Impacts of an opioid overdose prevention intervention delivered subsequent to acute care.

BACKGROUND: Opioid overdose is a major and increasing cause of injury and death. There is an urgent need for interventions to reduce overdose events among high-risk persons. METHODS: Adults at elevated risk for opioid overdose involving heroin or pharmaceutical opioids who had been cared for in an emergency department (ED) were randomised to overdose education combined with a brief behavioural intervention and take-home naloxone or usual care. Outcomes included: (1) time to first opioid overdose-related event resulting in medical attention or death using competing risks survival analysis; and (2) ED visit and hospitalisation rates, using negative binomial regression and adjusting for time at risk. RESULTS: During the follow-up period, 24% of the 241 participants had at least one overdose event, 85% had one or more ED visits and 55% had at least one hospitalisation, with no significant differences between intervention and comparison groups. The instantaneous risk of an overdose event was not significantly lower for the intervention group (sub-HR: 0.83; 95% CI 0.49 to 1.40). DISCUSSION: These null findings may be due in part to the severity of the population in terms of housing insecurity (70% impermanently housed), drug use, unemployment and acute healthcare issues. Given the high overdose and healthcare utilisation rates, more intensive interventions, such as direct referral and provision of housing and opioid agonist treatment medications, may be necessary to have a substantial impact on opioid overdoses for this high-acuity population in acute care settings. TRIAL REGISTRATION NUMBER: NCT0178830; Results.

A higher effort-based paradigm in physical activity and exercise for public health: making the case for a greater emphasis on resistance training.

It is well known that physical activity and exercise is associated with a lower risk of a range of morbidities and all-cause mortality. Further, it appears that risk reductions are greater when physical activity and/or exercise is performed at a higher intensity of effort. Why this may be the case is perhaps explained by the accumulating evidence linking physical fitness and performance outcomes (e.g. cardiorespiratory fitness, strength, and muscle mass) also to morbidity and mortality risk. Current guidelines about the performance of moderate/vigorous physical activity using aerobic exercise modes focuses upon the accumulation of a minimum volume of physical activity and/or exercise, and have thus far produced disappointing outcomes. As such there has been increased interest in the use of higher effort physical activity and exercise as being potentially more efficacious. Though there is currently debate as to the effectiveness of public health prescription based around higher effort physical activity and exercise, most discussion around this has focused upon modes considered to be traditionally 'aerobic' (e.g. running, cycling, rowing, swimming etc.). A mode customarily performed to a relatively high intensity of effort that we believe has been overlooked is resistance training. Current guidelines do include recommendations to engage in 'muscle strengthening activities' though there has been very little emphasis upon these modes in either research or public health effort. As such the purpose of this debate article is to discuss the emerging higher effort paradigm in physical activity and exercise for public health and to make a case for why there should be a greater emphasis placed upon resistance training as a mode in this paradigm shift.

Are medical marijuana users different from recreational users? The view from primary care.

BACKGROUND AND OBJECTIVES: Marijuana is currently approved for medical use in 23 states. Both clinicians and the lay public have questioned whether users of marijuana for medical purposes are different from users of marijuana for recreational purposes. This study examined similarities and differences in important clinical characteristics between users of medical marijuana and users of recreational marijuana. METHODS: The sample consisted of 868 adult primary care patients in Washington State, who reported use of medical marijuana (n = 131), recreational marijuana (n = 525), or drugs other than marijuana (n = 212). Retention was over 87% at 3-, 6-, 9-, and 12-month assessments. RESULTS: The majority of medical, psychiatric, substance use, and service utilization characteristic comparisons were not significant. However, medical marijuana users had significantly more medical problems, a significantly larger proportion reported >15 days medical problems in the past month, and significantly smaller proportions reported no pain and no mobility limitations (p < .001). Medical marijuana users also had significantly lower drug problem severity, lower alcohol problem severity, and significantly larger proportions reported using marijuana alone and concomitant opioid use only (p < .001). There was no significant difference between medical and recreational users in the percentage using marijuana with at least two additional substances (48% vs. 58%, respectively, p = .05). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Although our results suggest that there are few distinct differences between medical and recreational users of marijuana, the differences observed, while mostly very small in effect size (<.2), are consistent with at least some medical users employing marijuana to relieve symptoms and distress associated with medical illness.

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

IMPORTANCE: Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance). OBJECTIVE: To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual. DESIGN, SETTING, AND PARTICIPANTS: A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points. INTERVENTIONS: Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433). MAIN OUTCOMES AND MEASURES: The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior. RESULTS: Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, ß = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, ß = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes. CONCLUSIONS AND RELEVANCE: A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00877331.

A randomized stepped care intervention trial targeting posttraumatic stress disorder for surgically hospitalized injury survivors.

OBJECTIVE: To test the effectiveness of a stepped care intervention model targeting posttraumatic stress disorder (PTSD) symptoms after injury. BACKGROUND: Few investigations have evaluated interventions for injured patients with PTSD and related impairments that can be feasibly implemented in trauma surgical settings. METHODS: The investigation was a pragmatic effectiveness trial in which 207 acutely injured hospitalized trauma survivors were screened for high PTSD symptom levels and then randomized to a stepped combined care management, psychopharmacology, and cognitive behavioral psychotherapy intervention (n = 104) or usual care control (n = 103) conditions. The symptoms of PTSD and functional limitations were reassessed at 1, 3, 6, 9, and 12 months after the index injury admission. RESULTS: Regression analyses demonstrated that over the course of the year after injury, intervention patients had significantly reduced PTSD symptoms when compared with controls [group by time effect, CAPS (Clinician-Administered PTSD Scale): F(2, 185) = 5.50, P < 0.01; PCL-C (PTSD Checklist Civilian Version): F(4, 185) = 5.45, P < 0.001]. Clinically and statistically significant PTSD treatment effects were observed at the 6-, 9-, and 12-month postinjury assessments. Over the course of the year after injury, intervention patients also demonstrated significant improvements in physical function [MOS SF-36 PCS (Medical Outcomes Study Short Form 36 Physical Component Summary) main effect: F(1, 172) = 9.87, P < 0.01]. CONCLUSIONS: Stepped care interventions can reduce PTSD symptoms and improve functioning over the course of the year after surgical injury hospitalization. Orchestrated investigative and policy efforts could systematically introduce and evaluate screening and intervention procedures for PTSD at US trauma centers. ( TRIAL REGISTRATION: clinicaltrials.gov identifier: NCT00270959).

Monitoring spore washoff during a biological contamination incident response using automated stormwater samplers and sensors to predict contamination movement.

This study examined the washoff of Bacillus globigii (Bg) spores from concrete, asphalt, and grass surfaces by stormwater. Bg is a nonpathogenic surrogate for Bacillus anthracis, which is a biological select agent. Areas (2.74 m × 7.62 m) of concrete, grass, and asphalt were inoculated twice at the field site during the study. Spore concentrations were measured in runoff water after seven rainfall events (1.2-65.4 mm) and complimentary watershed data were collected for soil moisture, depth of water in collection troughs, and rainfall using custom-built telemetry units. An average surface loading of 107.79 Bg spores/m2 resulted in peak spore concentrations in runoff water of 102, 260, and 4.1 CFU/mL from asphalt, concrete, and grass surfaces, respectively. Spore concentrations in the stormwater runoff were greatly reduced by the third rain event after both inoculations, but still detectable in some samples. When initial rainfall events occurred longer after the initial inoculation, the spore concentrations (both peak and average) in the runoff were diminished. The study also compared rainfall data from 4 tipping bucket rain gauges and a laser disdrometer and found they performed similarly for values of total rainfall accumulation while the laser disdrometer provided additional information (total storm kinetic energy) useful in comparing the seven different rain events. The soil moisture probes are recommended for assistance in predicting when to sample sites with intermittent runoff. Sampling trough level readings were critical to understanding the dilution factor of the storm event and the age of the sample collected. Collectively the spore and watershed data are useful for emergency responders faced with remediation decisions after a biological agent incident as the results provide insight into what equipment to deploy and that spores may persist in runoff water at quantifiable levels for months. The spore measurements are also a novel dataset for stormwater model parameterization for biological contamination of urban watersheds.

Mussel Mass Mortality and the Microbiome: Evidence for Shifts in the Bacterial Microbiome of a Declining Freshwater Bivalve.

Freshwater mussels (Unionida) are suffering mass mortality events worldwide, but the causes remain enigmatic. Here, we describe an analysis of bacterial loads, community structure, and inferred metabolic pathways in the hemolymph of pheasantshells (Actinonaias pectorosa) from the Clinch River, USA, during a multi-year mass mortality event. Bacterial loads were approximately 2 logs higher in moribund mussels (cases) than in apparently healthy mussels (controls). Bacterial communities also differed between cases and controls, with fewer sequence variants (SVs) and higher relative abundances of the proteobacteria Yokenella regensburgei and Aeromonas salmonicida in cases than in controls. Inferred bacterial metabolic pathways demonstrated a predominance of degradation, utilization, and assimilation pathways in cases and a predominance of biosynthesis pathways in controls. Only two SVs correlated with Clinch densovirus 1, a virus previously shown to be strongly associated with mortality in this system: Deinococcota and Actinobacteriota, which were associated with densovirus-positive and densovirus-negative mussels, respectively. Overall, our results suggest that bacterial invasion and shifts in the bacterial microbiome during unionid mass mortality events may result from primary insults such as viral infection or environmental stressors. If so, bacterial communities in mussel hemolymph may be sensitive, if generalized, indicators of declining mussel health.

Deconstructing proficiency in motivational interviewing: mechanics of skilful practitioner delivery during brief simulated encounters.

BACKGROUND: Proficient delivery of motivational interviewing (MI) is often determined by global rating of relational elements or cumulative tallies of technical elements. Yet limited empirical evidence exists to clarify how relational and technical elements are associated, or if rates of skill indices and their constituent technical elements vary within a clinical encounter. AIMS: This study sought to document temporal variance in rates of MI skill indices and their constituent technical elements during brief clinical encounters with a standardized patient wherein delivery was "MI-proficient", and to distinguish those temporal patterns from those observed in encounters with "MI-inconsistent" delivery. METHOD: Data were accessed from a large MI training trial wherein relational and technical elements of MI delivery were scored for 503 recordings of a simulated 20-minute clinical encounter. Notably, independent raters tallied technical elements in 5-minute segments, allowing evaluation of potential variance among the encounter's quartile intervals. Global ratings of MI spirit identified subsets of recordings with MI-proficient (n = 49) and MI-inconsistent (n = 43) delivery for stratified analyses. RESULTS: Analyses contrast temporal trajectories of technical aspects of MI-proficient and MI-inconsistent delivery, with the former characterized by: 1) elicitation and reflective listening as primary opening strategies; 2) increased depth of reflective listening as a predominant strategy in subsequent, focused therapeutic discussion; and 3) increased use of elicitation and information provision in change planning as the encounter approached conclusion. CONCLUSIONS: Findings are generally consistent with seminal descriptions of MI (Miller and Rollnick, 1991, 2002), and document temporal aspects of skilful MI delivery in brief encounters.

Predicting adolescent alcohol drinking patterns after major injury.

BACKGROUND: Bedside alcohol counseling provided to injured adolescents during their acute medical care reduces subsequent alcohol consumption and reinjury. This counseling would be even more effective if extended beyond hospitalization to help injured youth return to normal functioning. To enhance this counseling, we first need to know the natural course of adolescent drinking during the year after injury, as well as the predictors of problem drinking during that year. METHODS: Prospective cohort study that described the natural history of adolescent drinking during the year after traumatic injury and identified predictors of increased alcohol use. Randomly sampled injured adolescents 12 years to 18 years of age, admitted to the surgical services of a Level I trauma center were interviewed to assess alcohol consumption at baseline and 2 months, 5 months, and 12 months after injury admission. RESULTS: Drinking increased steadily over the year, with this increase beginning in the months immediately after injury. Greater preinjury alcohol consumption, greater number of cumulative preinjury traumatic life experiences, and increasing age were independent positive predictors of increased drinking during the year after injury. Increased injury severity was a negative predictor such that the more severe the injury was, the less the adolescent drank during the year after injury. CONCLUSIONS: This documented postinjury drinking pattern and its predictors can now identify for the purposes of extended counseling those adolescents most likely to drink heavily during the year after injury.

Geographic variation and localised clustering of congenital anomalies in Great Britain.

BACKGROUND: Environmental pollution as a cause of congenital anomalies is sometimes suspected because of clustering of anomalies in areas of higher exposure. This highlights questions around spatial heterogeneity (clustering) in congenital anomaly rates. If spatial variation is endemic, then any one specific cluster is less remarkable, though the presence of uncontrolled geographically clustered risk factors is suggested. If rates are relatively homogeneous across space other than around specific hazards, then evidence for these hazards causing the clusters is strengthened. We sought to estimate the extent of spatial heterogeneity in congenital anomaly rates in the United Kingdom. METHODS: The study population covered about one million births from five registers in Britain from 1991-1999. We estimated heterogeneity across four geographical levels: register area, hospital catchment, electoral ward, and enumeration district, using a negative binomial regression model. We also sought clusters using a circular scan statistic. RESULTS: Congenital anomaly rates clearly varied across register areas and hospital catchments (p < 0.001), but not below this level (p > 0.2). Adjusting for socioeconomic deprivation and maternal age made little difference to the extent of geographical variation for most congenital anomaly subtypes. The two most significant circular clusters (of four ano-rectal atresias and six congenital heart diseases) contained two or more siblings. CONCLUSION: The variation in rates between registers and hospital catchment area may have resulted in part from differences in case ascertainment, and this should be taken into account in geographical epidemiological studies of environmental exposures. The absence of evidence for variation below this level should be interpreted cautiously in view of the low power of general heterogeneity tests. Nevertheless, the data suggest that strong localised clusters in congenital anomalies are uncommon, so clusters around specific putative environmental hazards are remarkable when observed. Negative binomial models applied at successive hierarchical levels provide an approach of intermediate complexity to characterising geographical heterogeneity.

Within-Provider Variability in Motivational Interviewing Integrity for Three Years after MI Training: Does Time Heal?

This study examined variability in Motivational Interviewing (MI) integrity among 15 providers for three years following training. Data come from an effectiveness trial in which providers were trained to deliver brief single-session MI interventions. Each session was audio-recorded and coded for MI integrity using the Motivational Interviewing Treatment Integrity (MITI) 3.1.1 rating system. Within-provider variation in MI integrity was large, especially for behavior count scores (e.g., open questions, complex reflections) and only slightly smaller for global session scores of MI Spirit and Empathy. Within-provider variability was in most cases larger than between-provider variability and there was no evidence that providers improved appreciably over time. These findings raise concerns about the quality of MI being delivered in large-scale implementation efforts and have implications for the monitoring and training of higher quality MI.

Utility of Point-of-care Urine Drug Tests in the Treatment of Primary Care Patients With Drug Use Disorders.

OBJECTIVES: To determine if urine drug tests (UDTs) can detect under-reporting of drug use (ie, negative self-report, but positive UDT) and identify patient characteristics associated with underreporting when treating substance use disorders in primary care. METHODS: Self-reported use (last 30 d) and UDTs were gathered at baseline, 3, 6, 9, and 12 months from 829 primary care patients participating in a drug use intervention study. Rates of under-reporting were calculated for all drugs, cannabis, stimulants, opioids, and sedatives. Logistic regressions were used to identify characteristics associated with under-reporting. RESULTS: Among the participants, 40% (n = 331) denied drug use in the prior 30 days despite a corresponding positive UDT during at least 1 assessment. Levels of under-reporting during 1 or more assessments were 3% (n = 22) for cannabis, 20% (n = 167) for stimulants, 27% (n = 226) for opioids, and 13% (n = 106) for sedatives. Older (odds ratio [OR] 1.04), female (OR 1.66), or disabled (OR 1.42) individuals were more likely to under-report any drug use. Under-reporting of stimulant use was also more likely in individuals with lower levels of educational attainment, previous arrests, and family and social problems. Under-reporting of opioid use was more likely in those with other drug problems, but less likely in those with better physical health, more severe alcohol and psychiatric comorbidities, and African-Americans. CONCLUSIONS: With the exception of cannabis, UDTs are important assessment tools when treating drug use disorders in primary care. UDTs might be particularly helpful when treating patients who are older, female, disabled, have legal and social problems, and have more severe drug problems.

A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors.

CONTEXT: Although posttraumatic stress disorder (PTSD) and alcohol abuse frequently occur among acutely injured trauma survivors, few real-world interventions have targeted these disorders. OBJECTIVE: We tested the effectiveness of a multifaceted collaborative care (CC) intervention for PTSD and alcohol abuse. DESIGN: Randomized effectiveness trial. PARTICIPANTS: We recruited a population-based sample of 120 male and female injured surgical inpatients 18 or older at a level I trauma center. INTERVENTION: Patients were randomly assigned to the CC intervention (n = 59) or the usual care (UC) control condition (n = 61). The CC patients received stepped care that consisted of (1) continuous postinjury case management, (2) motivational interviews targeting alcohol abuse/dependence, and (3) evidence-based pharmacotherapy and/or cognitive behavioral therapy for patients with persistent PTSD at 3 months after injury. MAIN OUTCOME MEASURES: We used the PTSD symptomatic criteria (PTSD Checklist) at baseline and 1, 3, 6, and 12 months after injury, and alcohol abuse/dependence (Composite International Diagnostic Interview) at baseline and 6 and 12 months after injury. RESULTS: Random-coefficient regression analyses demonstrated that over time, CC patients were significantly less symptomatic compared with UC patients with regard to PTSD (P =.01) and alcohol abuse/dependence (P =.048). The CC group demonstrated no difference (-0.07%; 95% confidence interval [CI], -4.2% to 4.3%) in the adjusted rates of change in PTSD from baseline to 12 months, whereas the UC group had a 6% increase (95% CI, 3.1%-9.3%) during the year. The CC group showed on average a decrease in the rate of alcohol abuse/dependence of -24.2% (95% CI, -19.9% to -28.6%), whereas the UC group had on average a 12.9% increase (95% CI, 8.2%-17.7%) during the year. CONCLUSIONS: Early mental health care interventions can be feasibly and effectively delivered from trauma centers. Future investigations that refine routine acute care treatment procedures may improve the quality of mental health care for Americans injured in the wake of individual and mass trauma.

Comparing the motivational interviewing integrity in two prevalent models of brief intervention service delivery for primary care settings.

This quasi experimental study compared the motivational interviewing (MI) integrity in two prevalent brief intervention (BI) service delivery models for drug abuse. Routine primary care providers (RCPs) and non-routine care providers (NRCPs) performed BIs using an MI style within the same medical setting, patient population, and Screening, Brief Intervention, and Referral for Treatment (SBIRT) protocol. Interventionists (9 RCPs and 6 NRCPs) underwent similar MI training and performed a total of 423 audiorecorded BIs. We compared the MI integrity scores for all audio recorded sessions from these two SBIRT models for up to 40 months post MI training. Both groups met the lower standard (beginning proficiency in MI) on 4 of 5 MI integrity scores, but NRCPs met more of the higher standards (competency in MI) than RCPs. There may be limitations with regards to MI fidelity when using RCPs to conduct BIs in some primary care settings. Further experimental investigation is warranted to replicate this finding and identify casual factors of observed differences in MI fidelity.

Correlates of Opioid Use in Adults With Self-Reported Drug Use Recruited From Public Safety-Net Primary Care Clinics.

OBJECTIVES: The purpose of this study was to compare demographic, clinical, and survival characteristics of drug-using safety-net primary care patients who used or did not use opioids, and to examine treatment implications of our findings. METHODS: The sample consisted of 868 adults who reported illicit drug use in the 90 days before study enrollment, 396 (45.6%) of whom were opioid users. RESULTS: Multiple measures indicated that, as a group, opioid users were less physically and psychiatrically healthy than drug users who did not endorse using opioids, and were heavy users of medical services (eg, emergency departments, inpatient hospitals, and outpatient medical) at considerable public expense. After adjusting for age, they were 2.61 (confidence interval, 1.48-4.61) times more likely to die in the 1 to 5 years after study enrollment and more likely to die from accidental poisoning than nonopioid users. Subgroup analyses suggested patients using any nonprescribed opioids had more serious drug problems including more intravenous drug use and greater HIV risk than patients using opioids only as prescribed. CONCLUSIONS: Use of opioids adds a dimension of severity over and above illicit drug use as it presents in the primary care setting. Opioid users may benefit from psychiatric and addiction care integrated into their primary care setting, naloxone overdose prevention kits, and prevention efforts such as clean needle exchanges. Addiction or primary care providers are in a key position to facilitate change among such patients, especially the third or more opioid users having a goal of abstinence from drugs.

Disseminating alcohol screening and brief intervention at trauma centers: a policy-relevant cluster randomized effectiveness trial.

BACKGROUND AND AIMS: In 2005 the American College of Surgeons passed a mandate requiring that level I trauma centers have mechanisms to identify and intervene with problem drinkers. The aim of this investigation was to determine if a multi-level trauma center intervention targeting both providers and patients would lead to higher-quality alcohol screening and brief intervention (SBI) when compared with trauma center mandate compliance without implementation enhancements. DESIGN: Cluster randomized trial in which intervention site (site n = 10, patient n = 409) providers received 1-day workshop training on evidence-based motivational interviewing (MI) alcohol interventions and four 30-minute feedback and coaching sessions; control sites (site n = 10, patient n = 469) implemented the mandate without study team training enhancements. SETTING: Trauma centers in the United States of America. PARTICIPANTS: A total of 878 blood alcohol-positive in-patients with and without traumatic brain injury (TBI). MEASUREMENTS: MI skills of providers were assessed with fidelity coded standardized patient interviews. All patients were interviewed at baseline and 6- and 12-months post-injury with the Alcohol Use Disorders Identification Test (AUDIT). FINDINGS: Intervention site providers consistently demonstrated enhanced MI skills compared with control providers. Intervention patients demonstrated an 8% reduction in AUDIT hazardous drinking relative to controls over the course of the year after injury (relative risk = 0.88, 95%, confidence interval = 0.79, 0.98). Intervention patients were more likely to demonstrate improvements in alcohol use problems in the absence of traumatic brain injury (TBI) (P = 0.002). CONCLUSION: Trauma center providers can be trained to deliver higher-quality alcohol screening and brief intervention (SBI) than untrained providers, which is associated with modest reductions in alcohol use problems, particularly among patients without TBI.

Evaluating therapist adherence in motivational interviewing by comparing performance with standardized and real patients.

OBJECTIVE: The goal of measuring therapist adherence is to determine whether a therapist can perform a given treatment. Yet, the evaluation of therapist behaviors in most clinical trials is limited. Typically, randomized trials have few therapists and minimize therapist variability through training and supervision. Furthermore, therapist adherence is confounded with uncontrolled differences in patients across therapists. Consequently, the extent to which adherence measures capture differences in actual therapist adherence versus other sources of variance is unclear. METHOD: We estimated intra-class correlations (ICCs) for therapist adherence in sessions with real and standardized patients (RPs and SPs), using ratings from a motivational interviewing (MI) dissemination trial (Baer et al., 2009) in which 189 therapists recorded 826 sessions with both patient types. We also examined the correlations of therapist adherence between SP and RP sessions, and the reliability of therapist level adherence scores with generalizability coefficients (GCs). RESULTS: ICCs for therapist adherence were generally large (average ICC for SPs = .44; average ICC for RPs = .40), meaning that a given therapist's adherence scores were quite similar across sessions. Both ICCs and GCs were larger for SP sessions compared to RPs on global measures of MI adherence, such as Empathy and MI Spirit. Correlations between therapist adherence with real and standardized patients were moderate to large on 3 of 5 adherence measures. CONCLUSION: Differences in therapist-level adherence ratings were substantial, and standardized patients have promise as tools to evaluate therapist behavior.

Should we trust our judgments about the proficiency of Motivational Interviewing counselors? A glimpse at the impact of low inter-rater reliability.

Standardized rating systems are often used to evaluate the proficiency of Motivational Interviewing (MI) counselors. The published inter-rater reliability (degree of coder agreement) in many studies using these instruments has varied a great deal; some studies report MI proficiency scores that have only fair inter-rater reliability, and others report scores with excellent reliability. How much can we to trust the scores with fair versus excellent reliability? Using a Monte Carlo statistical simulation, we compared the impact of fair (0.50) versus excellent (0.90) reliability on the error rates of falsely judging a given counselor as MI proficient or not proficient. We found that improving the inter-rater reliability of any given score from 0.5 to 0.9 would cause a marked reduction in proficiency judgment errors, a reduction that in some MI evaluation situations would be critical. We discuss some practical tradeoffs inherent in various MI evaluation situations, and offer suggestions for applying findings from formal MI research to problems faced by real-world MI evaluators, to help them minimize the MI proficiency judgment errors bearing the greatest cost.

Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) for alcohol at trauma centers study design.

OBJECTIVE: In 2005, the American College of Surgeons passed a mandate requiring that Level I trauma centers have a mechanism to identify patients who are problem drinkers and have the capacity to provide an intervention for patients who screen positive. The aim of the Disseminating Organizational Screening and Brief Intervention Services (DO-SBIS) cluster randomized trial is to test a multilevel intervention targeting the implementation of high-quality alcohol screening and brief intervention (SBI) services at trauma centers. METHOD: Twenty sites selected from all United States Level I trauma centers were randomized to participate in the trial. Intervention site providers receive a combination of workshop training in evidence-based motivational interviewing (MI) interventions and organizational development activities prior to conducting trauma-center-based alcohol SBI with blood-alcohol-positive injured patients. Control sites implement care as usual. Provider MI skills, patient alcohol consumption, and organizational acceptance of SBI implementation outcomes are assessed. RESULTS: The investigation has successfully recruited provider, patient and trauma center staff samples into the study, and outcomes are being followed longitudinally. CONCLUSION: When completed, the DO-SBIS trial will inform future American College of Surgeons' policy targeting the sustained integration of high-quality alcohol SBI at trauma centers nationwide.

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

BACKGROUND: A substantial body of research has established the effectiveness of brief interventions for problem alcohol use. Following these studies, national dissemination projects of screening, brief intervention (BI), and referral to treatment (SBIRT) for alcohol and drugs have been implemented on a widespread scale in multiple states despite little existing evidence for the impact of BI on drug use for non-treatment seekers. This article describes the design of a study testing the impact of SBIRT on individuals with drug problems, its contributions to the existing literature, and its potential to inform drug policy. METHODS/DESIGN: The study is a randomized controlled trial of an SBIRT intervention carried out in a primary care setting within a safety net system of care. Approximately 1,000 individuals presenting for scheduled medical care at one of seven designated primary care clinics who endorse problematic drug use when screened are randomized in a 1:1 ratio to BI versus enhanced care as usual (ECAU). Individuals in both groups are reassessed at 3, 6, 9, and 12 months after baseline. Self-reported drug use and other psychosocial measures collected at each data point are supplemented by urine analysis and public health-related data from administrative databases. DISCUSSION: This study will contribute to the existing literature by providing evidence for the impact of BI on problem drug use based on a broad range of measures including self-reported drug use, urine analysis, admission to drug abuse treatment, and changes in utilization and costs of health care services, arrests, and death with the intent of informing policy and program planning for problem drug use at the local, state, and national levels. TRIAL REGISTRATION: ClinicalTrials.gov NCT00877331.