A randomized controlled trial of brief interventions to reduce drug use among adults in a low-income urban emergency department: the HealthiER You study

Predictors of urine toxicology and other biologic specimen missingness in randomized trials of substance use disorders

BACKGROUND

High levels of missing outcome data for biologically confirmed substance use (BCSU) threaten the validity of substance use disorder (SUD) clinical trials. Underlying attributes of clinical trials could explain BCSU missingness and identify targets for improved trial design.

METHODS

We reviewed 21 clinical trials funded by the NIDA National Drug Abuse Treatment Clinical Trials Network (CTN) and published from 2005 to 2018 that examined pharmacologic and psychosocial interventions for SUD. We used configurational analysis-a Boolean algebra approach that identifies an attribute or combination of attributes predictive of an outcome-to identify trial design features and participant characteristics associated with high levels of BCSU missingness. Associations were identified by configuration complexity, consistency, coverage, and robustness. We limited results using a consistency threshold of 0.75 and summarized model fit using the product of consistency and coverage.

RESULTS

For trial design features, the final solution consisted of two pathways: psychosocial treatment as a trial intervention OR larger trial arm size (complexity=2, consistency=0.79, coverage=0.93, robustness score=0.71). For participant characteristics, the final solution consisted of two pathways: interventions targeting individuals with poly- or nonspecific substance use OR younger age (complexity=2, consistency=0.75, coverage=0.86, robustness score=1.00).

CONCLUSIONS

Psychosocial treatments, larger trial arm size, interventions targeting individuals with poly- or nonspecific substance use, and younger age among trial participants were predictive of missing BCSU data in SUD clinical trials. Interventions to mitigate missing data that focus on these attributes may reduce threats to validity and improve utility of SUD clinical trials.

Emergency Department Screening and Interventions for Adolescents With Substance Use: A Narrative Review

BACKGROUND

Adolescent substance use is a growing public health concern, particularly given rising mortality rates from drug overdose deaths. The emergency department (ED) provides a unique opportunity to screen adolescents for substance use and provide brief interventions and linkage to care.

OBJECTIVE OF THE REVIEW

This article provides a narrative review of the current evidence for ED screening and brief interventions for adolescents with substance use and identifies important opportunities, challenges, and areas for future research.

DISCUSSION

There are several validated substance use screening and assessment tools for use with adolescents that can be implemented into ED screening programs. Brief motivational interviewing interventions may reduce alcohol use, but evidence for reductions of other substances is limited due to insufficient research. Both screening and interventions are feasible and acceptable in the ED setting with the appropriate resources. Increased training and the use of emerging technology can provide emergency physicians with opportunities to incorporate these tools into practice to when treating adolescents. Linkage to outpatient care for adolescents with substance use is understudied. The research on adult patient ED interventions and linkage to care is more robust and can provide insights for future ED studies among adolescents.

CONCLUSION

ED-based adolescent substance use screening and interventions are necessary, feasible, and acceptable, but understudied. Future studies, focusing on optimizing ED interventions and linkage to care, are important next steps in determining the best care for adolescents with substance use who present to the ED.

A remote brief intervention plus social media messaging for cannabis use among emerging adults: A pilot randomized controlled trial in emergency department patients

INTRODUCTION

Interventions addressing cannabis use among emerging adults (ages 18-25) are currently needed to prevent negative outcomes. Emergency Department (ED) visits provide an opportunity to initiate interventions. In this pilot study, we created a brief intervention (BI), extended with private social media messaging for emerging adult ED patients who use cannabis regularly. Study aims were to examine intervention feasibility, acceptability, and descriptive outcomes.

METHODS

We recruited and randomized N = 58 emerging adults (M age 21.5 years, 65.5% female) who used cannabis from an ED in-person and remotely after their ED visit (given COVID-19 restrictions). Participants randomized to the intervention (N = 30) received a Motivational Interviewing-based BI and 4 weeks of health coaching via private social media; control participants received a resource brochure and entertaining social media messaging. Follow-ups occurred at 1-month and 3-months.

RESULTS

Most intervention participants liked the BI (95.8%), found it helpful to discuss cannabis use in the BI (91.7%), and liked interacting with coaches on social media (86.3%). Social media content (e.g., video clips, images/still pictures/memes) were highly rated. Descriptively, the intervention group showed theory-consistent changes in importance of and intentions to change cannabis (increases vs. decrease/stability in control group), whereas findings for cannabis consumption/consequences were mixed.

CONCLUSIONS

This BI paired with social media messaging was acceptable in a sample of emerging adults from an ED who used cannabis regularly. Despite feasibility challenges due to COVID-19, this intervention warrants future investigation with a larger sample and longer follow-up period, with attention to the changing cannabis landscape when measuring outcomes.

The EMBER trial for weight management engagement: A hybrid type 1 randomized controlled trial protocol

BACKGROUND

Almost 40% of Veterans Health Administration (VHA) users have obesity. VHA's national weight management program is associated with weight loss and improved health. However, while 94% of eligible VHA users are offered weight management programs, <8% use them. We developed EMBER - a novel, Motivational Interviewing-based, self-help tool - with the goal of Enhancing Motivation for Better Engagement and Reach for weight management. EMBER is not a weight management program; instead it engages people in existing programs by informing and guiding choices about weight management.

METHODS

The EMBER Trial is a randomized hybrid type 1 effectiveness implementation trial. Participants are Palo Alto or Houston VA Health Care System users with obesity who have not used a VHA weight management program in the past two years (target N = 470). Participants are randomly assigned to EMBER or an information-only control condition, after which they receive materials on paper or digitally, per their preference. The trial's primary goal is to determine whether participants randomized to EMBER are more likely to have any weight management engagement at two-month follow-up compared to those in the control condition. Secondary outcomes include 6-month retention in weight management, weight management behaviors, weight loss, quality of life, and implementation outcomes (e.g., reach, appropriateness).

CONCLUSION

EMBER is the first self-directed, Motivational Interviewing-based intervention designed to increase weight management program engagement. The study takes a low-touch, population health approach that could be modified for other programs if effective. The Hybrid Type 1 design will ensure results can be scaled and sustained.

Subthreshold opioid use disorder prevention (STOP) trial: a cluster randomized clinical trial: study design and methods

BACKGROUND

Preventing progression to moderate or severe opioid use disorder (OUD) among people who exhibit risky opioid use behavior that does not meet criteria for treatment with opioid agonists or antagonists (subthreshold OUD) is poorly understood. The Subthreshold Opioid Use Disorder Prevention (STOP) Trial is designed to study the efficacy of a collaborative care intervention to reduce risky opioid use and to prevent progression to moderate or severe OUD in adult primary care patients with subthreshold OUD.

METHODS

The STOP trial is a cluster randomized controlled trial, randomized at the PCP level, conducted in 5 distinct geographic sites. STOP tests the efficacy of the STOP intervention in comparison to enhanced usual care (EUC) in adult primary care patients with risky opioid use that does not meet criteria for moderate-severe OUD. The STOP intervention consists of (1) a practice-embedded nurse care manager (NCM) who provides patient participant education and supports primary care providers (PCPs) in engaging and monitoring patient-participants; (2) brief advice, delivered to patient participants by their PCP and/or prerecorded video message, about health risks of opioid misuse; and (3) up to 6 sessions of telephone health coaching to motivate and support behavior change. EUC consists of primary care treatment as usual, plus printed overdose prevention educational materials and an educational video on cancer screening. The primary outcome measure is self-reported number of days of risky (illicit or nonmedical) opioid use over 180 days, assessed monthly via text message using items from the Addiction Severity Index and the Current Opioid Misuse Measure. Secondary outcomes assess other substance use, mental health, quality of life, and healthcare utilization as well as PCP prescribing and monitoring behaviors. A mixed effects negative binomial model with a log link will be fit to estimate the difference in means between treatment and control groups using an intent-to-treat population.

DISCUSSION

Given a growing interest in interventions for the management of patients with risky opioid use, and the need for primary care-based interventions, this study potentially offers a blueprint for a feasible and effective approach to improving outcomes in this population.

TRIAL REGISTRATION

Clinicaltrials.gov, identifier NCT04218201, January 6, 2020.

A Digital Counselor-Delivered Intervention for Substance Use Among People With HIV: Development and Usability Study

BACKGROUND

Substance use disorders are prevalent and undertreated among people with HIV. Computer-delivered interventions (CDIs) show promise in expanding reach, delivering evidence-based care, and offering anonymity. Use in HIV clinic settings may overcome access barriers. Incorporating digital counselors may increase CDI engagement, and thereby improve health outcomes.

OBJECTIVE

We aim to develop and pilot a digital counselor-delivered brief intervention for people with HIV who use drugs, called "C-Raven," which is theory grounded and uses evidence-based practices for behavior change.

METHODS

Intervention mapping was used to develop the CDI including a review of the behavior change research in substance use, HIV, and digital counselors. We conducted in-depth interviews applying the situated-information, motivation, and behavior skills model and culturally adapting the content for local use with people with HIV. With a user interaction designer, we created various digital counselors and CDI interfaces. Finally, a mixed methods approach using in-depth interviews and quantitative assessments was used to assess the usability, acceptability, and cultural relevance of the intervention content and the digital counselor.

RESULTS

Participants found CDI easy to use, useful, relevant, and motivating. A consistent suggestion was to provide more information about the negative impacts of drug use and the interaction of drug use with HIV. Participants also reported that they learned new information about drug use and its health effects. The CDI was delivered by a "Raven," digital counselor, programmed to interact in a motivational interviewing style. The Raven was perceived to be nonjudgmental, understanding, and emotionally responsive. The appearance and images in the intervention were perceived as relevant and acceptable. Participants noted that they could be more truthful with a digital counselor, however, it was not unanimously endorsed as a replacement for a human counselor. The C-Raven Satisfaction Scale showed that all participants rated their satisfaction at either a 4 (n=2) or a 5 (n=8) on a 5-point Likert scale and all endorsed using the C-Raven program again.

CONCLUSIONS

CDIs show promise in extending access to care and improving health outcomes but their development necessarily requires integration from multiple disciplines including behavioral medicine and computer science. We developed a cross-platform compatible CDI led by a digital counselor that interacts in a motivational interviewing style and (1) uses evidence-based behavioral change methods, (2) is culturally adapted to people with HIV who use drugs, (3) has an engaging and interactive user interface, and (4) presents personalized content based on participants' ongoing responses to a series of menu-driven conversations. To advance the continued development of this and other CDIs, we recommend expanded testing, standardized measures to evaluate user experience, integration with clinician-delivered substance use treatment, and if effective, implementation into HIV clinical care.

Peer- and web-based interventions for risky drinking among US National Guard members: Mission Strong randomized controlled trial

AIMS

To test separatel the efficacy of a web-based and a peer-based brief intervention (BI), compared with an expanded usual care control (EUC) group, among military reserve component members using alcohoI in a hazardous and harmful manner.

DESIGN

In the randomized controlled trial, participants were assigned to: [1] web-based BI with web-based boosters (BI + web), [2] web-based BI with peer-based boosters (BI + peer) or [3] enhanced usual care (EUC).

SETTING

Michigan, USA.

PARTICIPANTS

A total of 739 Michigan Army National Guard members who reported recent hazardous alcohol use; 84% were male, the mean age was 28 years.

INTERVENTION

The BI consisted of an interactive program guided by a personally selected avatar. Boosters were delivered either on the web or personally by a trained veteran peer. A pamphlet, given to all participants, included information on hazardous alcohol use and military-specific community resources and served as the EUC condition.

MEASUREMENTS

The primary outcome measure was binge drinking episodes in the past 30 days, measured at 12 months after the BI.

FINDINGS

All randomized participants were included in the outcome analyses. In adjusted analyses, BI + peer [beta = -0.43, 95% confidence interval (CI) = -0.56 to -0.31, P < 0.001] and BI + web (beta = -0.34, 95% CI = -0.46 to -0.23, P < 0.001) reduced binge drinking compared with EUC.

CONCLUSION

This satudy was a web-based brief intervention for hazardous alcohol use, with either web- or peer-based boosters, reduced binge alcohol use among Army National Guard members.

Screening, brief intervention, and referral to treatment (SBIRT) for cannabis: A scoping review

INTRODUCTION

Screening, brief intervention, and referral to treatment (SBIRT) has been used to change substance use behavior. Despite cannabis being the most prevalent federally illicit substance, we have limited understanding of use of SBIRT for managing cannabis use. This review aimed to summarize the literature on SBIRT for cannabis use across age groups and contexts over the last two decades.

METHODS

This scoping review followed the a priori guide outlined by the PRISMA (Preferred Reporting Items for Scoping Reviews and Meta-Analyses) statement. We gathered articles from PsycINFO, PubMed, Sage Journals Online, ScienceDirect, and SpringerLink.

RESULTS

The final analysis includes forty-four articles. Results indicate inconsistent implementation of universal screens and suggest screens assessing cannabis-specific consequences and utilizing normative data may increase patient engagement. Broadly, SBIRT for cannabis demonstrates high acceptability. However, the impact of SBIRT on behavior change across various modifications to intervention content and modality has been inconsistent. In adults, patients with primary cannabis use are not engaging in recommended treatment at similar rates to other substances. Results also suggest a lack of research addressing referral to treatment in adolescents and emerging adults.

DISCUSSION

Based on this review, we offer several to improve each component of SBRIT that may increase implementation of screens, effectiveness of brief interventions, and engagement in follow-up treatment.

A randomized wait-list controlled trial to investigate the role of cognitive mechanisms in parenting interventions on mothers with substance use disorder

Background

Maternal substance use disorder (SUD) represents a risk condition for quality of parenting and child development. The current literature highlights the need to identify interventions that effectively enhance the quality of parenting and to better understand which mechanisms are involved in the process of change. The present study protocol describes a randomized wait-list controlled trial that aims to examine (1) the efficacy of the Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD) in improving the quality of parenting (i.e., sensitive parenting and sensitive discipline) in mothers with SUD, (2) whether the intervention affects parental cognitive mechanisms (i.e., attentional disengagement to infant negative emotions, inhibitory control confronted with children’s affective expression, and parental reflective functioning), and (3) whether changes in these processes act as mechanisms of change, mediating the effect of the VIPP-SD program on quality of parenting. Moreover, the study aims (4) to explore whether the VIPP-SD has an effect on parenting stress and (5) to compare mothers with SUD to low-risk mothers on the outcome measures.

Methods

The study will involve 40 mothers with SUD and 20 low-risk mothers of children aged between 14 months and 6 years old. Mothers in the SUD group will be randomly divided into two groups, one receiving the intervention (SUD experimental group) and one undergoing treatment as usual (SUD control group). All the mothers will be assessed pre-test and post-test. Quality of parenting will be assessed through observed parenting behaviors, whereas parental cognitive mechanisms will be assessed through neuropsychological tasks and self-report measures.

Discussion

The results of the study will reveal whether an intervention that has been proven effective in other at-risk samples is also effective in improving parenting behaviors in the context of SUD. The results will also provide insight into potential cognitive mechanisms involved in the process of change.

Trial registration

ISRCTN registry ISRCTN63070968. Registered on 25 June 2021. Retrospectively registered

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06420-8.

Substance use in the emergency department: Screening for risky drug use, using the ASSIST-Lite

INTRODUCTION

Substance use is a common contributing factor to emergency department (ED) presentations. While screening, brief intervention, and referral to treatment for alcohol and tobacco is common in ED settings, it is not routinely conducted for illicit substances. This study aimed to deploy the ASSIST-Lite to screen for risky use of alcohol and other drugs in the ED, to identify differences in risk based on between demographic characteristics.

METHOD

All ED attenders, aged 18 years or older, deemed well enough to participate were approached. Recruitment occurred at the Royal Adelaide Hospital ED between May and June 2017. Participants were asked to self-complete the ASSIST-Lite in the ED waiting room. Overall, 632 people were approached, of which 479 (75.8%) agreed to participate.

RESULTS

Alcohol (72.2%), tobacco (27.1%) and cannabis (15.2%) were most commonly reported. Eighty-nine participants reported moderate- or high-risk use of two substances, and a further 49 individuals reported moderate- or high-risk use of three or more substances. Across most substances, age, gender and employment status was associated with risky substance use, with higher likelihood of risk reported by males, unemployed and younger participants. Unemployment was also significantly associated with increased risk severity for both moderate and high-risk illicit use.

DISCUSSIONS AND CONCLUSIONS

The rate of risky illicit and polysubstance use found here highlight the need more focused research in ED settings. The findings also provide support for more routine screening, and early intervention approaches; and suggest the need for active referral pathways through an alcohol and other drug consultation liaison service.

Payment and Financing for Substance Use Screening and Brief Intervention for Adolescents and Adults in Health, School, and Community Settings

Screening and brief intervention (SBI) is an evidence-based, cost-effective practice to address unhealthy substance use. With SBI services expanding beyond healthcare settings (e.g., schools, community organizations) and reaching younger populations, sustainability efforts must consider payment and financing. This narrative review incorporated rapid scoping review methods and a search of the gray literature to determine payment and financing approaches for SBI with adolescents and to describe related barriers and facilitators for its sustainability. We sought information relevant to adolescents and settings in which they receive SBI, but also reviewed sources with an adult focus. Few peer-reviewed articles met inclusion criteria, and those mostly highlighted healthcare settings. School-based settings were better described in the gray literature; little was found about community settings. SBI is mostly paid through grant funding and public and commercial insurance; school-based settings use a range of approaches including grants, public insurance, and other public funding. We call upon researchers and providers to describe the payment and financing of SBI, to inform how the uptake of SBI may be practicable and sustainable. The increasing activation and use of insurance billing codes, and the expansion of SBI beyond healthcare, is encouraging to address unhealthy substance use by adolescents.

Implementing a text-messaging intervention for unhealthy alcohol use in emergency departments: protocol for implementation strategy development and a pilot cluster randomized implementation trial

BACKGROUND

Unhealthy alcohol use (UAU) is a leading cause of premature mortality among adults in the USA. Emergency departments (EDs) are key intervention settings for UAU but often have limited time and resources. One low-burden, scalable approach to address UAU is text-messaging interventions. Despite strong research support and promise for scalability, there is little research on how to implement such interventions in healthcare settings. The process of providers making them available to patients in an efficient way within already busy and overburdened ED workflows and patients adopting them remains a new area of research. The purpose of this three-phase study is to develop and test an implementation strategy for UAU text-messaging interventions in EDs.

METHOD

Our first aim is to examine barriers and facilitators to staff offering and patients accepting a text-messaging intervention in the ED using an explanatory, sequential mixed methods approach. We will examine alcohol screening data in the electronic health records of 17 EDs within a large integrated health system in the Northeast and conduct surveys among chairpersons in each. This data will be used to purposively sample 4 EDs for semi-structured interviews among 20 clinical staff, 20 patients, and 4 chairpersons. Our second aim is to conduct a stakeholder-engaged intervention mapping process to develop a multi-component implementation strategy for EDs. Our third aim is to conduct a mixed method 2-arm cluster randomized pilot study in 4 EDs that serve ~11,000 UAU patients per year to assess the feasibility, acceptability, and preliminary effectiveness of the implementation strategy. The Integrated Promoting Action on Research Implementation in Health Services framework will guide study activities.

DISCUSSION

Low-burden technology, like text messaging, along with targeted implementation support and strategies driven by identified barriers and facilitators could sustain large-scale ED-based alcohol screening programs and provide much needed support to patients who screen positive while reducing burden on EDs. The proposed study would be the first to develop and test this targeted implementation strategy and will prepare for a larger, fully powered hybrid effectiveness-implementation trial. Findings may also be broadly applicable to implementation of patient-facing mobile health technologies.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov (NCT05350878) on 4/28/2022.

Efficacy of Brief Intervention for Unhealthy Drug Use in Outpatient Medical Care: a Systematic Review and Meta-analysis

BACKGROUND

The efficacy of brief intervention (BI) for unhealthy drug use in outpatient medical care has not been sufficiently substantiated through meta-analysis despite its ongoing global delivery. This study aims to determine the efficacy of BI for unhealthy drug use and the expected length of effects, and describe subgroup analyses by outpatient setting.

METHODS

Trials comparing BI with usual care controls were retrieved through four databases up to January 13, 2021. Two reviewers independently screened, selected, and extracted data. Primary outcomes included drug use frequency (days used) and severity on validated scales at 4-8 months and were analyzed using random-effects model meta-analysis.

RESULTS

In total, 20 studies with 9182 randomized patients were included. There was insufficient evidence to support the efficacy of BI for unhealthy drug use among all outpatient medical care settings for use frequency (SMD = -0.07, 95% CI = -0.17, 0.02, p = 0.12, I² = 37%, high certainty of evidence) and severity (SMD = -0.27, 95% CI = -0.78, 0.24, p = 0.30, I² = 98%, low certainty of evidence). However, post hoc subgroup analyses uncovered significant effects for use frequency by setting (interaction p = 0.02), with significant small effects only in emergency departments (SMD = -0.15, 95% CI = -0.25, -0.04, p < 0.01). Primary care, student health, women's health, and HIV primary care subgroups were nonsignificant. Primary care BI revealed nonsignificant greater average use in the treatment group compared to usual care.

DISCUSSION

BI for unhealthy drug use lacks evidence of efficacy among all outpatient medical settings. However, small effects found in emergency departments may indicate incremental benefits for some patients. Clinical decisions for SBI or specialty treatment program referrals should be carefully considered accounting for these small effects in emergency departments.

REGISTRATION

PROSPERO (CRD42020157733).

The Emergency Department Longitudinal Integrated Care (ED-LINC) intervention targeting opioid use disorder: A pilot randomized clinical trial

INTRODUCTION

Opioid use disorder (OUD) and related comorbid conditions are highly prevalent among patients presenting to emergency department (ED) settings. Research has developed few comprehensive disease management strategies for at-risk patients presenting to the ED that both decrease illicit opioid use and improve initiation and retention in medication treatment for OUD (MOUD).

METHODS

The research team conducted a pilot pragmatic clinical trial that randomized 40 patients presenting to a single ED to a collaborative care intervention (n = 20) versus usual care control (n = 20) conditions. Interviewers blinded to patient intervention and control group status followed-up with participants at 1, 3, and 6 months after presentation to the ED. The 3-month Emergency Department Longitudinal Integrated Care (ED-LINC) collaborative care intervention for patients at risk for OUD included: 1) a Brief Negotiated Interview at bedside, 2) overdose education and facilitation of MOUD, 3) longitudinal proactive care management, 4) utilization of the statewide health information exchange platform for 24/7 tracking of recurrent ED utilization, and 5) weekly caseload supervision that incorporated measurement-based care treatment assessment with stepped-up care for patients with recalcitrant symptoms.

RESULTS

Overall, the ED-LINC intervention was feasibly delivered and acceptable to patients. The pilot study achieved >80% follow-up rates at 1, 3, and 6 months. In adjusted longitudinal mixed model regression analyses, no statistically significant differences existed in days of opioid use over the past 30 days for ED-LINC intervention patients when compared to patients receiving usual care (incidence-rate ratio (IRR) 1.50, 95% CI 0.54-4.16). The unadjusted mean number of days of illicit opioid use decreased at the 1-month and 3-month follow-up time points for both groups. ED-LINC intervention patients had increased rates of MOUD initiation compared to control patients (50% versus 30%); intervention versus control comparisons did not achieve statistical significance, although power to detect significant differences in the pilot was limited.

CONCLUSIONS

The ED-LINC intervention for patients with OUD can be feasibly implemented and warrants testing in larger scale, adequately powered randomized pragmatic clinical trial investigations.

CLINICALTRIALS

gov NCT03699085.

Effects of brief substance use interventions delivered in general medical settings: a systematic review and meta-analysis

AIMS

To estimate effects of brief substance use interventions delivered in general medical settings.

METHODS

A systematic review and meta-analysis of randomized trials conducted since 1990 of brief substance use interventions in patients of any age or severity level recruited in general medical settings. Primary outcomes were any measure of substance use or substance-related consequences (indexed with Hedges' g and risk ratios). Mixed-effects meta-regressions were used to estimate overall effects and predictors of effect variability. Analyses were conducted separately by brief intervention (BI) target substance: alcohol only or drugs.

FINDINGS

A total of 116 trials (64 439 participants) were identified; 111 (62 263 participants) provided effect size data and were included in the meta-analysis. Drug-targeted BIs yielded significant small improvements in multiple drug/mixed substance use (Hedges' g ( g ¯ ) = 0.08; 95% CI = 0.002, 0.15), but after adjusting for multiple comparisons, they did not produce significant effects on cannabis use ( g ¯ = 0.06; 95% CI = 0.001, 0.12), alcohol use ( g ¯ = 0.08; 95% CI = -0.0003, 0.17), or consequences ( g ¯ = 0.05; 95% CI = 0.01, 0.10). Drug-targeted BIs yielded larger improvements in multiple drug/mixed substance use when delivered by a general practitioner ( g ¯ = 0.19; 95% CI = 0.187, 0.193). Alcohol-targeted BIs yielded small beneficial effects on alcohol use ( g ¯ = 0.12; 95% CI 0.08, 0.16), but no evidence of an effect on consequences ( g ¯ = 0.05; 95% CI = -0.04, 0.13). However, alcohol-targeted BIs only had beneficial effects on alcohol use when delivered in general medical settings ( g ¯ = 0.17; 95% CI = 0.10, 0.24); the findings were inconclusive for those delivered in emergency department/trauma centers ( g ¯ = 0.05; 95% CI = 0.00, 0.10).

CONCLUSIONS

When delivered in general medical settings, alcohol-targeted brief interventions may produce small beneficial reductions in drinking (equivalent to a reduction in 1 drinking day per month). There is limited evidence regarding the effects of drug-targeted brief interventions on drug use.

Technological Interventions for the Treatment of Substance Use Disorders

Substance use disorders (SUDs) pose a major public health concern. In recent years, technological (i.e., e-health) interventions have emerged and are increasingly offered in a variety of settings, including substance use treatment. E-health interventions encompass a wide variety of advantages depending on the chosen delivery format. This chapter discusses existing interventions and the effectiveness of delivering them as an e-health intervention, with a focus on randomized controlled trials, for the treatment of alcohol, cannabis, opioid, psychostimulant, or poly-substance use, as well as in transdiagnostic interventions. Based on the literature, suggestions for future research and clinical implications are discussed.

An evaluation of StaySafe, a tablet app to improve health risk decision-making among people under community supervision

BACKGROUND

A self-administered tablet app, StaySafe, helps people under community supervision to make better decisions regarding health risk behaviors, especially those linked to HIV, viral hepatitis, and other sexually transmitted infections. The multi-session StaySafe design uses an interactive, analytical schema called WORKIT that guides users through a series of steps, questions, and exercises aimed at promoting critical thinking about health risks associated with substance use and unprotected sex. Repetition of the WORKIT schema is designed to enhance procedural memory that can be rapidly accessed when individuals are faced with making decisions about risky behaviors.

METHODS

A total of 511 participants under community supervision in community and residential treatment settings from three large Texas counties completed consent forms and baseline surveys, followed by randomization to one of two conditions: 12 weekly StaySafe sessions or standard practice (SP). The study also asked participants to complete a follow-up survey three months after baseline. Outcome measures included knowledge, confidence, and motivation (KCM) scales around HIV knowledge, avoiding risky sex, HIV services, and reducing health risks; decision-making; and reports of talking about issues such as making better decisions, avoiding HIV risks, and HIV prevention or treatment with others (probation officers, counselors, trusted friend or advisor, or family members).

RESULTS

Participants in both community and residential settings voluntarily completed multiple StaySafe sessions, with those in the residential settings completing more sessions. When compared with SP participants, StaySafe participants showed greater improvement in the KCM measures-HIV knowledge, avoiding sex risks, HIV services, and risk reduction skills. In addition, greater improvements in the KCM measures as well as an increased likelihood to discuss issues with others were associated with completing more StaySafe sessions.

CONCLUSION

These results suggest that the StaySafe app is a feasible and potentially effective tool for improving health risk reduction decision-making for individuals under community supervision.

Predictors of Booster Engagement Following a Web-Based Brief Intervention for Alcohol Misuse Among National Guard Members: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Alcohol misuse is a major health concern among military members. Reserve component members face unique barriers as they live off base with limited access to behavioral health services. Web and app-based brief interventions are a promising means to improve access to treatment for those who misuse alcohol, with the use of booster sessions to enhance effectiveness, solidify gains, and reinforce changes. However, little is known about who will engage in booster sessions.

OBJECTIVE

This study aims to evaluate booster engagement across booster delivery modalities (Web and Peer) and identify participant-specific factors associated with booster session engagement.

METHODS

Following a brief web-based alcohol misuse intervention in National Guard members (N=739), we examined engagement in a series of three booster sessions. Using unadjusted and adjusted models, demographic and clinical characteristics that may serve as predictors of booster session engagement were examined across the 2 arms of the trial with different types of booster sessions: peer-delivered (N=245) and web-delivered (N=246).

RESULTS

Booster session completion was greater for Peer than Web Booster sessions, with 142 (58%) service members in the Peer Booster arm completing all three boosters compared with only 108 (44%) of participants in the Web Booster arm (χ²₃=10.3; P=.006). In a model in which the 2 groups were combined, socioeconomic factors predicted booster engagement. In separate models, the demographic and clinical predictors of booster engagement varied between the 2 delivery modalities.

CONCLUSIONS

The use of peer-delivered boosters, especially among subsets of reserve members at risk of lack of engagement, may foster greater uptake and improve treatment outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02181283; https://clinicaltrials.gov/ct2/show/NCT02181283.

Brief Motivational Intervention to Improve Adolescent Sexual Health Service Uptake: A Pilot Randomized Controlled Trial in the Emergency Department

OBJECTIVE

To test the hypothesis that our motivational sexual health intervention (SexHealth) would increase health service uptake when compared with control.

STUDY DESIGN

In a randomized controlled trial at a pediatric emergency department, sexually active adolescents received either the SexHealth intervention or printed materials (control). SexHealth, delivered by a health educator, was a tablet-based, interactive intervention that included motivational techniques to promote sexual health, condom skills training, and tailored service recommendations. We assessed feasibility (eg, intervention completion, recommendations discussed, intervention duration), acceptability (ie, proportion enrolled and rating intervention as satisfactory), and efficacy; secondary outcomes were sexual and care-seeking behaviors at 6 months. The efficacy outcome was completion of ≥1 service at the index visit (ie, counseling, condoms, emergency contraception for immediate or future use, pregnancy/sexually transmitted infection/HIV testing, sexually transmitted infection treatment, and clinic referral).

RESULTS

We enrolled 91 participants (intervention = 44; control = 47). The intervention demonstrated high feasibility: 98% completed the intervention; 98% of recommendations were discussed; duration was 24.6 minutes, and acceptability: 87% of eligible adolescents enrolled and 93% rated the intervention as fairly to very satisfactory. Compared with controls, intervention participants were more likely to complete ≥1 service (98% vs 70%, P < .001) including HIV testing (33% vs 6%, P = .02) and emergency contraception (80% vs 0%, P = .01). There were no meaningful differences between arms in behaviors at follow-up.

CONCLUSIONS

SexHealth was feasible to implement, acceptable to youth, and resulted in increased uptake of health services during the emergency department visit. Additional strategies may be needed to extend intervention effects over time.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; NCT03341975.

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 for Cannabis Use in Healthcare Settings: Systematic Review and Meta-analyses of Randomized Trials

OBJECTIVES

The efficacy of brief interventions for cannabis use was assessed in a systematic review and meta-analyses.

METHODS

Systematic searches in academic databases were conducted, and reference lists of included studies were reviewed. Randomized trials were included that compared brief interventions with minimal control interventions for improving cannabis-specific outcomes among participants recruited from healthcare settings. Mean differences (MDs) based on change-from-baseline measurements were pooled using random-effects meta-analyses, with stratification by short term (≤3 months) and long term (>3 months).

RESULTS

Ten reports from 9 studies were included. Most studies were conducted in the United States, including participants who were adults and were recruited from primary care or emergency departments. There were no significant effects of brief interventions on cannabis-specific Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) scores in the short term (MD -1.27 points; 95% confidence interval [CI] -3.75, 1.21; I 84.40%). The null pattern of findings was also observed for number of days of cannabis use in the past 30 days in the short term (MD -0.22 days; 95% CI -2.27, 1.82; I 60.30%) and long term (MD -0.28 days; 95% CI -2.42, 1.86; I 60.50%). The evidence base for other outcomes not subjected to meta-analyses was limited and mixed.

CONCLUSIONS

Brief interventions did not result in reductions in cannabis-specific ASSIST scores or number of days of cannabis use, whereas the evidence base for other outcomes was limited and mixed. As such, brief interventions in healthcare settings may not be efficacious for cannabis use.

Piloting a brief intervention plus mobile boosters for drug use among emerging adults receiving emergency department care

PURPOSE

There are few efficacious prevention interventions for emerging adults (ages 18-25) drug use and concomitant risks (e.g., sexual risk behaviors). We developed and evaluated the feasibility and acceptability of an Emergency Department (ED)-initiated brief intervention (BI) combined with booster messaging as a clinician-extender primarily focusing on drug use, with a secondary focus on condomless sex. We examined descriptive outcomes of alcohol, drug use, and condomless sex.

PROCEDURES

We recruited N = 63 emerging adults who used drugs (primarily cannabis) from an ED (72.4 % participation rate). Their mean age was 21.7 years (SD = 2.3); 67 % were female and 52.4 % were Black/African American. Participants randomized to the intervention (N = 31) received a BI and 28 days of tailored booster messaging (based on drug use motives) daily, and the control condition received a community resource brochure. A post-test occurred at 1-month with a follow-up at 2-months.

RESULTS

The intervention was well-received (83.9 % allocated completed the BI) with 79 % overall liking the BI and 71 % finding it helpful to discuss substances. Mean ratings of booster messages were >4.0 (5-point scale); 77 % liked the daily messages and 91 % found them helpful. Descriptively, the intervention group evidenced absolute reductions over time on alcohol outcomes, cannabis use, and condomless sex.

CONCLUSIONS

This BI with booster messages was feasible and acceptable in the target population of emerging adults who use drugs (i.e., mostly cannabis). This intervention model, initiated during a healthcare visit and accompanied by a clinician-extender, should be tested in a future fully-powered trial.

Emergency department interventions for homelessness: a systematic review

BACKGROUND

The social determinants of health are economic and social conditions that contribute to health. Access to housing is a major social determinant of health and homeless patients often rely on emergency departments (EDs) for their healthcare. These patients are frequently discharged back to the street which further perpetuates the cycle of homelessness and negatively affects their health. Previous work has described the financial and systems implications of ED-housed interventions for homeless patients; this review summarizes ED-based interventions that seek to improve the social determinants of health of homeless patients.

METHODS

We conducted a search of multiple databases and gray literature for studies investigating interventions for homelessness that were initiated in the ED. Studies had to use a control group or use a pre/post-intervention design and measure outcomes that demonstrate an effect on health or the social determinants of health.

RESULTS

Thirteen studies were identified that met the inclusion criteria. Two studies were housing first interventions and were effective in providing housing and improving health. Seven studies used variations of case management and were able to address many of the social needs of people who are homeless.

CONCLUSION

This review demonstrated that ED interventions can be effective in improving the social determinants of health of homeless individuals and can be the place to initiate housing interventions. ED providers must advocate for the resources necessary to properly address the social needs of this marginalized population. Equipped with the proper resources, EDs can be one place where the cycle of homelessness is broken.

Preparing pharmacists to increase naloxone dispensing within community pharmacies under the Pennsylvania standing order

PURPOSE

Opioid misuse and overdose deaths remain a public health concern in the United States. Pennsylvania has one of the highest rates of opioid overdose deaths in the country, with Philadelphia County's being 3 times higher than the national average. Despite several multimodal interventions, including use of SBIRT (screening, brief intervention, and referral to treatment) methods and naloxone distribution, the rate of overdose deaths remains high.

METHODS

To gain insights on strategies for improving access to naloxone and naloxone distribution by pharmacists in Philadelphia County, a study was conducted in 11 community pharmacies (chain and independent) in Philadelphia. Twenty-four pharmacists were recruited and completed SBIRT and naloxone trainings. Each pharmacy elected to have at least 1 pharmacy champion who received additional training on and helped develop pharmacy site-specific naloxone dispensing protocols.

RESULTS

Pre-post survey results showed a reduction in stigmatizing attitudes regarding naloxone dispensing and an increase in pharmacists' understanding of the standing order and appropriate naloxone use. There was an increase in pharmacists' self-reported confidence in their ability to appropriately identify, discuss, and dispense naloxone to patients. All pharmacies increased their average monthly dispensing rate following protocol implementation.

CONCLUSION

Pharmacists who received both trainings were more likely to change naloxone dispensing practices, leading to an overall increase in naloxone dispensing by community pharmacists. The study addressed overall gaps in pharmacists' knowledge, reduced stigma, and prepared pharmacists to address opioid use and overdose prevention with their patients. The described pharmacist-led patient counseling and intervention service for overdose prevention may be explored as a model for other community pharmacies to adopt to improve naloxone dispensing and similar interventions to reduce overdose deaths.

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.

Considerations for remote delivery of behavioral economic interventions for substance use disorder during COVID-19 and beyond

The response to the COVID-19 crisis has created direct pressure on health care providers to deliver virtual care, and has created the opportunity to develop innovations in remote treatment for people with substance use disorders. Remote treatments provide an intervention delivery framework that capitalizes on technological innovations in remote monitoring of behaviors and can efficiently use information collected from people and their environment to provide personalized treatments as needed. Interventions informed by behavioral economic theories can help to harness the largely untapped potential of virtual care in substance use treatment. Behavioral economic treatments, such as contingency management, the substance-free activity session, and episodic future thinking, are positioned to leverage remote monitoring of substance use and to use personalized medicine frameworks to deliver remote interventions in the COVID-19 era and beyond.

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With increased remote care, there is an opportunity for virtual treatment development.

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Treatments can capitalize on remote technology to increase effectiveness.

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Behavioral economic interventions are well positioned to fill this need.

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Remote behavioral economic interventions can add to current treatments.

Dosage of booster phone calls following an SBIRT intervention in the emergency department for reducing substance use

Brief Interventions (BIs) for problematic drug use in general medical settings, including in Emergency Departments (EDs), have shown disappointing results compared to those that target problematic alcohol use. Telephone booster calls may augment the impact of a BI delivered in the ED. The current study uses data from the National Drug Abuse Treatment Clinical Trials Network (CTN) Protocol 0047, "Screening, Motivational Assessment, Referral, and Treatment in Emergency Departments (SMART-ED)", a multisite randomized clinical trial conducted in six EDs in the U.S. We examine dose effects of telephone boosters (0, 1, or 2 calls completed) with non-treatment seeking patients who we randomized to the BI-Booster condition and who endorsed problematic drug use during their ED visit (N = 427). We assessed primary outcomes at 3-, 6-, and 12-month follow-ups, which included past month use of the primary drug of choice, use of any drug, and heavy drinking. There were no significant differences among those completing 0, 1, or 2 booster calls on any of the three main outcomes at 3-, 6-, and 12-months post-BI in the ED. Patients who were older were significantly more likely to complete booster calls. Taken together, these findings raise questions about the clinical utility of booster phone calls following screening and BIs targeting heterogeneous drug use in the ED.

Screening and brief intervention for lower-risk drug use in primary care: A pilot randomized trial

AIMS

The efficacy of screening and brief intervention for lower-risk drug use is unknown. This pilot study tested the efficacy of two brief interventions (BIs) for drug use compared to no BI in primary care patients with lower-risk drug use identified by screening.

METHODS

We randomly assigned participants identified by screening with Alcohol Smoking and Substance Involvement Screening Test (ASSIST) drug specific scores of 2 or 3 to: no BI, a brief negotiated interview (BNI), or an adaptation of motivational interviewing (MOTIV). Primary outcome was number of days use of main drug in the past 30 as determined by validated calendar method at 6 months. Analyses were performed using negative binomial regression adjusted for baseline use and main drug.

RESULTS

Of 142 eligible adults, 61(43 %) consented and were randomized. Participant characteristics were: mean age 41; 54 % male; 77 % black. Main drug was cannabis 70 %, cocaine 15 %, prescription opioid 10 %; 7% reported injection drug use and mean days use of main drug (of 30) was 3.4. At 6 months, 93 % completed follow-up and adjusted mean days use of main drug were 6.4 (no BI) vs 2.1 (BNI) (incidence rate ratio, IRR 0.33[0.15-0.74]) and 2.3 (MOTIV) (IRR 0.36[0.15-0.85]).

CONCLUSIONS

BI appears to have efficacy for preventing an increase in drug use in primary care patients with lower-risk use identified by screening. These findings raise the potential that less severe patterns of drug use in primary care may be uniquely amenable to brief intervention and warrant replication.

Therapist and computer-based brief interventions for drug use within a randomized controlled trial: effects on parallel trajectories of alcohol use, cannabis use and anxiety symptoms

BACKGROUND AND AIMS

Despite their high comorbidity, the effects of brief interventions (BI) to reduce cannabis use, alcohol use and anxiety symptoms have received little empirical attention. The aims of this study were to examine whether a therapist-delivered BI (TBI) or computer-guided BI (CBI) to address drug use, alcohol consumption (when relevant) and HIV risk behaviors, relative to enhanced usual care (EUC), was associated with reductions in parallel trajectories of alcohol use, cannabis use and anxiety symptoms, and whether demographic characteristics moderated reductions over time.

DESIGN

Latent growth curve modeling was used to examine joint trajectories of alcohol use, cannabis use and anxiety symptoms assessed at 3, 6 and 12 months after baseline enrollment.

SETTING

Hurley Medical Center Emergency Department (ED) in Flint, MI, USA.

PARTICIPANTS

The sample was 780 drug-using adults (aged 18-60 years; 44% male; 52% black) randomly assigned to receive either a TBI, CBI or EUC through the HealthiER You study.

INTERVENTIONS AND COMPARATOR

ED-delivered TBI and CBIs involved touchscreen-delivered and audio-assisted content. The TBI was administered by a Master's-level therapist, whereas the CBI was self-administered using a virtual health counselor. EUC included a review of health resources brochures in the ED.

MEASUREMENTS

Assessments of alcohol use (10-item Alcohol Use Disorders Identification Test), cannabis use (past 30-day frequency) and anxiety symptoms (Brief Symptom Inventory-18) occurred at baseline and 3-, 6- and 12-month follow-up.

FINDINGS

TBI, relative to EUC, was associated with significant reductions in cannabis use [B = -0.49, standard error (SE) = 0.20, P < 0.05) and anxiety (B = -0.04, SE = 0.02, P < 0.05), but no main effect for alcohol use. Two of 18 moderation tests were significant: TBI significantly reduced alcohol use among males (B = -0.60, SE = 0.19, P < 0.01) and patients aged 18-25 years in the TBI condition showed significantly greater reductions in cannabis use relative to older patients (B = -0.78, SE = 0.31, P < 0.05). Results for CBI were non-significant.

CONCLUSIONS

Emergency department-based therapist-delivered brief interventions to address drug use, alcohol consumption (when relevant) and HIV risk behaviors may also reduce alcohol use, cannabis use and anxiety over time, accounting for the overlap of these processes.

Digital Mental Health for Alcohol and Substance Use Disorders

Purpose

Only about 20% of people suffering from substance use disorders access available treatments due to various obstacles; digital interventions could potentially overcome some of these. Meta-analyses suggest the strongest evidence for interventions targeting alcohol use reduction, followed by cannabis and illicit substances. However, most randomized controlled trials (RCTs) used unguided standalone interventions compared to non-active controls, with limited follow-up periods and disregarded comorbidity. This review examines the literature published over the last three years (2016–2019), with a focus on recent RCTs and whether they addressed some of these gaps.

Recent findings

Except for digital interventions targeting alcohol use, the number of RCTs in the last three years is limited. Although there is considerable heterogeneity between the studies, most of them applied unguided add-on interventions compared to active control groups, and a limited number investigated guided interventions. In addition, there is a need for longer follow-up periods, active rather than non-active control groups, outcome standardization, and increased focus on comorbidity.

Summary

Although the number of studies using guided add-on or blended interventions compared to active controls has increased, future studies should consider our identified gaps and suggestions to further strengthen the evidence of digital interventions for reducing the use of alcohol and other substances.

Passion for Marijuana Use Mediates the Relations between Refusal Self-Efficacy and Marijuana Use and Associated Consequences

Marijuana (MJ) refusal self-efficacy and obsessive/harmonious passion for MJ use are associated with use and related consequences but have not been examined simultaneously. We examined the relation among obsessive/harmonious passion for MJ use, refusal self-efficacy, frequency of use, and related consequences in an online community sample (n = 524; mean age = 23.78; 87.5% male). A path analysis revealed that, while controlling for the relationship between MJ use and consequences, lower refusal self-efficacy was related to greater obsessive passion and to greater harmonious passion, and was associated with more consequences but not with MJ use. Greater obsessive passion was associated with greater MJ use frequency and consequences, and greater harmonious passion was related to greater MJ use frequency and fewer consequences. Obsessive passion mediated the relation between lower refusal self-efficacy and greater MJ use and more consequences, and harmonious passion mediated the relation between lower refusal self-efficacy and consequences. Passion mediates the relationships between refusal self-efficacy and MJ use and consequences, with obsessive passion being the stronger mediator. Passion could be a relevant target in interventions aimed at changing a person's MJ use.

Health-related material needs and substance use among emergency department patients

Background: Emergency department (ED) visits related to substance use are common. ED patients also have high levels of health-related material needs (HRMNs), such as homelessness and food insecurity. However, little research has examined the intersection between ED patient HRMNs and substance use. Methods: We surveyed a random sample of public hospital ED patients. Surveys included validated single-item screeners for unhealthy alcohol and any drug use and questions on self-reported past-year material needs. We compared individual HRMNs and cumulative number of HRMNs by substance use screening status using bivariate and multivariable analyses. Results: A total of 2312 surveys were completed. Nearly one third of patients (32.3%, n = 747) screened positive for unhealthy alcohol use, and 21.8% (n = 503) screened positive for drug use. Prevalence of HRMNs for all patients-including food insecurity (50.8%), inability to meet essential expenses (40.8%), cost barriers to medical care (24.6%), employment issues (23.8%), and homelessness (21.4%)-was high and was significantly higher for patients with unhealthy alcohol use or drug use. In multivariable analyses, homelessness was independently associated with unhealthy alcohol use (adjusted odds ratio [aOR]: 1.61, 95% confidence interval [CI]: 1.24-2.09) and drug use (aOR: 2.30, 95% CI: 1.74-3.05). There was a significant stepwise increase in the odds of patient unhealthy alcohol or drug use as number of HRMNs increased. Conclusions: ED patients with unhealthy alcohol or drug use have higher prevalence of HRMNs than those without. Our findings suggest that HRMNs may act additively and that homelessness is particularly salient. Patients' comorbid HRMNs may affect the success of ED-based substance use interventions.

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.

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.

Overdose and adverse drug event experiences among adult patients in the emergency department

INTRODUCTION

Overdose is a leading cause of injury and death in the United States. Emergency Department (ED) patients have an elevated prevalence of substance use. This study describes overdose/adverse drug event experiences among adult ED patients to inform strategies to address overdose risk.

METHODS

Patients seeking care at a large ED in the city of Flint, Michigan participated in a computerized self-assessment during 2011-2013 (n=4571). Overdose was assessed with a broad definition and included occurrences that could be considered adverse drug events. Among those with this type of experience, additional items assessed symptoms, outcomes, and intent.

RESULTS

12% reported an overdose history. Of participants' most serious overdoses, 74% were without clear intent for self-harm, although this was true of only 61% of overdoses involving opiates or sedatives, and 52% had symptoms present that indicated that it was life-threatening. Binge drinking on a monthly basis (ORs=1.4) was associated with a medically serious overdose compared to never having an overdose. Compared to no drug use in the last year, use of one drug was associated with an OR of 1.8, two drugs was associated with an OR of 5.8, three drugs was associated with an OR of 8.4, and four or more drugs was associated with an OR of 25.1 of having had a medically serious overdose (all p<0.05).

CONCLUSIONS

Most overdose experiences among ED patients were without clear intent of self-harm. The ED may be an appropriate setting for efforts to reduce overdose risk, especially among polysubstance users.

Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department

Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing-specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment-interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.

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).

Prevalence and motives for drugged driving among emerging adults presenting to an emergency department

OBJECTIVES

Drugged driving [DD] is a public health concern, particularly among emerging adults who have the highest rates of drug use. Understanding involvement with DD could inform prevention efforts for this population. We evaluated the prevalence of, motives for, and correlates of past-year DD among emerging adults from an urban, under-resourced community.

METHODS

Emerging adults (N=586) ages 18-25years (54% male, 56% African American, 34% European American) seeking care in an urban emergency department completed past-year surveys of demographics, frequency of DD within 4h of substance use, reasons for DD, and substance use.

RESULTS

DD was reported by 24% of participants (with 25% of those engaging in high frequency DD). DD after cannabis use was most common (96%), followed by prescription opioids, sedatives, and stimulants (9%-19%). Common reasons for DD were: needing to go home (67%), not thinking drugs affected driving ability (44%), not having to drive far (33%), and not feeling high (32%). Demographics were not associated with DD, but, as expected, those with DD had riskier substance use.

CONCLUSIONS

In this clinical sample, using a conservative measure, DD, particularly following cannabis use, was relatively common among emerging adults. Based on these data, clinical interventions for cannabis and other drug use should include content on prevention of DD, with particular attention to motives such as planning ahead for alternatives to get home safely and weighing benefits and risks of DD.

Why do young people consume marijuana? Extending motivational theory via the Dualistic Model of Passion

We evaluated an extended model of motivation for consuming marijuana by combining motivational theory and the dualistic model of passion. An online sample of 524 young, frequent marijuana consumers (M_age = 24; 88% male; M_past-30-days=21; Mode=31; 50% used 25-31 days) self-administered several questionnaires including the Marijuana-Harmonious and Obsessive Passion Scale and the Marijuana Motives Measure. Intercorrelations among the obsessive and harmonious passion and motives subscales were small-to-medium. A canonical correlation analysis revealed that obsessive passion was significantly positively associated with coping and conformity motives, while controlling for marijuana use, other motives, and harmonious passion scores. Additionally, harmonious passion was significantly positively associated with expansion, social, enhancement, and coping motives, while controlling for marijuana use and obsessive passion scores. A second canonical correlation analysis revealed that, when motive and passion subscales were included as independent predictors of recent marijuana use and related consequences, high obsessive passion and coping motives emerged as significant predictors of recent use and related consequences. Moreover, high harmonious passion and using less for conformity motives emerged as significant predictors of recent marijuana use. These results demonstrate that passion is related to, but not a proxy for, previously established motives for marijuana use and that, when examined simultaneously, both types of passion predict recent consumption but appear to differentiate whether one will experience use-related consequences. Researchers and clinicians could evaluate whether addressing obsessive passion and coping motives reduces or ameliorates negative outcomes associated with consumption.

Impacts of an opioid overdose prevention intervention delivered subsequent to acute care

BACKGROUND

Opioid overdose is a major and increasing cause of injury and death. There is an urgent need for interventions to reduce overdose events among high-risk persons.

METHODS

Adults at elevated risk for opioid overdose involving heroin or pharmaceutical opioids who had been cared for in an emergency department (ED) were randomised to overdose education combined with a brief behavioural intervention and take-home naloxone or usual care. Outcomes included: (1) time to first opioid overdose-related event resulting in medical attention or death using competing risks survival analysis; and (2) ED visit and hospitalisation rates, using negative binomial regression and adjusting for time at risk.

RESULTS

During the follow-up period, 24% of the 241 participants had at least one overdose event, 85% had one or more ED visits and 55% had at least one hospitalisation, with no significant differences between intervention and comparison groups. The instantaneous risk of an overdose event was not significantly lower for the intervention group (sub-HR: 0.83; 95% CI 0.49 to 1.40).

DISCUSSION

These null findings may be due in part to the severity of the population in terms of housing insecurity (70% impermanently housed), drug use, unemployment and acute healthcare issues. Given the high overdose and healthcare utilisation rates, more intensive interventions, such as direct referral and provision of housing and opioid agonist treatment medications, may be necessary to have a substantial impact on opioid overdoses for this high-acuity population in acute care settings.

TRIAL REGISTRATION NUMBER

NCT0178830; Results.

Sexual HIV risk behavior outcomes of brief interventions for drug use in an inner-city emergency department: Secondary outcomes from a randomized controlled trial

BACKGROUND

Drug use is an established risk factor for HIV. Brief Interventions (BIs) targeting reductions in both drug use and HIV risk behaviors may help curtail these related epidemics. The present study evaluates the impact of BIs for drug use and HIV risk reduction on sexual HIV risk behaviors among a primarily marijuana-using sample during a 12-month post-intervention follow-up period.

METHODS

We conducted a randomized controlled trial of 780 adult patients in an Emergency Department (ED) with past 3-month drug use (primarily non-injecting). This study used a 3 × 2 factorial design (3 ED-based conditions: computer-delivered brief intervention [Computer BI], therapist-delivered, computer-guided BI [Therapist BI], or enhanced usual care (EUC-ED) for drug-using adults; 2 follow-up conditions at 3 months: booster or control). This analysis examines the outcomes of the BIs on sexual HIV risk behaviors at 3-, 6-, and 12-months.

RESULTS

Compared to the enhanced usual care control, the combined Therapist BI with booster resulted in significant reductions in scores on the sexual risk subscale of the HIV Risk Taking Behaviour Scale over 12-months, when controlling for baseline sexual risk, gender, and drug dependency status. The baseline interventions alone, booster alone, and Computer BI plus booster did not differ from the comparison group (EUC plus control).

CONCLUSIONS

A therapist-delivered BI for drug use and HIV risk behaviors, combined with a follow-up therapist-delivered booster, shows promise for reducing sexual HIV risk behaviors among a primarily marijuana using, non-injecting sample.

A pilot replication of QUIT, a randomized controlled trial of a brief intervention for reducing risky drug use, among Latino primary care patients

BACKGROUND

QUIT is the only primary care-based brief intervention that has previously shown efficacy for reducing risky drug use in the United States (Gelberg et al., 2015). This pilot study replicated the QUIT protocol in one of the five original QUIT clinics primarily serving Latinos.

DESIGN

Single-blind, two-arm, randomized controlled trial of patients enrolled from March-October 2013 with 3-month follow-up.

SETTING

Primary care waiting room of a federally qualified health center (FQHC) in East Los Angeles.

PARTICIPANTS

Adult patients with risky drug use (4-26 on the computerized WHO ASSIST): 65 patients (32 intervention, 33 control); 51 (78%) completed follow-up; mean age 30.8 years; 59% male; 94% Latino.

INTERVENTIONS AND MEASURES

Intervention patients received: 1) brief (typically 3-4 minutes) clinician advice to quit/reduce their risky drug use, 2) video doctor message reinforcing the clinician's advice, 3) health education booklet, and 4) up to two 20-30 minute follow-up telephone drug use reduction coaching sessions. Control patients received usual care and cancer screening information. Primary outcome was reduction in number of days of drug use in past 30days of the highest scoring drug (HSD) on the baseline ASSIST, from baseline to 3-month follow-up.

RESULTS

Controls reported unchanged HSD use between baseline and 3-month follow-up whereas Intervention patients reported reducing their use by 40% (p<0.001). In an intent-to-treat linear regression analysis, intervention patients reduced past month HSD use by 4.5 more days than controls (p<0.042, 95% CI: 0.2, 8.7). Similar significant results were found using a complete sample regression analysis: 5.2 days (p<0.03, 95% CI: 0.5, 9.9). Additionally, on logistic regression analysis of test results from 47 urine samples at follow-up, intervention patients were less likely than controls to test HSD positive (p<0.05; OR: 0.10, 95% CI: 0.01, 0.99).

CONCLUSIONS

Findings support the efficacy of the QUIT brief intervention for reducing risky drug use.

Collaborative care from the emergency department for injured patients with prescription drug misuse: An open feasibility study

Collaborative Care is a comprehensive longitudinal care management strategy. The purpose of this pilot effectiveness-implementation hybrid study was to determine the feasibility of a Collaborative Care intervention initiated from the Emergency Department and proceeding longitudinally for six months for injured patients with prescription drug misuse (PDM). Adult patients presenting to an urban ED with an injury were screened for eligibility from 2/2015-8/2015. Eligible participants with a positive screen for PDM were enrolled in the 'ED-LINC' intervention which included the following elements: 1) active care coordination and linkage, 2) medication safety and utilization of opioid guidelines 3) longitudinal care management and 4) utilization of Electronic Medical Record (EMR) innovations such as the statewide Emergency Department Information Exchange (EDIE) and statewide prescription monitoring program information for assessment and follow-up. Baseline characteristics of the sample were assessed and regression models were used to evaluate longitudinal trajectories of risk for PDM. A total of 36 participants (56% of patients approached) had PDM and 30 participants were enrolled. Of those enrolled, 37% had prescription stimulant misuse, 20% with prescription sedative misuse and 97% had prescription opioid misuse. Follow-up rates at all time points were ≥83%. Baseline levels of comorbidity were high; 57% endorsed recent heroin use and 70% endorsed symptoms consistent with major depression. Over 50% had five or more statewide ED visits and 53% had used three or more different ED's in the past year. On average, participants received a total of 85 minutes of ED-LINC over six months with 90% of participants receiving all four intervention elements. All patients had care coordinated with new or existing primary care providers (PCP's) and 23% were linked to a new PCP. A majority of patients (≥80%) reported receiving high quality, desired intervention services. There was no significant change in PDM over time. Collaborative Care initiated from the ED is feasible and acceptable to patients with trauma and PDM. Future directions could include effectiveness-implementation hybrid trials to study implementation barriers and strategies as well as patient-level outcomes of this intervention for this complex patient population.

Commentary on Blow et al. (2017): Leveraging technology may boost the effectiveness and adoption of interventions for drug use in emergency departments

The effect of brief interventions for drug use can depend upon the type and severity of substance use, as well as psychosocial stability and other variables. Innovative technology, such as the computer delivered or assisted approaches tested by Blow et al., should be used to support implementation of brief interventions by maintaining simplicity and enhancing efficiency.

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.