Organizational Acceptability of Implementing SBIRT for Adolescents in Primary Care.

INTRODUCTION: Adolescent illicit drug, tobacco, and alcohol use can result in sudden and long-term negative health consequences. Primary care environments present the optimal opportunity for screening and brief interventions that target prevention and curtailing use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a service delivery method that could potentially be well-integrated into primary care settings and used to serve a high volume of adolescents. Methods: This qualitative analysis of clinic staff interviews (N = 20), collected during a large cluster-randomized trial to implement two models of adolescent SBIRT, examined barriers and facilitating factors to overall acceptability of SBIRT. This study was conducted in a large, urban Federally Qualified Health Center (FQHC) at 7 sites throughout Baltimore City, Maryland, USA. Participants from each clinic included a range of various roles and responsibilities including: medical assistants (n = 3), nurses (n = 3), primary care providers (n = 4), behavioral health counselors (n = 4), and administrators (n = 6). Results: Results indicate both barriers and facilitating factors for acceptability of SBIRT in terms of (1) universal screening, (2) provider time demands, (3) behavioral health collaboration, and (4) behavioral health caseloads. Discussion: Universal screening was acceptable to participants across organizational roles, but brief interventions and referrals to treatment were found substantially less acceptable.

Novel tricyclics (e.g., GSK945237) as potent inhibitors of bacterial type IIA topoisomerases.

During the course of our research on the lead optimisation of the NBTI (Novel Bacterial Type II Topoisomerase Inhibitors) class of antibacterials, we discovered a series of tricyclic compounds that showed good Gram-positive and Gram-negative potency. Herein we will discuss the various subunits that were investigated in this series and report advanced studies on compound 1 (GSK945237) which demonstrates good PK and in vivo efficacy properties.

Misrepresenting the Accomplishments of Treatment.

The term "chronic relapsing disorder/disease" is viewed as an unfortunate shorthand expression that does an injustice to the accomplishments of treatment patients and treatment providers, and inadequately describes the findings from treatment evaluation research. Studies are reported that make clear relapse is not an inevitable consequence of substance abuse treatment, while substantial reductions in drug use and crime are routinely obtained consequent to treatment. It is past time to retire a term whose only virtue is brevity, and whose vices risk harm to a treatment population that is already stigmatized and a treatment system that is under frequent pressure. Thus, retiring this term provides the important benefit of recognizing the real achievements in behavior change obtained by treatment clients in conjunction with their service providers.

In Support of a National Treatment Evaluation Study.

Argument is made for the importance of conducting a national treatment evaluation to permit understanding of the nature and effectiveness of typical treatment programming. Only through such study can we hope to learn areas of success and failure of normative programming relative to population characteristics and treatment strategies, and the extent to which research-based initiatives have been adopted by the field. That information is central to efforts to draw up a research agenda appropriate to the needs of clients and the staffs responsible for their treatment, and to clarify and respond to gaps in the application of potentially useful treatment components. In spite of such need, our understanding of typical treatment programming and of its effectiveness is based on data collected from a treatment cohort of 20 years ago, although patterns of drug use, characteristics of clients, and the treatment components available have all undergone substantial change. The responsibility taken to provide such information to the field, once seen as a central task of research, needs to be reasserted to strengthen and support our treatment efforts.

Novel hydroxyl tricyclics (e.g., GSK966587) as potent inhibitors of bacterial type IIA topoisomerases.

During the course of our research to find novel mode of action antibacterials, we discovered a series of hydroxyl tricyclic compounds that showed good potency against Gram-positive and Gram-negative pathogens. These compounds inhibit bacterial type IIA topoisomerases. Herein we will discuss structure-activity relationships in this series and report advanced studies on compound 1 (GSK966587) which demonstrates good PK and in vivo efficacy properties. X-ray crystallographic studies were used to provide insight into the structural basis for the difference in antibacterial potency between enantiomers.

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

OBJECTIVE: Although many health care organizations have sought to increase the integration of substance use services into clinical practice, such practice changes can prove difficult to sustain. METHOD: Seven primary care clinics participated in an implementation study of screening and brief intervention (BI) services for adolescent patients (ages 12-17). All sites delivered screening and brief advice (BA) for low-risk use using a uniform protocol. Clinics were randomized to deliver BI using generalist (provider-delivered) or specialist (behavioral health clinician-delivered) models. Implementation was facilitated by multiple supporting activities (e.g., trainings, local "champion," electronic health record [EHR] integration of screening and documentation, individualized feedback, project-specific materials, etc.). Data on the penetration of screening, BA, and BI delivery (N = 14,486 adolescent patient visits) were abstracted from the EHR for the 20-month implementation phase and a 12-month sustainability phase (during which implementation supports were removed). RESULTS: Penetration of screening continued to slowly increase across the implementation-to-sustainability phases (62% vs. 70%; p = .04). Although uptake during implementation was low for BA (29%) and BI (22%), there was no significant decrease in service provision during the sustainability phase. Although overall delivery of BI was significantly higher in generalist compared with specialist sites (p < .001), sustainability did not differ by generalist versus specialist conditions. There were considerable differences in penetration across clinic sites. CONCLUSIONS: Clinics sustained a high level of substance use screening. Uptake of intervention services was low but did not decrease further following the cessation of implementation supports. This study illustrates the challenges of successfully implementing and sustaining substance use services in adolescent primary care.

HIV sex-risk behaviors among in- versus out-of-treatment heroin-addicted adults.

BACKGROUND: Relatively limited empirical evidence exists comparing the impact on HIV sex risk behavior for patients admitted to methadone treatment programs (MTPs) as compared with nontreatment seekers. METHODS: This longitudinal cohort study examined HIV sex-risk behavior among 164 out-of-treatment heroin-dependent adults recruited from the street and 351 newly admitted MTP patients. The AIDS Risk Assessment was administered at baseline, 6 months, and 12 months. Generalized linear mixed model and generalized estimating equation analyses were used to examine the changes in sex risk behavior over time. RESULTS: The participants mean age was 41.5 years, 74.8% were African-American, 24.3% were White, and 54.4% were men. There were no significant differences between the groups in age, race, or gender. At baseline, the out-of-treatment group compared with the in-treatment group reported more sex partners (p < .001) and higher frequency of sex (p = .001). There was a group x time interaction for three of the sex-risk items and the out-of-treatment group reported having significantly more sex partners at both follow-up time points and having significantly more frequent unprotected sex while high at 6 months (all values of p < .01). CONCLUSIONS: Nontreatment seekers are at higher HIV risk than those entering MTPs and should be a focus of sex-risk reduction interventions, even if they are not interested in treatment at that time.

A comparison of attitudes toward opioid agonist treatment among short-term buprenorphine patients.

BACKGROUND: Obtaining data on attitudes toward buprenorphine and methadone of opioid-dependent individuals in the United States may help fashion approaches to increase treatment entry and improve patient outcomes. OBJECTIVES: This secondary analysis study compared attitudes toward methadone and buprenorphine of opioid-dependent adults entering short-term buprenorphine treatment (BT) with opioid-dependent adults who are either entering methadone maintenance treatment or not entering treatment. METHODS: The 417 participants included 132 individuals entering short-term BT, 191 individuals entering methadone maintenance, and 94 individuals not seeking treatment. Participants were administered an Attitudes toward Methadone scale and its companion Attitudes toward Buprenorphine scale. Demographic characteristics for the three groups were compared using χ(2) tests of independence and one-way analysis of variance. A repeated-measures multivariate analysis of variance with planned contrasts was used to compare mean attitude scores among the groups. RESULTS: Participants entering BT had significantly more positive attitudes toward buprenorphine than toward methadone (p < .001) and more positive attitudes toward BT than methadone-treatment (MT) participants and out-of-treatment (OT) participants (p < .001). In addition, BT participants had less positive attitudes toward methadone than participants entering MT (p < .001). CONCLUSIONS: Participants had a clear preference for a particular medication. Offering a choice of medications to OT individuals might enhance their likelihood of entering treatment. Treatment programs should offer a choice of medications when possible to new patients, and future comparative effectiveness research should incorporate patient preferences into clinical trials. SCIENTIFIC SIGNIFICANCE: These data contribute to our understanding of why people seek or do not seek effective pharmacotherapy for opioid addiction.

Costs and Implementation Effectiveness of Generalist Versus Specialist Models for Adolescent Screening and Brief Intervention in Primary Care.

OBJECTIVE: This study analyzed the marginal service and program costs, and conducted a cost-effectiveness analysis (CEA) of two models of implementation of adolescent substance screening, brief intervention, and referral to treatment (SBIRT). METHOD: SBIRT was implemented at seven clinics in a multisite, cluster-randomized trial, through a Specialist model (behavioral health counselor-delivered brief intervention), and a Generalist model (primary care provider-delivered brief intervention). The CEA calculated marginal costs using an activity-based costing methodology for direct SBIRT services, and effectiveness was measured by the proportion of brief interventions delivered among patients who screened positive for alcohol, tobacco, or other drugs. Site-level program costs comprised start-up and maintenance (training and technical assistance). Costs were estimated in 2017 U.S. dollars. RESULTS: The marginal cost of SBIRT per patient with a positive screen for brief intervention was $6.72 in the Specialist model and $6.05 in the Generalist model. Implementation effectiveness was 7.2% (SE = 2.9%) in the Specialist model and 37.7% (SE = 5.6%) in the Generalist model. The program costs to provide SBIRT for 1 year per site were $13,548 for the Specialist site and $12,081 for the Generalist. CONCLUSIONS: The Generalist model was more effective in implementing brief intervention and less expensive than the Specialist model. Results were robust to sensitivity analysis. Brief intervention delivered by primary care providers rather than by handoff to a behavioral health counselor may ensure greater penetration and a lower cost of these services in primary care settings.

Redefining retention: recovery from the patient's perspective.

This study examines the process of discharge and treatment reentry for six participants who entered treatment voluntarily but were administratively discharged from methadone treatment programs. The participants completed semistructured interviews at treatment entry and at four, eight and 12 months post-treatment entry. Grounded theory methodology was used to examine the phenomenon of treatment reentry from the perspective of the patients, who often viewed their recovery as an accumulation of positive changes. Differences in terms of the patients' goals and motivations for seeking treatment from those of the treatment programs, combined with difficulties encountered during the treatment process eventually led to discharge. However, these patients were then able to navigate their way through the treatment system in different ways in order to remain in treatment. The authors conclude that failure to abide by treatment clinic rules do not necessary constitute "treatment failure" from the perspective of patients, who often wish to remain in treatment even if it is not progressing optimally from the program's perspective. As a result, the recovery process can be more fragmented and is often characterized by a series of cyclical treatment episodes rather than continuous time in treatment, thereby impeding their progress towards recovery.

Assessment of physical fitness aspects and their relationship to firefighters' job abilities.

The purpose of this study was to identify the relationships between various fitness parameters and firefighting performance on an "Ability Test" (AT) that included a set of 6 simulated firefighting tasks. The relationships between each fitness parameter and each task of the AT were determined. Ninety firefighters participated in this study (age 33 ± 7 years). The AT completion time was associated with abdominal strength (r = -0.53, p < 0.01), relative power (r = -0.44, p < 0.01), upper-body muscular endurance (push-ups, r = -0.27, p < 0.05) (sit-ups, r = -0.41, p < 0.01), and upper-body strength (1 repetition maximum bench press, r = -0.41, p < 0.01). In addition, poor performance on the AT was associated with high resting heart rate (r = 0.36, p < 0.01), high body mass index (r = 0.34, p < 0.01), high body fat (BF)% (r = 0.57, p < 0.01), increasing age (r = 0.42, p < 0.01), and large waist size (r = 0.67, p < 0.01). Multiple regression analyses indicated that a significant (F[5, 53] = 14.02, p < 0.01) proportion (60%) of the variation observed in the AT was explained by the variation of the fitness parameters used in the model. This study demonstrated that fitness variables, such as abdominal strength, power (step test), push-ups, resting Hr, and BF%, contributed significantly to the predictive power of firefighters' AT performance. The findings of this study may be useful to fire department instructors and trainers in the design and implementation of training programs that are more specifically tailored to improving both individual firefighting skills and general fire suppression performance.

Tetrasubstituted pyridines as potent and selective AKT inhibitors: Reduced CYP450 and hERG inhibition of aminopyridines.

The synthesis and evaluation of tetrasubstituted aminopyridines, bearing novel azaindazole hinge binders, as potent AKT inhibitors are described. Compound 14c was identified as a potent AKT inhibitor that demonstrated reduced CYP450 inhibition and an improved developability profile compared to those of previously described trisubstituted pyridines. It also displayed dose-dependent inhibition of both phosphorylation of GSK3beta and tumor growth in a BT474 tumor xenograft model in mice.

The role of patient satisfaction in methadone treatment.

BACKGROUND: Patient satisfaction surveys, widely used in health care delivery systems, may provide useful data for improving patient retention and outcomes. OBJECTIVES: This study examined the relationship between methadone patients' treatment satisfaction at three months post-admission and their 3-month treatment outcomes and 12-month treatment retention. METHODS: New methadone treatment admissions (N = 283) were assessed at 3 months post-admission for satisfaction with their counselors and programs. Correlations examined the relationship between 3-month satisfaction and Addiction Severity Index (ASI) scores. Regression analysis assessed the relationship between satisfaction and drug testing at 3 months and was used to predict whether participants were retained in treatment at 12 months. RESULTS: Participants who were more satisfied with their counselors and programs had lower Drug and Legal ASI composite scores at 3 months. Participants who were more satisfied with their programs remained in treatment for at least 12 months. CONCLUSIONS: Treatment programs should consider administering the CEF to their patients at 3 months post-admission to identify patients with low satisfaction scores who may be at risk for prematurely leaving treatment. SCIENTIFIC SIGNIFICANCE: Measuring patient satisfaction during treatment may help programs meet patients' needs and improve retention.

The relationship of social support to treatment entry and engagement: the Community Assessment Inventory.

This study was conducted to determine the psychometric properties of a measure of social support, the Community Assessment Inventory (CAI), and to examine the role of social support in recovery. The CAI and the Addiction Severity Index (ASI) were administered to 196 opioid-dependent adults in (n = 135) or out of (n = 61) methadone treatment in Baltimore, Maryland, between 2004 and 2006. Baseline CAI scale scores indicated a generally high level of internal consistency (alpha scores). Pearson correlations showed that the scales were stable and had good discriminant validity with the ASI composite scores. One-way analysis of variance indicated that in-treatment participants reported significantly more support at baseline than out-of-treatment participants. This study's findings indicate the CAI may be a useful measure of social support and that such support is an important factor in treatment entry.

Adolescent SBIRT implementation: Generalist vs. Specialist models of service delivery in primary care.

BACKGROUND: Drug, alcohol, and tobacco use among adolescents pose significant short- and long-term health consequences and are associated with more severe use as adults. Screening, brief intervention, and referral to treatment in primary care settings has the potential to deliver preventive interventions to a diverse range of adolescents, but optimal implementation of these services needs to be determined. The purpose of this study was to compare implementation of two different SBIRT service delivery models in primary care settings. METHODS: This cluster-randomized trial assigned 7 primary care clinics of a federally qualified health center to implement brief interventions (BI) using a Generalist model (4 sites), in which BIs were delivered by the primary care provider (PCP), or a Specialist model (3 sites), in which BIs were delivered by a behavioral health counselor (BHC) for adolescent patients ages 12-17 years. Implementation was tracked through the clinic's electronic health record, spanning 9639 clinic visits over 20 months. Multilevel logistic regression modeling was used to compare Generalist and Specialist strategies on penetration of BI for patients scoring ≥2 on the CRAFFT substance use screen, delivered by the PCP in the Generalist sites, and via warm hand-off to a BHC in the Specialist sites. RESULTS: Approximately 62% of adolescent patient visits were screened with the CRAFFT (with <4% screening positive with a CRAFFT score ≥ 2). The Generalist Condition had significantly higher self-reported penetration of BI delivery than the Specialist Condition (38% vs. 8%; Adjusted Odds Ratio = 6.53; p = .005). DISCUSSION: Despite having co-located behavioral health services at all sites, a Specialist approach to providing BI was less effectively implemented than a Generalist approach in this FQHC. BI delivered by PCPs rather than by hand-off to a BHC may ensure greater penetration of these services in primary care settings. Both implementation models provided a framework for identifying and intervening with adolescent primary care patients whose substance use might have otherwise gone undetected.

Application of System Dynamics to Inform a Model of Adolescent SBIRT Implementation in Primary Care Settings.

System dynamics (SD) modeling is used to compare and contrast strategies for effective implementation of an evidence-based adolescent behavioral health treatment in primary care settings. With qualitative and quantitative data from an on-going cluster-randomized trial in 7 federally qualified health center sites, two implementation conditions were compared: generalist vs. specialist. In the generalist approach, the primary care provider (PCP) delivered brief intervention (BI) for substance misuse (n = 4 clinics). In the specialist approach, BIs were delivered by behavioral health counselors (BHCs) (n = 3 clinics). The resultant SD model compared 'basecase' dynamics to strategic approaches to deploying continuous technical assistance (TA) and performance feedback reporting (PFR). The basecase effectively represented the SBIRT intervention, which reflected actual monthly volume of adolescent primary care visits (N = 9639), screenings (N = 5937), positive screenings (N = 246), and brief interventions (BIs; N = 50) over the 20-month implementation period. Insights gained suggest that implementation outcomes are sensitive to frequency of PFR, with bimonthly events generating the most rapid and sustained screening results. Simulated trends indicated that availability of the BHC directly impacts success of the specialist model. Similarly, understanding PCPs' perception of severity of need for intervention is key to outcomes in either condition.

Correction to Identification of Quinoline-Based RIP2 Kinase Inhibitors with an Improved Therapeutic Index to the hERG Ion Channel.

[This corrects the article DOI: 10.1021/acsmedchemlett.8b00344.].

Uses of diverted methadone and buprenorphine by opioid-addicted individuals in Baltimore, Maryland.

This study examined the uses of diverted methadone and buprenorphine among opiate-addicted individuals recruited from new admissions to methadone programs and from out-of-treatment individuals recruited from the streets. Self-report data regarding diversion were obtained from surveys and semi-structured qualitative interviews. Approximately 16% (n = 84) of the total sample (N = 515) reported using diverted (street) methadone two-three times per week for six months or more, and for an average of 7.8 days (SD = 10.3) within the past month. The group reporting lifetime use of diverted methadone as compared to the group that did not report such use was less likely to use heroin and cocaine in the 30 days prior to admission (ps <.01) and had lower ASI Drug Composite scores (p <.05). Participants in our qualitative sub-sample (n = 22) indicated that street methadone was more widely used than street buprenorphine and that both drugs were largely used as self-medication for detoxification and withdrawal symptoms. Participants reported using low dosages and no injection of either medication was reported.

Brief vs. extended buprenorphine detoxification in a community treatment program: engagement and short-term outcomes.

BACKGROUND: Despite evidence supporting the efficacy of buprenorphine relative to established detoxification agents such as clonidine, little research has examined: 1) how best to implement buprenorphine detoxification in outpatient settings; and 2) whether extending the length of buprenorphine detoxification improves treatment engagement and outcomes. OBJECTIVES: The current study examined the impact on 1) successful detoxification completion; 2) transition to longer-term treatment; and 3) treatment engagement of two different length opioid detoxifications using buprenorphine. METHODS: The study compared data obtained from two consecutive studies of early treatment engagement strategies. In one study (n = 364), opioid-addicted participants entered treatment through a Brief (5-day) buprenorphine detoxification. In the other study (n = 146), participants entered treatment through an Extended (i.e., 30-day) buprenorphine detoxification. RESULTS: Results indicated a greater likelihood of successful completion and of transition among participants who received the Extended as compared to the Brief detoxification. Extended detoxification participants attended more counseling sessions and submitted fewer drug-positive urine specimens during the first 30 days of treatment, inclusive of detoxification, than did Brief detoxification participants. CONCLUSIONS: Results demonstrate that longer periods of detoxification improve participant engagement in treatment and early treatment outcomes. SCIENTIFIC SIGNIFICANCE: Current findings demonstrate the feasibility of implementing an extended buprenorphine detoxification within a community-based treatment clinic.

Gender Differences Among In- and Out-of-Treatment Opioid-Addicted Individuals.

OBJECTIVE: Gender differences were explored among 355 in- and out-of-treatment opioid-addicted adults in Baltimore. METHODS: Addiction Severity Index and other variables were compared among: 1) in-treatment women vs. out-of-treatment women; 2) out-of-treatment: women vs. men; and, 3) in-treatment: women vs. men. RESULTS: Analysis indicated that in-treatment and out-of-treatment women worked less and used more cocaine than their male counterparts (ps < .01). Moreover, out-of-treatment women used heroin and cocaine more often, spent more money on drugs, earned more illegal income, and had fewer treatments than in-treatment women (ps < or = .01). CONCLUSIONS: Findings indicate greater severity of drug and employment problems of opioid-addicted women and underline the need for gender-specific drug-treatment services.