Improving assessment and progress monitoring in alcohol use disorder: An implementation evaluation of the instant assessment and personalised feedback system (iAx).

BACKGROUND: When treating patients with alcohol use disorder (AUD), best practice guidelines recommend the use of standardised assessment instruments to obtain reliable information about psychological symptoms and functioning to inform treatment. Due to time constraints and administrative burden, many mental health practitioners do not routinely use standardised assessments. To overcome these barriers, an instant assessment and feedback system (iAx) was developed that electronically administers standardised instruments. Responses are instantly scored and benchmarked against clinical norms for immediate interpretation. This allows for timely assessment and feedback. The aim of this study was to evaluate the implementation of the iAx system at a specialist alcohol and drug outpatient unit in a public hospital. METHODS: Baseline (pre-iAx implementation; paper-and-pencil assessments) and follow-up (post-iAx implementation) clinical audits collated records from 313 patients with AUD across 2,616 treatment sessions. Multilevel modelling was used to determine if use of standardised instruments increased post-iAx implementation. RESULTS: Post-iAx implementation, there was a significant increase in the probability of using standardised assessments during the initial assessment and throughout treatment (ps < 0.001). Specifically, the use of standardised assessments to inform initial assessment of patients increased from 51% to 89%, and progress monitoring of symptoms increased from 28% to 84%. A significant increase in treatment completion rates was also observed post-iAx implementation (from 15.6% to 32.4%). Psychologists and patients also provided feedback on iAx acceptability, appropriateness and feasibility. CONCLUSIONS: This study found support for the successful implementation of an electronic, theory-driven iAx system to improve assessment practices with patients with AUD in routine clinical settings.

Additive effectiveness and feasibility of a theory-driven instant assessment and feedback system in brief cannabis intervention: A randomised controlled trial.

Assessment and personalised feedback are important components of brief interventions (BIs) for cannabis use. A key outcome is to increase motivation to change during this short interaction. The diversity of available assessments and time burden scoring them pose a challenge for routine use in clinical practice. An instant assessment and feedback (iAx) system was developed to administer assessments informed by bioSocial Cognitive Theory, that were instantly scored and benchmarked against clinical norms, to provide patient feedback and guide treatment planning. This study evaluated the feasibility and additive effectiveness of the iAx on motivation to change cannabis use, when compared to treatment as usual (TAU), in a single-session BI. A randomised controlled trial was conducted in a public hospital alcohol and drug outpatient clinic. Eighty-seven cannabis users (Mage = 26.41; 66% male) were assigned to the BI utilising the iAx (iAx; n = 44) or to the standard BI (TAU; n = 43). Patients completed pre- and post-BI assessments of motivation to change and a post-BI measure of treatment satisfaction. Practitioners completed a feedback survey. Patients receiving iAx reported a significantly greater increase in motivation to change from pre- to post-BI compared to patients receiving TAU (d = 0.49, p = .03). Treatment satisfaction was high across both conditions, with no significant difference between groups (p = .57). Practitioners also reported a high level of satisfaction with the iAx system. In summary, findings support the feasibility and additive effectiveness of the iAx to enhance patient motivation during cannabis BI.

Duration of opioid use and association with socioeconomic status, daily dose and formulation: a two-decade population study in Queensland, Australia.

Background There is an association between the duration of prescription opioids use and an increased risk of serious harm, often unintentional. Objective (1) Describe the trends in duration of prescription opioids dispensing and, (2) determine the risk of long-term use (≥4 months) based on patients' socioeconomic status, daily dose in oral daily morphine milligram equivalent, and opioid formulation. Setting Residents of Queensland (2,827,727), Australia from the age 18 years and who were dispensed pharmaceutical opioids from 1 January 1997 to 31 December 2018. Method Retrospective, longitudinal population-based analysis using data obtained from the Monitoring of Drugs of Dependence system of the Monitored Medicines Unit of Queensland Health. Main outcome measure Contribution of socioeconomic status, and daily dose and opioid formulation (modified-release or immediate-release) to the risk of long-term opioid use. Results There was little difference between the number of patients dispensed opioids for ≥4 months and ≤3 months between 1997 and 2011. Thereafter, the number for those using opioids long-term increased. The highest risk of having opioids dispensed for ≥4 months were for patients in the lowest level of socioeconomic status (adjusted odds ratio 1.36; 95% CI, 1.34, 1.38), compared to people in the highest socioeconomic status areas, followed by the low-socioeconomic status areas, mid-socioeconomic status areas, and high-socioeconomic status areas respectively. The risk of being dispensed prescription opioids for ≥4 months significantly increased as the dose increased: adjusted odds ratio 1.73; 95% CI, 1.71, 1.75, adjusted odds ratio 1.89; 95% CI, 1.87, 1.92, and adjusted odds ratio 3.63; 95% CI, 3.58, 3.69 for the ≥20 to <50 oral daily morphine milligram equivalent, ≥50 to <100 oral daily morphine milligram equivalent and ≥100 oral daily morphine milligram equivalent dose categories, respectively. Conclusion Higher doses and living in a low socioeconomic status areas were associated with increased risk of long-term dispensing of opioid prescriptions.

Pharmaceutical opioids utilisation by dose, formulation, and socioeconomic status in Queensland, Australia: a population study over 22 years.

Background Prescription opioids are a central aspect of pain management and as the prevalence of pain is increasing so is the rate of use of prescription opioids. Increased opioid prescriptions increases the risk of deaths and morbidity. Objective To (a) describe the 22-year trend of prescription opioid dispensing in Queensland, (b) examine the effect of opioid dose, formulation and socioeconomic status on the number of prescriptions dispensed. Design/setting Retrospective analysis of data from the Monitoring of Drugs of Dependence system of the Monitored Medicines Unit of Queensland Health, Australia. Participants Queensland residents (3.3 million) from 18 years old dispensed 18.8 million opioid prescriptions from January 1997 to December 2018. Results Opioid prescriptions dispensed annually increased to over two million in 2018 from about 150,000 prescriptions in 1997. The number of prescriptions for modified-release formulations dispensed annually was three times higher compared to the immediate-release formulations. Oxycodone accounted for over 60% of prescriptions for pharmaceutical opioids since 2013. There was an increase in the number of prescriptions dispensed as socioeconomic status decreased and modified-release opioid formulations positively affects the pattern of dispensing. The highest increase in number of prescriptions dispensed (for all opioids) was observed among the high socioeconomic status (IRR = 1.25, 95% CI 1.25, 1.26). The disparities in the annual number of prescriptions across dose categories are wider in the modified-release than the immediate-release formulations. Conclusion The dispensing of opioids increased significantly in Queensland. There was a positive relationship between the increased dispensing of opioids and locations of lower socioeconomic status.

Brief Psychological Interventions for Reducing Prescription Opioid Use, Related Harm, and Pain Intensity in Patients With Chronic Pain: A Systematic Review and Assessment of Patient Interest.

OBJECTIVES: Brief psychological interventions (BPIs) have demonstrated effectiveness in reducing substance use and related harm. No systematic review has examined their potential to reduce or prevent prescription opioid use or related harm, and/or pain intensity in opioid-using patients with chronic noncancer pain (CNCP). Recognizing the importance of patient preferences in evidence-based practice, we also sought to assess patient interest in BPIs. MATERIALS AND METHODS: A systematic review of studies published between 1980 and 2020 was conducted using 5 databases. Eligible treatment studies included patients ≥18 years old, with CNCP, and who were using prescription opioids. An adjunctive study independent of our review was also undertaken in 188 prescription opioid-using patients (77% female; Mage=49 y) diagnosed with CNCP. Patients completed pain-related questionnaires online and indicated if they would consider BPI treatment options. RESULTS: The review identified 6 studies. Given the heterogeneity across studies, a meta-analysis was not conducted. A narrative review found that all of the 6 studies demonstrated some evidence for BPI effectiveness for reducing opioid use or related harms; these were assessed as having mostly low methodological quality. Mixed support for the effect on pain intensity was found in 1 study. Despite the inconclusive findings and heterogenous studies identified in the review, 92% of patients in our survey reported interest in receiving a BPI. DISCUSSION: In combination, these findings highlight the inconsistency between patient demand and the availability of evidence for BPIs targeting opioid use, related harm, and pain intensity. Future work should examine the effectiveness of BPIs in higher quality studies.

Availability of substances for use in personal vaporisers on three online cryptomarkets.

BACKGROUND: Personal vaporisers are gaining popularity as an alternative route of administration for a range of substances. Online cryptomarkets are becoming increasingly popular among people who use substances due to their perceived anonymity, ease of use, and reduced risk of violence compared to traditional face-to-face dealers. We examined the diversity of substances marketed for use in a personal vaporiser on these marketplaces. METHODS: Vaping related listings were extracted from three online cryptomarkets ('Agartha', 'Cryptonia', and 'Tochka') using The Onion Router browser. Data collection occurred between October and November 2019. RESULTS: We identified 1929 listings from 201 unique sellers. The top product on Agartha, Cryptonia, and Tochka were vape cartridges prefilled with the e-liquid (70.4 %, 39.4 %, 52.3 % respectively). The most common substance in these products was cannabis oil (96.1 %, 82.1 %, 87.8 %), followed by synthetic cannabinoids (3.7 %, 9.7 %, 9.8 %) and psychedelic substances (0.2 %, 6.4 %, 1.2 %). Vendors were primarily from the USA. Many products offered worldwide shipping (96.3 %, 42.4 %, 51.2 %). CONCLUSION: Vaping products listed on online cryptomarkets in 2019 primarily contained cannabis oils. Future studies should continue to examine cryptomarkets to identify emerging trends of substances that can be used in personal vaporisers.

Network Analysis and Visualisation of Opioid Prescribing Data.

In many countries around the world (including Australia), the prescribing of opioid analgesic drugs is an increasing trend associated with significant increases in drug-related patient harm such as abuse, overdose, and death. In Australia, the Medicines Regulation and Quality Unit within Queensland Health maintains a database recording opioid analgesic drug prescriptions dispensed across the State (population 4.703 million). In this work, we propose the use of network visualisation and analysis as a tool for improved understanding of these data. Prescribing data for Fentanyl patches, a strong opioid with high potential for misuse and subsequent harm, across Queensland, Australia from 2011 to 2018 is analysed as an example of using network analysis, where prescribing patterns are viewed as a dynamic, bipartite graph of the interactions between patients and prescribers over time. The technique provides a global view of a large state-wide prescribing dataset, including the distribution of subgraph structures present. Local analysis is also carried out to demonstrate the clinical utility of the technique, including the dynamics of the graph structure over time. A variety of network statistics that measure network structural and dynamic properties are presented to reveal the characteristics and trends of drug seeking and prescribing behaviours. This approach has been recognised by healthcare professionals at Queensland Health as leading to new and useful insights on the relationship between patients and prescribers and supporting their advisory role to reduce patient harm from inappropriate use of prescription drugs.

Alcohol consumption and consequences in adolescents in 68 low and middle-income countries - a multi-country comparison of risks by sex.

AIMS: Alcohol use is a leading risk factor for disease burden among youth. This study estimated sex differences in the prevalence of alcohol use and consequences among adolescents living in low and middle-income countries (LMIC). DESIGN: Multi-staged cross-sectional international standardized self-report questionnaires administered in the classroom. SETTING: The Global school-based student health survey (GSHS) comprised adolescents from 68 LMIC between 2003-2014. PARTICIPANTS: 271,156 students aged 13-17 years old. MEASUREMENTS: Alcohol measures included: past month alcohol consumption, history of intoxication and alcohol-related problems. Regions were based on the World Health Organization definitions: Africa, America, Eastern Mediterranean, Europe, South-east Asia, and Western Pacific. FINDINGS: Overall, males had higher odds of alcohol use (OR = 2.38 [1.91-2.96]), a history of intoxication (OR = 2.64 [2.11-3.31]), and alcohol-related problems (OR = 1.72 [1.41-2.10]) than females. All regions recorded overall greater odds of alcohol use by males versus females; five regions (excluding Europe) recorded greater odds of intoxication in males; and three regions (America, South-east Asia, and Western Pacific) recorded greater odds of alcohol-related problems amongst males. However, there were country-level differences - in some countries, adolescent drinking rates and consequences were comparable by sex. Countries with the highest odds of alcohol use among males compared to females were Indonesia, Myanmar, Cambodia, Tuvalu, Morocco, Senegal, Kiribati, and Thailand. CONCLUSIONS: Among adolescents living in LMIC, males had on average two-fold higher odds of drinking alcohol and experiencing adverse consequences. Growing affluence and improvements in sex equality in societies may increase the future prevalence of hazardous drinking in females in LMICs.

A laboratory model of impulsivity and alcohol use in late adolescence.

Impulsivity is a core characteristic of externalizing problems and a robust predictor of alcohol use in adolescence. There is little evidence on the causal mechanisms through which impulsivity influences drinking or how they are affected by key social factors (peer influence). This study reports the development of the first comprehensive laboratory model of adolescent impulsivity and alcohol use. One-hundred and twenty adolescents (50% female) of legal drinking age (M = 19.47 years, SD = 1.12) in Australia (18+ years) were subjected to 1 of 3 experimental manipulations to increase impulsive behavior (reward cue exposure, negative mood induction, ego depletion). Changes in disinhibition (stop-signal task) and reward-seeking (BAS-Fun Seeking) were measured before completing a laboratory drinking task alone or with a heavy-drinking confederate. Reward cue exposure increased alcohol consumption, with the effect mediated by increased reward-seeking. Negative mood induction increased disinhibition, but not drinking. The presence of a heavy-drinking peer directly increased alcohol consumption in an additive fashion. Findings provide causal evidence that extends survey-based research by highlighting the role of reward-related impulsivity in adolescent alcohol use. The new laboratory model can provide novel insights into the psychological processes underlying adolescent impulsivity and impulsivity-related drinking.

The Quik Fix study: a randomised controlled trial of brief interventions for young people with alcohol-related injuries and illnesses accessing emergency department and crisis support care.

BACKGROUND: Alcohol is a major preventable cause of injury, disability and death in young people. Large numbers of young people with alcohol-related injuries and medical conditions present to hospital emergency departments (EDs). Access to brief, efficacious, accessible and cost effective treatment is an international health priority within this age group. While there is growing evidence for the efficacy of brief motivational interviewing (MI) for reducing alcohol use in young people, there is significant scope to increase its impact, and determine if it is the most efficacious and cost effective type of brief intervention available. The efficacy of personality-targeted interventions (PIs) for alcohol misuse delivered individually to young people is yet to be determined or compared to MI, despite growing evidence for school-based PIs. This study protocol describes a randomized controlled trial comparing the efficacy and cost-effectiveness of telephone-delivered MI, PI and an Assessment Feedback/Information (AF/I) only control for reducing alcohol use and related harm in young people. METHODS/DESIGN: Participants will be 390 young people aged 16 to 25 years presenting to a crisis support service or ED with alcohol-related injuries and illnesses (including severe alcohol intoxication). This single blinded superiority trial randomized young people to (i) 2 sessions of MI; (ii) 2 sessions of a new PI or (iii) a 1 session AF/I only control. Participants are reassessed at 1, 3, 6 and 12 months on the primary outcomes of alcohol use and related problems and secondary outcomes of mental health symptoms, functioning, severity of problematic alcohol use, alcohol injuries, alcohol-related knowledge, coping self-efficacy to resist using alcohol, and cost effectiveness. DISCUSSION: This study will identify the most efficacious and cost-effective telephone-delivered brief intervention for reducing alcohol misuse and related problems in young people presenting to crisis support services or EDs. We expect efficacy will be greatest for PI, followed by MI, and then AF/I at 1, 3, 6 and 12 months on the primary and secondary outcome variables. Telephone-delivered brief interventions could provide a youth-friendly, accessible, efficacious, cost-effective and easily disseminated treatment for addressing the significant public health issue of alcohol misuse and related harm in young people. TRIAL REGISTRATION: This trial is registered with the Australian and New Zealand Clinical Trials Registry ACTRN12613000108718.

Family relationship quality and early alcohol use: evidence for gender-specific risk processes.

OBJECTIVE: Family characteristics (relationship quality, parental behaviors, and attitudes relating to alcohol use) are known to influence alcohol use in the mid-teen years, and there is evidence that family characteristics have different influences on mid-teen girls versus boys. This study examined child gender differences in the association of family relationship quality, parental disapproval of children's alcohol use, and parental alcohol use with early adolescent alcohol use. METHOD: Grade 6 and 8 students (modal age 11 and 13, respectively; N = 6,837; 52.6% female) were recruited from 231 schools across three Australian states. Hypotheses were tested using two-level ordinal logistic regression (individuals nested within schools). The main dependent measure was lifetime frequency of early adolescent alcohol consumption. Independent variables included mother's/father's alcohol use, closeness, conflict, and disapproval of adolescent alcohol use. Control variables included sensation seeking, peer alcohol use, and socioeconomic disadvantage. RESULTS: The key findings were that for the young age group (Grade 6), emotional closeness to the parent of the opposite sex was protective. Family conflict was associated with females' drinking in both age groups but not males' drinking. CONCLUSIONS: There was evidence of gender differences in the epidemiology of family relationship quality and early alcohol use. Social developmental models may need revision to account for these child gender differences. Gender-specific family dynamics may be an important consideration for family-oriented prevention strategy.

The cost effectiveness of naltrexone added to cognitive-behavioral therapy in the treatment of alcohol dependence.

The purpose of this study was to evaluate the comparative cost of treating alcohol dependence with either cognitive behavioral therapy (CBT) alone or CBT combined with naltrexone (CBT+naltrexone). Two hundred ninety-eight outpatients dependent on alcohol who were consecutively treated for alcohol dependence participated in this study. One hundred seven (36%) patients received adjunctive pharmacotherapy (CBT+naltrexone). The Drug Abuse Treatment Cost Analysis Program was used to estimate treatment costs. Adjunctive pharmacotherapy (CBT+naltrexone) introduced an additional treatment cost and was 54% more expensive than CBT alone. When treatment abstinence rates (36.1% CBT; 62.6% CBT+naltrexone) were applied to cost effectiveness ratios, CBT+naltrexone demonstrated an advantage over CBT alone. There were no differences between groups on a preference-based health measure (SF-6D). In this treatment center, to achieve 100 abstainers over a 12-week program, 280 patients require CBT compared with 160 CBT+naltrexone. The dominant choice was CBT+naltrexone based on modest economic advantages and significant efficiencies in the numbers needed to treat.