Budget Impact Tool for Implementing Contingency Management for Co-occurring Alcohol Use Disorders and Serious Mental Illness

OBJECTIVE

Contingency management (CM) is a behavioral intervention in which tangible incentives are provided to patients when they achieve a desired behavior (e.g., reducing or abstaining from alcohol use). The authors sought to describe the resource requirements and associated costs of various CM versions (usual, high magnitude, and shaping) tailored to a high-risk population with co-occurring serious mental illness and severe alcohol use disorder.

METHODS

A microcosting analysis was conducted to identify the resource requirements of the different CM versions. This approach included semistructured interviews with site investigators, who also staffed the intervention. The resource costing method-multiplying the number of units of each resource utilized by its respective unit cost-was used to value the resources from a provider's perspective. All cost estimates were calculated in 2021 U.S. dollars.

RESULTS

The cost of setting up a CM program was $6,038 per site. Assuming full capacity and 56% of urine samples meeting the requirement for receipt of the CM incentive, the average cost of 16 weeks of usual and shaping CM treatments was $1,119-$1,136 and of high-magnitude CM was $1,848-$1,865 per participant.

CONCLUSIONS

A customizable tool was created to estimate the costs associated with various levels of treatment success and CM design features. After the trial, the tool will be updated and used to finalize per-participant cost for incorporation into a comprehensive economic evaluation. This costing tool will help a growing number of treatment providers who are interested in implementing CM with budgeting for and sustaining CM in their practices.

Assessing Clinically Significant Cognitive Impairment Using the NIH Toolbox in Individuals with Co-occurring Serious Mental Illness and Alcohol Use Disorder

OBJECTIVE

Serious mental illnesses (SMI) and alcohol use disorder (AUD) co-occurrence (SMI-AUD) is common, yet little is known about the prevalence and risk factors of cognitive impairment for this population. We used the National Institutes of Health (NIH) Toolbox to identify clinically significant cognitive impairment (CSCI), describe the cognitive profile, and investigate whether psychiatric and AUD severity measures are associated with CSCI in individuals with SMI-AUD.

METHODS

CSCI was defined as 2 or more fully corrected fluid subtest T scores below a set threshold based on an individual's crystalized composite score. Psychiatric severity measures included the Structured Clinical Interview for DSM-V (SCID-5) for SMI diagnosis and the Positive and Negative Syndrome Scale. AUD severity measures included the SCID-5 for AUD symptom severity score, years of alcohol use, and urine ethyl glucuronide levels. A multivariable logistic regression was used to investigate the adjusted effects of each variable on the probability of CSCI.

RESULTS

Forty-one percent (N = 55/135) of our sample had CSCI compared with the base rate of 15% from the NIH Toolbox normative sample. Subtests measuring executive function most frequently contributed to meeting criteria for CSCI (Flanker and Dimensional Change Card Sort). A history of head injury ( P = 0.033), increased AUD symptom severity score ( P = 0.007) and increased negative symptom severity score ( P = 0.027) were associated with CSCI.

CONCLUSIONS

Cognition should be considered in the treatment of people with SMI-AUD, particularly in those with history of brain injury, higher AUD symptom severity, and/or negative symptom severity.

Contingency management for alcohol use disorder reduces cannabis use among American Indian and Alaska Native adults

OBJECTIVE

Determine whether a culturally tailored contingency management (CM) intervention targeting alcohol abstinence resulted in secondary effects on cannabis use among American Indian and Alaska Native (AI/AN) adults.

METHODS

The research team conducted this secondary data analysis to examine cannabis abstinence using data from a randomized control trial of CM for alcohol use among three AI/AN-serving organizations. One hundred and fifty-eight adults met the randomization criteria (i.e., submission of 50% or more urine samples and one alcohol-positive urine test during a 4-week, pre-randomization, observation period). For 12 weeks after randomization, participants received incentives for submitting a urine test negative for ethyl glucuronide (EtG < 150 ng/mL, CM group) or incentives for submitting a urine sample regardless of abstinence (Non-contingent [NC] Control group). Generalized linear mixed effects models assessed group differences in cannabis abstinence during the intervention, verified by urine tetrahydrocannabinol negative tests (11-nor-delta-9-tetrahydrocannabinol-9-carboxylic acid <50 ng/mL).

RESULTS

At baseline, 42.2% (n = 35) of participants in the NC group and 40.0% (n = 30) of those in the CM group had a cannabis positive urine test. An overall intervention by time interaction was detected for a cannabis negative urine test (χ2 = 13.40, p = 0.001). Compared to the NC group, the CM group had 3.92 (95% CI:1.23-12.46) times higher odds of having a cannabis negative urine test during the intervention period and 5.13 (95% CI:1.57-16.76) times higher odds of having a negative cannabis test at the end of intervention period.

CONCLUSION

CM addressing alcohol misuse may be an effective strategy for decreasing cannabis use among AI/AN adults.

TRIAL REGISTRATION

ClinicalTrials.gov number, Identifier: NCT02174315.

Development and Initial Pilot Testing of a fully integrated treatment for comorbid social anxiety disorder and alcohol use disorder in a community-based SUD clinic setting

OBJECTIVES

Social anxiety disorder (SAD) and alcohol use disorder (AUD) are highly comorbid and this comorbidity is associated with poorer clinical outcomes. Integrating exposure-based treatment for SAD into the context of typical AUD treatment programs should improve engagement and treatment outcomes for this population.

METHODS

After initial development of a fully integrated, intensive outpatient program (IOP) for individuals with comorbid SAD and AUD, patients with SAD and AUD were recruited from a community-based SUD specialty clinic (N = 56) and randomized to either (a) usual care (UC), consisting of the evidence-based Matrix Model of Addiction IOP; or (b) the Fully Integrated Treatment (FIT) for comorbid SAD and AUD IOP. Participants were assessed on indices of social anxiety and alcohol use.

RESULTS

By the 6-month follow-up, those in FIT showed superior improvement to UC on number of drinking days in the past 30 days and social anxiety severity at follow-up, but there were no differences between groups on quantity of alcohol consumed on drinking days. Alcohol-related problems improved in both groups, with no statistically significant differences. Within-group improvement was observed in FIT (but not in UC) on drinking to cope with social anxiety and avoidance of social situations without alcohol, but between-group effects were non-significant. In sum, the integrated treatment of SAD and AUD led to greater reductions in both the frequency of drinking and in social anxiety symptoms than usual care.

CONCLUSIONS

Targeting social anxiety in the context of AUD treatment is a promising approach to improving the treatment of this common comorbidity.

Effect of Incentives for Alcohol Abstinence in Partnership With 3 American Indian and Alaska Native Communities: A Randomized Clinical Trial

Importance

Many American Indian and Alaska Native communities are disproportionately affected by problems with alcohol use and seek culturally appropriate and effective interventions for individuals with alcohol use disorders.

Objective

To determine whether a culturally tailored contingency management intervention, in which incentives were offered for biologically verified alcohol abstinence, resulted in increased abstinence among American Indian and Alaska Native adults. This study hypothesized that adults assigned to receive a contingency management intervention would have higher levels of alcohol abstinence than those assigned to the control condition.

Design, Setting, and Participants

This multisite randomized clinical trial, the Helping Our Native Ongoing Recovery (HONOR) study, included a 1-month observation period before randomization and a 3-month intervention period. The study was conducted at 3 American Indian and Alaska Native health care organizations located in Alaska, the Pacific Northwest, and the Northern Plains from October 10, 2014, to September 2, 2019. Recruitment occurred between October 10, 2014, and February 20, 2019. Eligible participants were American Indian or Alaska Native adults who had 1 or more days of high alcohol-use episodes within the last 30 days and a current diagnosis of alcohol dependence. Data were analyzed from February 1 to April 29, 2020.

Interventions

Participants received treatment as usual and were randomized to either the contingency management group, in which individuals received 12 weeks of incentives for submitting a urine sample indicating alcohol abstinence, or the control group, in which individuals received 12 weeks of incentives for submitting a urine sample without the requirement of alcohol abstinence. Regression models fit with generalized estimating equations were used to assess differences in abstinence during the intervention period.

Main Outcomes and Measures

Alcohol-negative ethyl glucuronide (EtG) urine test result (defined as EtG<150 ng/mL).

Results

Among 1003 adults screened for eligibility, 400 individuals met the initial criteria. Of those, 158 individuals (39.5%; mean [SD] age, 42.1 [11.4] years; 83 men [52.5%]) met the criteria for randomization, which required submission of 4 or more urine samples and 1 alcohol-positive urine test result during the observation period before randomization. A total of 75 participants (47.5%) were randomized to the contingency management group, and 83 participants (52.5%) were randomized to the control group. At 16 weeks, the number who submitted an alcohol-negative urine sample was 19 (59.4%) in the intervention group vs 18 (38.3%) in the control group. Participants randomized to the contingency management group had a higher likelihood of submitting an alcohol-negative urine sample (averaged over time) compared with those randomized to the control group (odds ratio, 1.70; 95% CI, 1.05-2.76; P = .03).

Conclusions and Relevance

The study's findings indicate that contingency management may be an effective strategy for increasing alcohol abstinence and a tool that can be used by American Indian and Alaska Native communities for the treatment of individuals with alcohol use disorders.

Trial Registration

ClinicalTrials.gov Identifier: NCT02174315.

Aberrantly low STAT3 and STAT5 responses are associated with poor outcome and an inflammatory gene expression signature in pediatric acute myeloid leukemia

The relapse rate for children with acute myeloid leukemia is nearly 40% despite aggressive chemotherapy and often stem cell transplant. We sought to understand how environment-induced signaling responses are associated with clinical response to treatment. We previously reported that patients whose AML cells showed low G-CSF-induced STAT3 activation had inferior event-free survival compared to patients with stronger STAT3 responses. Here, we expanded the paradigm to evaluate multiple signaling parameters induced by a more physiological stimulus. We measured STAT3, STAT5 and ERK1/2 responses to G-CSF and to stromal cell-conditioned medium for 113 patients enrolled on COG trials AAML03P1 and AAML0531. Low inducible STAT3 activity was independently associated with inferior event-free survival in multivariate analyses. For inducible STAT5 activity, those with the lowest and highest responses had inferior event-free survival, compared to patients with intermediate STAT5 responses. Using existing RNA-sequencing data, we compared gene expression profiles for patients with low inducible STAT3/5 activation with those for patients with higher inducible STAT3/5 signaling. Genes encoding hematopoietic factors and mitochondrial respiratory chain subunits were overexpressed in the low STAT3/5 response groups, implicating inflammatory and metabolic pathways as potential mechanisms of chemotherapy resistance. We validated the prognostic relevance of individual genes from the low STAT3/5 response signature in a large independent cohort of pediatric AML patients. These findings provide novel insights into interactions between AML cells and the microenvironment that are associated with treatment failure and could be targeted for therapeutic interventions.

Suicide-Related Training, Self-Efficacy, and Mental Health Care Providers' Reactions Toward Suicidal Individuals

Background: Mental health care providers commonly encounter suicide ideation and suicidal behaviors among their patients despite a frequent lack of adequate knowledge and competence regarding suicide risk management. Aims: This study examined the associations among self-perceived sufficiency of training, self-efficacy, anxiety, and attitudes related to working with suicidal individuals. Method: Participants were 289 mental health care providers who completed a self-report survey. Results: Path analysis results indicated that perceived sufficiency of training was indirectly associated with negative attitudes (i.e., avoidance and discomfort) and cognitive and somatic anxiety about working with suicidal individuals through assessment self-efficacy. Limitations: The current study utilized cross-sectional data, and there were occupational heterogeneity and geographical homogeneity among the mental health care providers sampled. Conclusion: These findings suggest that sufficient suicide-related training focused on risk assessment may decrease mental health professionals' negative and anxious reactions toward suicidal individuals and enhance confidence in suicide risk management.

Association between methamphetamine use and retention among patients with opioid use disorders treated with buprenorphine

BACKGROUND

Methamphetamine use is increasing in parts of the U.S., yet its impact on treatment for opioid use disorder is relatively unknown.

METHODS

The study utilized data on adult patients receiving buprenorphine from Washington State Medication Assisted Treatment-Prescription Drug and Opioid Addiction program clinics between November 1, 2015 and April 31, 2018. Past 30-day substance use data were collected at baseline and 6-months, as well as date of program discharge. Cox proportional hazards regression was used to estimate the relative hazards for treatment discharge comparing methamphetamine users at baseline with non-users, adjusting for site, time period, age, gender, race, ethnicity, and education. For a subset of patients with data, we describe the proportion of individuals reporting methamphetamine use at baseline versus 6-months.

RESULTS

The sample included 799 patients, of which 237 (30%) reported using methamphetamine in the past 30 days; of those, 156 (66%) reported 1-10 days of use, 46 (19%) reported 11-20 days of use, and 35 (15%) reported 21-30 days of use. Baseline methamphetamine use was associated with more than twice the relative hazards for discharge in adjusted models (aHR = 2.39; 95% CI: 1.94-2.93). In the sub-sample with data (n = 516), there was an absolute reduction of 15% in methamphetamine use: 135 (26%) reported use at baseline versus 57 (11%) at follow-up.

CONCLUSIONS

In summary, this study found that patients who concurrently used methamphetamine were less likely to be retained in buprenorphine treatment compared to non-users. For persons who were retained, however, methamphetamine use decreased over time.

Randomized clinical trial evaluating the preliminary effectiveness of an integrated anxiety disorder treatment in substance use disorder specialty clinics

OBJECTIVE

Anxiety and substance use disorders are highly comorbid and mutually maintain each other. Treatments for anxiety disorders that are well integrated into substance use disorder treatment have the potential to improve both anxiety and substance use outcomes.

METHOD

Ninety-seven individuals seeking treatment at a community-based, evidence-based intensive outpatient program for substance use disorders who also had anxiety disorders were randomized to either (a) usual care (UC) at the intensive outpatient program; or (b) UC + coordinated anxiety learning and management for addiction recovery centers (CALM ARC), a 7-session, group-based, computer-assisted but therapist-directed treatment for anxiety disorders adapted for individuals with anxiety disorder and substance use disorder comorbidity.

RESULTS

CALM ARC + UC outperformed UC on measures of anxiety and substance use at posttreatment and at a 6-month follow-up.

CONCLUSIONS

Adding CALM ARC to UC for patients with comorbid anxiety disorders and substance use disorders is superior to UC alone. Implications for future research and clinical practice are discussed. (PsycINFO Database Record

Contingency management intervention targeting co-addiction of alcohol and drugs among American Indian adults: Design, methodology, and baseline data

BACKGROUND/AIMS

American Indian adults have some of the highest alcohol abstinence rates compared to the overall US population. Despite this, many American Indian people are more likely to concurrently use alcohol and illicit drugs and are less likely to participate and remain in outpatient treatment for alcohol and other drug use compared to the general US population. There is limited knowledge about effective interventions targeting alcohol and drug co-addiction among American Indian adults. Contingency management is a behavioral intervention designed to increase drug abstinence by offering monetary incentives in exchange for drug and alcohol negative urine samples. We aim to evaluate and describe a culturally tailored contingency management intervention to increase alcohol and other drug abstinence among American Indian adults residing in a Northern Plains reservation.

METHODS

This 2 × 2 factorial, randomized controlled trial currently includes 114 American Indian adults with alcohol and/or drug dependence who are seeking treatment. Participants were randomized into one of four groups that received (1) contingency management for alcohol, (2) contingency management for other drug, (3) contingency management for both substances, or (4) no contingency management for either substance. We present descriptive, baseline data to characterize the sample and describe the modified contingency management approach that is specific to the community wherein this trial was being conducted.

RESULTS

The sample is 49.1% male, with an average age of 35.8 years (standard deviation = 10.4 years). At baseline, 43.0% of the sample tested positive for ethyl glucuronide, 50.9% of participants self-reported methamphetamine as their most used drug, 36.8% self-reported cannabis, and 12.3% self-reported prescription opiates as their most used drug. Among randomized participants, 47.4% tested positive for cannabis, 28.1% tested positive for methamphetamine, 16.7% tested positive for amphetamines, and 2.1% tested positive for opiates.

CONCLUSION

This is the first study to examine a culturally tailored contingency management intervention targeting co-addiction of two substances among American Indian adults. By establishing a tribal-university partnership to adapt, implement, and evaluate contingency management, we will increase the literature on evidence-based addiction treatments and research, while improving trust for addiction interventions among American Indian communities through ongoing collaboration. Moreover, results have implications for the use of contingency management as an intervention for co-addiction in any population.

Change in anxiety sensitivity and substance use coping motives as putative mediators of treatment efficacy among substance users

OBJECTIVE

Anxiety sensitivity and coping motives for substance use are processes implicated in anxiety and substance use disorder (SUD) comorbidity, and are malleable treatment targets. Little is known about whether changes in anxiety sensitivity or coping motives during cognitive behavioral therapy (CBT) for anxiety disorders (with or without CBT for SUD) mediate substance use outcomes among patients with comorbid anxiety disorders and SUD. We examined whether changes in anxiety sensitivity and coping motives during treatment for comorbid SUD and anxiety disorders (either CBT for SUD only or CBT for SUD and anxiety disorders) were associated with substance use outcomes.

METHODS

Repeated measurements of anxiety sensitivity and coping motives throughout treatment were examined from a randomized clinical trial comparing usual, CBT-based treatment at a substance use disorder specialty clinic (UC) to that usual care plus a brief CBT for anxiety program for patients with comorbid anxiety and substance use disorders (CALM ARC).

RESULTS

Anxiety sensitivity decline during treatment was significantly steeper among those who received CALM ARC than those in UC. Decreases in anxiety sensitivity mediated the effect of treatment group on alcohol use following treatment such that the greater reduction in anxiety sensitivity in CALM ARC explained the superior outcomes for alcohol use in CALM ARC compared to UC. Declines in substance use coping motives were not observed in either condition, and did not differ between CALM ARC and UC. Thus, declines in coping motives did not mediate substance use after treatment.

CONCLUSIONS

These findings provide preliminary evidence suggesting alcohol use outcomes were related to decreasing anxiety sensitivity rather than decreasing coping motives. Implications and future directions are discussed.

User-Centered Design of Learn to Quit, a Smoking Cessation Smartphone App for People With Serious Mental Illness

Background

Smoking rates in the United States have been reduced in the past decades to 15% of the general population. However, up to 88% of people with psychiatric symptoms still smoke, leading to high rates of disease and mortality. Therefore, there is a great need to develop smoking cessation interventions that have adequate levels of usability and can reach this population.

Objective

The objective of this study was to report the rationale, ideation, design, user research, and final specifications of a novel smoking cessation app for people with serious mental illness (SMI) that will be tested in a feasibility trial.

Methods

We used a variety of user-centered design methods and materials to develop the tailored smoking cessation app. This included expert panel guidance, a set of design principles and theory-based smoking cessation content, development of personas and paper prototyping, usability testing of the app prototype, establishment of app’s core vision and design specification, and collaboration with a software development company.

Results

We developed Learn to Quit, a smoking cessation app designed and tailored to individuals with SMI that incorporates the following: (1) evidence-based smoking cessation content from Acceptance and Commitment Therapy and US Clinical Practice Guidelines for smoking cessation aimed at providing skills for quitting while addressing mental health symptoms, (2) a set of behavioral principles to increase retention and comprehension of smoking cessation content, (3) a gamification component to encourage and sustain app engagement during a 14-day period, (4) an app structure and layout designed to minimize usability errors in people with SMI, and (5) a set of stories and visuals that communicate smoking cessation concepts and skills in simple terms.

Conclusions

Despite its increasing importance, the design and development of mHealth technology is typically underreported, hampering scientific innovation. This report describes the systematic development of the first smoking cessation app tailored to people with SMI, a population with very high rates of nicotine addiction, and offers new design strategies to engage this population. mHealth developers in smoking cessation and related fields could benefit from a design strategy that capitalizes on the role visual engagement, storytelling, and the systematic application of behavior analytic principles to deliver evidence-based content.

Mental Health Professionals' Suicide Risk Assessment and Management Practices

BACKGROUND

Approximately 20% of suicide decedents have had contact with a mental health professional within 1 month prior to their death, and the majority of mental health professionals have treated suicidal individuals. Despite limited evidence-based training, mental health professionals make important clinical decisions related to suicide risk assessment and management.

AIMS

The current study aimed to determine the frequency of suicide risk assessment and management practices and the association between fear of suicide-related outcomes or comfort working with suicidal individuals and adequacy of suicide risk management decisions among mental health professionals.

METHOD

Mental health professionals completed self-report assessments of fear, comfort, and suicide risk assessment and management practices.

RESULTS

Approximately one third of mental health professionals did not ask every patient about current or previous suicidal thoughts or behaviors. Further, comfort, but not fear, was positively associated with greater odds of conducting evidence-based suicide risk assessments at first appointments and adequacy of suicide risk management practices with patients reporting suicide ideation and a recent suicide attempt.

LIMITATIONS

The study utilized a cross-sectional design and self-report questionnaires.

CONCLUSION

Although the majority of mental health professionals report using evidenced-based practices, there appears to be variability in utilization of evidence-based practices.

Proceedings of the 3rd Biennial Conference of the Society for Implementation Research Collaboration (SIRC) 2015: advancing efficient methodologies through community partnerships and team science : Seattle, WA, USA. 24-26 September 2015

Introduction to the 3rd Biennial Conference of the Society for Implementation Research Collaboration: advancing efficient methodologies through team science and community partnerships

Cara Lewis, Doyanne Darnell, Suzanne Kerns, Maria Monroe-DeVita, Sara J. Landes, Aaron R. Lyon, Cameo Stanick, Shannon Dorsey, Jill Locke, Brigid Marriott, Ajeng Puspitasari, Caitlin Dorsey, Karin Hendricks, Andria Pierson, Phil Fizur, Katherine A. Comtois

A1: A behavioral economic perspective on adoption, implementation, and sustainment of evidence-based interventions

Lawrence A. Palinkas

A2: Towards making scale up of evidence-based practices in child welfare systems more efficient and affordable

Patricia Chamberlain

A3: Mixed method examination of strategic leadership for evidence-based practice implementation

Gregory A. Aarons, Amy E. Green, Mark. G. Ehrhart, Elise M. Trott, Cathleen E. Willging

A4: Implementing practice change in Federally Qualified Health Centers: Learning from leaders’ experiences

Maria E. Fernandez, Nicholas H. Woolf, Shuting (Lily) Liang, Natalia I. Heredia, Michelle Kegler, Betsy Risendal, Andrea Dwyer, Vicki Young, Dayna Campbell, Michelle Carvalho, Yvonne Kellar-Guenther

A3: Mixed method examination of strategic leadership for evidence-based practice implementation

Gregory A. Aarons, Amy E. Green, Mark. G. Ehrhart, Elise M. Trott, Cathleen E. Willging

A4: Implementing practice change in Federally Qualified Health Centers: Learning from leaders’ experiences

Maria E. Fernandez, Nicholas H. Woolf, Shuting (Lily) Liang, Natalia I. Heredia, Michelle Kegler, Betsy Risendal, Andrea Dwyer, Vicki Young, Dayna Campbell, Michelle Carvalho, Yvonne Kellar-Guenther

A5: Efficient synthesis: Using qualitative comparative analysis and the Consolidated Framework for Implementation Research across diverse studies

Laura J. Damschroder, Julie C. Lowery

A6: Establishing a veterans engagement group to empower patients and inform Veterans Affairs (VA) health services research

Sarah S. Ono, Kathleen F. Carlson, Erika K. Cottrell, Maya E. O’Neil, Travis L. Lovejoy

A7: Building patient-practitioner partnerships in community oncology settings to implement behavioral interventions for anxious and depressed cancer survivors

Joanna J. Arch, Jill L. Mitchell

A8: Tailoring a Cognitive Behavioral Therapy implementation protocol using mixed methods, conjoint analysis, and implementation teams

Cara C. Lewis, Brigid R. Marriott, Kelli Scott

A9: Wraparound Structured Assessment and Review (WrapSTAR): An efficient, yet comprehensive approach to Wraparound implementation evaluation

Jennifer Schurer Coldiron, Eric J. Bruns, Alyssa N. Hook

A10: Improving the efficiency of standardized patient assessment of clinician fidelity: A comparison of automated actor-based and manual clinician-based ratings

Benjamin C. Graham, Katelin Jordan

A11: Measuring fidelity on the cheap

Rochelle F. Hanson, Angela Moreland, Benjamin E. Saunders, Heidi S. Resnick

A12: Leveraging routine clinical materials to assess fidelity to an evidence-based psychotherapy

Shannon Wiltsey Stirman, Cassidy A. Gutner, Jennifer Gamarra, Dawne Vogt, Michael Suvak, Jennifer Schuster Wachen, Katherine Dondanville, Jeffrey S. Yarvis, Jim Mintz, Alan L. Peterson, Elisa V. Borah, Brett T. Litz, Alma Molino, Stacey Young McCaughanPatricia A. Resick

A13: The video vignette survey: An efficient process for gathering diverse community opinions to inform an intervention

Nancy Pandhi, Nora Jacobson, Neftali Serrano, Armando Hernandez, Elizabeth Zeidler- Schreiter, Natalie Wietfeldt, Zaher Karp

A14: Using integrated administrative data to evaluate implementation of a behavioral health and trauma screening for children and youth in foster care

Michael D. Pullmann, Barbara Lucenko, Bridget Pavelle, Jacqueline A. Uomoto, Andrea Negrete, Molly Cevasco, Suzanne E. U. Kerns

A15: Intermediary organizations as a vehicle to promote efficiency and speed of implementation

Robert P. Franks, Christopher Bory

A16: Applying the Consolidated Framework for Implementation Research constructs directly to qualitative data: The power of implementation science in action

Edward J. Miech, Teresa M. Damush

A17: Efficient and effective scaling-up, screening, brief interventions, and referrals to treatment (SBIRT) training: a snowball implementation model

Jason Satterfield, Derek Satre, Maria Wamsley, Patrick Yuan, Patricia O’Sullivan

A18: Matching models of implementation to system needs and capacities: addressing the human factor

Helen Best, Susan Velasquez

A19: Agency characteristics that facilitate efficient and successful implementation efforts

Miya Barnett, Lauren Brookman-Frazee, Jennifer Regan, Nicole Stadnick, Alison Hamilton, Anna Lau

A20: Rapid assessment process: Application to the Prevention and Early Intervention transformation in Los Angeles County

Jennifer Regan, Alison Hamilton, Nicole Stadnick, Miya Barnett, Anna Lau, Lauren Brookman-Frazee

A21: The development of the Evidence-Based Practice-Concordant Care Assessment: An assessment tool to examine treatment strategies across practices

Nicole Stadnick, Anna Lau, Miya Barnett, Jennifer Regan, Scott Roesch, Lauren Brookman-Frazee

A22: Refining a compilation of discrete implementation strategies and determining their importance and feasibility

Byron J. Powell, Thomas J. Waltz, Matthew J. Chinman, Laura Damschroder, Jeffrey L. Smith, Monica M. Matthieu, Enola K. Proctor, JoAnn E. Kirchner

A23: Structuring complex recommendations: Methods and general findings

Thomas J. Waltz, Byron J. Powell, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Monica J. Matthieu, Enola K. Proctor, JoAnn E. Kirchner

A24: Implementing prolonged exposure for post-traumatic stress disorder in the Department of Veterans Affairs: Expert recommendations from the Expert Recommendations for Implementing Change (ERIC) project

Monica M. Matthieu, Craig S. Rosen, Thomas J. Waltz, Byron J. Powell, Matthew J. Chinman, Laura J. Damschroder, Jeffrey L. Smith, Enola K. Proctor, JoAnn E. Kirchner

A25: When readiness is a luxury: Co-designing a risk assessment and quality assurance process with violence prevention frontline workers in Seattle, WA

Sarah C. Walker, Asia S. Bishop, Mariko Lockhart

A26: Implementation potential of structured recidivism risk assessments with justice- involved veterans: Qualitative perspectives from providers

Allison L. Rodriguez, Luisa Manfredi, Andrea Nevedal, Joel Rosenthal, Daniel M. Blonigen

A27: Developing empirically informed readiness measures for providers and agencies for the Family Check-Up using a mixed methods approach

Anne M. Mauricio, Thomas D. Dishion, Jenna Rudo-Stern, Justin D. Smith

A28: Pebbles, rocks, and boulders: The implementation of a school-based social engagement intervention for children with autism

Jill Locke, Courtney Benjamin Wolk, Colleen Harker, Anne Olsen, Travis Shingledecker, Frances Barg, David Mandell, Rinad S. Beidas

A29: Problem Solving Teletherapy (PST.Net): A stakeholder analysis examining the feasibility and acceptability of teletherapy in community based aging services

Marissa C. Hansen, Maria P. Aranda, Isabel Torres-Vigil

A30: A case of collaborative intervention design eventuating in behavior therapy sustainment and diffusion

Bryan Hartzler

A31: Implementation of suicide risk prevention in an integrated delivery system: Mental health specialty services

Bradley Steinfeld, Tory Gildred, Zandrea Harlin, Fredric Shephard

A32: Implementation team, checklist, evaluation, and feedback (ICED): A step-by-step approach to Dialectical Behavior Therapy program implementation

Matthew S. Ditty, Andrea Doyle, John A. Bickel III, Katharine Cristaudo

A33: The challenges in implementing muliple evidence-based practices in a community mental health setting

Dan Fox, Sonia Combs

A34: Using electronic health record technology to promote and support evidence-based practice assessment and treatment intervention

David H. Lischner

A35: Are existing frameworks adequate for measuring implementation outcomes? Results from a new simulation methodology

Richard A. Van Dorn, Stephen J. Tueller, Jesse M. Hinde, Georgia T. Karuntzos

A36: Taking global local: Evaluating training of Washington State clinicians in a modularized cogntive behavioral therapy approach designed for low-resource settings

Maria Monroe-DeVita, Roselyn Peterson, Doyanne Darnell, Lucy Berliner, Shannon Dorsey, Laura K. Murray

A37: Attitudes toward evidence-based practices across therapeutic orientations

Yevgeny Botanov, Beverly Kikuta, Tianying Chen, Marivi Navarro-Haro, Anthony DuBose, Kathryn E. Korslund, Marsha M. Linehan

A38: Predicting the use of an evidence-based intervention for autism in birth-to-three programs

Colleen M. Harker, Elizabeth A. Karp, Sarah R. Edmunds, Lisa V. Ibañez, Wendy L. Stone

A39: Supervision practices and improved fidelity across evidence-based practices: A literature review

Mimi Choy-Brown

A40: Beyond symptom tracking: clinician perceptions of a hybrid measurement feedback system for monitoring treatment fidelity and client progress

Jack H. Andrews, Benjamin D. Johnides, Estee M. Hausman, Kristin M. Hawley

A41: A guideline decision support tool: From creation to implementation

Beth Prusaczyk, Alex Ramsey, Ana Baumann, Graham Colditz, Enola K. Proctor

A42: Dabblers, bedazzlers, or total makeovers: Clinician modification of a common elements cognitive behavioral therapy approach

Rosemary D. Meza, Shannon Dorsey, Shannon Wiltsey-Stirman, Georganna Sedlar, Leah Lucid

A43: Characterization of context and its role in implementation: The impact of structure, infrastructure, and metastructure

Caitlin Dorsey, Brigid Marriott, Nelson Zounlome, Cara Lewis

A44: Effects of consultation method on implementation of cognitive processing therapy for post-traumatic stress disorder

Cassidy A. Gutner, Candice M. Monson, Norman Shields, Marta Mastlej, Meredith SH Landy, Jeanine Lane, Shannon Wiltsey Stirman

A45: Cross-validation of the Implementation Leadership Scale factor structure in child welfare service organizations

Natalie K. Finn, Elisa M. Torres, Mark. G. Ehrhart, Gregory A. Aarons

A46: Sustainability of integrated smoking cessation care in Veterans Affairs posttraumatic stress disorder clinics: A qualitative analysis of focus group data from learning collaborative participants

Carol A. Malte, Aline Lott, Andrew J. Saxon

A47: Key characteristics of effective mental health trainers: The creation of the Measure of Effective Attributes of Trainers (MEAT)

Meredith Boyd, Kelli Scott, Cara C. Lewis

A48: Coaching to improve teacher implementation of evidence-based practices (EBPs)

Jennifer D. Pierce

A49: Factors influencing the implementation of peer-led health promotion programs targeting seniors: A literature review

Agathe Lorthios-Guilledroit, Lucie Richard, Johanne Filiatrault

A50: Developing treatment fidelity rating systems for psychotherapy research: Recommendations and lessons learned

Kevin Hallgren, Shirley Crotwell, Rosa Muñoz, Becky Gius, Benjamin Ladd, Barbara McCrady, Elizabeth Epstein

A51: Rapid translation of alcohol prevention science

John D. Clapp, Danielle E. Ruderman

A52: Factors implicated in successful implementation: evidence to inform improved implementation from high and low-income countries

Melanie Barwick, Raluca Barac, Stanley Zlotkin, Laila Salim, Marnie

Davidson

A53: Tracking implementation strategies prospectively: A practical approach

Alicia C. Bunger, Byron J. Powell, Hillary A. Robertson

A54: Trained but not implementing: the need for effective implementation planning tools

Christopher Botsko

A55: Evidence, context, and facilitation variables related to implementation of Dialectical Behavior Therapy: Qualitative results from a mixed methods inquiry in the Department of Veterans Affairs

Sara J. Landes, Brandy N. Smith, Allison L. Rodriguez, Lindsay R. Trent, Monica M. Matthieu

A56: Learning from implementation as usual in children’s mental health

Byron J. Powell, Enola K. Proctor

A57: Rates and predictors of implementation after Dialectical Behavior Therapy Intensive Training

Melanie S. Harned, Marivi Navarro-Haro, Kathryn E. Korslund, Tianying Chen, Anthony DuBose, André Ivanoff, Marsha M. Linehan

A58: Socio-contextual determinants of research evidence use in public-youth systems of care

Antonio R. Garcia, Minseop Kim, Lawrence A. Palinkas, Lonnie Snowden, John Landsverk

A59: Community resource mapping to integrate evidence-based depression treatment in primary care in Brazil: A pilot project

Annika C. Sweetland, Maria Jose Fernandes, Edilson Santos, Cristiane Duarte, Afrânio Kritski, Noa Krawczyk, Caitlin Nelligan, Milton L. Wainberg

A60: The use of concept mapping to efficiently identify determinants of implementation in the National Institute of Health--President’s Emergent Plan for AIDS Relief Prevention of Mother to Child HIV Transmission Implementation Science Alliance

Gregory A. Aarons, David H. Sommerfeld, Benjamin Chi, Echezona Ezeanolue, Rachel Sturke, Lydia Kline, Laura Guay, George Siberry

A61: Longitudinal remote consultation for implementing collaborative care for depression

Ian M. Bennett, Rinad Beidas, Rachel Gold, Johnny Mao, Diane Powers, Mindy Vredevoogd, Jurgen Unutzer

A62: Integrating a peer coach model to support program implementation and ensure long- term sustainability of the Incredible Years in community-based settings

Jennifer Schroeder, Lane Volpe, Julie Steffen

A63: Efficient sustainability: Existing community based supervisors as evidence-based treatment supports

Shannon Dorsey, Michael D Pullmann, Suzanne E. U. Kerns, Nathaniel Jungbluth, Lucy Berliner, Kelly Thompson, Eliza Segell

A64: Establishment of a national practice-based implementation network to accelerate adoption of evidence-based and best practices

Pearl McGee-Vincent, Nancy Liu, Robyn Walser, Jennifer Runnals, R. Keith Shaw, Sara J. Landes, Craig Rosen, Janet Schmidt, Patrick Calhoun

A65: Facilitation as a mechanism of implementation in a practice-based implementation network: Improving care in a Department of Veterans Affairs post-traumatic stress disorder outpatient clinic

Ruth L. Varkovitzky, Sara J. Landes

A66: The ACT SMART Toolkit: An implementation strategy for community-based organizations providing services to children with autism spectrum disorder

Amy Drahota, Jonathan I. Martinez, Brigitte Brikho, Rosemary Meza, Aubyn C. Stahmer, Gregory A. Aarons

A67: Supporting Policy In Health with Research: An intervention trial (SPIRIT) - protocol and early findings

Anna Williamson

A68: From evidence based practice initiatives to infrastructure: Lessons learned from a public behavioral health system’s efforts to promote evidence based practices

Ronnie M. Rubin, Byron J. Powell, Matthew O. Hurford, Shawna L. Weaver, Rinad S. Beidas, David S. Mandell, Arthur C. Evans

A69: Applying the policy ecology model to Philadelphia’s behavioral health transformation efforts

Byron J. Powell, Rinad S. Beidas, Ronnie M. Rubin, Rebecca E. Stewart, Courtney Benjamin Wolk, Samantha L. Matlin, Shawna Weaver, Matthew O. Hurford, Arthur C. Evans, Trevor R. Hadley, David S. Mandell

A70: A model for providing methodological expertise to advance dissemination and implementation of health discoveries in Clinical and Translational Science Award institutions

Donald R. Gerke, Beth Prusaczyk, Ana Baumann, Ericka M. Lewis, Enola K. Proctor

A71: Establishing a research agenda for the Triple P Implementation Framework

Jenna McWilliam, Jacquie Brown, Michelle Tucker

A72: Cheap and fast, but what is “best?”: Examining implementation outcomes across sites in a state-wide scaled-up evidence-based walking program, Walk With Ease

Kathleen P Conte

A73: Measurement feedback systems in mental health: Initial review of capabilities and characteristics

Aaron R. Lyon, Meredith Boyd, Abigail Melvin, Cara C. Lewis, Freda Liu, Nathaniel Jungbluth

A74: A qualitative investigation of case managers’ attitudes toward implementation of a measurement feedback system in a public mental health system for youth

Amelia Kotte, Kaitlin A. Hill, Albert C. Mah, Priya A. Korathu-Larson, Janelle R. Au, Sonia Izmirian, Scott Keir, Brad J. Nakamura, Charmaine K. Higa-McMillan

A75: Multiple pathways to sustainability: Using Qualitative Comparative Analysis to uncover the necessary and sufficient conditions for successful community-based implementation

Brittany Rhoades Cooper, Angie Funaiole, Eleanor Dizon

A76: Prescribers’ perspectives on opioids and benzodiazepines and medication alerts to reduce co-prescribing of these medications

Eric J. Hawkins, Carol A. Malte, Hildi J. Hagedorn, Douglas Berger, Anissa Frank, Aline Lott, Carol E. Achtmeyer, Anthony J. Mariano, Andrew J. Saxon

A77: Adaptation of Coordinated Anxiety Learning and Management for comorbid anxiety and substance use disorders: Delivery of evidence-based treatment for anxiety in addictions treatment centers

Kate Wolitzky-Taylor, Richard Rawson, Richard Ries, Peter Roy-Byrne, Michelle Craske

A78: Opportunities and challenges of measuring program implementation with online surveys

Dena Simmons, Catalina Torrente, Lori Nathanson, Grace Carroll

A79: Observational assessment of fidelity to a family-centered prevention program: Effectiveness and efficiency

Justin D. Smith, Kimbree Brown, Karina Ramos, Nicole Thornton, Thomas J. Dishion, Elizabeth A. Stormshak, Daniel S. Shaw, Melvin N. Wilson

A80: Strategies and challenges in housing first fidelity: A multistate qualitative analysis

Mimi Choy-Brown, Emmy Tiderington, Bikki Tran Smith, Deborah K. Padgett

A81: Procurement and contracting as an implementation strategy: Getting To Outcomes® contracting

Ronnie M. Rubin, Marilyn L. Ray, Abraham Wandersman, Andrea Lamont, Gordon Hannah, Kassandra A. Alia, Matthew O. Hurford, Arthur C. Evans

A82: Web-based feedback to aid successful implementation: The interactive Stages of Implementation Completion (SIC)^TM tool

Lisa Saldana, Holle Schaper, Mark Campbell, Patricia Chamberlain

A83: Efficient methodologies for monitoring fidelity in routine implementation: Lessons from the Allentown Social Emotional Learning Initiative

Valerie B. Shapiro, B.K. Elizabeth Kim, Jennifer L. Fleming, Paul A. LeBuffe

A84: The Society for Implementation Research Collaboration (SIRC) implementation development workshop: Results from a new methodology for enhancing implementation science proposals

Sara J. Landes, Cara C. Lewis, Allison L. Rodriguez, Brigid R. Marriott, Katherine Anne Comtois

A85: An update on the Society for Implementation Research Collaboration (SIRC) Instrument Review Project

A culturally-tailored behavioral intervention trial for alcohol use disorders in three American Indian communities: Rationale, design, and methods

BACKGROUND

Disproportionately high rates of alcohol use disorders are present in many American Indian/Alaska Native (AI/AN) communities, yet little information exists regarding the effectiveness of alcohol treatments in AI/AN populations. Contingency management is an intervention for illicit drug use in which tangible reinforcers (rewards) are provided when patients demonstrate abstinence as assessed by urine drug tests. Contingency management has not been widely studied as an intervention for alcohol problems because until recently, no alcohol biomarker has been available to adequately verify abstinence.

AIMS

The HONOR Study is designed to determine whether a culturally-tailored contingency management intervention is an effective intervention for AI/AN adults who suffer from alcohol use disorders.

METHODS

Participants include 400 AI/AN alcohol-dependent adults residing in one rural reservation, one urban community, as well as a third site to be decided, in the Western U.S. Participants complete a 4-week lead-in phase prior to randomization, then 12 weeks of either a contingency management intervention for alcohol abstinence, or a control condition where participants receive reinforcers for attending study visits regardless of alcohol use. Participants are then followed for 3-more months post-intervention. The primary study outcome is urinary ethyl glucuronide-confirmed alcohol abstinence; secondary outcomes include self-reported alcohol and drug use, HIV risk behaviors, and self-reported cigarette smoking.

DISCUSSION

This will be the largest randomized, controlled trial of any alcohol for AI/ANs and the largest contingency management study targeting alcohol use disorders, thus providing important information to AI/AN communities and the alcohol treatment field in general.

Suicide risk and associated demographic and clinical correlates among primary care patients with recent drug use

BACKGROUND

There is an increased need to prepare primary care clinicians to effectively gauge the risk of suicidal behavior occurring within primary care patients who may abuse drugs, especially those served in safety-net settings.

OBJECTIVES

The objectives of this paper were to explore suicide risk in a population of individuals endorsing recent drug use, and to describe patient demographic, medical, psychiatric, social, and substance use characteristics across different levels of suicide risk.

METHODS

A total of 867 primary care patients with reported drug use in the previous 90 days were studied. Based upon their responses to two Addiction Severity Index questions, four suicide risk categories were constructed: (1) low risk; (2) moderate-low (suicidal ideation in the past 30 days); (3) moderate-high (history of a lifetime suicide attempt); and (4) high risk (history of a lifetime suicide attempt and suicidal ideation in the past 30 days). The association between suicide risk groups and demographic and clinical variables were assessed.

RESULTS

A total of 40% of primary care patients endorsing recent drug use reported a lifetime suicide attempt. Compared to individuals in other suicide risk groups, individuals at high suicide risk had higher rates of substance use severity, recently used two or more substances, and were more likely to have a comorbid psychiatric condition.

CONCLUSION

These findings indicate that the percentage of patients with suicide risk may be higher among patients with recent drug use. Primary care clinicians should be aware that they may be encountering patients with suicide risk among those with recent drug use.

Clinical Needs of Patients with Problem Drug Use

INTRODUCTION

Illicit drug use is a serious public health problem associated with significant co-occurring medical disorders, mental disorders, and social problems. Yet most individuals with drug use disorders have never been treated, though they often seek medical treatment in primary care. The purpose of this study was to examine the baseline characteristics of people presenting in primary care with a range of problem drug use severity to identify their clinical needs.

METHODS

We examined sociodemographic characteristics, medical and psychiatric comorbidities, drug use severity, social and legal problems, and service utilization for 868 patients with drug problems. These patients were recruited from primary care clinics in a medical safety net setting. Based on Drug Abuse Screening Test results, individuals were categorized as having low, intermediate, or substantial/severe drug use severity.

RESULTS

Patients with substantial/severe drug use severity had serious drug use (opiates, stimulants, sedatives, intravenous drugs); high levels of homelessness (50%), psychiatric comorbidity (69%), and arrests for serious crimes (24%); and frequent use of expensive emergency department and inpatient hospitals. Patients with low drug use severity were primarily users of marijuana, with little reported use of other drugs, less psychiatric comorbidity, and more stable lifestyles. Patients with intermediate drug use severity fell in between the substantial/severe and low drug use severity subgroups on most variables.

CONCLUSIONS

Patients with the highest drug use severity are likely to require specialized psychiatric and substance abuse care, in addition to ongoing medical care that is equipped to address the consequences of severe/substantial drug use, including intravenous drug use. Because of their milder symptoms, patients with low drug use severity may benefit from a collaborative care model that integrates psychiatric and substance abuse care in the primary care setting. Patients with intermediate drug use severity may benefit from selective application of interventions suggested for patients with the highest and lowest drug use severity. Primary care safety net clinics are in a key position to serve patients with problem drug use by developing a range of responses that are locally effective and that may also inform national efforts to establish patient-centered medical homes and to implement the Affordable Care Act.

All-data approach to assessing financial capability in people with psychiatric disabilities

The goal of this project was to develop an evidence-based method to assess the ability of disabled persons to manage federal disability payments. This article describes the development of the Financial Incapability Structured Clinical Assessment done Longitudinally (FISCAL) measure of financial capability. The FISCAL was developed by an iterative process of literature review, pilot testing, and expert consultation. Independent assessors used the FISCAL to rate the financial capability of 118 participants (57% female, 58% Caucasian) who received Social Security disability payments, had recently been treated in acute care facilities for psychiatric disorders, and who did not have representative payees or conservators. Altogether, 48% of participants were determined financially incapable by the FISCAL, of whom 60% were incapable because of unmet basic needs, 91% were incapable because of spending that harmed them (e.g., on illicit drugs or alcohol), 56% were incapable because of both unmet needs and harmful spending, and 5% were incapable because of contextual factors. As expected, incapable individuals scored higher on a measure of money mismanagement (p < .001) compared with capable individuals. Interrater reliability for FISCAL capability determinations was very good (κ = .77) and interrater agreement was 89%. In this population, the FISCAL had construct validity; ratings demonstrated good reliability and correlated with a related measure. Potentially, the FISCAL can be used to validate other measures of capability and to help understand how people on limited incomes manage their funds.

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

INTERVENTIONS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00877331.

Preliminary findings: Contingency management targeting psycho-stimulant use results in secondary decreases in smoking for severely mentally ill adults

BACKGROUND

Treatments for drug addiction and smoking in severely mentally ill (SMI) adults are needed.

OBJECTIVES

To investigate the effect of a contingency management (CM) intervention targeting psycho-stimulant on cigarette smoking.

METHODS

126 stimulant dependent SMI smokers were assigned to CM or a non-contingent control condition. Rates of smoking-negative (<3 ppm) carbon monoxide breath-samples were compared.

RESULTS

Individuals who received CM targeting psycho-stimulants were 79% more likely to submit a smoking-negative breath-sample relative to controls.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

This study provides initial evidence that a behavioral treatment for drug use results in reductions in cigarette smoking in SMI adults.

The impact of prenatal alcohol exposure on addiction treatment

Fetal alcohol spectrum disorders (FASDs) are conditions caused by prenatal alcohol exposure in amounts sufficient to cause permanent deficits in brain functioning. Extent of damage largely depends on timing, dose, frequency, and pattern of exposure. Timing is especially important because prenatal alcohol exposure during critical periods of gestation can affect brain development in ways that produce varying patterns of neurocognitive deficits and associated adaptive impairments. This article describes some of the more serious neurophysiological and neuropsychological sequelae of prenatal alcohol exposure that contribute to increased risk for substance abuse problems among people with an FASD. We discuss the unique interface between pharmacological treatment and FASD, noting that failure to consider the possibility of FASD in treatment planning may result in treatment failure and/or relapse. Finally, we present a clinical case example and recommend service accommodations to address some of the impairments in FASD that limit substance abuse treatment success.

Predictors of stimulant abuse treatment outcomes in severely mentally ill outpatients

BACKGROUND

Severe mental illness is often exclusionary criteria for studies examining factors that influence addiction treatment outcome. Therefore, little is known about predictors of treatment response of individuals receiving psychosocial treatments for addictions who suffer from co-occurring severe mental illness.

METHODS

The impact of demographic, substance abuse severity, psychiatric severity, and service utilization variables on in-treatment performance (i.e., longest duration of abstinence) in a 12-week contingency management (CM) intervention for stimulant abuse in 96 severely mentally ill adults was investigated. A 4-step linear regression was used to identify independent predictors of in-treatment abstinence.

RESULTS

This model accounted for 37.4% of variance in the longest duration of abstinence outcome. Lower levels of stimulant use (i.e., stimulant-negative urine test) and psychiatric severity (i.e., lower levels of psychiatric distress), as well as higher rates of outpatient treatment utilization at study entry were independently associated with longer duration of drug abstinence.

CONCLUSION

These data suggest that individuals with low levels of stimulant use and psychiatric severity, as well as those actively engaged in services are most likely to succeed in a typical CM intervention. For others, modifications to CM interventions, such as increasing the value of reinforcement or adding CM to evidence based psychiatric interventions may improve treatment outcomes.

Testing the effects of brief intervention in primary care for problem drug use in a randomized controlled trial: rationale, design, and methods

BACKGROUND

A substantial body of research has established the effectiveness of brief interventions for problem alcohol use. Following these studies, national dissemination projects of screening, brief intervention (BI), and referral to treatment (SBIRT) for alcohol and drugs have been implemented on a widespread scale in multiple states despite little existing evidence for the impact of BI on drug use for non-treatment seekers. This article describes the design of a study testing the impact of SBIRT on individuals with drug problems, its contributions to the existing literature, and its potential to inform drug policy.

METHODS/DESIGN

The study is a randomized controlled trial of an SBIRT intervention carried out in a primary care setting within a safety net system of care. Approximately 1,000 individuals presenting for scheduled medical care at one of seven designated primary care clinics who endorse problematic drug use when screened are randomized in a 1:1 ratio to BI versus enhanced care as usual (ECAU). Individuals in both groups are reassessed at 3, 6, 9, and 12 months after baseline. Self-reported drug use and other psychosocial measures collected at each data point are supplemented by urine analysis and public health-related data from administrative databases.

DISCUSSION

This study will contribute to the existing literature by providing evidence for the impact of BI on problem drug use based on a broad range of measures including self-reported drug use, urine analysis, admission to drug abuse treatment, and changes in utilization and costs of health care services, arrests, and death with the intent of informing policy and program planning for problem drug use at the local, state, and national levels.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00877331.

Self-reported alcohol and drug use six months after brief intervention: do changes in reported use vary by mental-health status?

Background

Although brief intervention (BI) for alcohol and other drug problems has been associated with subsequent decreased levels of self-reported substance use, there is little information in the extant literature as to whether individuals with co-occurring hazardous substance use and mental illness would benefit from BI to the same extent as those without mental illness. This is an important question, as mental illness is estimated to co-occur in 37% of individuals with an alcohol use disorder and in more than 50% of individuals with a drug use disorder. The goal of this study was to explore differences in self-reported alcohol and/or drug use in patients with and without mental illness diagnoses six months after receiving BI in a hospital emergency department (ED).

Methods

This study took advantage of a naturalistic situation where a screening, brief intervention, and referral to treatment (SBIRT) program had been implemented in nine large EDs in the US state of Washington as part of a national SBIRT initiative. A subset of patients who received BI was interviewed six months later about current alcohol and drug use. Linear regression was used to assess whether change in substance use measures differed among patients with a mental illness diagnosis compared with those without. Data were analyzed for both a statewide (n = 828) and single-hospital (n = 536) sample.

Results

No significant differences were found between mentally ill and non-mentally ill subgroups in either sample with regard to self-reported hazardous substance use at six-month follow-up.

Conclusion

These results suggest that BI may not have a differing impact based on the presence of a mental illness diagnosis. Given the high prevalence of mental illness among individuals with alcohol and other drug problems, this finding may have important public health implications.

Substance use and posttraumatic stress disorder symptoms in trauma center patients receiving mandated alcohol screening and brief intervention

In an effort to integrate substance abuse treatment at trauma centers, the American College of Surgeons has mandated alcohol screening and brief intervention (SBI). Few investigations have assessed trauma center inpatients for comorbidities that may impact the effectiveness of SBI that exclusively focuses on alcohol. Randomly selected SBI eligible acute care medical inpatients (N=878) were evaluated for alcohol, illegal drugs, and symptoms consistent with a diagnosis of posttraumatic stress disorder (PTSD) using electronic medical record, toxicology, and self-report assessments; 79% of all patients had one or more alcohol, illegal drug, or PTSD symptom comorbidity. Over 70% of patients receiving alcohol SBI (n=166) demonstrated one or more illegal drug or PTSD symptom comorbidity. A majority of trauma center inpatients have comorbidities that may impact the effectiveness of mandated alcohol SBI. Investigations that realistically capture, account for, and intervene upon these common comorbid presentations are required to inform the iterative development of college policy targeting integrated substance abuse treatment at trauma centers.

Impact of brief interventions and brief treatment on admissions to chemical dependency treatment

This study examined two issues. One, whether individuals with possible substance use disorders were more likely to be admitted to specialized chemical dependency (CD) treatment after receiving a brief intervention (BI) - either alone or in combination with other services - than similar individuals who did not receive a BI. Two, whether participation in brief treatment (BT) following a BI was helpful in facilitating admission to CD treatment. The study took place in the emergency department (ED) of a large urban safety-net hospital where CD professionals screened patients for alcohol/drug problems and provided BI, BT, and referral to specialized CD treatment when appropriate (SBIRT). Substance use disorders were indicated by alcohol/drug problems noted in administrative records. Hospital records were used to match patients with likely substance use disorders who received BI with similar ED patients who had not been screened. Admission to publicly funded CD treatment was determined by matching patient identifiers to state administrative records of CD treatment. Results indicated that individuals with a likely substance use disorder who received a BI (regardless of subsequent participation in BT) were significantly more likely to enter specialized CD treatment in the subsequent year than similar individuals who did not receive a BI. This result was particularly pronounced for patients with no CD treatment in the past two years. Results also indicated that participation in BT facilitated admission into CD treatment. The results suggest that SBIRT programs could serve an important role in increasing entry to specialized treatment for individuals with substance use disorders.

Metabolic risk factors among medicaid outpatients with schizophrenia receiving second-generation antipsychotics

OBJECTIVE

Schizophrenia is associated with significant reductions in life expectancy, largely because of the increased incidence of cardiovascular disease. This study examined the prevalence of metabolic risk factors for cardiovascular disease among Medicaid recipients diagnosed as having schizophrenia and taking second-generation antipsychotics (medications associated with increased risk of metabolic abnormalities contributing to cardiovascular disease).

METHODS

Fifteen community health centers in King County, Washington, identified 1,317 eligible individuals, of whom 819 completed screenings for obesity, impaired fasting glucose levels or diabetes, hypertension, and dyslipidemia.

RESULTS

Fasting serum levels were obtained for 675 individuals, of whom 90% were diagnosed as having at least one risk factor, with elevated body mass index and dyslipidemia the most prevalent factors. About one-third of the individuals approached to participate did not obtain laboratory work necessary for the screening.

CONCLUSIONS

The study indicates that this population has a high rate of metabolic risk of cardiovascular disease and that treatment will require addressing barriers to screening.

Insight into alcohol-related problems and its associations with severity of alcohol consumption, mental health status, race, and level of acculturation in southern Taiwanese indigenous people with alcoholism

OBJECTIVE

While not well known in the West, Taiwan has a substantial indigenous population, and this population has rapidly developed alcohol problems. This study examined the level of insight into alcohol-related problems and its associations with the severity of alcohol consumption, mental health status, race, and the level of acculturation among indigenous populations with alcohol problems in southern Taiwan.

METHODS

A total of 332 indigenes, whose total Alcohol Use Disorders Identification Test (AUDIT) score was equal to 8 or higher, were interviewed. The associations between the level of insight into alcohol-related problems and the severity of alcohol drinking on the AUDIT, mental health status on the Chinese Health Questionnaire-12 (>or= 4 vs. < 4), race (Bunun vs. non-Bunun), and the level of acculturation on the Taiwan Aboriginal Acculturation Scale were examined using logistic regression models.

RESULTS

The results of this study found that 72.6% of the participants had poor insight into alcohol-related problems and no participant had good insight. Participants who had more severe alcohol drinking or poor mental health were more likely to have a higher level of insight into alcohol-related problems. Participants who were non-Bunun were also more likely to have a higher level of insight into alcohol-related problems, but the level of acculturation was not associated with the level of insight into alcohol-related problems.

CONCLUSIONS

These findings suggest that most alcoholic indigenes in southern Taiwan have poor insight into their own alcohol-related problems. Cultural specific interventions targeting and improving the indigenes' insight into alcohol-related problems are needed.

[Growth and differentiation factor 5 (GDF-5) composite improves the healing of necrosis of the femoral head in a sheep model. Analysis of an animal model]

MATERIALS AND METHODS

After creation of necrosis in 23 sheep, the composites were implanted in half of the animals. The animals were sacrificed 6 and 12 weeks after implantation and the femora were harvested. The specimens were investigated by microradiography, computed tomography, and histologically.

RESULTS

The GDF-5 composites were effective in the necrosis model. Osseous regeneration of the necrosis and the drill track were accelerated and enhanced by the composites. In treated animals the necrosis was nearly healed and the drill track was filled with bone after 12 weeks. In the control group the track was partially filled with fibrous tissue and necrotic lesions were still present. Specific side effects of the growth factor or the matrix were not documented. This was documented by histological scoring and CT investigation.

DISCUSSION

The application of an absorbable GDF-5 composite in combination with a core decompression procedure may enhance the healing of devitalized bone defects and is a promising approach for further studies.

Development of Service Intensity Criteria and Program Categories for Individuals with Co-Occurring Disorders

Many patients present a clinical situation in which psychiatric symptomatology and substance related symptomatology are inextricably intertwined. A paradox exists for these patients, in that both the addictions and mental health systems of care, and the level of care assessment methodologies associated with each system, are designed for one type of disorder only, or only one disorder at a time. As a result, these individuals are perceived as "system misfits." Our inability to assess these patients accurately and place them appropriately contributes to poor outcomes and high costs. These costs consist of expensive utilization of scarce system resources. There is a growing need for a more integrated methodology for level of care assessment, in which both psychiatric and substance symptomatology can be assessed simultaneously to generate a wider array of programmatic interventions for individuals with co-occurring disorders. This article describes efforts to build upon the Patient Placement Criteria published by the American Society of Addiction Medicine, Second Edition (ASAM PPC-2) to develop a revised instrument that is much more capable of evaluating the placement needs of individuals who present with combinations of psychiatric and substance symptomatology.

Heparin-binding epidermal growth factor-like growth factor: a component in chromaffin granules which promotes the survival of nigrostriatal dopaminergic neurones in vitro and in vivo

Chromaffin cells can restore function to the damaged nigrostriatal dopaminergic system in animal models of Parkinson's disease. It has been reported that a protein which is released from chromaffin granules can promote the survival of dopaminergic neurones in vitro and protect them against N-methylpyridinium ion toxicity. This neurotrophic effect has been found to be mediated by astroglial cells and blocked by inhibitors of the epidermal growth factor (EGF) receptor signal transduction pathway. Here we report the identification of bovine heparin-binding EGF-like growth factor (HB-EGF) in chromaffin granules and the cloning of the respective cDNA from bovine-derived adrenal gland. Protein extracts from bovine chromaffin granules were found to promote the survival of embryonic dopaminergic neurones in culture, to the same extent as recombinant human HB-EGF. Furthermore, the neurotrophic action of the chromaffin granule extract could be abolished by antiserum to recombinant human HB-EGF. We also show that intracerebral injection of recombinant human HB-EGF protected the nigrostriatal dopaminergic system in an in vivo adult rat model of Parkinson's disease. Intracerebral administration of this protein at the same time as a 6-hydroxydopamine lesion of the medial forebrain bundle was found to spare dopamine levels in the striatum and tyrosine hydroxylase-immunopositive neurones in the midbrain. This study has found that the main component in chromaffin granules responsible for their neurotrophic effect on dopaminergic neurones is HB-EGF. Furthermore, HB-EGF has significant protective effects on nigrostriatal dopaminergic neurones in vivo, making it a potential candidate for use in the treatment of Parkinson's disease.

Barriers to identification and treatment of hazardous drinkers as assessed by urban/rural primary care doctors

This pilot study analyzed three types of barriers encountered by forty family physicians when identifying and treating patients with hazardous drinking and alcohol dependence. The Patient Centered category included patient denial and lack of motivation to change. The Physician Centered category included lack of physician time and lack of addiction medicine training. The System Centered category included lack of community resources and distance to treatment programs. The Patient Centered barriers were rated significantly greater (p < .001) than the Physician Centered or the System Centered barriers. There was also a significant negative correlation (r = -0.49, p < .001) between the Physician Centered and the Patient Centered categories, meaning that the more problematic the patients were rated, the less problematic the physicians rated their time or training. The types of barriers that were rated as most problematic varied depending on rural/urban practice location and how current the physician's training was.

Factors associated with high use of public mental health services by persons with borderline personality disorder

OBJECTIVE

The research presented here was a pilot study to identify clinical factors associated with high use (as opposed to lower use) of inpatient psychiatric services by persons with borderline personality disorder.

METHODS

The initial sample was a random sample of English- and Spanish-speaking persons aged 18 to 60 years who had received at least one outpatient mental health service in the previous 90-day period and were enrolled in one of the participating mental health centers in King County, Washington. A random sample of persons who met selection criteria was randomly drawn; persons with high levels of use were oversampled to ensure adequate representation. Twenty-nine participants met full criteria for borderline personality disorder on the Personality Disorders Examination structured interview and completed all measures. Fifteen (52 percent) of these had a high level of use of inpatient services, and 14 did not.

RESULTS

High use of inpatient psychiatric services was predicted by a history of parasuicide in the previous two years but not by the number or severity of parasuicides; by the presence and number of anxiety disorders but not by depression or psychotic or substance use disorders; and by poorer cognitive functioning. Life stressors, global functioning, and health service variables did not differentiate patients with high levels of service use from other patients with borderline personality disorder.

CONCLUSIONS

Further research should explore these predictors of service use to determine whether they are replicated in larger samples, and treatments that target these variables should be evaluated.

Eating disorder symptoms among adults with severe and persistent mental illness

This article presents pilot data examining the: (1) prevalence of eating disorder symptoms among adults with severe and persistent mental illness (SPMI) and (2) clinical and demographic predictors of eating disorder symptoms. Participants were 149 adults with SPMI who were receiving community mental health services. The Eating Attitudes Test, Body Image Avoidance Questionnaire, purging questions, and Body Mass Index were used to assess eating disorder symptoms. Forty percent of participants indicated eating disorder symptoms. Predictors of eating disorder symptoms included female gender and greater clinical severity. The findings suggest the need for clinical attention to eating disorders for this population.

Use of psychiatric emergency services and enrollment status in a public managed mental health care plan

OBJECTIVE

This study examined the sociodemographic and clinical characteristics of acute-care psychiatric patients who visited the emergency department at a large public hospital in terms of the patients' enrollment status in the region's public managed mental health care plan. The results of the analyses were expected to provide information about the degree and types of access to care for individuals who are and are not enrolled in the plan.

METHODS

Data were collected over a seven-month period for 2,419 patients who visited a large, inner-city crisis triage unit. Patients were grouped according to whether they were currently enrolled, previously enrolled, or never enrolled in the public managed mental health care plan. Univariate and logistic regression models were used to determine differences between the three groups.

RESULTS

In general, patients who were currently enrolled in the plan had a higher rate of functional psychosis, past use of psychiatric services, and functional disability and lower rates of substance use and homelessness. Previously enrolled patients had a more moderate rate of psychosis but a higher rate of substance use, functional disability, and homelessness. The never-enrolled patients had a lower rate of psychosis, functional disability, and past use of psychiatric services, and moderate substance use.

CONCLUSIONS

The region's public health plan appeared to be succeeding in engaging and keeping the most psychiatrically impaired patients in treatment; however, individuals with moderate psychiatric symptoms and high levels of substance abuse may never have been enrolled in the plan because of Medicaid ineligibility or because they dropped out of treatment. Problematic behavior and history of hospitalization were the best predictors of enrollment status.

Reliability and validity of screening instruments for drug and alcohol abuse in adults seeking evaluation for attention-deficit/hyperactivity disorder

A growing number of adults are seeking evaluation for Attention-Deficit/Hyperactivity Disorder (ADHD). Screening for substance use disorders should be included as part of any comprehensive ADHD evaluation. We describe the validity and reliability of the Drug Abuse Screening Test (DAST) and the Alcohol Use Disorders Identification Test (AUDIT) in adults seeking evaluation for ADHD. Internal reliability estimates were excellent for both instruments. Scores on the DAST and AUDIT were higher among patients with a DSM-IV diagnosis of current drug abuse or dependence or current alcohol abuse or dependence, respectively. A cutoff score of 6 or above appears to be optimal for identifying individuals who are current drug abusers. A cutoff score of 6 or above on the AUDIT is suggested for detection of current alcohol abuse in this population. Comparable rates of substance use disorders were observed in ADHD and non-ADHD patients. Both measures are valid and reliable instruments for screening for alcohol and drug abuse among adults seeking evaluation for ADHD.

Bone morphogenetic protein-2 and growth and differentiation factor-5 enhance the healing of necrotic bone in a sheep model

INTRODUCTION

Osteotropic growth factors enhance bone repair, but their efficacy in an area of necrotic bone is not known. The purpose of this study was to investigate the effects and potential side effects of an intraosseous application of absorbable bone morphogenetic protein-2 (BMP-2) and growth and differentiation factor-5 (GDF-5) composites in a sheep model for partial necrosis of the femoral head.

MATERIALS AND METHODS

The direct injection of ethanol under fluoroscopy into the superior centre of the right femoral head produced histologically documentable necrosis of the central region of the head in a previous study of ten sheep. Another 27 sheep constituted the sample to study the effects of BMP-2 and GDF-5. Necrosis was produced in the same fashion in these animals. Four weeks later nine sheep received 300 microg recombinant BMP-2 and nine sheep 300 microg recombinant GDF-5 on an absorbable carrier by surgical implantation. Nine sheep received the carrier alone (control group). The animals were sacrificed at 3, 6, and 12 weeks after implantation and both femora were harvested.

RESULTS

Bone density analysis and microscopic examination indicated that bone formation was noticeably induced as early as 3 weeks postoperatively in the growth factor treated animals. Bone regeneration was enhanced by growth factor composites. This was documented by histological scoring and histomorphometric analysis. No severe local side effects secondary to the growth factors, such as heterotopic ossification or inflammation, were observed in either group.

DISCUSSION

The application of an absorbable growth factor composite in combination with established surgical techniques is a promising approach, that may enhance the healing of devitalised bone defects. Based on these results, further studies regarding biodegradation, dosage of the protein and surgical technique are required.

Localization of activin beta(A)-, beta(B)-, and beta(C)-subunits in humanprostate and evidence for formation of new activin heterodimers of beta(C)-subunit

Activin ligands are formed by dimerization of activin ss(A)- and/or ss(B)-subunits to produce activins A, AB, or B. These ligands are members of the transforming growth factor-ss superfamily and act as growth and differentiation factors in many cells and tissues. New additions to this family include activin ss(C)-, ss(D)-, and ss(E)-subunits. The aim of this investigation was to examine the localization of and dimerization among activin subunits; the results demonstrate that activin ss(C) can form dimers with activin ss(A) and ss(B) in vitro, but not with the inhibin alpha-subunit. Using a specific antibody, activin ss(C) protein was localized to human liver and prostate and colocalized with ss(A)- and ss(B)-subunits to specific cell types in benign and malignant prostate tissues. Activin C did not alter DNA synthesis of the prostate tumor cell line, LNCaP, or the liver tumor cell line, HepG2, in vitro when added alone or with activin A. Therefore, the capacity to form novel activin heterodimers (but not inhibin C) resides in the human liver and prostate. Activin A, AB, and B have diverse actions in many tissues, including liver and prostate, but there is no known biological activity for activin C. Thus, the evidence of formation of activin AC or BC heterodimers may have significant implications in the regulation of levels and/or biological activity of other activins in these tissues.

A brief medical necessity scale for mental disorders: reliability, validity, and clinical utility

Managed care organizations (MCOs) use the concept of "medical necessity" to decide whether a prescribed treatment is warranted for a given medical condition. Because mental disorders lack the objective disease criteria common to medical illness, behavioral health administrators need a validated means to identify and quantify the severity of "medically important" aspects of mental disorders. The authors developed and tested a brief medical necessity scale for mental disorders in 205 patients presenting for initial evaluation. The scale had a factor structure with four subscales; good internal consistency, interrater reliability, and concurrent and predictive validity; and modest ability to identify patients requiring hospitalization and, in hospitalized patients, those requiring involuntary hospitalization. The authors propose use of the scale to better clarify decisions about level of care assignments and to better assess patient characteristics predictive of good outcome.

The MOS 36-Item Short Form Health Survey: reliability, validity, and preliminary findings in schizophrenic outpatients

OBJECTIVES

The authors test the reliability and validity of the Medical Outcomes Study Short Form 36-Item Health Survey (SF-36) as a written, self-administered survey in outpatients with chronic schizophrenia.

METHODS

Thirty-six schizophrenic outpatients completed a written and oral form of the SF-36. A psychiatrist rated the patients using the Brief Psychiatric Rating Scale to determine severity of psychopathology. Cognitive functioning and academic achievement were also assessed. Internal consistency, test-retest reliability, concurrent and discriminative validity of the oral and written versions were determined.

RESULTS

The SF-36 in both forms was shown to have good internal consistency, stability, and concurrent validity. The mental health SF-36 subscales had poor discriminant validity, compared with the physical functioning scale that demonstrated good discriminant validity.

CONCLUSIONS

The validity of using the written form of the SF-36 on a sample of patients with chronic mental illness was demonstrated. The SF-36 appears to be an appropriate outcome measure for changes in physical and role functioning in consumers of outpatient mental health programs.