Background: Opioid use and its sequalae have contributed to rising morbidity and mortality that has accelerated during the COVID-19 pandemic. Life-saving treatments for opioid use disorder (OUD) can be provided in primary care but are underutilized. Comorbid depression and other conditions increase the complexity of OUD management, especially in primary care. The More Individualized Care: Assessment and Recovery through Engagement (MI-CARE) trial is a randomized encouragement (Zelen) trial to test a collaborative care (CC) intervention for patients with OUD and depressive symptoms.Methods: Adult primary care patients with OUD and depressive symptoms (n≥800) will be enrolled from two statewide health care systems: Kaiser Permanente Washington and Indiana University Health. A random sub-sample (50%) of eligible patients is offered the MI-CARE intervention: a 12-month nurse-driven collaborative care intervention that includes motivational interviewing and behavioral activation. The remaining 50% of the study cohort comprise the usual care comparison group. The primary outcome is days of buprenorphine treatment provided during the intervention period. The powered secondary outcome is change in Patient Health Questionnaire (PHQ)-9 depression screening scores. Both outcomes are obtained from secondary electronic healthcare sources and compared in 'intent-to-treat' analyses.Conclusion: The MI-CARE trial addresses the need for rigorous encouragement trials to evaluate the benefit of offering CC to generalizable samples of patients with OUD and mental health conditions identified from electronic health records, as they would be in practice, and comparing outcomes to usual primary care. We describe the design and implementation of such a trial, currently underway.
Alcohol Behavioral Couple Therapy (ABCT) is an efficacious treatment for alcohol use disorders. Coding treatment integrity can shed light on the active ingredients of ABCT, but there are no published studies of treatment integrity instruments for ABCT. The present study describes the development and initial reliability of the Treatment Integrity Rating System - Couples Version (C-TIRS) for ABCT.The C-TIRS was used to rate 284 first- and mid-treatment ABCT sessions of 188 couples in four randomized clinical trials.Average inter-rater reliability for distinguishing ratings between C-TIRS items was fair-to-good for quantity items (intraclass correlation [ICC] = 0.64) and poor-to-fair for quality items (ICC = 0.41). Five C-TIRS subscales were defined a priori to measure treatment components involving cognitive-behavioral therapy, spouse involvement, couple therapy, common therapeutic factors, and overall adherence to the treatment protocol and had adequate internal reliability (α = 0.74-0.89). Inter-rater reliability was fair to good on seven of ten scales but poor on three scales (ICC range = 0.17-0.72).The C-TIRS was designed to provide information about quantity and quality of the delivery of ABCT components; however, further refinement of the C-TIRS is warranted before it should be used in frontline practice. Clinical implications and recommendations for future research are discussed.
Alcohol use disorder (AUD) is a highly prevalent public health problem associated with considerable individual and societal costs. Abstinence from alcohol is the most widely accepted target of treatment for AUD, but it severely limits treatment options and could deter individuals who prefer to reduce their drinking from seeking treatment. Clinical validation of reduced alcohol consumption as the primary outcome of alcohol clinical trials is critical for expanding treatment options. One potentially useful measure of alcohol treatment outcome is a reduction in the World Health Organization (WHO, International Guide for Monitoring Alcohol Consumption and Related Harm. Geneva, Switzerland, 2000) risk levels of alcohol use (very high risk, high risk, moderate risk, and low risk). For example, a 2-shift reduction in WHO risk levels (e.g., high risk to low risk) has been used by the European Medicines Agency (2010, Guideline on the Development of Medicinal Products for the Treatment of Alcohol Dependence. UK) to evaluate nalmefene as a treatment for alcohol dependence (AD; Mann et al. 2013, Biol Psychiatry 73, 706-13).The current study was a secondary data analysis of the COMBINE study (n = 1,383; Anton et al., ) to examine the association between reductions in WHO risk levels and reductions in alcohol-related consequences and mental health symptoms during and following treatment in patients with AD.Any reduction in WHO risk drinking level during treatment was associated with significantly fewer alcohol-related consequences and improved mental health at the end of treatment and for up to 1 year posttreatment. A greater reduction in WHO risk drinking level predicted a greater reduction in consequences and greater improvements in mental health.Changes in WHO risk levels appear to be a valid end point for alcohol clinical trials. Based on the current findings, reductions in WHO risk drinking levels during treatment reflect meaningful reductions in alcohol-related consequences and improved functioning.
In the Washington State Juvenile Code, the Manifest Injustice (MI) provision allows judges to sentence youth outside of the standard guidelines. We compared rates of Juvenile Rehabilitation Administration (JRA) involvement and MI between racial minority youth and Caucasian youth. Although not statistically significant, there was a trend toward African American and multiracial youth having MI used to decrease their sentence less frequently than Caucasian youth. African American youth were about half as likely to have MI used to intensify their sentence compared with Caucasian youth (rate ratio = .49, p = .002), whereas multiracial youth were 42 percent less likely (rate ratio = .58, p = .04). More African American youth reside in urban and liberal parts of the state where judges may be more progressive and less likely to use MI to intensify sentences. More diversion programs targeting minority youth exist in urban areas of Washington, and more African American youth are transferred to adult court; both reduce the likelihood of minority youth receiving MI. Judges in rural areas of the state, which have fewer treatment resources, may be using MI to access services only available to court-involved youth. It is imperative that community behavioral health services are available so that youth and families can be justly served.
Abstract Background and aims Drinking urges during treatment for alcohol use disorders (AUDs) are common, can cause distress and predict relapse. Clients may have little awareness of how their drinking urges might be expected to change during AUD treatment in general and in response to initiating abstinence. The aim of the present study was to test whether drinking urges change on a daily level during treatment and after initiating abstinence. Design Secondary data analysis was performed using daily drinking urge ratings from two randomized clinical trials. Setting and Participants Women ( n = 98) and men ( n = 79) with AUDs in separate clinical trials of out‐patient AUD‐focused cognitive–behavioral therapy. Measurements Daily dichotomous indicators of any drinking urges or acute escalations in urges (i.e. at least two more urges compared with the previous day) were examined using generalized linear mixed growth‐curve modeling. Findings Participants who initiated abstinence reported reductions in urges immediately thereafter (log odds ratios: women B = −0.701, P < 0.001; men B = −0.628, P = 0.018), followed by additional, gradual reductions over time (women B = −0.118, P < 0.001; men B = −0.141, P < 0.001). Participants who entered treatment abstaining from alcohol also reported significant reductions in urges over time (women B = −0.147, P < 0.001; men B = −0.142, P < 0.001). Participants who drank throughout treatment had smaller (women B = −0.042, P = 0.012) or no reductions in urges (men B = 0.015, P = 0.545). There was no evidence that urges increased systematically in response to initiating abstinence. Conclusions Drinking urges during out‐patient behavioral treatment for alcohol use disorders may be maintained in part by alcohol consumption. Initiating abstinence is associated with reductions in drinking urges immediately and then more gradually over time.
Objective: In a pilot feasibility and effectiveness study, illness management and recovery (IMR), a curriculum-based program to help people with serious mental illness pursue personal recovery goals, was integrated into assertive community treatment (ACT) to improve participants’ recovery and functioning. Methods: A small-scale cluster randomized controlled design was used to test implementation of IMR within ACT teams in two states. Eight high-fidelity ACT teams were assigned to provide IMR (ACT+IMR; four teams) or standard ACT services (ACT only; four teams). Clinical outcomes from 101 individuals with schizophrenia-spectrum or bipolar disorders were assessed at baseline, six months, and one year. Results: Exposure to IMR (session attendance and module completion) varied between the ACT+IMR teams, with participants on one team having significantly less exposure. Results from intent-to-treat analyses showed that participants in ACT+IMR demonstrated significantly better outcomes with a medium effect size at follow-up on clinician-rated illness self-management. A nonsignificant, medium effect size was found for one measure of functioning, and small effect sizes were observed for client-rated illness self-management and community integration. Session and module completion predicted better outcomes on four of the 12-month outcome measures. Conclusions: Findings support the feasibility of implementing IMR within ACT teams. Although there were few significant findings, effect sizes on some variables in this small-scale study and the dose-response relationships within ACT+IMR teams suggest this novel approach could be promising for improving recovery for people with serious mental illness. Further large-scale studies utilizing a hybrid effectiveness-implementation design could provide a promising direction in this area.
The objective of this study was to estimate the associations of jail-initiated medication for opioid use disorder (MOUD) and patient navigation (PN) with opioid use disorder (OUD) at 6 months post-release. Three randomized trials (combined N = 330) were combined to assess whether MOUD (extended-release naltrexone or interim methadone) initiated prior to release from jail with or without PN would reduce the likelihood of a DSM-5 diagnosis of OUD 6 months post-release relative to enhanced treatment-as-usual (ETAU). Across the three studies, assignment to MOUD compared to ETAU was not associated with an OUD diagnosis at 6 months post-release (69% vs. 75%, respectively, OR = 0.67, 95% CI: 0.42 to 1.20). Similarly, PN compared to MOUD without PN was not associated with an OUD diagnosis (63% vs 77%, respectively, OR = 0.61, 95% CI: 0.27 to 1.53). Results underscore the need to further optimize the effectiveness of MOUD for patients initiating treatment in jail, beginning with an emphasis on post-release treatment adherence.
Client language reflecting motivation for changing substance use (i.e. change talk) has been shown to predict outcomes in motivational interviewing. While previous work has shown that change talk may be elicited by clinician behaviors, little is known about intrapersonal factors that may elicit change talk, including clients' baseline motivation for change. The present study tested whether in-session change talk differs between clients based on their readiness for change.First-session audio recordings from Project MATCH, a large multi-site clinical trial of alcohol treatments.Project MATCH out-patients (n = 69) and aftercare patients (n = 48) receiving motivational enhancement therapy (MET).Client language from first-session MET was coded using the Sequential Code for Observing Process Exchanges. Readiness and stages of change were assessed using both categorical and dimensional variables derived from the University of Rhode Island Change Assessment and the Stages of Change Readiness and Treatment Eagerness Scale, administered prior to first treatment sessions.Stage of change scales followed some of the expected correspondence with change talk, although the associations were generally small in magnitude and inconsistent across measures and treatment arms. Higher overall readiness did not predict more overall change talk, contemplation had mixed associations with preparatory change talk, and preparation/action did not predict commitment language.Motivational language used in initial sessions by people receiving counselling for excessive alcohol consumption does not appear to be associated with readiness to change as construed by the Transtheoretical Model.
