Using Acceptance and Commitment Therapy during Methadone Dose Reduction: Rationale, Treatment Description, and a Case Report.

Many clients who undergo methadone maintenance (MM) treatment for heroin and other opiate dependence prefer abstinence from methadone. Attempts at methadone detoxification are often unsuccessful, however, due to distressing physical as well as psychological symptoms. Outcomes from a MM client who voluntarily participated in an Acceptance and Commitment Therapy (ACT) - based methadone detoxification program are presented. The program consisted of a 1-month stabilization and 5-month gradual methadone dose reduction period, combined with weekly individual ACT sessions. Urine samples were collected twice weekly to assess for use of illicit drugs. The participant successfully completed the program and had favorable drug use outcomes during the course of treatment, and at the one-month and one-year follow-ups. Innovative behavior therapies, such as ACT, that focus on acceptance of the inevitable distress associated with opiate withdrawal may improve methadone detoxification outcomes

Opioid dependence treatment: options in pharmacotherapy.

The development of effective treatments for opioid dependence is of great importance given the devastating consequences of the disease. Pharmacotherapies for opioid addiction include opioid agonists, partial agonists, opioid antagonists, and alpha-2-adrenergic agonists, which are targeted toward either detoxification or long-term agonist maintenance. Agonist maintenance therapy is currently the recommended treatment for opioid dependence due to its superior outcomes relative to detoxification. Detoxification protocols have limited long-term efficacy, and patient discomfort remains a significant therapy challenge. Buprenorphine\u27s effectiveness relative to methadone remains a controversy and may be most appropriate for patients in need of low doses of agonist treatment. Buprenorphine appears superior to alpha-2 agonists, however, and office-based treatment with buprenorphine in the USA is gaining support. Studies of sustained-release formulations of naltrexone suggest improved effectiveness for retention and sustained abstinence; however, randomized clinical trials are needed

Illusory predictors: Generalizability of findings in cocaine treatment retention research.

Treatment retention is of paramount importance in cocaine treatment research as treatment completion rates are often 50% or less. Failure to retain cocaine patients in treatment has both significant research and clinical implications. In this paper we qualitatively and quantitatively demonstrate the inconsistency found across analyses of retention predictors in order to highlight the problem. First, a qualitative review of the published literature was undertaken to identify the frequency of predictors studied and their relations to treatment retention. Second, an empirical demonstration of predictor stability was conducted by testing a common set of variables across three similar 12-week cocaine clinical trials conducted by the same investigators in the same research clinic within a five-year period. Results of the literature review indicated inconsistently selected variables of convenience, widely varying statistical procedures, and discrepant findings of significance. Further, quantitative analyses resulted in discrepancies in variables identified as significant predictors of retention among the three studies. Potential sources of heterogeneity affecting the consistency of findings across studies and recommendations to improve the validity and generalizability of predictor findings in future studies are proposed

PRimary Care Opioid Use Disorders treatment (PROUD) trial protocol: a pragmatic, cluster-randomized implementation trial in primary care for opioid use disorder treatment

BACKGROUND: Most people with opioid use disorder (OUD) never receive treatment. Medication treatment of OUD in primary care is recommended as an approach to increase access to care. The PRimary Care Opioid Use Disorders treatment (PROUD) trial tests whether implementation of a collaborative care model (Massachusetts Model) using a nurse care manager (NCM) to support medication treatment of OUD in primary care increases OUD treatment and improves outcomes. Specifically, it tests whether implementation of collaborative care, compared to usual primary care, increases the number of days of medication for OUD (implementation objective) and reduces acute health care utilization (effectiveness objective). The protocol for the PROUD trial is presented here. METHODS: PROUD is a hybrid type III cluster-randomized implementation trial in six health care systems. The intervention consists of three implementation strategies: salary for a full-time NCM, training and technical assistance for the NCM, and requiring that three primary care providers have DEA waivers to prescribe buprenorphine. Within each health system, two primary care clinics are randomized: one to the intervention and one to Usual Primary Care. The sample includes all patients age 16-90 who visited the randomized primary care clinics from 3 years before to 2 years after randomization (anticipated to be \u3e 170,000). Quantitative data are derived from existing health system administrative data, electronic medical records, and/or health insurance claims ( electronic health records, [EHRs]). Anonymous staff surveys, stakeholder debriefs, and observations from site visits, trainings and technical assistance provide qualitative data to assess barriers and facilitators to implementation. The outcome for the implementation objective (primary outcome) is a clinic-level measure of the number of patient days of medication treatment of OUD over the 2 years post-randomization. The patient-level outcome for the effectiveness objective (secondary outcome) is days of acute care utilization [e.g. urgent care, emergency department (ED) and/or hospitalizations] over 2 years post-randomization among patients with documented OUD prior to randomization. DISCUSSION: The PROUD trial provides information for clinical leaders and policy makers regarding potential benefits for patients and health systems of a collaborative care model for management of OUD in primary care, tested in real-world diverse primary care settings

Using Item Response Theory to Improve Alcohol Dependence Screening for African American and White Male and Female College Students

Background: Alcohol-dependent college students rarely seek treatment, despite the availability of efficacious interventions. Overly simplistic screening procedures, failing to account for differential patterns across demographic groupings, exacerbate this when students in need of intervention are not identified. Objective: The criterion validity of the Alcohol Use Disorders Identification Test was evaluated, emphasizing sex-related and race-related invariance. Methods: Item Response Theory was used to evaluate data (collected: 2008 to 2009) from 1500 lifetime-drinking, southeastern US college students, across sex and self-identified race (ie, White, non-Hispanic and Black/African American). Alcohol dependence criteria were used in the sensitivity/specificity analyses. Results: Item Response Theory results led to item 9’s removal (for race-related noninvariance) and a cut score of 4 (problems/dependence subscale) offered more balanced intergroup scoring. Discussion: Optimal college student screening may differ by sex and race

Preliminary Feasibility and Efficacy of a Brief Motivational Intervention with Psychophysiological Feedback for Cocaine Abuse

Motivational interviewing (MI) with personalized feedback, particularly related to biological markers of risk or harm, has been found effective for alcohol use disorders, but has not been fully investigated in cocaine use disorders. A randomized, controlled pilot study evaluating the feasibility and preliminary efficacy of a brief MI intervention using EEG/ERP graphical feedback for cocaine abusers was conducted. Treatment-seeking cocaine abusers (N = 31) were randomly assigned to a two-session MI intervention or a minimal control condition. All participants received EEG assessments at intake and post-treatment. Results indicated that the MI intervention was feasible and the subjective impact of the EEG feedback was positive. Significant group differences in percentage of cocaine positive urine screens across the study were found, favoring the MI group; 84.9% for the control group and 62.6% in the MI group, p \u3e .05. Further research must determine the specific conditions under which MI is most appropriate and efficacious

An Assessment of How Clinicians and Staff Members Use a Diabetes Artificial Intelligence Prediction Tool: Mixed Methods Study

BackgroundNearly one-third of patients with diabetes are poorly controlled (hemoglobin A1c≥9%). Identifying at-risk individuals and providing them with effective treatment is an important strategy for preventing poor control. ObjectiveThis study aims to assess how clinicians and staff members would use a clinical decision support tool based on artificial intelligence (AI) and identify factors that affect adoption. MethodsThis was a mixed methods study that combined semistructured interviews and surveys to assess the perceived usefulness and ease of use, intent to use, and factors affecting tool adoption. We recruited clinicians and staff members from practices that manage diabetes. During the interviews, participants reviewed a sample electronic health record alert and were informed that the tool uses AI to identify those at high risk for poor control. Participants discussed how they would use the tool, whether it would contribute to care, and the factors affecting its implementation. In a survey, participants reported their demographics; rank-ordered factors influencing the adoption of the tool; and reported their perception of the tool’s usefulness as well as their intent to use, ease of use, and organizational support for use. Qualitative data were analyzed using a thematic content analysis approach. We used descriptive statistics to report demographics and analyze the findings of the survey. ResultsIn total, 22 individuals participated in the study. Two-thirds (14/22, 63%) of respondents were physicians. Overall, 36% (8/22) of respondents worked in academic health centers, whereas 27% (6/22) of respondents worked in federally qualified health centers. The interviews identified several themes: this tool has the potential to be useful because it provides information that is not currently available and can make care more efficient and effective; clinicians and staff members were concerned about how the tool affects patient-oriented outcomes and clinical workflows; adoption of the tool is dependent on its validation, transparency, actionability, and design and could be increased with changes to the interface and usability; and implementation would require buy-in and need to be tailored to the demands and resources of clinics and communities. Survey findings supported these themes, as 77% (17/22) of participants somewhat, moderately, or strongly agreed that they would use the tool, whereas these figures were 82% (18/22) for usefulness, 82% (18/22) for ease of use, and 68% (15/22) for clinic support. The 2 highest ranked factors affecting adoption were whether the tool improves health and the accuracy of the tool. ConclusionsMost participants found the tool to be easy to use and useful, although they had concerns about alert fatigue, bias, and transparency. These data will be used to enhance the design of an AI tool

Developing interagency collaboration to address the opioid epidemic: A scoping review of joint criminal justice and healthcare initiatives.

BACKGROUND: With the current opioid epidemic impacting well over half of all counties across the United States, initiatives that encourage interagency collaboration between first responder organizations appear necessary to comprehensively address this crisis. Police, fire, and emergency medical services (EMS) are in a unique position to identify substance users and provide necessary resources to initiate treatment, yet there is not sufficient evidence of joint collaborative programs between law enforcement/first responders and healthcare providers. METHODS: In this scoping review we examine the current state of joint criminal justice and healthcare interventions, specifically, opioid and substance use pre-arrest initiatives via emergency first responders and police officers. We relied on data from the last 10 years across three major databases to assess the extent of criminal justice (CJ) and healthcare collaborations as a response to individuals with opioid use disorder (OUD). We specifically focused on interventional programs between criminal justice first responders (pre-arrest) and healthcare providers where specific outcomes were documented. RESULTS: We identified only a small number (6) of studies involving interventions that met this criteria, suggesting very limited study of joint interagency collaboration between law enforcement first responders and healthcare providers. Most had small samples, none were in the southern states, and all but one were initiated within the last 5 years. CONCLUSIONS: Although studies describing joint efforts of early intercept criminal justice responses and healthcare interventions were few, existing studies suggest that such programs were effective at improving treatment referral and retention outcomes. Greater resources are needed to encourage criminal justice and healthcare collaboration and policies, making it easier to share data, refer patients, and coordinate care for individuals with OUD