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There is a critical need to improve linkage to alcohol care for veterans in primary care with hazardous drinking and PTSD and/or depression symptoms (A-MH). We adapted an alcohol care linkage intervention, "Connect to Care" (C2C), for this population. We conducted separate focus groups with veterans with A-MH, providers, and policy leaders. Feedback centered on how psychologists and other providers can optimally inform veterans about their care options and alcohol use, and how to ensure C2C is accessible. Participants reported that veterans with A-MH may not view alcohol use as their primary concern but rather as a symptom of a potential co-occurring mental health condition. Veterans have difficulty identifying and accessing existing alcohol care options within the Veterans Health Administration. C2C was modified to facilitate alcohol care linkage for this population specific to their locality, provide concrete support and education, and offer care options to preserve privacy. [ABSTRACT FROM AUTHOR]

Background: In studies of the general population and of military veterans, many primary care patients with hazardous drinking and PTSD and/or depression (abbreviated here as HD +) do not initiate or engage with alcohol-related care. To address this gap in care, we identified and will pilot test a promising evidence-based intervention, Connect To Care (C2C). C2C is a strengths-based approach, delivered by a Care Coach by telephone and/or video, with four components: (1) identifying and leveraging patient strengths to facilitate care initiation, (2) collaborative decision-making around a menu of care options, (3) identifying and resolving barriers to care, and (4) monitoring and facilitating progress toward care initiation by, for example, checking on barriers, identifying solutions, and revisiting care options. Methods/Design: Aim 1 will involve adapting C2C for use in Veterans Affairs' (VA) primary care. We will use an iterative process that includes focus groups and semi-structured interviews with key stakeholders (patients, primary care providers, and VA national policy leaders). In Aim 2, we will conduct a two-site, pilot randomized controlled trial to determine the feasibility of conducting a larger scale trial to test C2C's effectiveness, ascertain the acceptability of C2C among primary care patients with HD + , and explore the efficacy of C2C to improve veteran patients' initiation of and engagement in alcohol care, and their alcohol and mental health (PTSD, depression) outcomes, at 3-month follow-up. We will explore explanatory mechanisms by which C2C is effective. Discussion: Study findings are likely to have implications for clinical practice to enhance current approaches to linking patients with HD + to alcohol care by applying a practical intervention such as C2C. The results may improve treatment outcomes for people with HD + by drawing on patients' strengths to problem-solve barriers to care following a process of shared decision-making with a coach. In addition to possibly accelerating the translation of C2C into practice, study findings will also support additional research in terms of a planned effectiveness-implementation hybrid trial, adding to this study's potential for high impact. Trial registration: ClinicalTrials.gov Identifier: NCT05023317. [ABSTRACT FROM AUTHOR]

Objective: Criminal recidivism is common among patients in mental health residential treatment programs. Moral reconation therapy (MRT) has empirical support for reducing criminal recidivism by modifying antisocial cognitions and behaviors; however, its implementation potential in noncorrectional settings has been rarely studied. This potential was examined in a three-site effectiveness-implementation trial of MRT for justice-involved veterans receiving residential mental health treatment in the U.S. Veterans Health Administration.Methods: Semistructured interviews were conducted with 36 veterans who received MRT and 13 residential program staff who were involved in its implementation during the trial. Interviews were guided by the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework and a focus on patient engagement and context. Content analysis was used to identify facilitators of and barriers to MRT implementation in residential mental health treatment.Results: Participants viewed MRT as unique and complementary to usual residential care, with benefits beyond recidivism reduction. However, time intensity of the MRT curriculum, challenges in adapting its content and format, and long-term costs of maintaining MRT were viewed as barriers to implementation. To facilitate implementation, participants suggested streamlining the MRT curriculum, adding motivational components, and establishing partnerships in- and outside the health care system.Conclusions: The findings suggest strategies and modifications to MRT, which, if shown to be effective, may facilitate its wider implementation in mental health residential treatment programs. [ABSTRACT FROM AUTHOR]

Effective means of accurately identifying problematic opioid prescribing are needed. Using an iterative approach with the Arkansas State Medical Board Pain Subcommittee, we modified existing opioid prescriber criteria to create seven metrics to be deployed in Arkansas. These included metrics of dose and days' supply, concomitant use of opioid and benzodiazepines, solid dosage units, and numbers of opioid patients and certain opioid prescriptions. Two of these metrics (average MME daily dose per prescription and total oxycodone 30 mg or hydromorphone prescriptions) were weighted by 2, creating a maximum score of 9 of which each prescriber could receive. Twenty prescribers with a score of 7 or greater were identified and referred to the Arkansas State Medical Board Pain Subcommittee for review and subsequent investigation if deemed necessary. Of those 20 prescribers, four were previously investigated and under disciplinary action, and three were under current investigation for misconduct related to prescribing practices. Five prescribers had new investigations opened due to the findings from the metrics, and disciplinary action was taken. Therefore, 12 of the 20 prescribers referred to the Arkansas State Medical Board were deemed worthy of investigation and disciplinary action. The Arkansas opioid prescriber metrics are able to accurately identify prescribers with potentially problematic opioid prescribing. [ABSTRACT FROM AUTHOR]

Aims: To test the effectiveness of an intervention, Al-Anon Intensive Referral (AIR), to facilitate participation in Al-Anon Family Groups (Al-Anon). Design, Setting and Participants: Multi-site, randomized controlled trial of AIR versus usual care (UC), with follow-up assessments at 3, 6 and 12 months. The 12-month follow-up rate was 74%. Residential alcohol use disorder (AUD) treatment programs in three US locations. Concerned others (COs) of patients in treatment for AUD. COs were mainly women (77%) who were patients' spouses (33%) or parents (25%). Intervention and Comparator: AIR (n = 128) consisted of four sessions over 3 months with an Al-Anon coach. UC (n = 151) was the treatment program's offer of educational sessions for COs. Measurements: Primary outcome: COs' self-reports of any Al-Anon attendance (yes or no) at 3 months. Secondary outcomes: number of Al-Anon meetings and the CO-patient relationship (stressors, resources). Potential predictors of outcomes examined in generalized linear mixed models were their baseline value, time, CO-patient relationship type (marital or non-marital), treatment program and condition. Findings: There was no effect of condition for the primary outcome (28% in AIR, 21% in UC; Bayes factor = 1.86). Relationship stressors at follow-ups were more severe for COs in a marital relationship with the patient than for COs in a non-marital relationship [ß = 2.19, 95% confidence interval (CI) = 1.07, 3.32]. For CO-patient relationship resources at follow-ups, the main effect for condition was significant (ß = 1.33, 95% CI = 0.04, 2.61). COs assigned to the AIR condition had more resources than COs who were in the UC condition. Conclusions: Relative to usual care, Al-Anon Intensive Referral was not associated with increases in participation of concerned others in Al-Anon, but was associated with more resources in the concerned other-patient relationship. [ABSTRACT FROM AUTHOR]

Moral Reconation Therapy (MRT), an evidence-based intervention to reduce risk for criminal recidivism among justice-involved adults, was developed and primarily tested in correctional settings. Therefore, a better understanding of the implementation potential of MRT within non-correctional settings is needed. To address this gap in the literature, we evaluated the adoption and sustainment of MRT in the US Veterans Health Administration (VHA) following a national training initiative in fiscal years 2016 and 2017. In February 2019, surveys with 66 of the 78 VHA facilities that participated in the training were used to estimate the prevalence of MRT adoption and sustainment, and qualitative interviews with key informants from 20 facilities were used to identify factors associated with sustainment of MRT groups. Of the 66 facilities surveyed, the majority reported adopting (n = 52; 79%) and sustaining their MRT group until the time of the survey (n = 38; 58%). MRT sustainment was facilitated by strong intra-facility (e.g., between veterans justice and behavioral health services) and inter-agency collaborations (e.g., between VHA and criminal justice system stakeholders), which provided a reliable referral source to MRT groups, external incentives for patient engagement, and sufficient staffing to maintain groups. Additional facilitators of MRT sustainment were adaptations to the content and delivery of MRT for patients and screening of referrals to the groups. The findings provide guidance to clinics and healthcare systems that are seeking to implement MRT with justice-involved patient populations, and inform development of implementation strategies to be formally tested in future trials. [ABSTRACT FROM AUTHOR]

aim of this study was to evaluate whether a video-based, patient-focused opioid education tool delivered in the perioperative period would decrease acute and chronic post-operative opioid prescription dispensations and increase self-rated knowledge about opioids. Methods: We enrolled 110 patients with no reported opioid use in the previous 30 days, undergoing ambulatory surgery for breast, orthopedic, gynecologic, or other outpatient procedures for which opioids would be prescribed. Patients were randomized to receive either post-operative opioid education by the surgical team (control arm) or pre-operative education via a novel 5-minute video plus post-operative education by the surgical team (intervention arm). All patients received follow-up phone calls on post-operative day (POD) 7 to assess self-rated knowledge of opioids on a scale of 1 to 10, 10 being most informed, and self-reported opioid use (primary outcome). Arkansas Prescription Drug Monitoring Program (AR PDMP) data were obtained to assess opioid dispensations at POD 90– 150 days. Results: Seventy-seven percent of participants completed POD7 survey. Participants in the intervention arm rated their knowledge of opioids after surgery significantly higher than those in the control arm (p=0.013). Data from the AR PDMP reveal trends (non-significant) that show increased use of opioids in the control group when compared to the video intervention group at POD 30 (88.7% vs 76%) and POD 90– 150 (22.6% vs 10%). Conclusion: Video-based, patient-focused opioid education can be effectively implemented in a large university hospital during the perioperative period and is effective for increasing a patient's perception of opioid-related knowledge. A fully powered, randomized control trial is needed to further explore observed trends and determine if this novel tool can decrease chronic post-operative opioid dispensations. [ABSTRACT FROM AUTHOR]

Background and aims: Reducing alcohol consumption by liver disease patients can reduce morbidity and mortality. This study compared a computer‐delivered brief alcohol intervention (cBAI) with standard care in a sample of US military veterans with liver disease. Design Multi‐site, randomized controlled trial of a cBAI plus standard care (n = 67) versus standard care only (n = 71). Participants were assessed at baseline and 3‐ and 6‐month follow‐up. Setting: US Veterans Health Administration liver clinics. Participants: Participants were mostly male and diagnosed with hepatitis C. Interventions and comparators: A cBAI tailored to veterans with liver disease and consisting of assessment and personalized feedback. Standard care was brief education and advice about alcohol and liver disease. Measurement Primary outcomes were self‐reported number of drinking days and unhealthy drinking days (defined as more than two drinks for men and more than one for women) in the past 30 days at 6‐month follow‐up. Secondary outcomes were these two variables at 3‐month follow‐up, and drinks consumed per drinking day, depression and overall health at 3‐ and 6‐month follow‐ups. Missing data were imputed using multiple imputation. Findings Compared with standard care, cBAI participants reported significantly fewer drinking days at 6‐month follow‐up and fewer unhealthy drinking days at both 3‐ and 6‐month follow‐ups. Least square means (LS‐means) for number of drinking days were 3.78 for the cBAI condition and 6.89 for the standard care condition at 6 months [LS‐mean ratio = 3.78/6.89 = 0.55, 95% confidence interval (CI) = 0.34, 0.89]. LS‐means for number of unhealthy drinking days were 1.04 for the cBAI condition and 2.57 for the standard care condition at 3‐month follow‐up (LS‐mean ratio = 1.04/2.57 = 0.41, 95% CI = 0.19, 0.85). At 6‐months follow‐up, LS‐means were 1.18 for the cBAI condition and 2.75 for the standard care condition (LS‐mean ratio = 1.18/2.75 = 0.43, 95% CI = 0.20, 0.91). Conclusions: A computer‐delivered brief alcohol intervention reduced drinking days and unhealthy drinking days at 6‐month follow up in military veterans with liver disease compared with brief education and advice to reduce consumption. [ABSTRACT FROM AUTHOR]

Purpose: Many US military veterans experience anxiety, depression, and trauma‐related disorders. A major goal of the Veterans Health Administration (VHA) has been to increase access to evidence‐based psychotherapies (EBPs) such as cognitive‐behavioral therapy to address veterans' substantial health burden. However, despite widespread implementation of EBPs throughout the VHA, smaller clinics that often serve rural veterans face barriers to delivering these interventions. The Veterans Affairs Coordinated Anxiety Learning and Management (VA CALM) program aims to empower providers in rural areas with varying levels of training and experience in delivering EBPs to provide high‐quality cognitive‐behavioral therapy for anxiety, depression, and trauma‐related disorders. The goal of this study was to better understand, through qualitative interviews, VHA community‐based outpatient clinic providers' perspectives on implementing VA CALM. Methods: Qualitative interviews with providers (N = 22) were conducted to understand implementation of VA CALM. Template analysis was used to organize and summarize responses. Findings: Providers noted several facilitators for implementing VA CALM in rural community clinics, including its perceived effectiveness, broad applicability, and structure. Barriers to implementation included scheduling problems and patient‐related barriers. Conclusions: Incorporating providers' perspectives on factors that affect implementing cognitive‐behavioral therapy in this setting may inform future efforts to disseminate‐implement EBPs in smaller, more remote VHA clinics. [ABSTRACT FROM AUTHOR]

A recent clinical trial found that a computer-delivered BAI (cBAI) was effective in reducing alcohol use among patients, in the Department of Veterans Affairs (VA), with liver disease. This is encouraging clinically, but whether the intervention can be rolled on within VA nationally depends on its economic impact. We conducted a randomized clinical trial in 110 patients with liver disease in two VA clinics. We used VA national administrative data to obtain and evaluate health utilization and costs 12 months before and after implementing the cBAI, using a difference-in-differences (DID) approach. The cBAI and usual care group did not differ on inpatient, outpatient, and pharmacy health care utilization and costs at baseline. The results of the DID analysis of the total health services expenses demonstrated similar costs between the cBAI and usual care group, 12 months before and after BAI intervention. Implementing a cBAI in VA liver clinics reduces alcohol consumption while not having any long-term impact on health care utilization and costs. [ABSTRACT FROM AUTHOR]

Purpose: To explore the feasibility and utility of using a workshop, and supervision‐consultation plus external facilitation to disseminate and implement cognitive‐behavioral therapy in Veterans Affairs (VA) community‐based outpatient clinics (CBOCs). Methods: This study occurred in the context of a randomized controlled trial aimed at comparing 2 methods for implementing Coordinated Anxiety Learning Management (CALM) in VA CBOCs. A 3‐phase (workshop, supervision‐consultation, external facilitation) model was used to support 32 VA CBOC mental health providers in learning and adopting CALM in their clinical practice. Qualitative data describe training activities and the feasibility and utility of each training phase in addressing challenges to adopting CALM. Findings: All 3 phases of the model were feasible to use with our sample of CBOC mental health providers. Providers reported challenges learning CALM during the workshop and concerns about not having enough training post‐workshop to use CALM in practice. Providers primarily utilized supervision‐consultation to tailor CALM to their practice, including learning how to prioritize a target disorder, "switch" the focus of treatment to a different disorder when comorbidities were present, and modify CALM sessions to fit shorter treatment visits. Providers primarily utilized external facilitation to further tailor CALM to their practice through implementation (eg, concrete help) and support‐oriented help. Key lessons for implementing CALM in CBOCs are presented and discussed. Conclusions: Findings provide initial evidence for the feasibility and utility of using each component of a facilitation‐enhanced training model to promote CBOC VA providers' implementation of a computer and manual version of CALM in their practice. [ABSTRACT FROM AUTHOR]

Background: Poor functioning among Concerned Others (COs; family and friends of an individual with an alcohol or other substance use disorder) is a significant public health problem. The purpose of this study was to inform interventions for COs by examining potential correlates of 3 aspects of functioning: quality of life, mental health, and knowledge of how to handle problems related to their drinker. Methods: This study collected data from 277 COs when their friend or family member (their "drinker") was entering treatment for an alcohol use disorder. Potential correlates were the drinker's substance use severity, the CO–drinker relationship and communication, and COs' coping and perceived stigma related to involvement with their drinker. Results: In a summary analysis, only stressors in the CO–drinker relationship (the drinker's criticism, disagreement, anger, and demands) were consistently associated with poorer functioning as indicated by COs' poorer quality of life and mental health. In contrast, only COs' use of approach coping was associated with COs' knowing how to handle problems related to the drinker. Conclusions: Because reducing both relationship stressors and the link between stressors and poor functioning can be achieved through CO and drinker education and intervention, these findings inform how to effectively support COs' goals for better functioning. [ABSTRACT FROM AUTHOR]

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There is limited knowledge about age-related differences in health outcomes and treatment utilization among rural stimulant users. The current study examined physical health, mental health, and treatment utilization (hospital, mental health, and substance use care) among 710 stimulant users living in rural areas of the United States. Generalized estimating equations (GEE) were used to examine associations between age and physical health, mental health, and treatment utilization over a 3-year period. Analyses controlled for participants' gender, race, and education. To capture age-related differences, participants were grouped into emerging adults (18-25 years old, n = 223), early-mid adults (26-44 years old; n = 384), and older adults (45-61 years old; n = 103). At baseline, older stimulant users were in significantly poorer health even though they had significantly fewer substance use problems than emerging adult users. GEE models indicated that substance use outcomes improved for all participants over the course of the study but other outcomes remained stable. Older stimulant users continued to have worse physical health and mental health, even though they had fewer substance use problems, than the other age groups. Older adults also used more hospital and mental health services than the other age groups. White participants tended to be at higher risk for negative outcomes than nonwhite participants. We conclude that rural older adults who use stimulants have poor health despite having milder substance use problems and using more health care resources, and need targeted intervention to improve health outcomes. [ABSTRACT FROM AUTHOR]

Background: Negative views toward substance use treatment among some rural substance users and limited treatment resources in rural areas likely affect substance use utilization. It is therefore important to determine whether accessing healthcare options other than substance use treatment, specifically outpatient medical care (OMC), is associated with reductions in substance use.Objectives: We examined whether use of OMC was associated with reductions in substance use among rural substance users over a three-year period. We also explored whether substance user characteristics, including substance-use severity and related-problems, moderated this potential relationship.Methods: Data were collected from an observational study of 710 (61% male) stimulant users using respondent-driven sampling. Participants were recruited from rural counties of Arkansas, Kentucky, and Ohio.Results: We found a significant main effect of having at least one OMC visit (relative to none) on fewer days of alcohol, crack cocaine, and methamphetamine use over time. Fewer days of alcohol, crack cocaine, and methamphetamine use were reported in participants with at least one OMC visit (relative to those with none) among those reporting higher Addiction Severity Index employment and psychiatric severity scores, and low education, respectively.Conclusion: Our findings extend the results from prior studies with urban substance users to show that contact with an outpatient medical care clinic is associated with reductions in substance use over time among rural substance users with especially poorer functioning. These findings highlight the potential importance of OMCs in addressing unhealthy substance use in rural communities. [ABSTRACT FROM AUTHOR]

Objective: This study adapted an existing computer-delivered brief alcohol intervention (cBAI) for use in Veterans with the hepatitis C virus (HCV) and examined its acceptability and feasibility in this patient population.Methods: A four-stage model consisting of initial pilot testing, qualitative interviews with key stakeholders, development of a beta version of the cBAI, and usability testing was used to achieve the study objectives.Results: In-depth interviews gathered feedback for modifying the cBAI, including adding HCV-related content such as the health effects of alcohol on liver functioning, immune system functioning, and management of HCV, a preference for concepts to be displayed through "newer looking" graphics, and limiting the use of text to convey key concepts. Results from usability testing indicated that the modified cBAI was acceptable and feasible for use in this patient population.Conclusions: The development model used in this study is effective for gathering actionable feedback that can inform the development of a cBAI and can result in the development of an acceptable and feasible intervention for use in this population. Findings also have implications for developing computer-delivered interventions targeting behavior change more broadly. [ABSTRACT FROM AUTHOR]

Background. Although rates of unhealthy drinking are high among women Veterans with mental health comorbidities, most women Veterans with mental comorbidities who present to primary care with unhealthy drinking do not receive alcohol-related care. Barriers to alcohol-related treatment could be reduced through patient-centered approaches to care, such as shared decision-making.Aims. We assessed the feasibility and acceptability of a telephone-delivered shared decision-making intervention for promoting alcohol behavior change in women Veterans with unhealthy drinking and co-morbid depression and/or probable post-traumatic stress disorder.Methods. We used 3, 2-hour focus group discussions with 19 women Veterans to identify barriers and solicit recommendations for using the intervention with women Veterans who present to primary care with unhealthy drinking and mental health comorbidities. Transcripts from the focus groups were qualitatively analyzed using template analysis.Results. Although participants perceived that the intervention was feasible and acceptable for the targeted patient population, they identified the treatment delivery modality, length of telephone sessions, and some of the option grid content as potential barriers. Facilitators included strategies for enhancing the telephone-delivered shared decision-making sessions and diversifying the treatment options contained in the option grids. Focus group feedback resulted in preliminary adaptations to the intervention that are mindful of women Veterans' individual preferences for care and realistic in the everyday context of their busy lives. [ABSTRACT FROM PUBLISHER]

Computer-delivered cognitive behavioural therapy (cCBT) is an effective alternative to provider-delivered treatment for depression and anxiety, but high attrition poses a significant challenge to its use. Peer support is a feasible approach to improving cCBT engagement, but less is known about its acceptability among Veterans. Aims: To obtain feedback from Veterans (n = 24) with depression and/or anxiety on their preferences for (a) activities of Veterans Administration Peer Support Specialists (VA PSS) in helping Veterans useMoving Forward, a cCBT-based protocol developed by VA, and (b) methods for delivering support to Veterans using this programme. Method: Four focus groups (5-7 Veterans per group) provided feedback to be used in the development of a peer-supported engagement intervention to help Veterans with depression and anxiety use Moving Forward. Content areas included roles that a VA PSS might play in supporting the use of and engagement in Moving Forward, as well as methods of delivering that support. Results: Veteran preferences for PSS activity focused on practical aspects of using Moving Forward, including orientation to the programme, technical support, and monitoring progress. Feedback also suggested that Veterans preferred more personal roles for the PSS, including emotional support, as well as application of Moving Forward to 'real life' problems. Conclusions: The findings extend the literature on online, patient-facing mental health protocols by identifying emotional support and 'real life' skills application as Veteran-preferred components of a peer-support protocol designed to enhance use of and engagement in cCBT for depression and anxiety. [ABSTRACT FROM AUTHOR]

AimTo better understand barriers and facilitators that hinder or help women veterans discuss their alcohol use with providers in primary care in order to better identify problematic drinking and enhance provider–patient communication about harmful drinking.BackgroundWomen presenting to primary care may be less likely than men to disclose potentially harmful alcohol use. No studies have qualitatively examined the perspectives of primary care providers about factors that affect accurate disclosure of alcohol use by women veterans during routine clinic visits.MethodsProviders (n=14) were recruited from primary care at two veterans Administration Women’s Health Clinics in California, United States. An open-ended interview guide was developed from domains of the consolidated framework for implementation science. Interviews elicited primary care providers’ perspectives on barriers and facilitators to women veterans’ (who may or may not be using alcohol in harmful ways) disclosure of alcohol use during routine clinic visits. Interview data were analyzed deductively using a combination of template analysis and matrix analysis.FindingsParticipants reported six barriers and five facilitators that they perceived affect women veteran’s decision to accurately disclose alcohol use during screenings and openness to discussing harmful drinking with a primary care provider. The most commonly described barriers to disclosure were stigma, shame, and discomfort, and co-occuring mental health concerns, while building strong therapeutic relationships and using probes to ‘dig deeper’ were most often described as facilitators. Findings from this study may enhance provider–patient discussions about alcohol use and help primary care providers to better identify problematic drinking among women veterans, ultimately improving patient outcomes. [ABSTRACT FROM PUBLISHER]

Aims and objectives This systematic review describes studies evaluating screening tools and brief interventions for addressing unhealthy substance use in primary care patients with hypertension, diabetes or depression. Background Primary care is the main entry point to the health care system for most patients with comorbid unhealthy substance use and chronic medical conditions. Although of great public health importance, systematic reviews of screening tools and brief interventions for unhealthy substance use in this population that are also feasible for use in primary care have not been conducted. Design Systematic review. Methods We systematically review the research literature on evidence-based tools for screening for unhealthy substance use in primary care patients with depression, diabetes and hypertension, and utilising brief interventions with this population. Results Despite recommendations to screen for and intervene with unhealthy substance use in primary care patients with chronic medical conditions, the review found little indication of routine use of these practices. Limited evidence suggested the Alcohol Use Disorders Identification Test and Alcohol Use Disorders Identification Test-C screeners had adequate psychometric characteristics in patients with the selected chronic medical conditions. Screening scores indicating more severe alcohol use were associated with health-risk behaviours and poorer health outcomes, adding to the potential usefulness of screening for unhealthy alcohol use in this population. Conclusions Studies support brief interventions' effectiveness with patients treated for hypertension or depression who hazardously use alcohol or cannabis, for both substance use and chronic medical condition outcomes. Relevance to clinical practice Although small, the international evidence base suggests that screening with the Alcohol Use Disorders Identification Test or Alcohol Use Disorders Identification Test-C and brief interventions for primary care patients with chronic medical conditions, delivered by nurses or other providers, are effective for identifying unhealthy substance use and associated with healthy behaviours and improved outcomes. Lacking are studies screening for illicit drug use, and using single-item screening tools, which could be especially helpful for frontline primary care providers including nurses. [ABSTRACT FROM AUTHOR]

The article reports on a study which identify factors associated with women Veterans' receptivity to recommendation for alcohol related care when they present to Veterans Affairs (VA) primary care with alcohol misuse. It states that qualitative analyses identified several themes associated with women's receptivity which included self-appraisal of drinking behavior as severe, the provider's presentation of treatment options and availability of gender-specific services.

Background: Because substance use disorder (SUD) treatment is expanding, and detoxification (detox) is often the entry point to SUD treatment, it is critical to provide ready access to detox services. Objectives: The purpose of the current study was to examine patient, program, and system barriers or facilitators to detox access within an integrated health care system with variable rates of detox utilization across facilities. Methods: Inpatient and outpatient providers from 31 different U.S. Veterans Health Administration detox programs were interviewed. Results: Qualitative analyses identified six facilitators and 11 barriers to detox access. Facilitators included program staff and program characteristics such as encouragement and immediate access, as well as systemic cooperation and patient circumstances. Barriers to detox included programmatic and systemic problems, including lack of available detox services, program rules or admission requirements, funding shortages, stigma related to a SUD diagnosis or receiving detox services, and a deficiency of education and training. Other major barriers pertained to patients' lack of motivation and competing responsibilities. Conclusions/Importance: To improve detox access, health care settings should consider enhancing supportive relationships by emphasizing outreach, engagement, and rapport-building with patients, improving systemic communication and teamwork, educating patients on available detox services and the detox process, and addressing patient centered barriers such as resistance to detox or competing responsibilities. In addition, programs should consider open-door and immediate-admission policies. These approaches may improve detox access, which is important for increasing the likelihood of transitioning patients to SUD treatment, thus improving outcomes and reducing utilization of high-cost services. [ABSTRACT FROM AUTHOR]

Background: Religiosity and perceived social support (SS) may serve as protective factors for more severe substance use in adults.Objectives: This study sought to examine whether aspects of religiosity and SS are associated with longitudinal reductions in stimulant use over three years in an untreated sample of rural drug users.Methods: Respondent-driven sampling was used to recruit stimulant users (N= 710) from Arkansas, Kentucky, and Ohio. Follow-up interviews were conducted at 6-month intervals for 36 months.Results: Our bivariate findings indicate that higher religiosity was associated with lower odds and fewer days of methamphetamine and cocaine use. After controlling for covariates, higher religiosity was associated with fewer days of crack cocaine use, but more days of methamphetamine use among a small sample of users in the two final interviews. Higher SS from drug-users was also associated with higher odds and days of methamphetamine and powder cocaine use, while higher SS from nondrug users was associated with fewer days of methamphetamine use.Conclusions/Importance: Our bivariate findings suggest that higher levels of religiosity may be helpful for some rural individuals in reducing their drug use over time. However, our multivariate findings suggest a need for further exploration of the potential effects of religiosity on longer-term drug use, especially among those who continue to use methamphetamine and/or remain untreated. Our findings also highlight the potential deleterious effect of SS from drug users on the likelihood and frequency of methamphetamine and powder cocaine use over time among untreated rural drug users. [ABSTRACT FROM PUBLISHER]

Background: Broadly disseminating and implementing evidence-based psychotherapies with high fidelity, particularly cognitive behavioral therapy (CBT), has proved challenging for many health-care systems, including the Department of Veterans Affairs, especially in primary care settings such as small or remote clinics. A computer-based tool (based on the coordinated anxiety learning and management (CALM) program) was designed to support primary care-based mental health providers in delivering CBT. The objectives of this study are to modify the CALM tool to meet the needs of mental health clinicians in veterans affairs (VA) community-based outpatient clinics (CBOCs) and rural "veterans", use external facilitation to implement CBT and determine the effect of the CALM tool versus a manualized version of CALM to improve fidelity to the CBT treatment model, and conduct a needs assessment to understand how best to support future implementation of the CALM tool in routine care.Methods/design: Focus groups will inform the redesign of the CALM tool. Mental health providers at regional VA CBOCs; CBT experts; VA experts in implementation of evidence-based mental health practices; and veterans with generalized anxiety disorder, panic disorder, social anxiety disorder, posttraumatic stress disorder, "with or without" depression will be recruited. A hybrid type III design will be used to examine the effect of receiving CBT training plus either the CALM tool or a manual version of CALM on treatment fidelity. External facilitation will be used as the overarching strategy to implement both CBT delivery methods. Data will also be collected on symptoms of the targeted disorders. To help prepare for the future implementation of the CALM tool in VA CBOCs, we will perform an implementation need assessment with mental health providers participating in the clinical trial and their CBOC directors.Discussion: This project will help inform strategies for delivering CBT with high fidelity in VA CBOCs to veterans with anxiety disorders and PTSD with or without depression. If successful, results of this study could be used to inform a national rollout of the CALM tool in VA CBOCs including providing recommendations for optimizing the adoption and sustained use of the computerized CALM tool among mental health providers in this setting.Trial Registration: ClinicalTrials.gov, NCT02488551. [ABSTRACT FROM AUTHOR]

This study's purpose was to identify distinct publishing trajectories among 442 participants in three prominent mentored health services research career development programs (Veterans Affairs, National Institutes of Health, and Agency for Healthcare Research & Quality) in the 10 years after award receipt and to examine awardee characteristics associated with different trajectories. Curricula vitae (CVs) of researchers receiving awards between 1991 and 2010 were coded for publications, grants, and awardee characteristics. We found that awardees published at constant or increasing rates despite flat or decreasing rates of first-author publications. Senior-author publications rose concurrently with rates of overall publications. Higher overall publication trajectories were associated with receiving more grants, more citations as measured by the h-index, and more authors per article. Lower trajectory groups were older and had a greater proportion of female awardees. Career development awards supported researchers who generally published successfully, but trajectories varied across individual researchers. Researchers' collaborative efforts produced an increasing number of articles, whereas first author articles were written at a more consistent rate. Career development awards in health services research supported the careers of researchers who published at a high rate; future research should further examine reasons for variation in publishing among early career researchers. [ABSTRACT FROM AUTHOR]

Purpose: To address research gaps regarding women Veterans' alcohol consumption and mortality risk as compared to non-Veterans, the current study evaluated whether alcohol consumption amounts differed between women Veterans and non-Veterans, whether Veterans and non-Veterans within alcohol consumption groups differed on all-cause mortality, and whether Veteran status modified the association between alcohol consumption and all-cause mortality. Design and Methods: Six alcohol consumption groups were created using baseline data from the Women's Health Initiative Program (N = 145,521): lifelong abstainers, former drinkers, less than 1 drink/week (infrequent drinkers), 1-7 drinks/week (moderate drinkers), 8-14 drinks/week (moderately heavy drinkers), and 15 or more drinks/week (heavy drinkers). The proportions of Veteran and non-Veteran women within each alcohol consumption category were compared. Mortality rates within each alcohol consumption category were compared by Veteran status. Cox proportional hazard models, including a multiplicative interaction term for Veteran status, were fit to estimate adjusted mortality hazard (rate) ratios for each alcohol consumption category relative to a reference group of either lifelong abstainers or moderate drinkers. Results: Women Veterans were less likely to be lifelong abstainers than non-Veterans. Women Veterans who were former or moderate drinkers had higher age-adjusted mortality rates than did non-Veterans within these alcohol consumption categories. In the fully adjusted multivariate models, Veteran status did not modify the association between alcohol consumption category and mortality with either lifelong abstainers or moderate drinkers as referents. Implications: The results suggest that healthcare providers may counsel Veteran and non-Veteran women in similar ways regarding safe and less safe levels of alcohol consumption. [ABSTRACT FROM AUTHOR]

The article discusses a study of the retention in medication-assisted treatment among patients suffering from opiate dependence. Topics covered include the medication and behavioral therapy factors associated with retention, the difference in the retention rates of patients who received a placebo and those who were treated with naltrexone or buprenorphine, and the potential of contingency management to improve the retention.

AimThis article presents a conceptual model to help facilitate the transition from primary care to specialty substance use disorder (SUD) care for appropriate patients.BackgroundSubstance misuse is a common health condition among patients presenting to primary care settings and may complicate the treatment of chronic health conditions such as diabetes and hypertension. It is therefore critical that primary care providers be prepared to identify and determine appropriate treatment options for patients presenting with substance misuse.MethodsWe conducted a narrative review that occurred in three stages: literature review of health care transition models, identification of conceptual domains common across care transition models, and identification of SUD-specific model elements.FindingsThe conceptual model presented describes patient, provider, and system-level facilitators and barriers to the transition process, and includes intervention strategies that can be utilized by primary care clinics to potentially improve the process of transitioning patients from primary care to SUD care. Recognizing that primary care clinics vary in available resources, we present three examples of care practices along an intensity continuum from low (counseling and referral) to moderate (telephone monitoring) to high (intensive case management) resource demands for adoption. We also provide a list of common outcomes clinics might consider when evaluating the impact of care transition practices in this patient population; these include process outcomes such as patients’ increased knowledge of available treatment resources, and health outcomes such as patients’ reduced substance use and better quality of life. [ABSTRACT FROM AUTHOR]

Alcohol misuse and post-traumatic stress disorder (PTSD) are highly prevalent among veterans presenting to primary care. PTSD is associated with depression and increased substance use which can complicate the treatment of alcohol misuse. No studies have examined severity of depressive symptoms, rates and type of illicit drug use, and alcohol use severity in veterans with PTSD and alcohol misuse in primary care. Therefore, we examined (a) rates of PTSD and associated mental health comorbidities (depression, suicidal ideation), (b) current and lifetime illicit drug use and (c) alcohol use severity in relation to PTSD status in a sample of veterans presenting to primary care with alcohol misuse. We also tested the hypothesis that greater depressive symptoms, illicit drug use and alcohol use severity would be independently associated with greater likelihood of PTSD, after controlling for age and ethnicity. Veterans (N = 166) were recruited from primary care as part of an intervention study between the years 2010 and 2011. Veterans participating in the study completed an in-person semi-structured interview with study staff. Using the post-traumatic Stress Disorder Checklist-Military version, we found a 16.3% rate of PTSD. PTSD was associated with greater depressive symptoms, rates of suicidal ideation, alcohol use severity, current use of hypnotics and lifetime use of cocaine and amphetamines. Using logistic regression, we found that severity of depressive symptoms and lifetime cocaine use were independently associated with greater likelihood of PTSD, after controlling for age and ethnicity. Treatment implications of these findings are discussed. [ABSTRACT FROM PUBLISHER]

The Veterans Health Administration (VHA) has implemented initiatives to increase rates of brief alcohol counseling (BAC). Half of eligible veterans do not receive such care. Understanding patient characteristics associated with drinking behavior may identify patients for whom BAC may be acceptable. Data collected from veterans between January 2010 and September 2011 ( N = 167) were examined. Results find that alcohol-related concerns and perceptions of peer alcohol consumption are associated with reduced drinking behavior. These findings suggests that assessing drinking concerns and perceptions of peer alcohol use may help to identify patients interested in changing drinking behavior, receiving care, and assist providers in delivering appropriate counseling. [ABSTRACT FROM AUTHOR]

Despite long-standing recommendations that patients with substance use disorders receive primary care, only one-half of patients with substance use disorders receive such care. This article presents a conceptual model to facilitate the transition of patients from addiction treatment to primary care. A narrative review of the healthcare transition literature was conducted with an emphasis on identifying substance use disorder-specific model elements. The resulting model is intended to guide addiction treatment and primary care providers and researchers in understanding factors that impact care coordination between addiction treatment and primary care and to provide an overview of evidence-based methods for supporting this care transition. [ABSTRACT FROM AUTHOR]

Substance abuse treatment utilization and patient characteristics of veterans (N= 167) drinking alcohol at risky levels at a Department of Veterans Affairs hospital were examined. Rates of brief intervention and specialty care were higher than those found in national samples in 2010, but fall short of recommended guidelines. Veterans receiving more care were older, lower-income, and less likely to be in a relationship. Care-receiving veterans had higher rates of mental health comorbidities and mental health treatment in the prior year for an issue other than substance use. Understanding patients’ recent care history may help primary care providers to deliver care effectively. [ABSTRACT FROM AUTHOR]

An increasing percentage of women are U.S. Military Veterans. We review the substance misuse rates and comorbidities and the risk factors for and consequences of substance use among women Veterans. Women Veterans may have higher rates of substance misuse and comorbid psychiatric and medical disorders than male Veterans and women who are not Veterans. Studies support the AUDIT-C as a scaled marker of alcohol-related risk among female Veterans, but validated drug screening instruments are needed. We discuss evidence-based approaches in terms of treating women Veterans’ substance misuse in primary and specialty care settings, along with knowledge gaps and potential research priorities to improve care in this special population. [ABSTRACT FROM PUBLISHER]

Hazardous drinking is a major barrier to antiviral treatment eligibility among hepatitis C (HCV) patients. We evaluated differences in substance-related coping, drinking-related consequences, and importance and confidence in ability to change alcohol use among hazardous drinkers with and without HCV ( N = 554; 93.5% male). We examined group differences between HCV+ patients (n = 43) and their negative HCV counterparts (n = 511). Results indicate a higher percentage of HCV+ patients report using substances to cope with possible symptoms of PTSD ( P < .05) and depression ( P < .01), and endorse more lifetime drinking-related negative consequences than HCV patients ( P < .01). Furthermore, HCV+ patients place greater importance on changing alcohol use ( P < .01) but report less confidence in their ability to change ( P < .01). Use of brief assessment and feedback with skills-based interventions to decrease alcohol use may be well-received by HCV+ patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Veterans Health Administration (VHA) is implementing the patient-centered medical home (PCMH) model of primary care which emphasizes patient-centered care and the promotion of healthy lifestyle changes. Motivational Interviewing (MI) is effective for promoting various health behaviors, thus a training protocol for primary care staff was implemented in a VHA health care setting. OBJECTIVES: We examined the effect of the training protocol on MI knowledge, confidence in ability to use MI-related skills and apply them to written vignettes, perceived comfort level and skill in lifestyle counseling, and job-related burnout. DESIGN: Training was provided by experts in MI. The training protocol consisted of three sessions-one half day in-person workshop followed by a 60-minute virtual training, followed by a second workshop. Each of the sessions were spaced two weeks apart and introduced trainees to the theory, principles, and skills of using MI in health care settings. PARTICIPANTS: All primary care staff at the Veterans Affairs Palo Alto Health Care System were invited to participate. MEASUREMENTS: Trainees completed a short set of questionnaires immediately before and immediately after the training. RESULTS: We found support for our primary hypotheses related to knowledge, confidence, and written responses to the vignettes. Changes in perceived comfort level and skill in lifestyle counseling, and job-related burnout were not observed. CONCLUSIONS: Training primary care staff in MI is likely to become increasingly common as health care systems transition to the PCMH model of care. Therefore, it is important for health care systems to have low-cost methods for evaluating the effectiveness of such trainings. This study is a first step in developing a brief written assessment with the potential of measuring change in a range of behaviors and skills consistent with MI. [ABSTRACT FROM AUTHOR]

A host of interventions are now known to be helpful to alleviate subjective distress and improve well-being in dementia caregivers. However, few intervention studies have focused on measures of physical health, and none have examined cortisol as an outcome-despite the fact that cortisol is regarded as a crucial biological intermediary by which chronic stress leads to disease. In this study, we examined demographic and psychosocial factors as predictors of salivary cortisol at a baseline assessment, among a sample of 175 Latino/Hispanic and Caucasian women caring for a family member with dementia. We also examined the influence of a cognitive-behaviour-based psychoeducational intervention (Coping with Caregiving) on cortisol at a post-treatment assessment, compared with a minimal support condition. Results revealed that caregivers with high intensity caregiving situations, characterized by long hours of care and co-residence with the care recipient, tended to have less adaptive cortisol patterns. However, these 'at-risk' caregivers benefited most from the Coping with Caregiving intervention and had more normal cortisol patterns at post-treatment, compared with caregivers in the control condition. Copyright © 2011 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

High voluntary turnover of substance abuse counsellors is a recognised and pervasive problem, likely due in large part to job-related burnout experienced by providers. This article explores the influence of the type of training on three facets of burnout (emotional exhaustion, depersonalisation and a reduced perception of personal accomplishments) among substance abuse counsellors participating in an online training protocol consisting of cognitive-behavioural therapy for substance use. Two training types were used: high fidelity (i.e. structured, didactic ''classroom''-style training), and low fidelity (i.e. more flexible and customisable training). Participation in a more flexible training model predicted lower burnout scores for participants both immediately and 6 months after training. Participants with a history of personal recovery from substance abuse and those working in positions of leadership also reported lower burnout scores after training. We conclude that perception of support and flexibility in the workplace may be helpful to prevent burnout and decrease existing burnout. [ABSTRACT FROM AUTHOR]

Objectives: The present study examined the relationship between self-reported physical health, depressive symptoms, and the occurrence of depression diagnosis in Hispanic female dementia caregivers. Participants: Participants were 89 Hispanic female dementia caregivers. Design: This study used a cross-sectional design. Baseline depression and physical health data were collected from participants enrolled in the 'Reducing Stress in Hispanic Anglo Dementia Caregivers' study sponsored by the National Institute on Aging. Measurements: Physical health was assessed using the Medical Outcome Study Short Form-36 (SF-36), a one-item self-report health rating, body mass index, and the presence or history of self-reported physical illness. Depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression Scale (CES-D). The occurrence of depression diagnosis was assessed using the Clinical Interview for DSM-IV Axis I Disorders (SCID). Analysis: Multiple linear and logistic regression analysis was used to examine the extent to which indices of physical health and depressive symptoms accounted for variance in participants' depressive symptoms and depressive diagnoses. Results. Self-reported indices of health (e.g., SF-36) accounted for a significant portion of variance in both CES-D scores and SCID diagnoses. Caregivers who reported worsened health tended to report increased symptoms of depression on the CES-D and increased likelihood of an SCID diagnosis of a depressive disorder. Conclusion. Self-reported health indices are helpful in identifying Hispanic dementia caregivers at risk for clinical levels of depression. [ABSTRACT FROM AUTHOR]

Historically, clinicians have learned about evidence-based psychotherapies (EBPs) by reading therapy manuals and/or attending clinical training workshops. However, researchers agree that such methods alone are insufficient to support the implementation of EBPs. This article explores the concept of blended learning (BL) and its potential for facilitating the implementation of EBPs. Blended learning refers to integration of multiple methods of information delivery into a single learning system. Implementation of EBPs describes a specific set of activities that are designed to promote the uptake and sustained adoption of a psychotherapeutic approach, strategy, or technique that has demonstrable empirical support. This article reviews the most common methods by which EBPs are currently disseminated and implemented, defines the concept of BL, and presents some examples of different elements that can be combined into a BL system. Three models of BL are presented and illustrations of these BL formulations are provided using examples from the extant literature. This article concludes with a summary and recommendations for future research. [ABSTRACT FROM AUTHOR]

Three experiments investigated the role of ‘change blindness’ in mistaken eyewitness identifications of innocent bystanders to a simulated crime. Two innocent people appeared briefly in a filmed scene in a supermarket. The ‘continuous innocent’ (CI) walked down the liquor aisle and passed behind a stack of boxes, whereupon the perpetrator emerged and stole a bottle of liquor, thereby resulting in an action sequence promoting the illusion of continuity between perpetrator and innocent. The ‘discontinuous innocent’ (DI) was shown immediately afterward in the produce aisle. Results revealed that: (1) more than half of participants failed to notice the change between the CI and the perpetrator, (2) among those who failed to notice the change, more misidentified the ‘CI’ than the ‘DI’, a pattern that did not hold for those who did notice the change. Participants were less likely to notice the change when they were distracted while watching the video. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Information technology (IT) is increasingly being used to facilitate, complement, and support the implementation of evidence-based practices (EBP) in psychology. This article reviews recent randomised trials that evaluate the integration of IT applications into the process of delivering EBP. More specifically, we review 11 studies that illustrate how IT has been successfully integrated into traditional clinician-delivered psychotherapy to promote the adoption of EBP. Advantages and disadvantages of this approach are discussed. The paper concludes with practical recommendations for clinicians who are interested in integrating IT into their practice. [ABSTRACT FROM AUTHOR]

Purpose – Risk-adjustment is designed to predict healthcare costs to align capitated payments with an individual's expected healthcare costs. This can have the consequence of reducing overpayments and incentives to under treat or reject high cost individuals. This paper seeks to review recent studies presenting risk-adjustment models. Design/methodology/approach – This paper presents a brief discussion of two commonly reported statistics used for evaluating the accuracy of risk adjustment models and concludes with recommendations for increasing the predictive accuracy and usefulness of risk-adjustment models in the context of predicting future healthcare costs. Findings – Over the last decade, many advances in risk-adjustment methodology have been made. There has been a focus on the part of researchers to transition away from including only demographic data in their risk-adjustment models to incorporating patient data that are more predictive of healthcare costs. This transition has resulted in more accurate risk-adjustment models and models that can better identify high cost patients with chronic medical conditions. Originality/value – The paper shows that the transition has resulted in more accurate risk-adjustment models and models that can better identify high cost patients with chronic medical conditions. [ABSTRACT FROM AUTHOR]

The role of psychologists in medical settings is evolving to include the development, delivery, and evaluation of psychosocial treatments for individuals who use disproportionate amounts of medical services. The primary purpose of this article is to present a model of psychological factors that drive health care utilization. A stepped care model of treatment delivery is also discussed along with a brief literature review depicting the impact of treatment approaches on high utilizing populations. This article concludes with recommendations for psychologists interested in providing treatment to medical utilizers. [ABSTRACT FROM AUTHOR]