IVESA - Visual Analysis of Time-Stamped Event Sequences.

Time-stamped event sequences (TSEQs) are time-oriented data without value information, shifting the focus of users to the exploration of temporal event occurrences. TSEQs exist in application domains, such as sleeping behavior, earthquake aftershocks, and stock market crashes. Domain experts face four challenges, for which they could use interactive and visual data analysis methods. First, TSEQs can be large with respect to both the number of sequences and events, often leading to millions of events. Second, domain experts need validated metrics and features to identify interesting patterns. Third, after identifying interesting patterns, domain experts contextualize the patterns to foster sensemaking. Finally, domain experts seek to reduce data complexity by data simplification and machine learning support. We present IVESA, a visual analytics approach for TSEQs. It supports the analysis of TSEQs at the granularities of sequences and events, supported with metrics and feature analysis tools. IVESA has multiple linked views that support overview, sort+filter, comparison, details-on-demand, and metadata relation-seeking tasks, as well as data simplification through feature analysis, interactive clustering, filtering, and motif detection and simplification. We evaluated IVESA with three case studies and a user study with six domain experts working with six different datasets and applications. Results demonstrate the usability and generalizability of IVESA across applications and cases that had up to 1,000,000 events.

Association of parental and adolescent emotion-related factors with adolescent chronic pain behaviors.

ABSTRACT: Chronic pain is a prevalent condition in youth, and the pain experience is strongly influenced by emotional processes. Studying emotion variability and regulation (ER) may help better understand pain behavior. As the development of emotion-related abilities predominantly takes place in the family context, examining ER within parent-adolescent dyads is important. We set out to test the association of parent and adolescent ER and adolescent emotional variability with adolescent pain behavior (ie, pain interference, activity avoidance, and activity engagement). A sample of 56 adolescents (Mage = 14.5, 85.7% women) with chronic pain and one of their parents (92.9% mothers) participated in this study. Adolescents completed baseline measures of average pain intensity, ER, and mean positive and negative affect. Furthermore, adolescents completed an electronic diary for 14 consecutive days, reporting on emotional state, activity avoidance, activity engagement, and pain interference. Parents completed measures of ER and their own history of pain. We performed a variable selection procedure, the least absolute shrinkage and selection operator method, to determine important predictors of adolescent pain behavior. Adolescent high positive affect was associated with more activity engagement, less pain interference, and less activity avoidance, indicating that positive affect might enhance the willingness to engage in activities in the presence of pain. Adolescent ER strategy emotional reappraisal and parents' own history of pain were predictors of less activity engagement. Parent ER was not related to adolescent ER. In conclusion, our results highlight the potential of enhancing positive affect as an intervention target for chronic pain.

Compassion, stigma, and professionalism among emergency personnel responding to the opioid crisis: An exploratory study in New Hampshire, USA.

OBJECTIVE: Drug overdoses are the leading cause of death in the United States for those under 50 years of age, and New Hampshire has been disproportionately affected, resulting in increased encounters with the emergency response system. The ensuing impact on emergency personnel has received little attention. The present study aimed to explore the experiences and perspectives of emergency personnel responding to the opioid crisis in NH, with a focus on their views toward people who use opioids. METHODS: Thirty-six emergency personnel (emergency department clinicians, n = 18; emergency medical service providers, n = 6; firefighters, n = 6; and police officers, n = 6) in 6 New Hampshire counties were interviewed about their experiences responding to overdoses and their perspectives on individuals who use opioids. Directed content analysis was used to identify themes in the transcribed, semistructured interviews. The results were reviewed for consensus. RESULTS: Several categories of themes were identified among emergency personnel's accounts of their overdose response experiences and perspectives, including varied degrees of compassion and stigma toward people who use opioids; associations between compassion or stigma and policy- and practice-related themes, such as prehospital emergency care and the role of emergency departments (EDs); and primarily among personnel expressing compassion, a sense of professional responsibility that outweighed personal biases. CONCLUSIONS: Despite the magnitude of the ongoing opioid crisis, some emergency personnel in New Hampshire have sustained or increased their compassion for people who use opioids. Others' perspectives remain or have become increasingly stigmatizing. The associations of compassion and stigma with various policy- and practice-related themes warrant further investigation.

Implementation of a New Hampshire community-initiated response to the opioid crisis: A mixed-methods process evaluation of Safe Station.

BACKGROUND: New Hampshire (NH) ranked first for fentanyl- and all opioid-related overdose deaths per capita from 2014 to 2016 and third in 2017 with no rate reduction from the previous year relative to all other states in the US. In response to the opioid crisis in NH, Manchester Fire Department (MFD), the state's largest city fire department, launched the Safe Station program in 2016 in partnership with other community organizations. This community-based response to the crisis-described as a connection to recovery-focuses on reducing barriers to accessing resources for people with substance use and related problems. The study aim is to characterize the multi-organizational partnerships and workflow of the Safe Station model and identify key components that are engaging, effective, replicable, and sustainable. METHODS: A mixed-methods design included: semi-structured qualitative interviews conducted with 110 stakeholders from six groups of community partners (Safe Station clients, MFD staff and leadership, and local emergency department, ambulance, and treatment partner staff); implementation and sustainability surveys (completed by MFD stakeholders); and ethnographic observations conducted at MFD. Qualitative data were content analyzed and coded using the Consolidated Framework for Implementation Research. Survey subscales were scored and evaluated to corroborate the qualitative findings. RESULTS: Community partners identified key program characteristics including firefighter compassion, low-threshold access, and immediacy of service linkage. Implementation and sustainability survey data corroborate the qualitative interview and observation data in these areas. All participants agreed that community partnerships are key to the program's success. There were mixed evaluations of the quality of communication among the organizations. CONCLUSION: Safe Station is a novel response to the opioid crisis in New Hampshire that offers immediate, non-judgmental access to services for persons with opioid use disorders requiring community-wide engagement and communication. Data convergence provides guidance to the sustainability and replicability of the program.

Early implementation of screening for substance use in rural primary care: A rapid analytic qualitative study.

Background: Few primary care patients are screened for substance use. As part of a phased feasibility study examining the implementation of electronic health record-integrated screening with the Tobacco, Alcohol, and Prescription Medication Screening (TAPS) Tool and clinical decision support (CDS) in rural primary care clinics, focus groups were conducted to identify early indicators of success and challenges to screening implementation. Method: Focus groups (n = 6) were conducted with medical assistants (MAs: n = 3: 19 participants) and primary care providers (PCPs: n = 3: 13 participants) approximately one month following screening implementation in three Federally Qualified Health Centers in Maine. Rapid analysis and matrix analysis using Proctor's Taxonomy of Implementation Outcomes were used to explore implementation outcomes. Results: There was consensus that screening is being used, but use of the CDS was lower, in part due to limited positive screens. Fidelity was high among MAs, though discomfort with the CDS surfaced among PCPs, impacting adoption and fidelity. The TAPS Tool's content, credibility and ease of workflow integration were favorably assessed. Challenges include screening solely at annual visits and self-administered screening for certain patients. Conclusions: Results reveal indicators of implementation success and strategies to address challenges to screening for substance use in primary care.

The application of digital health to the assessment and treatment of substance use disorders: The past, current, and future role of the National Drug Abuse Treatment Clinical Trials Network.

The application of digital technologies to better assess, understand, and treat substance use disorders (SUDs) is a particularly promising and vibrant area of scientific research. The National Drug Abuse Treatment Clinical Trials Network (CTN), launched in 1999 by the U.S. National Institute on Drug Abuse, has supported a growing line of research that leverages digital technologies to glean new insights into SUDs and provide science-based therapeutic tools to a diverse array of persons with SUDs. This manuscript provides an overview of the breadth and impact of research conducted in the realm of digital health within the CTN. This work has included the CTN's efforts to systematically embed digital screeners for SUDs into general medical settings to impact care models across the nation. This work has also included a pivotal multi-site clinical trial conducted on the CTN platform, whose data led to the very first "prescription digital therapeutic" authorized by the U.S. Food and Drug Administration (FDA) for the treatment of SUDs. Further CTN research includes the study of telehealth to increase capacity for science-based SUD treatment in rural and under-resourced communities. In addition, the CTN has supported an assessment of the feasibility of detecting cocaine-taking behavior via smartwatch sensing. And, the CTN has supported the conduct of clinical trials entirely online (including the recruitment of national and hard-to-reach/under-served participant samples online, with remote intervention delivery and data collection). Further, the CTN is supporting innovative work focused on the use of digital health technologies and data analytics to identify digital biomarkers and understand the clinical trajectories of individuals receiving medications for opioid use disorder (OUD). This manuscript concludes by outlining the many potential future opportunities to leverage the unique national CTN research network to scale-up the science on digital health to examine optimal strategies to increase the reach of science-based SUD service delivery models both within and outside of healthcare.

Understanding the increase in opioid overdoses in New Hampshire: A rapid epidemiologic assessment.

BACKGROUND: New Hampshire (NH) has had among the highest rates of fentanyl-related overdose deaths per capita in the United States for several years in a row-more than three times the national average in 2016. This mixed-methods study investigated drug-using practices and perspectives of NH residents who use opioids to inform policy in tackling the overdose crisis. METHODS: Seventy-six participants from six NH counties completed demographic surveys and semi-structured interviews focused on drug-using practices and perspectives, including use precursors, fentanyl-seeking behaviors, and experiences with overdose. Rigorous qualitative methods were used to analyze interview data including transcription, coding and content analysis. Descriptive statistics were calculated on quantitative survey data. RESULTS: Eighty-four percent of interviewees had knowingly used fentanyl in their lifetime, 70 % reported overdosing at least once, and 42 % had sought a batch of drugs known to have caused an overdose. The majority stated most heroin available in NH was laced with fentanyl and acknowledged that variability across batches increased overdose risk. Participants reported high availability of fentanyl and limited access to prevention, treatment, and harm reduction programs. There was widespread support for expanding education campaigns for youth, increasing treatment availability, and implementing needle exchange programs. CONCLUSIONS: A confluence of factors contribute to the NH opioid overdose crisis. Despite consensus that fentanyl is the primary cause of overdoses, individuals continue to use it and affirm limited availability of resources to address the problem. Policies targeting innovative prevention, harm reduction, and treatment efforts are needed to more effectively address the crisis.

Assessing the Integration of Behavioral Health Services in Primary Care in Colombia.

Integration of behavioral health care into primary care can improve health and economic outcomes. This study adapted the Behavioral Health Integration in Medical Care (BHIMC) index to the Colombian context and assessed the baseline level of behavioral health integration in a sample of primary care organizations. The BHIMC was able to detect the capacity to provide integrated behavioral care in Colombian settings. Results indicate a minimal to partial integration level across all sites, and that it is possible to measure the degree of integrated care capacity and identify improvement areas for better behavioral health care provision.

Barriers to naloxone use and acceptance among opioid users, first responders, and emergency department providers in New Hampshire, USA.

BACKGROUND: The United States is in the midst of a devastating opioid crisis, and the state of New Hampshire (NH) has been disproportionately impacted. Naloxone is an opioid overdose reversal medication that is critical for saving lives. This study was conducted to understand emergency responders' and opioid users' experiences with, and opinions about, naloxone use and distribution in NH. METHODS: Semi-structured interviews were conducted with 76 opioid users and 36 emergency responders in six NH counties in 2016-2017. Interviews focused on respondents' experiences with opioid use and overdose. Interviews were transcribed, coded, and reviewed for consensus among coders. Directed content analysis was used to review high-level domains and identify subthemes. RESULTS: Users and responders largely agreed that naloxone had become increasingly available in NH at the time of the study. Reported responder barriers to naloxone acceptance included perceptions that increased naloxone availability may enable riskier opioid use and fails to address the underlying causes of addiction. Reported opioid-user barriers included cost, legality, and lack of knowledge regarding distribution locations and indications for use. CONCLUSION: Opioid users' and emergency responders' perceptions about naloxone may limit the optimal use of naloxone within the community. This study identifies opportunities to address misconceptions about naloxone and challenges in accessing naloxone, which may improve opioid overdose prevention strategies.

"You can see those concentric rings going out": Emergency personnel's experiences treating overdose and perspectives on policy-level responses to the opioid crisis in New Hampshire.

BACKGROUND: In parallel to a substantial increase in opioid overdose deaths in New Hampshire (NH), emergency personnel experienced an increase in opioid-related encounters. To inform public health responses to this crisis, insights into the experiences and perspectives of those emergency personnel who treat opioid-related overdoses are warranted. AIMS: Systematically examine emergency personnel's experiences treating opioid overdoses and obtain their perspectives on policy-level responses to the opioid crisis in NH. METHODS: Semi-structured qualitative interviews were conducted with 18 first responders [firefighters (n = 6), police officers (n = 6), emergency medical service providers (n = 6)] and 18 emergency department personnel employed in six NH counties. Interviews focused on emergency personnel's perspectives on fentanyl/heroin formulations, experiences treating overdoses, harm reduction strategies, and experiences with treatment referral. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis. RESULTS: Emergency personnel cited the potency and inconsistency of fentanyl-laced heroin as primary drivers of opioid overdose. Increases in overdose-related encounters took a substantial emotional toll on emergency personnel, who described a range of responses including feelings of burnout, exhaustion, and helplessness. While some emergency personnel felt conflicted about the implementation of harm reduction strategies like syringe services programs, others emphasized the necessity of these services. Emergency personnel expressed frustration with barriers to treatment referral in the state and recommended immediate treatment access after overdose events. CONCLUSIONS: Findings suggest that interventions addressing trauma and burnout are necessary to support emergency personnel, while expanded harm reduction and treatment access are critical to support those who experience opioid overdose in NH.

Screening for Substance Use in Rural Primary Care: a Qualitative Study of Providers and Patients.

BACKGROUND: Substance use frequently goes undetected in primary care. Though barriers to implementing systematic screening for alcohol and drug use have been examined in urban settings, less is known about screening in rural primary care. OBJECTIVE: To identify current screening practices, barriers, facilitators, and recommendations for the implementation of substance use screening in rural federally qualified health centers (FQHCs). DESIGN: As part of a multi-phase study implementing electronic health record-integrated screening, focus groups (n = 60: all stakeholder groups) and individual interviews (n = 10 primary care providers (PCPs)) were conducted. PARTICIPANTS: Three stakeholder groups (PCPs, medical assistants (MAs), and patients) at three rural FQHCs in Maine. APPROACH: Focus groups and interviews were recorded, transcribed, and content analyzed. Themes surrounding current substance use screening practices, barriers to screening, and recommendations for implementation were identified and organized by the Knowledge to Action (KTA) Framework. KEY RESULTS: Identifying the problem: Stakeholders unanimously agreed that screening is important, and that universal screening is preferred to targeted approaches. Adapting to the local context: PCPs and MAs agreed that screening should be done annually. Views were mixed regarding the delivery of screening; patients preferred self-administered, tablet-based screening, while MAs and PCPs were divided between self-administered and face-to-face approaches. Assessing barriers: For patients, barriers to screening centered around a perceived lack of rapport with providers, which contributed to concerns about trust, judgment, and privacy. For PCPs and MAs, barriers included lack of comfort, training, and preparedness to address screening results and offer treatment. CONCLUSIONS: Though stakeholders agree on the importance of implementing universal screening, concerns about the patient-provider relationship, the consequences of disclosure, and privacy appear heightened by the rural context. Findings highlight that strong relationships with providers are critical for patients, while in-clinic resources and training are needed to increase provider comfort and preparedness to address substance use.

Towards detecting cocaine use using smartwatches in the NIDA clinical trials network: Design, rationale, and methodology.

Cocaine use in clinical trials is often measured via self-report, which can be inaccurate, or urine drug screens, which can be intrusive and burdensome. Devices that can automatically detect cocaine use and can be worn conveniently in daily life may provide several benefits. AutoSense is a wearable, physiological-monitoring suite that can detect cocaine use, but it may be limited as a method for monitoring cocaine use because it requires wearing a chestband with electrodes. This paper describes the design, rationale, and methodology of a project that seeks to build upon and extend previous work in the development of methods to detect cocaine use via wearable, unobtrusive mobile sensor technologies. To this end, a wrist-worn sensor suite (i.e., MotionSense HRV) will be developed and evaluated. Participants who use cocaine (N = 25) will be asked to wear MotionSense HRV and AutoSense for two weeks during waking hours. Drug use will be assessed via thrice-weekly urine drug screens and self-reports, and will be used to isolate periods of cocaine use that will be differentiated from other drug use. The present study will provide information on the feasibility and acceptability of using a wrist-worn device to detect cocaine use.

Pododermatitis in group housed rabbit does in Switzerland-Prevalence, severity and risk factors.

In rabbits (Oryctolagus cuniculus L.), pododermatitis is a chronic multifactorial skin disease that appears mainly on the plantar surface of the hind legs. In later stages, it causes pain leading to poor welfare of affected animals. Pododermatitis is commonly observed in commercial rabbit production in breeding does housed with wire mesh flooring. However, the prevalence in breeding does that are housed in groups on litter and plastic slats is not known. The aim of this cross-sectional study was to investigate the frequency, the severity and possible risk factors of pododermatitis in group housed breeding does in Switzerland on litter and plastic slats. Between June and September 2016 about 30% of all adult female breeding rabbits (1090 animals in total) were evaluated for the presence and the severity of pododermatitis on 17 commercial rabbit farms with group housing. The latter was done with a tagged visual-analogue-scale. Additionally, various animal-related (e.g. hybrid, age or body weight) and environmental risk factors (e.g. temperature, relative humidity or wet area per pen) known from the literature were recorded. The risk factors were analysed with generalized linear models, additive Bayesian network (ABN) models resulting in directed acyclic graphs (DAGs) and random forests with variable importance plots. On average, 25% of the rabbits displayed ulcerative pododermatitis likely to be painful on at least one hind leg, while the prevalence varied between farms from 4 to 49%. The age, body weight and claw-length of the animals were positively associated with pododermatitis as the most important risk factors. The best model explained 37.4% of the observed variance in the primary outcome measure for pododermatitis. These findings demonstrate that pododermatitis is prevalent in female breeding does even in group housing systems with litter and plastic slats. However, the results of this cross-sectional study also indicate that important risk factors may have been missed or were not recorded precisely enough. Thus, more in-depth research is needed to assess risk factors of pododermatitis in view of effectively preventing the occurrence of this painful disease.

[Pulmonary Rehabilitation after Acute Exacerbation of COPD Reduces the Rate of Reexacerbations]. / Eine pneumologische Rehabilitation nach akuter Exazerbation der COPD senkt die Rate erneuter Exazerbationen.

Objective Acute exacerbation of COPD (AECOPD) provides for patients a significant hazard and is crucial for the prognosis. Data on the effects of pulmonary rehabilitation (PR) on the frequency of reexacerbations after AECOPD are inconsistent. A prospective, case-control study was conducted with the aim of measuring the impact of PR on the frequency of reexacerbations after AECOPD. Patients and Methods A PR was performed in 57 patients with COPD after AECOPD. 30 participants were followed-up after one year and compared to 32 Control-Group (KG = hospitalized for AECOPD without PR). The rate of reexacerbations was both retrospectively in the year preceding the AECOPD, and prospectively in the year after AECOPD analyzed within groups and between groups. Results In the intra group comparison the exacerbation rate was significantly lower in the PR-group in the year after rehabilitation (0.97 ±â€Š2.67 vs. 1.52 ±â€Š1.12; p < 0.001). The intergroup comparison also showed a significantly lower number of exacerbations for the PR-group (0.97 ±â€Š1.52 vs 2.16 ±â€Š1.25; p < 0.001). Conclusion It was shown that the exacerbation rate after an AECOPD could be significantly reduced in the PR-group in comparison to the KG-group during the investigation period of one year by PR. More prospective studies are required to define the value of PR in the context of AECOPD.

The influence of family and social problems on treatment outcomes of persons with co-occurring substance use disorders and PTSD.

OBJECTIVE: Family and social problems may contribute to negative recovery outcomes in patients with co-occurring substance use and psychiatric disorders, yet few studies have empirically examined this relationship. This study investigates the impact of family and social problems on treatment outcomes among patients with co-occurring substance use and posttraumatic stress disorder (PTSD). METHOD: A secondary analysis was conducted using data collected from a randomized controlled trial of an integrated therapy for patients with co-occurring substance use and PTSD. Substance use, psychiatric symptoms, and social problems were assessed. Longitudinal outcomes were analyzed using generalized estimating equations (GEE) and multiple linear regression. RESULTS: At baseline, increased family and social problems were associated with more severe substance use and psychiatric symptoms. Over time, all participants had comparable decreases in substance use and psychiatric problem severity. However, changes in family and social problem severity were predictive of PTSD symptom severity, alcohol use, and psychiatric severity at follow-up. CONCLUSIONS: For patients with co-occurring substance use and PTSD, family and social problem severity is associated with substance use and psychiatric problem severity at baseline and over time. Targeted treatment for social and family problems may be optimal.

Using a Learning Collaborative Strategy With Office-based Practices to Increase Access and Improve Quality of Care for Patients With Opioid Use Disorders.

OBJECTIVES: Rapidly escalating rates of heroin and prescription opioid use have been widely observed in rural areas across the United States. Although US Food and Drug Administration-approved medications for opioid use disorders exist, they are not routinely accessible to patients. One medication, buprenorphine, can be prescribed by waivered physicians in office-based practice settings, but practice patterns vary widely. This study explored the use of a learning collaborative method to improve the provision of buprenorphine in the state of Vermont. METHODS: We initiated a learning collaborative with 4 cohorts of physician practices (28 total practices). The learning collaborative consisted of a series of 4 face-to-face and 5 teleconference sessions over 9 months. Practices collected and reported on 8 quality-improvement data measures, which included the number of patients prescribed buprenorphine, and the percent of unstable patients seen weekly. Changes from baseline to 8 months were examined using a p-chart and logistic regression methodology. RESULTS: Physician engagement in the learning collaborative was favorable across all 4 cohorts (85.7%). On 6 of the 7 quality-improvement measures, there were improvements from baseline to 8 months. On 4 measures, these improvements were statistically significant (P < 0.001). Importantly, practice variation decreased over time on all measures. The number of patients receiving medication increased only slightly (3.4%). CONCLUSIONS: Results support the effectiveness of a learning collaborative approach to engage physicians, modestly improve patient access, and significantly reduce practice variation. The strategy is potentially generalizable to other systems and regions struggling with this important public health problem.

Convergence of macroscopic tongue anatomy in ruminants and scaling relationships with body mass or tongue length.

Various morphological measures demonstrate convergent evolution in ruminants with their natural diet, in particular with respect to the browser/grazer dichotomy. Here, we report quantitative macroanatomical measures of the tongue (length and width of specific parts) of 65 ruminant species and relate them to either body mass (BM) or total tongue length, and to the percentage of grass in the natural diet (%grass). Models without and with accounting for the phylogenetic structures of the dataset were used, and models were ranked using Akaike's Information Criterion. Scaling relationships followed geometric principles, that is, length measures scaled with BM to the power of 0.33. Models that used tongue length rather than BM as a body size proxy were consistently ranked better, indicating that using size proxies that are less susceptible to a wider variety of factors (such as BM that fluctuates with body condition) should be attempted whenever possible. The proportion of the freely mobile tongue tip of the total tongue (and hence also the corpus length) was negatively correlated to %grass, in accordance with concepts that the feeding mechanism of browsers requires more mobile tongues. It should be noted that some nonbrowsers, such as cattle, use a peculiar mechanism for grazing that also requires long, mobile tongues, but they appear to be exceptions. A larger corpus width with increasing %grass corresponds to differences in snout shape with broader snouts in grazers. The Torus linguae is longer with increasing %grass, a finding that still warrants functional interpretation. This study shows that tongue measures covary with diet in ruminants. In contrast, the shape of the tongue (straight or "hourglass-shaped" as measured by the ratio of the widest and smallest corpus width) is unrelated to diet and is influenced strongly by phylogeny.

The impact of addiction medications on treatment outcomes for persons with co-occurring PTSD and opioid use disorders.

BACKGROUND AND OBJECTIVES: Previous research has been inconclusive about whether adding psychosocial treatment to medication assisted treatment (MAT) improves outcomes for patients with co-occurring psychiatric and opioid use disorders. This study evaluated the impact of MAT and psychosocial therapies on treatment outcomes for patients with co-occurring opioid use disorders and PTSD. METHODS: Patients meeting criteria for PTSD and substance use disorders were randomly assigned to one of three treatment conditions: Standard Care (SC) alone, Integrated Cognitive Behavioral Therapy (ICBT) plus SC, or Individual Addiction Counseling (IAC) plus SC. Substance use and psychiatric symptoms were assessed at baseline and 6 months. Only patients with opioid use disorders were included in the present analyses (n = 126). Two-way ANOVAS and logistic regression analyses were used to examine associations between treatment conditions and MAT, for substance use and psychiatric outcomes. RESULTS: MAT patients receiving ICBT had significantly decreased odds of a positive urine drug screen, compared to non-MAT patients receiving SC alone (OR = .07, 95% CI = .01, .81, p = .03). For PTSD symptoms, a significant MAT by psychosocial treatment condition interaction demonstrated that MAT patients had comparable declines in PTSD symptoms regardless of psychosocial treatment type (F(2, 88) = 4.74, p = .011). Non-MAT patients in ICBT had significantly larger reductions in PTSD. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: For patients with co-occurring opioid use disorders and PTSD, MAT plus ICBT is associated with more significant improvement in substance use. For non-MAT patients, ICBT is most beneficial for PTSD symptoms.

Adherence and competence in two manual-guided therapies for co-occurring substance use and posttraumatic stress disorders: clinician factors and patient outcomes.

BACKGROUND: The challenges of implementing and sustaining evidence-based therapies into routine practice have been well-documented. OBJECTIVES: This study examines the relationship among clinician factors, quality of therapy delivery, and patient outcomes. METHODS: Within a randomized controlled trial, 121 patients with current co-occurring substance use and posttraumatic stress disorders were allocated to receive either manualized Integrated Cognitive Behavioral Therapy (ICBT) or Individual Addiction Counseling (IAC). Twenty-two clinicians from seven addiction treatment programs were trained and supervised to deliver both therapies. Clinician characteristics were assessed at baseline; clinician adherence and competence were assessed over the course of delivering both therapies; and patient outcomes were measured at baseline and 6-month follow-up. RESULTS: Although ICBT was delivered at acceptable levels, clinicians were significantly more adherent to IAC (p < 0.05). At session 1, clinical female gender (p < 0.05) and lower education level (p < 0.05) were predictive of increased clinician adherence and competence across both therapies. Adherence and competence at session 1 in either therapy were significantly predictive of positive patient outcomes. ICBT adherence (p < 0.05) and competence (p < 0.01) were predictive of PTSD symptom reduction, whereas IAC adherence (p < 0.01) and competence (p < 0.01) were associated with decreased drug problem severity. CONCLUSIONS: The differential impact of adherence and competence for both therapy types is consistent with their purported primary target: ICBT for PTSD and IAC for substance use. These findings also suggest the benefits of considering clinician factors when implementing manual-guided therapies. Future research should focus on diverse clinician samples, randomization of clinicians to therapy type, and prospective designs to evaluate models of supervision and quality monitoring.

A randomized controlled trial of treatments for co-occurring substance use disorders and post-traumatic stress disorder.

BACKGROUND AND AIMS: Post-traumatic stress disorder (PTSD) is common among people with substance use disorders, and the comorbidity is associated with negative outcomes. We report on a randomized controlled trial comparing the effect of integrated cognitive-behavioral therapy (ICBT) plus standard care, individual addiction counseling plus standard care and standard care alone on substance use and PTSD symptoms. DESIGN: Three-group, multi-site randomized controlled trial. SETTING: Seven addiction treatment programs in Vermont and New Hampshire, USA. PARTICIPANTS/CASES: Recruitment took place between December 2010 and January 2013. In this single-blind study, 221 participants were randomized to one of three conditions: ICBT plus standard care (SC) (n = 73), individual addiction counseling (IAC) plus SC (n = 75) or SC only (n = 73). One hundred and seventy-two patients were assessed at 6-month follow-up (58 ICBT; 61 IAC; 53 SC). Intervention and comparators: ICBT is a manual-guided therapy focused on PTSD and substance use symptom reduction with three main components: patient education, mindful relaxation and flexible thinking. IAC is a manual-guided therapy focused exclusively on substance use and recovery with modules organized in a stage-based approach: treatment initiation, early abstinence, maintaining abstinence and recovery. SC are intensive out-patient program services that include 9-12 hours of face-to-face contact per week over 2-4 days of group and individual therapies plus medication management. MEASUREMENTS: Primary outcomes were PTSD severity and substance use severity at 6 months. Secondary outcomes were therapy retention. FINDINGS: PTSD symptoms reduced in all conditions with no difference between them. In analyses of covariance, ICBT produced more favorable outcomes on toxicology than IAC or SC [comparison with IAC, parameter estimate: 1.10; confidence interval (CI) = 0.17-2.04; comparison with SC, parameter estimate: 1.13; CI = 0.18-2.08] and had a greater reduction in reported drug use than SC (parameter estimate: -9.92; CI = -18.14 to -1.70). ICBT patients had better therapy continuation versus IAC (P<0.001). There were no unexpected or study-related adverse events. CONCLUSIONS: Integrated cognitive behavioral therapy may improve drug-related outcomes in post-traumatic stress disorder sufferers with substance use disorder more than drug-focused counseling, but probably not by reducing post-traumatic stress disorder symptoms to a greater extent.