Team-Based Learning Exercise Efficiently Teaches Brief Intervention Skills to Medicine Residents

ABSTRACT

Background: Evaluations of substance use screening and brief intervention (SBI) curricula typically focus on learner attitudes and knowledge, although effects on clinical skills are of greater interest and utility. Moreover, these curricula often require large amounts of training time and teaching resources. This study examined whether a 3-hour SBI curriculum for internal medicine residents utilizing a team-based learning (TBL) format is effective for SBI skills as measured by a standardized patient (SP) assessment. Methods: A waitlist-controlled design was employed. Results: Twenty-four postgraduate year 2 (PGY-2) and PGY-3 residents participated in a SP assessment prior to the TBL session (waitlist control group) and 32 participated in a SP assessment after the TBL session (intervention group). The intervention residents demonstrated better brief intervention skills than waitlist control residents, but there were no differences between the groups in screening and assessment skills. Residents receiving the TBL curriculum prior to the SP assessment reported increased confidence in all SBI skills. Conclusion: Findings indicate that a brief educational intervention can improve brief intervention skills. However, more intensive education may be needed to improve substance use screening and assessment.     

Early Risky Drug Use Detection in Primary Healthcare: How Does It Work in the Real World?

Despite effectiveness in research, the efficacy of screening and brief intervention (SBI) for risky substance users is not adequately understood in routine clinical practice. Primary healthcare professionals (n = 103) from three cities in a metropolitan area in Brazil were trained and supervised in SBI and then screened 40 patients. One year later, meetings were held in each city to obtain feedback. Twenty professionals who fulfilled the task (Yes [Y]) and 24 who did not (No [N]) were individually interviewed about their SBI experience. Reports were independently interpreted and codified by two researchers. The Y and N groups reported the same barriers and positive beliefs, but only the Y group reported no negative issues. The present study lasted from 2007 to 2009.     

Feasibility and acceptability of an audio computer-assisted self-interview version of the Alcohol,Smoking and Substance Involvement Screening Test (ASSIST) in primary care patients

ABSTRACT

Background: This study explores the feasibility and acceptability of a computer self-administered approach to substance use screening from the perspective of primary care patients. Methods: Forty-eight patients from a large safety net hospital in New York City completed an audio computer-assisted self-interview (ACASI) version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) and a qualitative interview to assess feasibility and acceptability, comprehension, comfort with screening questions, and preferences for screening mode (interviewer or computer). Qualitative data analysis organized the participants' feedback into major themes. Results: Participants overwhelmingly reported being comfortable with the ACASI ASSIST. Mean administration time was 5.2 minutes (range: 1.6–14.8 minutes). The major themes from the qualitative interviews were (1) ACASI ASSIST is feasible and acceptable to patients, (2) Social stigma around substance use is a barrier to patient disclosure, and (3) ACASI screening should not preclude personal interaction with providers. Conclusions: The ACASI ASSIST is an appropriate and feasible approach to substance use screening in primary care. Because of the highly sensitive nature of substance use, screening tools must explain the purpose of screening, assure patients that their privacy is protected, and inform patients of the opportunity to discuss their screening results with their provider.     

How and when health-care practitioners in Aboriginal Community Controlled Health Services deliver alcohol screening and brief intervention, and why they don't: a qualitative study

Introduction. Indigenous Australians experience a disproportionately high burden of alcohol‐related harm. Alcohol screening and brief intervention (SBI) offers the potential to reduce this harm if barriers to its delivery in Aboriginal Community Controlled Health Services (ACCHSs) can be optimally targeted. Aims. Examine health‐care practitioners' perceptions of, and practices in, alcohol SBI in ACCHSs. Methods. Semi‐structured group interviews with 37 purposively selected health staff across five ACCHSs. Results. Alcohol screening independent of standard health assessments was generally selective. The provision of brief intervention was dependent upon factors related to the patient. Four key factors underlying health‐care practitioners' perceptions of alcohol SBI were prominent: outcome expectancy; role congruence; utilisation of clinical systems and processes; and options for alcohol referral. Discussion. The influence of outcome expectancy and role congruence on health‐care practitioners' alcohol SBI practices has been identified previously, as has to a lesser extent, their less than optimal use of clinical systems and processes. The influence of options for alcohol referral on health‐care practitioners' willingness to deliver alcohol SBI primarily related to their misunderstanding of alcohol SBI and the lack of culturally appropriate alcohol referral options for their patients. Conclusion. An intervention combining interactive, supportive and reinforcing evidence‐based dissemination strategies is most likely required to enhance health‐care practitioners' knowledge and skills in alcohol SBI delivery, positively orientate them to their role in its delivery, and facilitate integration of evidence‐based alcohol SBI into routine clinical processes and locally available systems.[Clifford A, Shakeshaft A, Deans C. How and when health‐care practitioners in Aboriginal Community Controlled Health Services deliver alcohol screening and brief intervention, and why they don't: A qualitative study. Drug Alcohol Rev 2012;31:13–19]     

Understanding How People with Mental Health Difficulties Experience Substance Use

Background: Quantitative studies dominate research exploring reasons for substance use and experiences of substance use by people with mental health difficulties. This limits the depth of understanding which can be gained about these experiences. Objectives: In the present article, we synthesized current qualitative research in this area to provide enhanced theoretical knowledge of these experiences. Methods: Following a systematic literature search, we identified 12 studies which explored how people with mental health difficulties experienced using substances, and which met additional inclusion criterion. We used Noblit and Hare's metaethnographic approach to qualitatively synthesize these studies. Results: Synthesis led to the development of two themes; “substance use mediates acceptance and social inclusion” and “substance use provides perceived opportunities for control and power.” Conclusions/Importance: The findings suggest that in the studies reviewed people's motivation for substance use was embedded in social and psychological contexts. It indicated that substance use could provide perceived benefits such as mediating the impact of mental health stigma, enabling the development of alternative identities, increasing their sense of power and providing opportunities for social inclusion. Mental health and substance use workers should therefore aim to develop alternative opportunities for people with co-occurring disorders to gain such benefits, and seek to challenge mental health stigma.     

Adopting early intervention for substance use disorders: a preliminary study of primary healthcare professionals in New York State

Abstract

Aims: Research has reported a lack of practice of early intervention for substance use disorders among primary healthcare professionals, and only a fraction of patients were asked about their substance use when visiting a primary healthcare office. This study examines conditions that may influence the adoption of early intervention [i.e., screening, brief intervention and referral to treatment (SBIRT)] among primary healthcare professionals. Methods: A pilot survey was emailed to primary care physicians, nurse practitioners, and physician assistants in New York State, and 248 recipients responded to the survey. Findings: Three areas appear to be associated with the adoption of SBIRT: percentage of respondents’ patients using marijuana (β?=?0.14; p?<?0.05); perceived ability to perform intervention (β?=?0.32; p?<?0.05); and perception of early intervention as a responsibility of primary care professionals (β?=?0.29; p?<?0.05). Conclusions: Training and education to promote SBIRT for primary care workers should focus on increasing their favourable attitudes towards the intervention as a strategy of preventive medicine and include the knowledge of the infrastructure of services for substance use disorders, especially for medical providers who see large numbers of patients at a high risk for alcohol and drug misuse.     

ASSIST-Y V1.0: First-Stage Development of the WHO Alcohol,Smoking and Substance Involvement Screening Test (ASSIST) and Linked Brief Intervention for Young People

ABSTRACT

While the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is a useful screening and brief intervention tool for use with adults, the risk cut-offs are not appropriate for people under 18 years of age. Drawing on the literature available and expert clinical consultation and consensus, two distinct ASSIST-Youth (ASSIST-Y) questionnaires and Feedback Report cards with different score weightings were proposed, reflecting the dynamic nature of substance use-related risk in developing adolescents ages 10 to 14 years and ages 15 to 17 years old. Appropriate interventions also were recommended, with a strong emphasis on referral for assessment and management of broader psychosocial issues. This revised ASSIST for young people was developed with the intention that this “first-pass” set of cut-off scores and associated materials might form the basis for further psychometric validation of the youth ASSIST in the future, while still providing practitioners with a screening brief intervention option for using with young people in the interim.     

The state of substance use education in Master of Social Work programs: A content analysis of course listings and faculty profiles

Background: Substance use is currently a pervasive problem among a large proportion of populations served by the social work profession. Several studies have indicated that social workers routinely provide services to clients with direct and indirect substance use needs, making knowledge of substance use interventions and public policies a necessity for social workers to operate effectively in the field. However, despite the regularity of interaction with substance using clients, previous research has suggested that a significant deficit of substance use education currently exists in Master of Social Work (MSW) programs. Methods: To determine the extent of substance use education currently offered by master’s-level schools of social work, a content analysis of course listings and full-time faculty profiles was performed on all Council on Social Work Education–accredited programs in the United States (N?=?263). The goals of the content analysis were (1) to identify the current prevalence and content of substance use education offered to entire cohorts of MSW students at the national and programmatic levels and (2) to examine the capacity of the full-time MSW faculty workforce to deliver substance use education to MSW students in individual programs. Results: The results of the analyses showed that a significant deficit of formal substance use education does exist in the field of social work education, and that a large proportion of programs lack the faculty personnel necessary to sufficiently offer substance use education to their students. Conclusions: The social work profession needs to make a concerted effort to improve substance use education if social work is to ethically and effectively remain at the forefront of mental health practice in the United States.     

Training Community-Based Clinicians in Screening and Brief Intervention for Substance Abuse Problems: Translating Evidence into Practice

Screening and brief intervention in general health care settings are efficacious but have not been widely adopted. Our objective was to assess the effect of an educational intervention on clinicians' substance abuse-related clinical practices. The study was a telephone survey of practicing physicians, nurses, psychologists, physician's assistants, and social workers who attended a half-day continuing education course on one of four occasions. The course covered the stages of behavioral change and motivational counseling, using primarily role play with standardized patients. Of 87 course attendees, 70 (80%) completed the interview. Months to years after the course, most (91%) reported that the course made an impact on their practice. Most (78%) of respondents reported that they frequently or always asked new patients who drank alcohol a formal screening questionnaire such as the CAGE, and 94% frequently or always assessed their substance abusing patients' readiness to change. Most respondents reported that since taking the course they were more likely (1) to screen patients for alcohol or drug related problems (86%) and (2) to ask patients about their substance abuse on a follow-up visit (96%). After exposure to an active-learning half-day continuing education course, clinicians reported improvement with and high rates of desirable substance abuse-related clinical practices up to 5 years later. Continuing education efforts that incorporate active learning directed toward practicing clinicians show promise for improving rates of brief intervention for alcohol and other drug abuse.     

Screening and Brief Interventions for Illicit Drug Use and Alcohol Use in Methadone Maintained Opiate-Dependent Patients: Results of a Pilot Cluster Randomized Controlled Trial Feasibility Study

Background and Objectives: The present study evaluated the effectiveness of a single clinician delivered brief intervention (BI) to reduce problem alcohol use and illicit substance use in an opiate-dependent methadone maintained cohort of patients attending for treatment. Methods: Four addiction treatment centers were randomly assigned to either treatment as usual (TAU; control group) or BI (intervention group). Clinicians screened patients using the alcohol, smoking, and substance involvement screening test (ASSIST) screening tool at baseline and again at three-month follow up. Fidelity checks were performed to ensure that training was delivered effectively and uniformly across all study sites. Feasibility of administering a BI within daily practice was assessed through intervention fidelity checks, patient satisfaction questionnaires and process evaluation. Results: A total of 465 patients were screened (66% of the overall eligible population) with a total of 433 (93%) ASSIST positive cases. Randomization was effective, with no differences in the control versus the intervention arms at baseline for key demographic or clinical indicators including substance us. There was a statistically significant difference between global risk score for the intervention (x = 39.36, sd = 25.91) group and the control group (x = 45.27, SD = 27.52) at 3-month follow-up (t(341) = ?2.07, p < .05). Conclusions: This trial provides the first evidence that a single clinician delivered BI can result in a reduction in substance use within a methadone maintained opiate-dependent cohort, and this effect is sustained at three month follow up.     

The reliability and validity of the Alcohol,Smoking and Substance Involvement Screening Test (ASSIST) in first-episode psychosis

Aims

The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) is a brief, easily administered, valid and reliable screening instrument for all psychoactive substances in drug treatment and primary care settings. This study aims to determine the reliability and validity of the ASSIST for detecting substance use disorders in first-episode psychosis.

Participants

Participants were 214 first-episode psychosis patients attending the Early Psychosis Prevention and Intervention Centre (EPPIC) in Melbourne, Australia.

Measurements

Participants were administered the ASSIST, Alcohol Use Disorders Identification Test (AUDIT), the Severity of Dependence Scale (SDS) and the Brief Psychiatric Rating Scale (BPRS). Presence of DSM-IV substance abuse and dependence disorders in the previous 12 months was assessed using the Structured Clinical Interview for DSM-IV (SCID-IV).

Findings

The ASSIST total substance involvement (TSI) score and specific substance involvement (SSI) scores for cannabis, alcohol and amphetamine use demonstrated high levels of internal consistency and acceptable levels of concurrent and discriminative validity. Individuals with cutoff scores of ≥ 2, 4 and 1 on the ASSIST cannabis, alcohol and amphetamine SSI scores were 5 to 6 times more likely to meet the diagnostic criteria for these substance use disorders.

Conclusions

The ASSIST is a psychometrically sound measure of cannabis, alcohol and amphetamine use disorders in first-episode psychosis.     

Prevalence of Substance Use Among Patients of Community Health Centers in East Los Angeles and Tijuana

Background: Given the increased use of psychoactive substances on the United States–Mexico border, a binational study (Tijuana, Mexico–Los Angeles, USA) was conducted to identify the prevalence of substance use in primary care settings. Objectives: To compare the prevalence and characteristics of patients at risk for substance use disorders in Tijuana and East Los Angeles (LA) community clinics with special attention paid to drug use. Methods: This was an observational, cross-sectional, analytical study, comparing substance use screening results from patients in Tijuana and LA. The settings were 2 community clinics in LA and 6 in Tijuana. Participants were 2,507 adult patients in LA and 2,890 in Tijuana eligible for WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) screening during March–October 2013. Patients anonymously self-administered the WHO ASSIST on a tablet PC in the clinic waiting rooms. Results: Of eligible patients, 96.4% completed the ASSIST in Tijuana and 88.7% in LA (mean 1.34 minutes and 4.20 minutes, respectively). The prevalence of patients with moderate-to-high substance use was higher in LA than Tijuana for each substance: drugs 19.4% vs. 5.7%, alcohol 15.2% vs. 6.5%, tobacco 20.4% vs. 16.2%. LA patients born in Mexico had 2x the odds and LA patients born in the United States had 6x the odds of being a moderate-to-high drug user compared to Tijuana patients born in Mexico. Conclusions: Moderate-to-high drug use is higher in LA than in Tijuana but rates are sufficiently high in both to suggest that screening for drug use (along with alcohol and tobacco use) should be integrated into routine primary care of community clinics in both cities.     

Mortality risk in a sample of emergency department patients who use cocaine with alcohol and/or cannabis

Background: Illicit drug use is common among emergency department (ED) patients, yet the association between drug use and subsequent mortality is not well understood. This study examines 36-month mortality rates for a sample of ED patients based on reported use of alcohol, cannabis, and cocaine, both individually and in combination. Methods: Patients (N = 1669) from 2 urban EDs were surveyed at the time of the visit. The patient survey included the Alcohol Smoking and Substance Involvement Screening Test (ASSIST) and information on physical and mental health, health care utilization, and risk factors associated with substance use. ASSIST scores were used to categorize patients into drug risk groups. Mortality information from the National Death Index was used to calculate mortality rates from 2009 to 2012. A Cox regression model identified associations between drug risk groups and mortality while controlling for patient demographics. Results: The use of cocaine and cannabis both individually and in combination was associated with significantly higher mortality risk compared with other ED patients. Conclusions: ED patients who use cannabis and cocaine have higher mortality risks than other patients. Further research is necessary to determine whether this result is stable across racial/ethnic groups.     

Training community‐based clinicians in screening and brief intervention for substance abuse problems: Translating evidence into practice

Screening and brief intervention in general health care settings are efficacious but have not been widely adopted. Our objective was to assess the effect of an educational intervention on clinicians’ substance abuse‐related clinical practices. The study was a telephone survey of practicing physicians, nurses, psychologists, physician's assistants, and social workers who attended a half‐day continuing education course on one of four occasions. The course covered the stages of behavioral change and motivational counseling, using primarily role play with standardized patients. Of 87 course attendees, 70 (80%) completed the interview. Months to years after the course, most (91%) reported that the course made an impact on their practice. Most (78%) of respondents reported that they frequently or always asked new patients who drank alcohol a formal screening questionnaire such as the CAGE, and 94% frequently or always assessed their substance abusing patients’ readiness to change. Most respondents reported that since taking the course they were more likely (1) to screen patients for alcohol or drug related problems (86%) and (2) to ask patients about their substance abuse on a follow‐up visit (96%). After exposure to an active‐learning half‐day continuing education course, clinicians reported improvement with and high rates of desirable substance abuse‐related clinical practices up to 5 years later. Continuing education efforts that incorporate active learning directed toward practicing clinicians show promise for improving rates of brief intervention for alcohol and other drug abuse.     

Effects of Screening,Brief Intervention,and Referral to Treatment (SBIRT) Education and Training on Nursing Students’ Attitudes Toward Working With Patients Who Use Alcohol and Drugs

ABSTRACT

Background: Screening, Brief Intervention, and Referral to Treatment (SBIRT) can reduce alcohol use and negative health outcomes in patients with risky substance use. However, negative attitudes that some health care professionals have toward patients who use substances are a barrier to implementing SBIRT. Methods: The University of Pittsburgh School of Nursing, in partnership with the Institute for Research, Education, and Training in Addictions (IRETA), developed a curriculum to train baccalaureate student nurses to deliver SBIRT. Results: Following SBIRT education and training, students’ perceived attitudes toward patients who use alcohol became more positive. Less robust changes were found for attitudes related to patients who use drugs. Conclusions: Nurses composing the largest group of healthcare workers are in key positions to screen, intervene, and provide education about substance use.     

The Cost-Effectiveness and Cost-Benefit of Screening and Brief Intervention for Unhealthy Alcohol Use in Medical Settings

SUMMARY

Economic evaluation can be a valuable tool for assessing the efficiency and value of health care programs. To examine the literature on the economic evaluation of alcohol screening and brief intervention in medical settings, relevant studies were identified in the MEDLINE database (1966 through November 2006) and by hand-searching the references of identified articles and relevant journals. The 15 identified studies used a range of economic evaluation methods, including cost analysis, cost-benefit, cost-effectiveness, and cost-utility. Nearly all of the studies supported the use of alcohol screening and brief intervention. The studies that prospectively collected cost and effect data and/or conformed closely to methodological guidelines demonstrated a strong economic benefit of alcohol screening and brief intervention when compared to usual care. Overall, the reviewed studies support alcohol SBI in medical settings as a wise use of health care resources and illustrate the usefulness of economic evaluation for assessing alcohol prevention and treatment programs.     

Routine opioid outcome monitoring in community pharmacy: Pilot implementation study protocol

BackgroundIncreases in opioid use and related harms such as mortality are occurring in many high income countries. Community pharmacists are often in contact with patients at risk of opioid-related harm and represent an ideal point for intervention. Best practice in monitoring opioid-related outcomes involves assessing analgesia, pain functioning, mood, risks and harms associated with opioid use. Community pharmacists are well-placed to undertake these tasks.ObjectivesOur pilot study will test the implementation of a computer-facilitated screening and brief intervention (SBI). The SBI will support pharmacist identification of opioid-related problems and provide capacity for brief intervention including verbal reinforcement of tailored information sheets, supply of naloxone and referral back to the opioid prescriber. The SBI utilises software that embeds study procedures into dispensing workflow and assesses opioid outcomes with domains aligned with a widely accepted clinical framework.MethodsWe will recruit and train 75 pharmacists from 25 pharmacies to deliver the Routine Opioid Outcome Monitoring (ROOM) SBI. Pharmacists will complete the SBI with up to 500 patients in total (20 per pharmacy). Data will be collected on pharmacists’ knowledge and confidence through pre- and post-intervention online surveys. Data on feasibility, acceptability and implementation outcomes, including naloxone supply, will also be collected.Project impactOur study will examine changes in pharmacists’ knowledge and confidence to deliver the SBI. Through the implementation pilot, we will establish the feasibility and acceptability of a pharmacist SBI that aims to improve monitoring and clinical management of patients who are prescribed opioids.