Ten years of implementing screening, brief intervention, and referral to treatment (SBIRT): Lessons learned.

The US Surgeon General recently issued a comprehensive report indicating that substance use is a major public health concern that must be addressed using a number of strategies. Screening, brief intervention, and referral to treatment (SBIRT) is one such strategy. SBIRT Colorado, funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), has implemented a statewide initiative for the past 10 years that has provided ample opportunities to identify key components for successful implementation. Successful implementation requires (1) strong clinical and management advocates; (2) full integration of services into practices' workflow utilizing technology whenever possible; (3) interprofessional team approaches; (4) appropriate options for the small proportion of patients screening positive for a possible substance use disorder; (5) cannabis screening that accounts for legalization, and interventions that acknowledge differences between alcohol and cannabis use; (6) incorporating SBIRT into standard health care professionals' training; and (7) addressing the significant issues regarding reimbursement through private and public payers for SBIRT services. Implementing and sustaining SBI as a standard of integrated care is essential to reduce the burden of substance use. Interdisciplinary approaches, technology, and training to increase practitioner confidence and skill are fundamental.

Pilot Validation of a Brief Screen Tool for Substance Use Detection in Emergency Care.

BACKGROUND: Screening and brief intervention for substance use in health care systems is recommended to identify and intervene with patients who abuse alcohol and other substances. However, there is limited research on the utility of short, single-item questions to identify illicit substance users. OBJECTIVE: Pilot validation of two single-item screening questions to detect illicit substance use, one for marijuana and one for other illicit drugs. The goal was to identify sensitive, time-efficient screening questions that can be easily integrated into busy health care settings. METHODS: A cross-sectional design was used. At intake, along with questions for tobacco and alcohol, nurses administered two brief screen questions to adult patients seen in designated areas in a large urban medical center. After patients were triaged to rooms, health educators (blind to brief screen responses) administered the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) as the reference standard. RESULTS: On the ASSIST, 14% and 9% of participants reported risky marijuana and illicit (nonmarijuana) drug use, respectively. Sensitivity values for the marijuana and street drug questions were 72% (95% confidence interval [CI] 67% to 78%) and 40% (95% CI 32% to 48%), respectively. Specificity values for the marijuana and street drug questions were 96% (95% CI 95% to 97%) and 99% (95% CI 98% to 99%), respectively. Values differed minimally as a function of patient characteristics. CONCLUSIONS: It is important to use validated questions to identify substance misuse so that individuals are not missed in the screening process. It is the possible that administration protocols play a role in detection rates. Future research is needed to identify easy-to-administer drug use screening questions.

Frequency and Risk of Marijuana Use among Substance-Using Health Care Patients in Colorado with and without Access to State Legalized Medical Marijuana.

With increasing use of state legalized medical marijuana across the country, health care providers need accurate information on patterns of marijuana and other substance use for patients with access to medical marijuana. This study compared frequency and severity of marijuana use, and use of other substances, for patients with and without state legal access to medical marijuana. Data were collected from 2,030 patients who screened positive for marijuana use when seeking health care services in a large, urban safety-net medical center. Patients were screened as part of a federally funded screening, brief intervention, and referral to treatment (SBIRT) initiative. Patients were asked at screening whether they had a state-issued medical marijuana card and about risky use of tobacco, alcohol, and other illicit substances. A total of 17.4% of marijuana users had a medical marijuana card. Patients with cards had higher frequency of marijuana use and were more likely to screen at moderate than low or high risk from marijuana use. Patients with cards also had lower use of other substances than patients without cards. Findings can inform health care providers of both the specific risks of frequent, long-term use and the more limited risks of other substance use faced by legal medical marijuana users.

Trends in detection rates of risky marijuana use in Colorado health care settings.

BACKGROUND: Over the past several years, many states, including Colorado, have approved medical marijuana legislation. There is concern that increased access to and visibility of medical marijuana may lead to harmful use. METHODS: This study examined changes in patients' marijuana use in 12 health care settings through a statewide screening, brief intervention, and referral to treatment (SBIRT) initiative. RESULTS: Beginning in 2009, the odds of screening positive for risk-prone marijuana use significantly increased, coinciding with dramatic increases in use of Colorado's medical marijuana program. Young males were most likely to screen positive. Among users, there was a small, statistically significant increase in severity of use over time. CONCLUSIONS: Findings suggest that health care providers may be serving increasing numbers of patients using marijuana for medical or recreational purposes.

Longitudinal associations between parents' hostility and siblings' externalizing behavior in the context of marital discord.

This study examined longitudinal associations between parents' hostility and siblings' externalizing behavior in the context of interparental discord. The sample included 116 families (mothers, fathers, 2 siblings) assessed in middle childhood, when siblings were, on average, 8 and 10 years old, and in adolescence, at average ages of 14 and 16 years. Parents reported on their hostility toward each child and on each child's externalizing problems. Raters observed interparental hostility, and parents rated their marital quality. Results indicated both within-family and between-families effects. Specifically, the child who received more parental hostility than his or her sibling showed greater increases in externalizing problems than his or her sibling; this association was moderated by marital discord. In addition, the child who exhibited more behavioral problems than his or her sibling received greater increases in hostile mothering than did his or her sibling. Between-families effects were evident, in that children's externalizing problems were associated with increases in mothers' hostility toward both children in the family. Results support transactional models of development and family systems theory.

Changes in children's appraisals of marital discord from childhood through adolescence.

The study examined how children's appraisals of marital conflict (threat and self-blame) changed across development, whether changes in exposure to marital conflict were associated with corresponding changes in appraisals, and whether the appraisal process was different for boys and girls. Data were collected on 112 families (224 children) at 4 time points. At each wave, children (mean ages ranged from 8 to 19) provided information on their appraisals of marital conflict, and parents provided information on children's exposure to marital conflict. Results indicated that appraisals of threat declined rapidly from childhood to adolescence and then declined less rapidly across adolescence; appraisals of self-blame showed little change over time. Second, changes in exposure to marital discord covaried with changes in threat over time, but not with changes in self-blame. Finally, boys experienced more self-blame than girls on average, and gender moderated the association between exposure to marital discord and threat. Results suggest that development, exposure to marital conflict, and gender are important in determining why some children appraise their parents' disputes negatively.

Longitudinal associations between hostility in adolescents' family relationships and friendships and hostility in their romantic relationships.

This study examined longitudinal predictors of hostility in adolescents' romantic relationships. The sample included 110 adolescents and their parents from 72 families. Observational measures of parents' marital hostility and parent-child hostility and self-reports of hostility in close friendships were collected when adolescents ranged from 14 to 16 years old. Three years later, when they were 17 to 19 years old, adolescents reported on the hostility in their romantic relationships. Results indicated that hostility in parents' marital relationships and in adolescents' friendships accounted for independent variance in hostility in adolescents' later romantic relationships. Results highlight the importance of both family relationships and friendships for predicting hostility in adolescents' romantic relationships over time.

The impact of employee assistance services on workplace outcomes: Results of a prospective, quasi-experimental study.

Employee Assistance Programs (EAPs) are widely used to help employees experiencing personal or work-related difficulties that impact work productivity. However, rigorous research on the effectiveness of programs to improve work-related outcomes is lacking. The current study represents a major advance in EAP research by using a prospective, quasi-experimental design with a large and diverse employee base. Using propensity scores calculated from demographic, social, work-related, and psychological variables collected on baseline surveys, we matched 156 employees receiving EAP to 188 non-EAP employees. Follow-up surveys were collected from 2 to 12 months post-baseline (M = 6.0). At follow-up, EAP employees had significantly greater reductions in absenteeism (b = -.596, p = .001) and presenteeism (b = -.217, p = .038), but not workplace distress (b = -.079, p = .448), than did non-EAP employees. Tests of moderation of baseline alcohol use, depression, anxiety, and productivity indicate that for the most part, the program works equally well for all groups. However, EAP did more to reduce absenteeism for those who began with lower severity of depression and anxiety at baseline. Results provide the scientific rigor needed to demonstrate EAP impact on improved work outcomes. In the first study of its kind, findings confirm the value of EAPs to help employees address personal and work-related concerns that are affecting job performance. (PsycINFO Database Record

Associations between family cohesion and adolescent siblings' externalizing behavior.

This study asked whether family cohesion, a measure of whole family functioning, was associated with adolescent siblings' externalizing problems, controlling for the quality of each sibling's relationship with his or her parents. The sample included 93 families (mothers, fathers, and 2 adolescent siblings). Family cohesion was measured from videotaped observations of parents and 2 of their adolescent children discussing family conflict and limit setting. Adolescents reported on hostility in their relationships with mothers and fathers, and parents rated adolescents' externalizing problems. Results from multilevel modeling showed that family cohesion was negatively associated with adolescents' externalizing problems, independent of variance explained by hostility in dyadic parent-child relationships. Results support family systems theory, suggesting that whole family functioning has implications for adolescents' behavioral problems beyond those accounted for by dyadic family relationships.

Impact of Employee Assistance Services on Depression, Anxiety, and Risky Alcohol Use: A Quasi-Experimental Study.

OBJECTIVE: To test the impact of Employee Assistance Programs (EAPs) on reducing employee depression, anxiety, and risky alcohol use, and whether improvements in clinical symptoms lead to improved work outcomes. METHODS: The study used a prospective, quasi-experimental design with propensity score matching. Participants (n = 344) came from 20 areas of state government. EAP (n = 156) and non-EAP (n = 188) employees were matched on baseline demographic, psychosocial, and work-related characteristics that differentiate EAP from non-EAP users. Follow-up surveys were collected 2 to 12 months later (M = 6.0). RESULTS: EAP significantly reduced symptoms of depression and anxiety, but not at-risk alcohol use. EAP reductions in depression and anxiety mediated EAP-based reductions in absenteeism and presenteeism. CONCLUSIONS: EAPs provide easy-to-access work-based services that are effective at improving employee mental health.

Longitudinal associations between sibling relationship quality, parental differential treatment, and children's adjustment.

This study examined associations between changes in sibling relationships and changes in parental differential treatment and corresponding changes in children's adjustment. One hundred thirty-three families were assessed at 3 time points. Parents rated children's externalizing problems, and children reported on sibling relationship quality, parental differential treatment, and depressive symptoms. On average, older siblings were 10, 12, and 16 years old, and younger siblings were 8, 10, and 14 years old at Waves 1, 2, and 3, respectively. Results from hierarchical linear modeling indicated that as sibling relationships improved over time, children's depressive symptoms decreased over time. In addition, as children were less favored over their siblings over time, children's externalizing problems increased over time. Findings highlight the developmental interplay between the sibling context and children's adjustment.

Maternal caregiving and infant security in two cultures.

Attachment theory proposes that early care plays a key role in the emergence and organization of secure-base behavior across a wide range of cultures and contexts. Most studies on the topic have been conducted with Caucasian North American and European samples. Research needs to address questions concerning the cross-cultural generality of the sensitivity-security link, the appropriateness of the conceptualization of caregiving offered by attachment theory in other cultures, and the identification of caregiving domains other than those proposed by the theory. The authors address these issues in a study of maternal care and infant security in 2 different countries. Q descriptions of maternal behavior were obtained from observations at home. Infant security was assessed in a laboratory environment in Denver, Colorado and in the home environment in Bogota, Colombia. Findings are discussed in terms of the generality of the sensitivity-security link, the appropriateness of the model of caregiving suggested by attachment theory in both countries, and the relevance of other domains of caregiving to security.

Siblings' differential experiences of marital conflict and differences in psychological adjustment.

The present study examined whether siblings experience marital conflict differently and whether such differences, if present, were associated with differences in their adjustment. Self-report data about marital conflict, children's depressed mood, behavioral conduct, and externalizing problems were obtained from 122 sibling pairs (mean ages = 10 and 12 years) and their parents. Results indicated that siblings were significantly different in exposure to and appraisals of marital conflict. Differences in siblings' exposure to marital conflict were significantly correlated with differences in their depressed mood, behavioral conduct, and externalizing problems. Differences in siblings' feelings of self-blame for marital conflict were significantly correlated with differences in their depressed mood and behavioral conduct. Children who experienced more marital conflict than their siblings had more adjustment problems than their siblings. These results highlight the importance of studying siblings' unique experiences of marital conflict to better understand its impact on children's adjustment.

Maternal secure base support and preschoolers' secure base behavior in natural environments.

Bowlby and Ainsworth's theory of attachment poses that concurrent caregiving behavior is a key factor in influencing and maintaining a child's organization of secure-base behavior, and ultimately, security throughout childhood. Empirical demonstrations of the relation between the constructs after infancy are relatively scant and research is needed to examine the relation between the variables across a wide range of contexts, over longer observational periods, and in developmentally appropriate ways. Two studies of preschoolers and their mothers were conducted in naturalistic settings. Fifty child-mother middle-class dyads, predominantly Caucasian, participated in Study 1 and 40 in Study 2. The mean age for children was 52 months (Study 1) and 36 months (Study 2). In Study 1, a home and a playground visits were conducted. In Study 2, two home and a playground visits were conducted. Observers used the Maternal Behavior for Preschoolers Q-Set to provide age-relevant descriptions of maternal behavior, and the Attachment Q-Set to provide descriptions of child behavior. Overall, findings indicated that maternal secure base support was significantly related to the organization of child secure base behavior (r = .31 and .49 for Study 1 and Study 2, respectively). Results are discussed in terms of the importance of specifying caregiving domains and contexts of assessments, and their implications for attachment theory.