CI=[1.99-8.00]. Compared to UC, those in the pediatrician-only arm had lower odds of treatment initiation (OR=0.53, 95% CI=[0.28-0.99]), while patients in the embedded-BHC arm had marginally higher odds (OR=1.83, 95% CI=[0.99-3.38]). Black patients and those with other/unknown race/ethnicity had lower odds of treatment initiation compared with white adolescents; there were no gender or age differences. We found no differences in treatment engagement across the three arms.

CONCLUSIONS

Embedded BHCs can have a significant positive impact on facilitating treatment initiation for pediatric primary care adolescents referred to addiction and/or psychiatry services.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov #NCT02408952.

Computer-Based Prevention and Intervention to Reduce Substance Use in Youth

Purpose of Review

Computer-based programs for substance use prevention and intervention among youth are on the ascendancy. Whether delivered by computer per se or by electronic tablet or smartphone, technology-driven programs are harmonious with how young people access information and interact with their worlds. This review examines recent evidence on computer-based programs aimed at substance use among youth, with particular attention to results from randomized trials.

Recent Findings

Outcome studies of computer-based, substance use-related programs published over the past 5 years reveal mixed results amidst diverse intervention approaches and delivery settings. Many studies are marred by high attrition. Notable in the recent literature is the international nature of technology-driven substance use prevention and intervention programs. With some exceptions, most programs appear to not have been customized for their recipient populations. Though few in number, the highest-quality studies of computer-based programs show positive outcomes in reduced substance use rates.

Summary

Based on recent findings, considerable work needs to happen before computer-delivered approaches are a proven means for reducing substance use among youth. Original programs, expressly developed for subgroups of youth, are in short supply. Though controlled designs are becoming commonplace, too many studies of computer-based programs suffer from flaws-including high rates of attrition-that limit the discovery of positive outcomes.

Marijuana use trajectories among drug-using youth presenting to an urban emergency department: Violence and social influences

AIMS

This paper examined longitudinal marijuana use trajectories among drug-using youth presenting to the ED to inform intervention development.

METHODS

Given interest in substance use and violence, this study oversampled those presenting with assault injuries. Assault-injured youth (ages 14-24) endorsing past 6-month drug use (n=349), and a sex and age proportionally-sampled comparison group (n=250) endorsing drug use, completed a baseline assessment and follow-ups at 6, 12, 18, and 24 months. Latent class trajectory analyses examined days of marijuana use over 2 years. Multinomial regression analyses examined baseline, 12-month and 24-month factors associated with substance use trajectory groups.

RESULTS

Trajectory analyses identified 5 groups: Low (Low; 28.2%; n=169); Intermittent (INT; 16.2%; n=97); Moderate Decline (MD; 12.0%; n=72); High decline (HD, 13.2%; n=79) and Chronic (C; 30.4%; n=182). At baseline, as compared to the Low group, the other trajectory groups were more likely to be male and have greater levels of physical aggression. At 12- and 24-months, negative and positive peer influences, incarceration and community violence were additional characteristics associated with the greater marijuana use trajectories (as compared to the Low group).

CONCLUSIONS

Interventions for drug-using youth presenting to the urban ED should address peer influences, physical aggression and community violence exposure, given the association between these characteristics and greater marijuana use trajectories.

Research on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go?

We reviewed research regarding system- and visit-level strategies to enhance clinical preventive service delivery and quality for adolescents and young adults. Despite professional consensus on recommended services for adolescents, a strong evidence base for services for young adults, and improved financial access to services with the Affordable Care Act's provisions, receipt of preventive services remains suboptimal. Further research that builds off successful models of linking traditional and community clinics is needed to improve access to care for all youth. To optimize the clinical encounter, promising clinician-focused strategies to improve delivery of preventive services include screening and decision support tools, particularly when integrated into electronic medical record systems and supported by training and feedback. Although results have been mixed, interventions have moved beyond increasing service delivery to demonstrating behavior change. Research on emerging technology-such as gaming platforms, mobile phone applications, and wearable devices-suggests opportunities to expand clinicians' reach; however, existing research is based on limited clinical settings and populations. Improved monitoring systems and further research are needed to examine preventive services facilitators and ensure that interventions are effective across the range of clinical settings where youth receive preventive care, across multiple populations, including young adults, and for more vulnerable populations with less access to quality care.

A Consensus-Driven Agenda for Emergency Medicine Firearm Injury Prevention Research

STUDY OBJECTIVE

To identify critical emergency medicine-focused firearm injury research questions and develop an evidence-based research agenda.

METHODS

National content experts were recruited to a technical advisory group for the American College of Emergency Physicians Research Committee. Nominal group technique was used to identify research questions by consensus. The technical advisory group decided to focus on 5 widely accepted categorizations of firearm injury. Subgroups conducted literature reviews on each topic and developed preliminary lists of emergency medicine-relevant research questions. In-person meetings and conference calls were held to iteratively refine the extensive list of research questions, following nominal group technique guidelines. Feedback from external stakeholders was reviewed and integrated.

RESULTS

Fifty-nine final emergency medicine-relevant research questions were identified, including questions that cut across all firearm injury topics and questions specific to self-directed violence (suicide and attempted suicide), intimate partner violence, peer (nonpartner) violence, mass violence, and unintentional ("accidental") injury. Some questions could be addressed through research conducted in emergency departments; others would require work in other settings.

CONCLUSION

The technical advisory group identified key emergency medicine-relevant firearm injury research questions. Emergency medicine-specific data are limited for most of these questions. Funders and researchers should consider increasing their attention to firearm injury prevention and control, particularly to the questions identified here and in other recently developed research agendas.

Technology-based Interventions for Preventing and Treating Substance Use Among Youth

Preventing or mitigating substance use among youth generally involves 3 different intervention frameworks: universal prevention, selective prevention, and treatment. Each of these levels of intervention poses unique therapeutic and implementation challenges. Technology-based interventions provide solutions to many of these problems by delivering evidence-based interventions in a consistent and cost-effective manner. This article summarizes the current state of the science of technology-based interventions for preventing substance use initiation and mitigating substance use and associated consequences among youth.

The future of screening, brief intervention and referral to treatment in adolescent primary care: research directions and dissemination challenges

PURPOSE OF REVIEW

Screening, brief intervention and referral to treatment (SBIRT) offers a practical, integrated model for addressing substance use in primary care settings. This review provides an update of the research on SBIRT for adolescents in primary care, examines current dissemination challenges and suggests future research directions.

RECENT FINDINGS

A number of brief screening tools for adolescents have been developed and tested relative to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) substance use disorders. Computerized previsit screening promotes standardization and is a more time-efficient alternative to provider interview. The adolescent brief intervention literature is growing, particularly with respect to technology-based tools, but is still limited, with evidence greatest for alcohol, and for motivational enhancement therapy interventions. Increasing SBIRT implementation in pediatric primary care remains a challenge. Using nonphysician behavioral health providers to deliver SBIRT, and embedding a screener and decision support tool in electronic medical record systems are strategies being investigated to promote SBIRT implementation.

SUMMARY

Substance use begins in adolescence, and pediatric SBIRT could help to achieve a population-level reduction of substance use-related harms. With a growing number of available tools, adolescent SBIRT effectiveness and feasibility are increasing, but more studies are needed to grow its evidence base, and elucidate strategies to increase implementation.

Prevention of alcohol and other drug use and related harm in the digital age: what does the evidence tell us?

PURPOSE OF REVIEW

Alcohol and other drug use are major contributors to the global burden of disease. Prevention is critical and evidence is beginning to support the use of online mediums to prevent alcohol and other drug use and harms among adolescents. This study aims to expand the evidence base by conducting a systematic review of recent universal prevention programs delivered by computers and the Internet.

RECENT FINDINGS

A total of 12 papers reporting outcomes from trials of nine universal online prevention programs were identified. Of the identified interventions, five targeted multiple substances, two focused solely on alcohol, one targeted only cannabis and one primarily addressed smoking. The majority of programs were delivered at school; however one was implemented in a primary care setting. Six programs demonstrated significant, but modest, effects for alcohol and/or other drug use outcomes.

SUMMARY

Evidence to support the efficacy of computer and Internet-based prevention programs for alcohol and other drug use and related harms among adolescents is rapidly emerging, demonstrating that online prevention is an area of increasing promise. Further replication work, longer-term trials and attempts to increase the impact are required.

Readiness-to-change as a moderator of a web-based brief intervention for marijuana among students identified by health center screening

INTRODUCTION

Electronic screening and brief intervention has been identified as a low cost strategy to address marijuana use among students, however there is little known about who may be most responsive to this intervention approach. This study examined whether readiness-to-change moderated the influence of a web-based intervention on frequency of use at 3-month outcomes.

METHODS

One-hundred twenty-three students who smoked marijuana at least monthly were identified by screening in a student health center. Baseline and 3-month outcome assessments were conducted on-line. Participants were randomly assigned to either eCHECKUP TO GO-marijuana or a control condition after completing marijuana measures and the Readiness-to-Change Questionnaire (RTCQ). Negative binomial regression analyses were conducted to examine whether the effect of the intervention on marijuana use at 3-month outcomes was moderated by the Action and Problem Recognition dimensions of the RTCQ, adjusting for baseline use.

RESULTS

Analyses showed a significant Intervention × Action interaction. Probing of interaction effects showed that among those with high scores on the Action scale participants in the intervention group reported significantly fewer days of use than those in the control condition at follow-up (IRR=0.53, 95%CI: 0.94, 2.08). The Problem Recognition dimension did not moderate the influence of the intervention on outcomes.

CONCLUSION

These results suggest that this eSBI may bolster change efforts among students who have begun taking steps toward changing their marijuana use.

Clinician Attitudes, Screening Practices, and Interventions to Reduce Firearm-Related Injury

Firearm injury is a leading cause of injury-related morbidity and mortality in the United States. We sought to systematically identify and summarize existing literature on clinical firearm injury prevention screening and interventions. We conducted a systematic search of PubMed, Web of Science, Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsycInfo, and ClinicalTrials.gov for English-language original research (published 1992-2014) on clinical screening methods, patient-level firearm interventions, or patient/provider attitudes on the same. Unrelated studies were excluded through title, abstract, and full-text review, and the remaining articles underwent data abstraction and quality scoring. Of a total of 3,260 unique titles identified, 72 were included in the final review. Fifty-three articles examined clinician attitudes/practice patterns; prior training, experience, and expectations correlated with clinicians' regularity of firearm screening. Twelve articles assessed patient interventions, of which 6 were randomized controlled trials. Seven articles described patient attitudes; all were of low methodological quality. According to these articles, providers rarely screen or counsel their patients-even high-risk patients-about firearm safety. Health-care-based interventions may increase rates of safe storage of firearms for pediatric patients, suicidal patients, and other high-risk groups. Some studies show that training clinicians can increase rates of effective firearm safety screening and counseling. Patients and families are, for the most part, accepting of such screening and counseling. However, the current literature is, by and large, not high quality. Rigorous, large-scale, adequately funded studies are needed.