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...on Clinical Issues
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www.ProjectCork.org
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Fall 2010
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An improved brief measure of cannabis misuse: The Cannabis Use Disorders Identification Test-Revised (CUDIT-R)Adamson SJ; Kay-Lambkin FJ; Baker AL; Lewin TJ; Thornton L; Kelly BJ et al. Drug and Alcohol Dependence 110(1-2): 137-143, 2010. (40 refs.)
Background: Cannabis is widely used and significant problems are associated with heavier consumption. When a cannabis misuse screening tool, the CUDIT, was originally published it was noted that although it performed well there was concern about individual items. Methods: 144 patients enrolled in a clinical trial for concurrent depression and substance misuse were administered an expanded CUDIT, containing the original 10 items and 11 candidate replacement items. All patients were assessed for a current cannabis use disorder with the SCID. Results: A revised CUDIT-R was developed containing 8 items, two each from the domains of consumption, cannabis problems (abuse), dependence, and psychological features. Although the psychometric adequacy of the original CUDIT was confirmed, the CUDIT-R was shorter and had equivalent or superior psychometric properties. High sensitivity (91%) and specificity (90%) were achieved. Conclusions: The 8-item CUDIT-R has improved performance over the original scale and appears well suited to the task of screening for problematic cannabis use. It may also have potential as a brief routine outcome measure. Copyright 2010, Elsevier Science
Clinician acquisition and retention of motivational interviewing skills: A two-and-a-half-year exploratory studyForsberg L; Forsberg LG; Lindqvist H; Helgason AR. Substance Abuse Treatment, Prevention and Policy 5: article 8, 2010. (39 refs.)
Background: Motivational interviewing (MI) is a collaborative, client-centred counselling style aimed at eliciting and strengthening clients' intrinsic motivation to change. There is strong research evidence supporting the efficacy of MI, notably in its application among alcohol and drug abuse populations. MI interventions in smoking cessation may yield modest but significant increases in quitting. The present study sought to assess the acquisition and retention of MI skills in counsellors at the Swedish National Tobacco Quitline. Methods: Three audio-recorded sessions from each of three counsellors were assessed using the Motivational Interviewing Treatment Integrity (MITI) Code Version 3.0 over 11 assessment periods at fixed intervals in a two-and-a-half year period during which counsellors received ongoing supervision. Results: The mean skill for all counsellors improved throughout the study period in most MITI variables. However, great variations in MI skill between counsellors were observed, as well as fluctuations in performance in counsellors over time. Conclusion: The present exploratory study covers a longer time period than most evaluations of MI training, and has several advantages with regard to study design. It may provide a basis for (larger sample) replication to test MI skill (as measured by the MITI) in relation to behaviour change in clients, to evaluate MI training, and to assess the acquisition and retention of MI skill over time. Difficulties in acquiring and retaining MI skill may raise the issue of a selection policy for MI training. Moreover, fluctuations in MI skill over time emphasise the greater importance of continuous feedback and supervision over initial MI training, and the need for the use of validated treatment integrity assessment instruments in ordinary clinical implementations of MI. Copyright 2010, Biomedical Central
Individual, partner and relationship factors associated with non-medical use of prescription drugsHomish GG; Leonard KE; Cornelius JR. Addiction 105(8): 1457-1465, 2010. (26 refs.)
Aims: The objective of the current report was to examine individual, partner and relationship factors (e.g. relationship satisfaction) associated with the non-medical use of prescription drugs (NMUPD) in a community sample of married adults. Design: The current report used two waves of data from an ongoing study of couples who were recruited at the time they applied for their marriage license and are now in the 10th year of follow-up. Logistic regression models examined the relation between individual, partner and relationship factors and NMUPD. Participants: This report is based on 273 couples. Measurements: Participants completed questionnaires that assessed prescription drug use, alcohol use, other substance use, depression, marital satisfaction and socio-demographic factors. Findings: Among wives, there was evidence that a partner's prescription drug use and relationship factors were associated with increased risk for NMUPD. There was some evidence suggesting that it was the increased access or availability, and not the partner's use per se, that was related to the NMUPD. These results persisted after controlling for other illicit drug use, heavy drinking, depressive symptomatology and socio-demographic factors. Among men, neither partner use nor relationship factors were associated with NMUPD after considering the impact of individual-level risk factors. Conclusion: Prevention and intervention efforts directed at reducing the risk for NMUPD should consider the influence of partner and relationship factors in addition to individual-level risk factors. Copyright 2010, Wiley-Blackwell
Grandparents raising grandchildren: The association of grandparents' self-reported use of alcohol and drugs and their emotional well-beingLongoria RA. American Journal of Orthopsychiatry 80(3): 401-411, 2010. (65 refs.)
The research literature on the emotional well-being of grandparents raising grandchildren has identified an array of factors that predict psychological distress among this population of caregivers. However, little is known about whether grandparents' alcohol and/or other drug (AOD) use among some grandparents may negatively affect their emotional well-being. Moreover, a synthesis of the research literature on mental health and AOD misuse suggests a plausible link between psychological distress and AOD use may exist among some grandparents raising grandchildren. Using a probability sample of grandparents raising their grandchildren, multivariate analyses conducted in this study show that grandparents who misused a drug and used alcohol had lower levels of emotional well-being compared with grandparents who did not use or misuse such substances. Clinical implications concerning the mental health needs of this underserved population of caregivers are discussed. Copyright 2010, American Psychological Association
Caregiver burden and alcohol use in a community sampleRospenda KM; Minich LM; Milner LA; Richman JA. Journal of Addictive Diseases 29(3): 314-324, 2010. (60 refs.)
Little attention has been paid to the relationship between caregiver burden and alcohol use. It is important to examine the particular aspects of caregiver burden that most influence alcohol use. A mail survey was conducted using a representative sample of 998 employed Chicago residents who provided informal care for at least one person. Ordinary least squares regression models were computed to examine the relationship between caregiver burden and drinking outcomes. Findings suggest that caregivers who experience social and emotional burdens related to caregiving are at risk for problematic alcohol use and warrant attention from health care and mental health service professionals. Copyright 2010, Haworth Press
Candidate performance measures for screening for, assessing, and treating unhealthy substance use in hospitals: Advocacy or evidence-based practice?Saitz R. Annals of Internal Medicine 153(1): 40-43, 2010. (18 refs.)
The Joint Commission recently proposed candidate performance measures addressing unhealthy substance use in hospitalized patients. The proposed measures of screening and brief intervention (SBI) assume that interventions that work in one setting (primary care outpatient practice) would work in another (hospital); treatment would have the same benefits for persons identified by screening as for those with symptoms who seek help; treatments that work for persons less severely affected by substance use would also work for those with more severe illness; and an approach that works for nondependent, unhealthy alcohol use would work for drug use. However, these assumptions extrapolate evidence of the effectiveness of SBI for primary care outpatients with nondependent, unhealthy alcohol use to the inpatient setting, persons with dependence, and other substances. Although quality of care for unhealthy substance use in all medical settings needs to improve, the evidence base for SBI in the hospital is too limited for the implementation of performance measures assessing this care. Copyright 2010, American College of Physicians
A transitional opioid program to engage hospitalized drug usersShanahan CW; Beers D; Alford DP; Brigandi E; Samet JH. Journal of General Internal Medicine 25(8): 803-808, 2010. (28 refs.)
Many opioid-dependent patients do not receive care for addiction issues when hospitalized for other medical problems. Based on 3 years of clinical practice, we report the Transitional Opioid Program (TOP) experience using hospitalization as a "reachable moment" to identify and link opioid-dependent persons to addiction treatment from medical care. A program nurse identified, assessed, and enrolled hospitalized, out-of-treatment opioid-dependent drug users based on their receipt of methadone during hospitalization. At discharge, patients transitioned to an outpatient interim opioid agonist program providing 30-day stabilization followed by 60-day taper. The nurse provided case management emphasizing HIV risk reduction, health education, counseling, and medical follow-up. Treatment outcomes included opioid agonist stabilization then taper or transfer to long-term opioid agonist treatment. From January 2002 to January 2005, 362 unique hospitalized, opioid-dependent drug users were screened; 56% (n = 203) met eligibility criteria and enrolled into the program. Subsequently, 82% (167/203) presented to the program clinic post-hospital discharge; for 59% (119/203) treatment was provided, for 26% (52/203) treatment was not provided, and for 16% (32/203) treatment was not possible (pursuit of TOP objectives precluded by medical problems, psychiatric issues, or incarceration). Program patients adhered to a spectrum of medical recommendations (e.g., obtaining prescription medications, medical follow-up). The Transitional Opioid Program (TOP) identified at-risk hospitalized, out-of-treatment opioid-dependent drug users and, by offering a range of treatment intensity options, engaged a majority into addiction treatment. Hospitalization can be a "reachable moment" to engage and link drug users into addiction treatment. Copyright 2010, Springer
Medical marijuana users in substance abuse treatmentSwartz R. Harm Reduction Journal 7: article 2, 2010. (34 refs.)
Background: The rise of authorized marijuana use in the U. S. means that many individuals are using cannabis as they concurrently engage in other forms of treatment, such as substance abuse counseling and psychotherapy. Clinical and legal decisions may be influenced by findings that suggest marijuana use during treatment serves as an obstacle to treatment success, compromises treatment integrity, or increases the prevalence or severity of relapse. In this paper, the author reviews the relationship between authorized marijuana use and substance abuse treatment utilizing data from a preliminary pilot study that, for the first time, uses a systematic methodology to collect data examining possible effects on treatment. Methods: Data from the California Outcomes Measurement System (CalOMS) were compared for medical (authorized) marijuana users and non-marijuana users who were admitted to a public substance abuse treatment program in California. Behavioral and social treatment outcomes recorded by clinical staff at discharge and reported to the California Department of Alcohol and Drug Programs were assessed for both groups, which included a sample of 18 reported medical marijuana users. Results: While the findings described here are preliminary and very limited due to the small sample size, the study demonstrates that questions about the relationship between medical marijuana use and involvement in drug treatment can be systematically evaluated. In this small sample, cannabis use did not seem to compromise substance abuse treatment amongst the medical marijuana using group, who (based on these preliminary data) fared equal to or better than non-medical marijuana users in several important outcome categories (e. g., treatment completion, criminal justice involvement, medical concerns). Conclusions: This exploratory study suggests that medical marijuana is consistent with participation in other forms of drug treatment and may not adversely affect positive treatment outcomes. These findings call for more extensive sampling in future research to allow for more rigorous research on the growing population of medical marijuana users and non-marijuana users who are engaged in substance abuse treatment. Copyright 2010, BioMed Central
An exploratory study of engagement in a technology-supported substance abuse interventionVanDeMark NR; Burrell NR; LaMendola WF; Hoich CA; Berg NP; Medina E. Substance Abuse Treatment, Prevention and Policy 5: Article 10, 2010. (43 refs.)
Background: The continuing gap between the number of people requiring treatment for substance use disorders and those receiving treatment suggests the need to develop new approaches to service delivery. Meanwhile, the use of technology to provide counseling and support in the substance abuse field is exploding. Despite the increase in the use of technology in treatment, little is known about the impact of technology-supported interventions on access to services for substance use disorders. The E-TREAT intervention brings together the evidence-based practice of Motivational Interviewing and theories of Persuasive Technology to sustain clients' motivation to change substance use behaviors, provide support for change, and facilitate continuity across treatment settings. Methods: This study used descriptive statistics, tests of statistical significance, and logistic regression to explore the characteristics and perceptions of the first 157 people who agreed to participate in E-TREAT and the predictors of their active engagement in E-TREAT services. In addition, responses to open-ended questions about the participants' experiences with the intervention were analyzed. Results: The data reveal that clients who engaged in E-TREAT were more likely than those who did not engage to be female, have children and report a positive relationship with their recovery coach, and were less likely to have completed treatment for a substance use disorder in the past. A majority of people engaging in E-TREAT reported that it was helpful to talk with others with similar problems and that the program assisted them in developing a sense of community. Conclusions: The authors conclude that technology-assisted interventions hold promise in expanding access to treatment for substance use disorders especially for women and parents. Further, the characteristics of the relationship with a coach or helper may be critical to engagement in technology-supported interventions. Additional investigation into ways technology may be useful to enhance treatment access for certain subgroups is needed. Copyright 2010, Biomedical Central
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