Randomized controlled trial to evaluate screening and brief intervention for drug-using multiethnic emergency and trauma department patients

BACKGROUND: Screening and brief intervention (SBI) is a comprehensive, integrated public health approach to identify and deliver a spectrum of early detection and intervention services for substance use in general medical care settings. Although the SBI approach has shown promise for alcohol use, relatively little is known about its effectiveness for illicit drug use. We are evaluating the SBI approach for drug use using a rigorous randomized controlled trial. The purpose of the report is to describe the overall trial and its programmatic and methodological strengths with a focus on health educator (HE) selection and training. In addition, the baseline characteristics of the recently enrolled multiethnic cohort are described. METHODS/DESIGN: A randomized two-group repeated measures design is being used in which drug-related outcomes of an intervention group will be compared with those of an attention-placebo control group. Selection of bicultural paraprofessional HEs—their training in research concepts, comorbid mental health issues, special treatment of marijuana use, and nonscripted enhanced motivational interviewing as well as their ongoing monitoring and evaluation—are among the features described. The HEs enrolled, consented, and conducted an intervention among 700 illicit drug users in two large hospital emergency departments/trauma units. To be eligible, a participant needed to be an adult (age ≥18 years), an English or Spanish speaker, awake and able to give consent, and reachable by telephone to schedule a six-month follow-up interview. DISCUSSION: A comprehensive HE training protocol combined with rigorous, ongoing process measurement resulted in skill mastery in many areas and a successful participant recruitment period. Strengths and limitations of the study protocol are discussed as well as the characteristics of those recruited. This trial will be among the first to provide information about the effectiveness of SBI for illicit drug use. Outcome analysis has not yet been completed, but demonstrated programming and design successes have implications for future research and service delivery. TRIAL REGISTRATION: http://NCT0168322

Fourth Annual Report: 2007 Pre-Construction Eelgrass Monitoring and Propagation for King County Outfall Mitigation

King County proposes to build a new sewer outfall discharging to Puget Sound near Point Wells, Washington. Construction is scheduled for 2008. The Point Wells site was selected to minimize effects on the nearshore marine environment, but unavoidable impacts to eelgrass (Zostera marina) beds are anticipated during construction. To mitigate these impacts and prepare for post-construction restoration, King County began implementing a multiyear eelgrass monitoring and restoration program in 2004, with the primary goal of returning intertidal and shallow subtidal habitat and eelgrass to pre-construction conditions. Major program elements related to eelgrass are (a) pre-construction monitoring, i.e., documenting initial eelgrass conditions and degree of fluctuation over 5 years prior to construction, (b) eelgrass transplanting, including harvesting, offsite propagating, and stockpiling of local plants for post-construction planting, and (c) post-construction planting and subsequent monitoring. The program is detailed in the Eelgrass Restoration and Biological Resources Implementation Workplan (King County 2006). This report describes calendar year 2007 pre-construction activities conducted by Pacific Northwest National Laboratory (PNNL) for King County. Activities included continued propagation of eelgrass shoots at the PNNL Marine Sciences Laboratory (MSL) in Sequim, Washington, and monitoring of the experimental harvest plots in the marine outfall corridor area to evaluate recovery rates relative to harvest rates. In addition, 490 eelgrass shoots were also harvested from the Marine Outfall Corridor in July 2007 to supplement the plants in the propagation tank at the MSL, bringing the total number of shoots to 1464. Eelgrass densities were monitored in four of five experimental harvest plots established in the Marine Outfall Corridor. Changes in eelgrass density were evaluated in year-to-year comparisons with initial harvest rates. A net increase in eelgrass density from 2004 post-harvest to 2007 was observed in all plots, despite density decreases observed in 2006 in all plots and at most harvest rates. Eelgrass densities within individual subplots were highly variable from year to year, and the change in density in any interannual period was not related to initial 2004 harvest rate. Harvest rates of neighboring subplots did not appear to affect subplot eelgrass density (Woodruff et al. 2007). Three years post-harvest, eelgrass shoot densities were not significantly different from pre-harvest shoot densities at any harvest level. Additional plans are being discussed with King County to harvest all eelgrass from the construction corridor and hold in the propagation tanks at the MSL for post-construction planting. Under this plan, plants that would have been lost to construction will be held offsite until construction is completed. This strategy reduces and possibly eliminates the need to harvest eelgrass from donor beds located south of the construction area, allowing them to remain undisturbed. However, if eelgrass is harvested from donor beds, the monitoring of eelgrass growth at different harvest rates should help determine an optimum harvest rate that supports rapid recovery of donor eelgrass beds

Randomized clinical trial of the effects of screening and brief intervention for illicit drug use: the Life Shift/Shift Gears study.

BackgroundAlthough screening, brief intervention, and referral to treatment (SBIRT) has shown promise for alcohol use, relatively little is known about its effectiveness for adult illicit drug use. This randomized controlled trial assessed the effectiveness of the SBIRT approach for outcomes related to drug use among patients visiting trauma and emergency departments (EDs) at two large, urban hospitals.MethodsA total of 700 ED patients who admitted using illegal drugs in the past 30 days were recruited, consented, provided baseline measures of substance use and related problems measured with the Addiction Severity Index-Lite (ASI-Lite), and then randomized to the Life Shift SBIRT intervention or to an attention-placebo control group focusing on driving and traffic safety (Shift Gears). Both groups received a level of motivational intervention matched to their condition and risk level by trained paraprofessional health educators. Separate measurement technicians conducted face-to-face follow-ups at 6 months post-intervention and collected hair samples to confirm reports of abstinence from drug use. The primary outcome measure of the study was past 30-day drug abstinence at 6 months post-intervention, as self-reported on the ASI-Lite.ResultsOf 700 participants, 292 (42%) completed follow-up. There were no significant differences in self-reported abstinence (12.5% vs. 12.0% , p = 0.88) for Life Shift and Shift Gears groups, respectively. When results of hair analyses were applied, the abstinence rate was 7 percent for Life Shift and 2 percent for Shift Gears (p = .074). In an analysis in which results were imputed (n = 694), there was no significant difference in the ASI-Lite drug use composite scores (Life Shift +0.005 vs. Shift Gears +0.017, p = 0.12).ConclusionsIn this randomized controlled trial, there was no evidence of effectiveness of SBIRT on the primary drug use outcome.Trial registrationClinicalTrials.gov NCT01683227

Enforcement of State Indoor Tanning Laws in the United States

Introduction Twenty-eight US states have passed legislation for indoor tanning facilities. To our knowledge, whether these state laws are actually enforced has not been evaluated previously in all 28 states. Therefore, we interviewed key informants in these states to assess enforcement practices. Methods Two trained interviewers used a structured survey instrument to interview 28 key informants who were knowledgeable about enforcement practices for laws regarding indoor tanning. Respondents provided information specific to the most populous city in their states. Results Licensure for indoor tanning businesses was required in 22 of the 28 cities. Slightly less than half of the cities gave citations to tanning facilities that violated state law. Approximately 32% of the cities did not inspect indoor tanning facilities for compliance with state law, and another 32% conducted inspections less than annually. Of those cities that inspected at all, most conducted unannounced inspections. Conclusion The relatively low rates of annual inspections and citations are of concern. We recommend that future studies assess whether legislation, enforcement practices, or a combination of the 2 affects the practices of indoor tanning facilities or of consumers

Third Annual Report: 2006 Pre-Construction Eelgrass Monitoring and Propagation for King County Outfall Mitigation

King County proposes to build a new sewer outfall discharging to Puget Sound near Point Wells, Washington. Construction is scheduled for 2008. The Point Wells site was selected to minimize effects on the nearshore marine environment, but unavoidable impacts to eelgrass (Zostera marina) beds are anticipated during construction. To mitigate for these impacts and prepare for post-construction restoration, King County began implementation of a multi-year eelgrass monitoring and restoration program in 2004, with the primary goal of returning intertidal and shallow subtidal habitat and eelgrass to pre-construction conditions. Major program elements are a) pre-construction monitoring, i.e., documenting initial eelgrass conditions and degree of fluctuation over 5 years prior to construction, b) eelgrass transplanting, including harvesting, offsite propagating and stockpiling of local plantstock, and post-construction planting, and c) post-construction monitoring. The program is detailed in the Eelgrass Restoration and Biological Resources Implementation Workplan (King County 2006). This report describes calendar year 2006 pre-construction activities conducted by Pacific Northwest National Laboratory (PNNL) in support of King County. Activities included continued propagation of eelgrass shoots and monitoring of the experimental harvest plots in the marine outfall corridor area to evaluate recovery rates relative to harvest rates. Approximately 1500 additional shoots were harvested from the marine outfall corridor in August 2006 to supplement the plants in the propagation tank at the PNNL Marine Sciences Laboratory in Sequim, Washington, bringing the total number of shoots to 4732. Eelgrass densities were monitored in the five experimental harvest plots established in the marine outfall corridor. Changes in eelgrass density were evaluated in year-to-year comparisons with initial harvest rates. Net eelgrass density decreased from 2004 post-harvest to 2006 in all plots, despite density increases observed in 2005 in some plots and at some harvest rates. Eelgrass densities within individual subplots were highly variable from year to year, and the change in density in any interannual period did not correlate to the initial 2004 harvest rate. Continued monitoring should help project managers determine an optimum harvest rate that supports rapid recovery of donor eelgrass beds

Effect of maternal panic disorder on mother-child interaction and relation to child anxiety and child self-efficacy

To determine whether mothers with panic disorder with or without agoraphobia interacted differently with their children than normal control mothers, 86 mothers and their adolescents (aged between 13 and 23 years) were observed during a structured play situation. Maternal as well as adolescent anxiety status was assessed according to a structured diagnostic interview. Results showed that mothers with panic disorder/agoraphobia showed more verbal control, were more criticizing and less sensitive during mother-child interaction than mothers without current mental disorders. Moreover, more conflicts were observed between mother and child dyadic interactions when the mother suffered from panic disorder. The comparison of parenting behaviors among anxious and non-anxious children did not reveal any significant differences. These findings support an association between parental over-control and rejection and maternal but not child anxiety and suggest that particularly mother anxiety status is an important determinant of parenting behavior. Finally, an association was found between children’s perceived self-efficacy, parental control and child anxiety symptoms

Respiratory Symptoms Items from the COPD Assessment Test Identify Ever-Smokers with Preserved Lung Function at Higher Risk for Poor Respiratory Outcomes

Rationale: Ever-smokers without airflow obstruction scores greater than or equal to 10 on the COPD Assessment Test (CAT) still have frequent acute respiratory disease events (exacerbation-like), impaired exercise capacity, and imaging abnormalities. Identification of these subjects could provide new opportunities for targeted interventions. Objectives: We hypothesized that the four respiratory-related items of the CAT might be useful for identifying such individuals, with discriminative ability similar to CAT, which is an eight-item questionnaire used to assess chronic obstructive pulmonary disease impact, including nonrespiratory questions, with scores ranging from 0 to 40. Methods: We evaluated ever-smoker participants in the Subpopulations and Intermediate Outcomes in COPD Study without airflow obstruction (FEV1/FVC≥0.70; FVC above the lower limit of normal). Using the area under the receiver operating characteristic curve, we compared responses to both CAT and the respiratory symptom–related CAT items (cough, phlegm, chest tightness, and breathlessness) and their associations with longitudinal exacerbations. We tested agreement between the two strategies (k statistic), and we compared demographics, lung function, and symptoms among subjects identified as having high symptoms by each strategy. Results: Among 880 ever-smokers with normal lung function (mean age, 61 yr; 52% women) and using a CAT cutpoint greater than or equal to 10, we classified 51.8% of individuals as having high symptoms, 15.3% of whom experienced at least one exacerbation during 1-year follow-up. After testing sensitivity and specificity of different scores for the first four questions to predict any 1-year followup exacerbation, we selected cutpoints of 0–6 as representing a low burden of symptoms versus scores of 7 or higher as representing a high burden of symptoms for all subsequent comparisons. The four respiratory-related items with cutpoint greater than or equal to 7 selected 45.8% participants, 15.6% of whom experienced at least one exacerbation during follow-up. The two strategies largely identified the same individuals (agreement, 88.5%; k = 0.77; P \u3c 0.001), and the proportions of high-symptoms subjects who had severe dyspnea were similar between CAT and the first four CAT questions (25.9% and 26.8%, respectively), as were the proportions reporting impaired quality of life (66.9% and 70.5%, respectively) and short walking distance (22.4% and 23.1%, respectively). There was no difference in area under the receiver operating characteristic curve to predict 1-year follow-up exacerbations (CAT score ≥10, 0.66; vs. four respiratory items from CAT ≥ 7 score, 0.65; P = 0.69). Subjects identified by either method also hadmore depression/anxiety symptoms, poor sleep quality, and greater fatigue. Conclusions: Four CAT items on respiratory symptoms identified high-risk symptomatic ever-smokers with preserved spirometry as well as the CAT did. These data suggest that simpler strategies can be developed to identify these high-risk individuals in primary care

Meeting Report: Moving Upstream—Evaluating Adverse Upstream End Points for Improved Risk Assessment and Decision-Making

Background Assessing adverse effects from environmental chemical exposure is integral to public health policies. Toxicology assays identifying early biological changes from chemical exposure are increasing our ability to evaluate links between early biological disturbances and subsequent overt downstream effects. A workshop was held to consider how the resulting data inform consideration of an “adverse effect” in the context of hazard identification and risk assessment. Objectives Our objective here is to review what is known about the relationships between chemical exposure, early biological effects (upstream events), and later overt effects (downstream events) through three case studies (thyroid hormone disruption, antiandrogen effects, immune system disruption) and to consider how to evaluate hazard and risk when early biological effect data are available. Discussion Each case study presents data on the toxicity pathways linking early biological perturbations with downstream overt effects. Case studies also emphasize several factors that can influence risk of overt disease as a result from early biological perturbations, including background chemical exposures, underlying individual biological processes, and disease susceptibility. Certain effects resulting from exposure during periods of sensitivity may be irreversible. A chemical can act through multiple modes of action, resulting in similar or different overt effects. Conclusions For certain classes of early perturbations, sufficient information on the disease process is known, so hazard and quantitative risk assessment can proceed using information on upstream biological perturbations. Upstream data will support improved approaches for considering developmental stage, background exposures, disease status, and other factors important to assessing hazard and risk for the whole population