Publications by authors named "Daniel Alford"

72 Publications

Doctors of chiropractic working with or within integrated healthcare delivery systems: a scoping review protocol.

BMJ Open 2021 01 25;11(1):e043754. Epub 2021 Jan 25.

Département Chiropratique, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada.

Introduction: Back and neck pain are the leading causes of disability worldwide. Doctors of chiropractic (DCs) are trained to manage these common conditions and can provide non-pharmacological treatment aligned with international clinical practice guidelines. Although DCs practice in over 90 countries, chiropractic care is rarely available within integrated healthcare delivery systems. A lack of DCs in private practice, particularly in low-income communities, may also limit access to chiropractic care. Improving collaboration between medical providers and community-based DCs, or embedding DCs in medical settings such as hospitals or community health centres, will improve access to evidence-based care for musculoskeletal conditions.

Methods And Analyses: This scoping review will map studies of DCs working with or within integrated healthcare delivery systems. We will use the recommended six-step approach for scoping reviews. We will search three electronic data bases including Medline, Embase and Web of Science. Two investigators will independently review all titles and abstracts to identify relevant records, screen the full-text articles of potentially admissible records, and systematically extract data from selected articles. We will include studies published in English from 1998 to 2020 describing medical settings that have established formal relationships with community-based DCs (eg, shared medical record) or where DCs practice in medical settings. Data extraction and reporting will be guided by the Proctor Conceptual Model for Implementation Research, which has three domains: clinical intervention, implementation strategies and outcome measurement. Stakeholders from diverse clinical fields will offer feedback on the implications of our findings via a web-based survey.

Ethics And Dissemination: Ethics approval will not be obtained for this review of published and publicly accessible data, but will be obtained for the web-based survey. Our results will be disseminated through conference presentations and a peer-reviewed publication. Our findings will inform implementation strategies that support the adoption of chiropractic care within integrated healthcare delivery systems.
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http://dx.doi.org/10.1136/bmjopen-2020-043754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7839851PMC
January 2021

A National Survey on Patient Provider Agreements When Prescribing Opioids for Chronic Pain.

J Gen Intern Med 2021 Mar 8;36(3):600-605. Epub 2021 Jan 8.

Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.

Background: Many national guidelines recommend the use of patient provider agreements (PPAs) when prescribing opioids for chronic pain. There are no standards for PPA content, readability, or administration processes.

Objective: Conduct a national survey of providers who use PPAs to describe the process of administering them, assess views on their utility, and obtain PPAs to evaluate thematic content and readability.

Design: Cross-sectional electronic survey and request for PPAs.

Participants: Registrants for the Safer/Competent Opioid Prescribing Education (SCOPE of Pain) Program between March 2013 and June 2017.

Main Measures: Respondents' reports on how PPAs are administered and views on their usefulness. A sample of PPAs assessed for themes and readability.

Key Results: Using a convenience sample of 62,530 SCOPE of Pain registrants, we obtained a cohort of 430 individuals from 43 states who use PPAs. The majority of respondents worked in primary care (64%) and pain (18%) specialties. Reviewing PPAs with patients was primarily done by prescribers (80%), and the average perceived time to administer PPAs was 13 min. Although 66% of respondents thought PPAs were "often" or "always" worth the effort, only 28% considered them "often" or "always" effective in reducing opioid misuse. The PPA reading burden surpassed recommended patient education standards, with only 2.5% at or below fifth-grade reading level. PPAs focused more on rules and consequences of patients' non-compliance than on a shared treatment plan.

Conclusions: Most respondents perceive patient provider agreements (PPAs) as time-consuming and minimally effective in reducing opioid misuse yet still view them as valuable. PPAs are written far above recommended reading levels and serve primarily to convey consequences of non-compliance. Because PPAs are recommended by national safer opioid prescribing guidelines as a risk mitigation strategy, it would be beneficial to develop a standard PPA and study its effectiveness.
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http://dx.doi.org/10.1007/s11606-020-06364-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7947101PMC
March 2021

The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based practices in the HEALing Communities Study.

Drug Alcohol Depend 2020 12 4;217:108325. Epub 2020 Oct 4.

National Institute on Drug Abuse, National Institutes of Health, 6001 Executive Boulevard, Rockville, MD 20892, USA.

Background: The number of opioid-involved overdose deaths in the United States remains a national crisis. The HEALing Communities Study (HCS) will test whether Communities That HEAL (CTH), a community-engaged intervention, can decrease opioid-involved deaths in intervention communities (n = 33), relative to wait-list communities (n = 34), from four states. The CTH intervention seeks to facilitate widespread implementation of three evidence-based practices (EBPs) with the potential to reduce opioid-involved overdose fatalities: overdose education and naloxone distribution (OEND), effective delivery of medication for opioid use disorder (MOUD), and safer opioid analgesic prescribing. A key challenge was delineating an EBP implementation approach useful for all HCS communities.

Methods: A workgroup composed of EBP experts from HCS research sites used literature reviews and expert consensus to: 1) compile strategies and associated resources for implementing EBPs primarily targeting individuals 18 and older; and 2) determine allowable community flexibility in EBP implementation. The workgroup developed the Opioid-overdose Reduction Continuum of Care Approach (ORCCA) to organize EBP strategies and resources to facilitate EBP implementation.

Conclusions: The ORCCA includes required and recommended EBP strategies, priority populations, and community settings. Each EBP has a "menu" of strategies from which communities can select and implement with a minimum of five strategies required: one for OEND, three for MOUD, and one for prescription opioid safety. Identification and engagement of high-risk populations in OEND and MOUD is an ORCCArequirement. To ensure CTH has community-wide impact, implementation of at least one EBP strategy is required in healthcare, behavioral health, and criminal justice settings, with communities identifying particular organizations to engage in HCS-facilitated EBP implementation.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108325DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533113PMC
December 2020

Faculty education in addiction training (FEAT): Evaluating an online training program for multidisciplinary health professions educators.

Subst Abus 2020 ;41(3):292-296

School of Medicine and Boston Medical Center, Boston University, Boston, Massachusettes, USA.

Many health professionals lack adequate training needed to effectively address alcohol and other drug (AOD)-related problems. Building upon our previously successful in-person faculty training programs, we designed and pilot tested the brief online Faculty Education in Addiction Training (FEAT) Program for social work and internal medicine residency faculty. The present study examines baseline and post-FEAT Program AOD knowledge and teaching confidence and preparedness among faculty participants. The FEAT Program curriculum included didactic videos, online engagement with content experts, recommended readings, and a live virtual classroom experience. Participants completed self-assessments of knowledge and teaching confidence and preparedness pre- and post-FEAT program. In this pilot test, thirty faculty completed the FEAT program: 15 social work and 15 internal medical residency program faculty. Both groups showed significant improvement ( < 0.001) in overall AOD-related knowledge with medium-to-large effects (Cohen's  = 1.83 [social work], 0.72 [medicine]). Both groups showed significant increases in teaching confidence ( < 0.001) for all items with large effects (Cohen's values range from 1.08 to 1.92) and significant increases and large effects for all teaching preparedness items for social work (at least  < 0.01 | Cohen's range = 1.03-1.56) and internal medical residency faculty ( < 0.001 | Cohen's range = 1.08-1.69). Multidisciplinary health professions educators' AOD knowledge and teaching confidence and preparedness can be improved by participation in a brief online program designed to circumvent the logistical and fiscal challenges presented by in-person programs.
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http://dx.doi.org/10.1080/08897077.2020.1783739DOI Listing
January 2020

Screening and brief intervention for lower-risk drug use in primary care: A pilot randomized trial.

Drug Alcohol Depend 2020 Apr 25;213:108001. Epub 2020 Apr 25.

Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA, and Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, and the Grayken Center for Addiction, Boston Medical Center and Boston University School of Medicine, Boston, MA 02118, USA. Electronic address:

Aims: The efficacy of screening and brief intervention for lower-risk drug use is unknown. This pilot study tested the efficacy of two brief interventions (BIs) for drug use compared to no BI in primary care patients with lower-risk drug use identified by screening.

Methods: We randomly assigned participants identified by screening with Alcohol Smoking and Substance Involvement Screening Test (ASSIST) drug specific scores of 2 or 3 to: no BI, a brief negotiated interview (BNI), or an adaptation of motivational interviewing (MOTIV). Primary outcome was number of days use of main drug in the past 30 as determined by validated calendar method at 6 months. Analyses were performed using negative binomial regression adjusted for baseline use and main drug.

Results: Of 142 eligible adults, 61(43 %) consented and were randomized. Participant characteristics were: mean age 41; 54 % male; 77 % black. Main drug was cannabis 70 %, cocaine 15 %, prescription opioid 10 %; 7% reported injection drug use and mean days use of main drug (of 30) was 3.4. At 6 months, 93 % completed follow-up and adjusted mean days use of main drug were 6.4 (no BI) vs 2.1 (BNI) (incidence rate ratio, IRR 0.33[0.15-0.74]) and 2.3 (MOTIV) (IRR 0.36[0.15-0.85]).

Conclusions: BI appears to have efficacy for preventing an increase in drug use in primary care patients with lower-risk use identified by screening. These findings raise the potential that less severe patterns of drug use in primary care may be uniquely amenable to brief intervention and warrant replication.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108001DOI Listing
April 2020

Medicine, with a focus on physicians: Addressing substance use in the 21st century.

Subst Abus 2019 27;40(4):396-404. Epub 2019 Nov 27.

Boston University School of Medicine, Boston Medical Center, Boston, Masachussetts, USA.

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http://dx.doi.org/10.1080/08897077.2019.1691130DOI Listing
August 2020

Opioid discontinuation as an institutional mandate: Questions and answers on why we wrote to the Centers for Disease Control and Prevention.

Subst Abus 2019 30;40(4):466-468. Epub 2019 Jul 30.

Clinical Addiction Research and Education (CARE) Unit, Boston University School of Medicine & Boston Medical Center, Boston, Massachusetts, USA.

On March 6, 2019, a self-designated committee sent a public letter to the Centers for Disease Control and Prevention (CDC) urging the agency to address the widespread misapplication of its 2016 guideline on prescribing opioids. Three hundred and eighteen health care professionals, and three former Directors of the White House Office of National Drug Control Policy (Drug Czars) signed the letter, as did the parent organization for Substance Abuse Journal, the Association for Multidisciplinary Education and Research on Substance use and Addiction. The letter reflected concern about a wide range of initiatives and policies by payers, quality metric agencies, health care organizations, and other regulators enforced to strongly incentivize or mandate forced opioid dose reductions on long-term opioid recipients who were otherwise stable. In April of 2019, both the United States Food and Drug Administration and the CDC's Director issued statements that could help to reduce ongoing harms resulting from such forced reductions, provided they are taken seriously. This commentary explains the rationale for the original letter, and the optimum course of action now that the CDC has responded.
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http://dx.doi.org/10.1080/08897077.2019.1635973DOI Listing
August 2020

Opioid discontinuation as an institutional mandate: Questions and answers on why we wrote to the Centers for Disease Control and Prevention.

Subst Abus 2019 17;40(1):4-6. Epub 2019 May 17.

e Clinical Addiction Research and Education (CARE) Unit , Boston University School of Medicine and Boston Medical Center , Boston , Massachusetts , USA.

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http://dx.doi.org/10.1080/08897077.2019.1613830DOI Listing
April 2020

NEJM Knowledge+ Pain Management and Opioids - A New Adaptive Learning Module.

N Engl J Med 2019 04 10;380(16):1576-1577. Epub 2019 Apr 10.

From Brigham and Women's Hospital (O.-P.R.H.), Harvard Medical School (O.-P.R.H.), Boston University School of Medicine (D.P.A., I.T.H.), and Boston Medical Center (D.P.A.), Boston, and NEJM Group, Waltham (O.-P.R.H., C.T.R.) - all in Massachusetts.

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http://dx.doi.org/10.1056/NEJMe1903798DOI Listing
April 2019

National Trends in Prescription Opioid Risk Mitigation Practices: Implications for Prescriber Education.

Pain Med 2019 05;20(5):907-915

The Barry M. Manuel Continuing Medical Education Office, Boston University School of Medicine, Boston, Massachusetts, USA.

Objectives: To assess national trends in selected prescription opioid risk mitigation practices and associations with prescriber type, state-specific opioid overdose severity, and required pain education.

Methods: Analysis of the national SCOPE of Pain registrants' baseline self-report of five safer opioid prescribing practices over three years (March 2013-Februrary 2016).

Results: Of 6,889 registrants for SCOPE of Pain, 70-94% reported performing each of five opioid risk mitigation practices for "most or all" patients, with 49% doing so for all five practices. Only 28% performed all five practices for "all" patients prescribed opioids. There were few differences among three yearly cohorts. Advanced practice nurses reported performing practices for "all" patients more often than physicians or physician assistants. Clinicians from states with high opioid overdose rates reported significantly higher implementation of most practices, compared with clinicians from states with low rates.

Conclusions: Prescribers report low levels of employing five opioid risk mitigation practices for all patients prescribed opioids before attending a safer opioid prescribing training.

Policy Implications: Safer opioid prescribing education should transition from knowledge acquisition toward universal implementation of opioid risk mitigation practices.
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http://dx.doi.org/10.1093/pm/pny298DOI Listing
May 2019

Challenges with Implementing the Centers for Disease Control and Prevention Opioid Guideline: A Consensus Panel Report.

Pain Med 2019 04;20(4):724-735

University of Washington School of Medicine, Seattle, Washington, USA.

Background: A national crisis of opioid-related morbidity, mortality, and misuse has led to initiatives to address the appropriate role of opioids to treat pain. Deployment of a guideline from the Centers for Disease Control and Prevention to reduce the risks of opioid therapy has raised substantial clinical and public policy challenges. The agency anticipated implementation challenges and committed to reevaluating the guideline for intended and unintended effects on clinician and patient outcomes.

Observations: A multidisciplinary expert panel met to review the influence of the core recommendations of the guideline on pain management practices, principally regarding the estimated 5 to 8 million Americans with chronic pain currently on opioids. The panel identified implementation challenges, including application of dosage ceilings and prescription duration guidance, failure to appreciate the importance of patient involvement in decisions to taper or discontinue opioids, barriers to diagnosis and treatment of opioid use disorder, and impeded access to recommended comprehensive, multimodal pain care. Furthermore, policy-making and regulatory bodies may misapply guideline recommendations without flexibility and, sometimes, without full awareness of what the guideline contains.

Conclusions And Relevance: The panel largely supported the guideline, endorsing its focal points of safety and comprehensive assessment and monitoring. To mitigate clinical and policy challenges identified with implementing the guideline, the panel discussed areas where viewpoints diverged and arrived at consensus proposals. The target audience includes the leaders and institutions that create policy and influence guideline implementation to include regulatory agencies, legislators, public and private payers, and health care systems.
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http://dx.doi.org/10.1093/pm/pny307DOI Listing
April 2019

Utilizing a Faculty Development Program to Promote Safer Opioid Prescribing for Chronic Pain in Internal Medicine Resident Practices.

Pain Med 2019 04;20(4):707-716

Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts.

Objective: To implement a skills-based faculty development program (FDP) to improve Internal Medicine faculty's clinical skills and resident teaching about safe opioid prescribing.

Design: An FDP for Internal Medicine attendings that included a one-hour didactic presentation followed immediately by an Objective Structured Clinical Examination (OSCE) that focused on assessing and managing opioid misuse risk, opioid treatment outcomes (benefits and harms), and aberrant opioid use behaviors. The evaluation compared pre- and three-months-post-FDP changes in faculty's safe opioid prescribing knowledge, attitudes, confidence (clinical and teaching), and self-reported resident teaching.

Results: The 25 Internal Medicine faculty participants had a mean of 13 years in clinical practice, including 10 years precepting residents. During the three months post-FDP, faculty treated a mean of 22 patients with chronic pain on long-term opioids and precepted a mean of seven residents caring for patients on long-term opioids. At three months post-FDP, there were significant improvements in correct responses to knowledge questions (68% to 79% P = 0.008), "high-level" confidence in safer opioid prescribing clinical practice (43.5% to 82.6% P = 0.007) and resident teaching (45.8% to 83.3%, P = 0.007), and improvements in alignment of desired attitudes toward safer opioid prescribing. There were nonsignificant increases in self-reported safe opioid prescribing resident teaching.

Conclusions: A skills-based faculty development program that includes a lecture followed by an OSCE can improve Internal Medicine faculty safe opioid prescribing knowledge, attitudes, and clinical and teaching confidence. Improving resident teaching may require additional training in safe opioid prescribing teaching skills.
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http://dx.doi.org/10.1093/pm/pny292DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6442747PMC
April 2019

Prescription Medication Misuse.

Semin Neurol 2018 12 6;38(6):654-664. Epub 2018 Dec 6.

Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA.

In the United States, there is a prescription medication misuse crisis including increases in unintentional drug overdose deaths, medications obtained on the illicit market (i.e., diversion), and in the number of individuals seeking treatment for addiction to prescription medications. Neurologists manage patients suffering from conditions (e.g., pain, seizures, spasticity) where the prescriptions of medications with misuse potential are indicated. It is therefore imperative that neurologists understand which medications are liable to misuse and institute strategies to minimize the harm associated with these medications. The authors review the most common medications prescribed by neurologist with misuse potential, and briefly discuss the behaviors that are suggestive of medication misuse and tools for monitoring patients to minimize medication-related harm from misuse.
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http://dx.doi.org/10.1055/s-0038-1673691DOI Listing
December 2018

Opioid and cocaine use among primary care patients on buprenorphine-Self-report and urine drug tests.

Drug Alcohol Depend 2018 11 25;192:245-249. Epub 2018 Sep 25.

Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, United States; Boston University School of Public Health, Boston, MA, United States.

Background: Urine drug tests (UDTs) are recommended to monitor patients treated for opioid use disorder in primary care. The aims are to (1) estimate the frequency of self-report and UDT results of opioid and cocaine use and (2) evaluate the association between treatment time with non-disclosure of opioid or cocaine use and having a positive UDT.

Methods: We conducted a retrospective review of patients enrolled in a primary care-based buprenorphine program between January 2011-April 2013. We describe three clinical visits types: no disclosure of opioid/cocaine use and positive UDT; disclosure of opioid or cocaine use and a negative or positive UDT; and no disclosure of opioid or cocaine use and a negative UDT. We fit generalized estimating equations logistic regression models to evaluate whether treatment time is associated with non-disclosure of opioids or cocaine use and a positive UDT.

Results: Among all UDT results (n = 1755) from 130 patients, 10% were positive for illicit opioids and 4% for cocaine. Among UDTs with illicit opioid or cocaine positive results, in 57% and 76% of these scenarios, the patient did not disclose. The odds of non-disclosure and having a positive UDT was higher in the first 180 days for opioids and 90 days for cocaine.

Conclusion: Among primary care patients treated with buprenorphine, a small but substantial percentage of UDTs were cocaine or opioid positive. As treatment time increased, non-disclosure was less common but persisted even after six months. Among primary care patients treated with buprenorphine, UDTs contribute information to optimize clinical care.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.08.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6291245PMC
November 2018

Promoting addiction medicine teaching through functional mentoring by co-training generalist chief residents with faculty mentors.

Subst Abus 2018 5;39(3):377-383. Epub 2018 Apr 5.

a Clinical Addiction Research and Education Unit, Boston Medical Center , Boston , Massachusetts , USA.

Background: Generalist physicians should play a vital role in identifying and managing individuals with substance use but are inadequately trained to do so.

Methods: This 5-year (2008-2012) controlled educational study assessed whether internal medicine and family medicine chief residents' (CRs) addiction medicine teaching increased by co-training with faculty mentors at a Chief Resident Immersion Training (CRIT) program in addiction medicine. All CRIT CR attendees identified a residency program faculty mentor to support addiction medicine teaching after CRIT through functional mentoring with a focus on developing and implementing an Addiction Medicine Teaching Project ("Teaching Project"). Approximately half of the CRs attended CRIT with their mentor (co-trained) and half without their mentor (solo-trained). Addiction medicine teaching outcomes were compared between groups using 6- and 11-month questionnaires and 4 bimonthly teaching logs. Of co-trained CRs, mentor characteristics that positively influenced addiction medicine teaching outcomes were identified.

Results: One hundred CRs from 74 residency programs attended CRIT from 2008 to 2012; 47 co-trained with their mentors and 53 solo-trained without their mentors. At 6-month follow-up, the co-trained CRs were more likely to meet at least monthly with their mentor (22.7% vs. 9.6%, P < .01) and more likely to identify their mentor as a facilitator for Teaching Project implementation (82.2% vs. 38.5%, P < .01). At 11-month follow-up, a higher percentage of co-trained CRs had completed their Teaching Project (34.0% vs. 15.1%, P < .05). Both CR groups had similarly large increases in other addiction medicine teaching outcomes. Mentors with more experience, including years of teaching, was associated with better CR Teaching Project outcomes.

Conclusions: Co-training generalist chief residents with a faculty mentor appeared to facilitate functional mentoring-driven Teaching Project implementation but did not further increase already high levels of other addiction medicine teaching. Faculty mentors with more years of teaching experience were more effective in facilitating Teaching Project implementation.
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http://dx.doi.org/10.1080/08897077.2018.1439799DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6128783PMC
April 2019

Advancing Alcohol and Other Drug Education among Social Work Faculty: An Evaluation of Social Work Faculty Immersion Training.

J Soc Work Pract Addict 2018 20;18(1):49-70. Epub 2018 Feb 20.

School of Medicine, Boston University, Boston, MA, United States.

This study is an educational evaluation of participants (N = 50) in a four-day immersion training program funded by the National Institute of Alcohol Abuse and Alcoholism. Using a pretest-posttest design, clinical social work faculty participants showed statistically significant (p < .001) improvement in overall alcohol and other drug-related knowledge (Baseline: Mean[SD] = 8.75 [2.44]; Post-Intervention: Mean[SD] = 13.88[1.96], Cohen's d = -2.16) in the domains of screening/assessment, brief intervention, medication-assisted treatment, and recovery and relapse prevention. Corresponding increases were also observed for faculty confidence in teaching clinical skills related to alcohol and other drug screening, assessment, and treatment.
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http://dx.doi.org/10.1080/1533256X.2017.1412977DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714988PMC
February 2018

The Alcohol and Other Drugs Education Program for Social Work Faculty: A Model for Immersion Training.

J Soc Work Pract Addict 2018 20;18(1):8-29. Epub 2018 Feb 20.

Professor, School of Medicine, Boston University, Boston, MA, United States.

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http://dx.doi.org/10.1080/1533256X.2017.1412980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715135PMC
February 2018

Rational Urine Drug Monitoring in Patients Receiving Opioids for Chronic Pain: Consensus Recommendations.

Pain Med 2018 01;19(1):97-117

Scientific Affairs, PRA International, Salt Lake City, Utah, USA.

Objective: To develop consensus recommendations on urine drug monitoring (UDM) in patients with chronic pain who are prescribed opioids.

Methods: An interdisciplinary group of clinicians with expertise in pain, substance use disorders, and primary care conducted virtual meetings to review relevant literature and existing guidelines and share their clinical experience in UDM before reaching consensus recommendations.

Results: Definitive (e.g., chromatography-based) testing is recommended as most clinically appropriate for UDM because of its accuracy; however, institutional or payer policies may require initial use of presumptive testing (i.e., immunoassay). The rational choice of substances to analyze for UDM involves considerations that are specific to each patient and related to illicit drug availability. Appropriate opioid risk stratification is based on patient history (especially psychiatric conditions or history of opioid or substance use disorder), prescription drug monitoring program data, results from validated risk assessment tools, and previous UDM. Urine drug monitoring is suggested to be performed at baseline for most patients prescribed opioids for chronic pain and at least annually for those at low risk, two or more times per year for those at moderate risk, and three or more times per year for those at high risk. Additional UDM should be performed as needed on the basis of clinical judgment.

Conclusions: Although evidence on the efficacy of UDM in preventing opioid use disorder, overdose, and diversion is limited, UDM is recommended by the panel as part of ongoing comprehensive risk monitoring in patients prescribed opioids for chronic pain.
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http://dx.doi.org/10.1093/pm/pnx285DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6516588PMC
January 2018

Comparison of Post-Cesarean Section Opioid Analgesic Requirements in Women With Opioid Use Disorder Treated With Methadone or Buprenorphine.

J Addict Med 2017 Sep/Oct;11(5):397-401

Boston Medical Center, Boston, MA (ALV, SMB, EMW, KS, DPA); Boston University School of Medicine, Boston, MA (SMB, FR-M, EMW, KS, DPA); Boston University School of Public Health, Boston, MA (KAH); and QuintilesIMS, Cambridge, MA (KAH).

Objective: Buprenorphine is a highly effective treatment for opioid use disorders, but its continuation in the perioperative setting remains controversial, unlike the accepted practice of perioperative methadone continuation.

Methods: We conducted a retrospective cohort study from 2006 to 2014 comparing post-cesarean section opioid analgesic requirements of women with opioid use disorders treated with methadone or buprenorphine. Preoperative, intraoperative, and postoperative opioid requirements (morphine equivalent dose [MED]), postoperative complications, and length of stay were compared between the methadone and buprenorphine groups.

Results: During the 9-year study period, there were 185 women treated with methadone (mean dose 93.7 mg, SD 2.6) and 88 women treated with buprenorphine (mean dose 16.1 mg, SD 7.8). There were no statistically significant differences in MED requirements in the methadone versus buprenorphine groups: preoperative MED (11.4 mg [SD 31.5] vs 20.0 mg [SD 15.1]; mean difference [MD] 8.6, 95% confidence interval [CI] -1.9, 19.1), intraoperative MED (3.5 mg [SD 6.6] vs 5.2 mg [SD 13.7]; MD 1.8, 95% CI -1.1, 4.6), and postoperative MED during hospitalization (97.7 mg [SD 65.6] vs 85.1 mg [SD 73.0]; MD -12.6, 95% CI -31.1, 5.8). There were no statistically significant differences in postoperative complications or length of stay.

Conclusions: Our study suggests that buprenorphine treatment will not interfere more than methadone with pain management after a cesarean section with no significant differences in opioid analgesic requirements, postoperative complications, or length of hospital stay. Future studies should investigate the generalizability to other surgeries.
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http://dx.doi.org/10.1097/ADM.0000000000000339DOI Listing
May 2018

Improving Adherence to Long-term Opioid Therapy Guidelines to Reduce Opioid Misuse in Primary Care: A Cluster-Randomized Clinical Trial.

JAMA Intern Med 2017 09;177(9):1265-1272

Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts.

Importance: Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines.

Objective: To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk.

Design, Setting, And Participants: Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices.

Interventions: Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only.

Main Outcomes And Measures: Primary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language.

Results: Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6-10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4-32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8-5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7-1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3-2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001).

Conclusions And Relevance: A multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills.

Trial Registration: clinicaltrials.gov Identifier: NCT01909076.
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http://dx.doi.org/10.1001/jamainternmed.2017.2468DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5710574PMC
September 2017

Safe and competent opioid prescribing education: Increasing dissemination with a train-the-trainer program.

Subst Abus 2017 Apr-Jun;38(2):168-176

a The Barry M. Manuel Office of Continuing Medical Education , Boston University School of Medicine , Boston , Massachusetts , USA.

Background: Due to the high prevalence of prescription opioid misuse, the US Food and Drug Administration (FDA) mandated a Risk Evaluation and Mitigation Strategy (REMS) requiring manufacturers of extended-release/long-acting (ER/LA) opioids to fund continuing education based on an FDA curricular Blueprint. This paper describes the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) train-the-trainer program and its impact on (1) disseminating the SCOPE of Pain curriculum and (2) knowledge, confidence, attitudes, and performance of the participants of trainer-led compared with expert-led meetings.

Methods: SCOPE of Pain is a 3-hour ER/LA opioid REMS education. In addition to expert-led live statewide meetings, a 2-hour train-the-trainer (TTT) workshop was developed to increase dissemination nationally. The trainers were expected to conduct SCOPE of Pain meetings at their institutions. Participants of both the trainer-led and expert-led SCOPE of Pain programs were surveyed immediately post and 2 months post meetings to assess improvements in knowledge, confidence, attitudes, and self-reported safe opioid prescribing practices.

Results: During 9 months (May 2013 to February 2014), 89 trainers were trained during 9 TTT workshops in 9 states. Over 24 months (May 2013 to April 2015), 33% of the trainers conducted at least 1 SCOPE of Pain training, with a total of 79 meetings that educated 1419 participants. The average number of meetings of those who conducted at least 1 meeting was 2.8 (range: 1-19). The participants of the trainer-led programs were significantly more likely to be practicing in rural settings than those who participated in the expert-led meetings (39% vs. 26%, P < .001). At 2 months post training, there were no significant differences in improvements in participant knowledge, confidence, attitudes, and performance between expert-led and trainer-led meetings.

Conclusions: The SCOPE of Pain TTT program holds promise as an effective dissemination strategy to increase guideline-based safe opioid prescribing knowledge, confidence, attitudes, and self-reported practices.
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http://dx.doi.org/10.1080/08897077.2016.1275927DOI Listing
March 2018

What do providers want to know about opioid prescribing? A qualitative analysis of their questions.

Subst Abus 2017 Apr-Jun;38(2):222-229. Epub 2017 Apr 10.

a Boston University School of Medicine , Boston , Massachusetts , USA.

Background: In 2012, the US Food and Drug Administration (FDA) responded to the opioid crisis with a Risk Evaluation and Mitigation Strategy, requiring manufacturers of extended-release/long-acting opioids to fund continuing medical education based on the "FDA Blueprint for Prescriber Education." Topics in the Blueprint are "Assessing Patients for Treatment," "Initiating Therapy, Modifying Dosing, and Discontinuing Use," "Managing Therapy," "Counseling Patients and Caregivers about Safe Use," "General Drug Information," and "Specific Drug Information." Based on the FDA Blueprint, Boston University School of Medicine's "Safe and Competent Opioid Prescribing Education" (SCOPE of Pain) offers live trainings for physicians and other prescribers. During trainings, participants submit written questions about the curriculum and/or their clinical experiences.

Methods: The objective was to compare themes that arose from questions asked by SCOPE of Pain participants with content of the FDA Blueprint in order to evaluate how well the Blueprint answers prescribers' concerns. The authors conducted qualitative analyses of all 1309 questions submitted by participants in 29 trainings across 16 states from May 2013 to May 2015, using conventional content analysis to code the questions. Themes that emerged from participants' questions were then compared with the Blueprint.

Results: Most themes fell into the topic categories of the Blueprint. Five main themes diverged: Participants sought information on (1) safe alternatives to opioids, (2) overcoming barriers to safe opioid prescribing, (3) government regulations of opioid prescribing, (4) the role of marijuana in opioid prescribing, and (5) maintaining a positive provider-patient relationship while prescribing opioids.

Conclusions: In addition to learning the mechanics of safe opioid prescribing, providers want to understand government regulations and effective patient communication skills. Aware of the limitations of opioids in managing chronic pain, providers seek advice on alternatives therapies. Future updates to the FDA Blueprint and other educational guidelines on opioid prescribing should address providers' additional questions.
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http://dx.doi.org/10.1080/08897077.2017.1296525DOI Listing
March 2018

Training internal medicine residents to manage chronic pain and prescription opioid misuse.

Subst Abus 2017 Apr-Jun;38(2):200-204. Epub 2017 Apr 10.

c Cleveland Clinic Foundation , Cleveland , Ohio , USA.

Background: Residents feel unprepared to care for patients with chronic pain on long-term opioids who exhibit signs of prescription opioid misuse.

Objective: Describe an educational intervention for internal medicine residents to improve confidence, practices, attitudes, and self-reported knowledge of resources for chronic pain and opioid misuse.

Methods: The intervention included 2 sessions. Session 1 (3 hours): a lecture on chronic pain, prescription opioid misuse, and opioid use disorders and communication skills practice. The residents were asked to use one of these skills during the following week. Session 2 (1.5 hours): debriefing of patient encounters and overview of: prescription opioid monitoring strategies, discontinuation of prescription opioids when appropriate, and treatment for opioid use disorders. Pre- and post-assessments evaluated change in residents' safe opioid prescribing confidence, self-reported practices, attitudes, and self-reported knowledge of available patient resources.

Results: Ninety-one residents completed the intervention, with 44 and 43 completing the pre- and post-assessments, respectively. Utilizing a 4-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = agree 4 = strongly agree), residents reported improved confidence in skills managing patients with chronic pain (3.0 vs. 2.4, P < .0001), skills identifying which patients with chronic pain have developed an opioid use disorder (3.0 vs. 2.4, P < .0001), and understanding how to monitor for benefit versus harm (3.0 vs. 2.5, P < .0005). They also noted improved ability identifying resources for patients with chronic pain and opioid use disorders. There was a nonsignificant improvement in resident reported comfort talking to patients about the need to discontinue opioids. Residents did not report an increase in use of safe opioid prescribing monitoring strategies or feelings of support in their prescribing decisions by preceptors.

Conclusions: A brief training can improve residents' self-reported knowledge and confidence in managing patients with chronic pain and safe opioid prescribing practices. How this change in confidence affects patient care requires further study.
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http://dx.doi.org/10.1080/08897077.2017.1296526DOI Listing
March 2018

How Would You Manage Opioid Use in These Three Patients?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center.

Ann Intern Med 2017 04;166(7):506-513

The increase in overdose deaths from prescription opioids and heroin in the United States over the past 20 years is believed to have resulted from increases in prescription of opioids for management of acute and chronic pain. Managing chronic pain is challenging for primary care clinicians for many reasons, including the lack of evidence to guide practice. The Centers for Disease Control and Prevention published a comprehensive guideline in 2016 to help clinicians with opioid prescribing for chronic pain. In this Grand Rounds, the guideline is reviewed and an expert discusses its application to 3 patients prescribed opioids to treat chronic pain.
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http://dx.doi.org/10.7326/M17-0287DOI Listing
April 2017

The Surgeon General's Facing Addiction report: An historic document for health care.

Subst Abus 2017 Apr-Jun;38(2):122

l Division of Epidemiology, Department of Medicine , University of Utah School of Medicine , Salt Lake City , Utah , USA.

The publication of Facing Addiction in America: The Surgeon General's Report on Alcohol, Drugs, and Health presents an historic moment not only for the field of addiction medicine, but also for the United States as a nation. The Board of Directors of the Association for Medical Education and Research in Substance Abuse (AMERSA), on behalf of our organization, would like to express our appreciation of the efforts of Dr. Vivek Murthy and the Surgeon General's Office to publish the first surgeon general's report covering substance misuse and substance use disorders.
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http://dx.doi.org/10.1080/08897077.2017.1309935DOI Listing
March 2018

Chronic pain, craving, and illicit opioid use among patients receiving opioid agonist therapy.

Drug Alcohol Depend 2016 Sep 27;166:26-31. Epub 2016 Jun 27.

Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, 801 Massachusetts Ave., Second Floor, Boston, MA 02118, United States; Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave., Second Floor, Boston, MA 02118, United States; Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Ave., Second Floor, Boston, MA 02118, United States.

Aims: In a sample of patients receiving opioid agonist therapy, we evaluated whether having chronic pain was associated with (a) craving for opioids and (b) illicit opioid use.

Methods: In a cross-sectional study of adults on buprenorphine or methadone maintenance recruited from an urban medical center, we examined any craving for opioids (primary dependent variable) in the past week and recent illicit opioid use (secondary dependent variable). Illicit opioid use was defined as a positive urine drug test (UDT) for opiates and chronic pain was defined as bodily pain that had been present for at least 3 months. Multivariable logistic regression models were fit for each outcome, adjusting for age, sex, and non-white race. Additional models adjusted for depression (PHQ-9) and anxiety (STAI).

Results: The sample included 105 adults on methadone or buprenorphine maintenance. Mean age was 43.8 (SD ±9.4)years; 48% were female and 32% non-white; 19% were on methadone. Chronic pain was present in 68% of the sample, 51% reported craving opioids in the past week, and 16% had a positive UDT. Chronic pain was associated with 3-fold higher odds of reporting craving in the past week (aOR=3.10; 95% CI: 1.28-7.50, p-value=0.01). The relative odds for having a positive UDT were not statistically significant (aOR=2.52; 95% CI: 0.64-9.90, p=0.18).

Conclusion: In this sample of patients treated with opioid agonist therapy, those with chronic pain had higher odds of reporting craving for opioids. Chronic pain with associated opioid craving potentially places this population at risk for relapse.
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http://dx.doi.org/10.1016/j.drugalcdep.2016.06.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4983520PMC
September 2016

Improving Residents' Safe Opioid Prescribing for Chronic Pain Using an Objective Structured Clinical Examination.

J Grad Med Educ 2016 Jul;8(3):390-7

Background: Internal medicine residents care for a sizable number of patients with chronic pain. Programs need educational strategies to promote safe opioid prescribing.

Objective: To describe a safe opioid prescribing education program utilizing an objective structured clinical examination (OSCE) and report the resulting impact on residents' knowledge, confidence, and self-reported practices.

Methods: Using a quasi-experimental design, 39 internal medicine residents from an urban academic medical center were assigned to 1 of 4 groups: 1-hour lecture only, lecture followed by immediate OSCE, lecture followed by 4-month delayed OSCE, and control. Safe opioid prescribing knowledge, confidence, and self-reported practices were assessed at baseline and at 8 months.

Results: At 8 months, knowledge, confidence, and self-reported practices improved in the control and in all 3 intervention groups. The immediate OSCE group had the greatest improvements in combined confidence scores within group (0.74, P = .01) compared to controls (0.52, P = .05), using a 5-point scale. This group also had the greatest improvement in self-reported practice changes (1.04, P = .04), while other groups showed nonsignificant improvements-delayed OSCE (0.43, P = .44), lecture only (0.66, P = .24), and control (0.43, P = .19).

Conclusions: Safe opioid prescribing education that includes a lecture immediately followed by an OSCE had an impact on residents' confidence and self-reported practices greater than those for delayed OSCE or lecture only groups. There was no difference in knowledge improvement among the groups. Lecture followed by an OSCE was highly regarded by residents, but required additional resources.
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http://dx.doi.org/10.4300/JGME-D-15-00273.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4936858PMC
July 2016

Opioid Prescribing for Chronic Pain--Achieving the Right Balance through Education.

Authors:
Daniel P Alford

N Engl J Med 2016 Jan;374(4):301-3

From the Boston University School of Medicine and Boston Medical Center - both in Boston.

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http://dx.doi.org/10.1056/NEJMp1512932DOI Listing
January 2016

Primary Care Patients with Drug Use Report Chronic Pain and Self-Medicate with Alcohol and Other Drugs.

J Gen Intern Med 2016 May 25;31(5):486-91. Epub 2016 Jan 25.

Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Avenue, 2nd floor, Boston, MA, 02118, USA.

Background: Chronic pain is common among patients with drug use disorders. The prevalence of chronic pain and its consequences in primary care patients who use drugs is unknown.

Objectives: To examine: 1) the prevalence of chronic pain and pain-related dysfunction among primary care patients who screen positive for drug use, and 2) the prevalence of substance use to self-medicate chronic pain in this population.

Design: This was a cross-sectional analysis.

Participants: This study included 589 adult patients who screened positive for any illicit drug use or prescription drug misuse, recruited from an urban, hospital-based primary care practice.

Main Measures: Both pain and pain-related dysfunction were assessed by numeric rating scales, and grouped as: (0) none, (1-3) mild, (4-6) moderate, (7-10) severe. Questions were asked about the use of substances to treat pain.

Key Results: Among 589 participants, chronic pain was reported by 87% (95% CI: 84-90%), with 13% mild, 24% moderate and 50% severe. Pain-related dysfunction was reported by 74% (95% CI: 70-78%), with 15% mild, 23% moderate, and 36% severe. Of the 576 that used illicit drugs (i.e., marijuana, cocaine, and/or heroin), 51% reported using to treat pain (95% CI: 47-55% ). Of the 121 with prescription drug misuse, 81% (95% CI: 74-88%) used to treat pain. Of the 265 participants who reported any heavy drinking in the past 3 months, 38% (95% CI: 32-44%) did so to treat pain compared to 79% (95% CI: 68-90%) of the 57 high-risk alcohol users.

Conclusions: Chronic pain and pain-related dysfunction were the norm for primary care patients who screened positive for drug use, with nearly one-third reporting both severe pain and severe pain-related dysfunction. Many patients using illicit drugs, misusing prescription drugs and using alcohol reported doing so in order to self-medicate their pain. Pain needs to be addressed when patients are counseled about their substance use.
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http://dx.doi.org/10.1007/s11606-016-3586-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4835374PMC
May 2016

Brief intervention for daily marijuana users identified by screening in primary care: A subgroup analysis of the ASPIRE randomized clinical trial.

Subst Abus 2016 Apr-Jun;37(2):336-42. Epub 2015 Oct 9.

a Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine , Department of Medicine, Boston Medical Center and Boston University School of Medicine , Boston , Massachusetts , USA.

Background: The use of brief intervention for decreasing frequent marijuana use holds potential, but its efficacy in primary care is not known.

Methods:

Objective: To assess the impact of 2 brief interventions on marijuana use among daily/or almost daily marijuana users.

Design: Subgroup analysis of a 3-arm randomized clinical trial of 2 brief counseling interventions compared with no brief intervention on daily marijuana use in a primary care setting (ASPIRE).

Participants: ASPIRE study participants who both reported 21-30 days of marijuana use during the past month and identified marijuana as their drug of most concern.

Interventions: (1) brief negotiated interview (BNI), a 10-15-minute structured interview, and (2) an adaptation of motivational interviewing (MOTIV), a 30-45-minute intervention. Control group participants received only a list of substance use treatment resources.

Main Measures: The primary outcome was number of days of marijuana use in the past 30 days at the 6-month follow-up. Secondary outcomes were (1) number of days of marijuana use at 6-week follow-up and (2) drug problems (Short Inventory of Problems-Drugs, SIP-D) at 6-week and 6-month follow-ups. Differences between intervention groups were analyzed using negative binomial regression models.

Results: Among the 167 eligible participants, we did not find any significant impact of either of the 2 interventions on past 30 days of marijuana use at 6 months (adjusted incidence rate ratio [aIRR]: 0.95, 95% confidence interval [CI]: 0.75-1.15, P = .82 for BNI vs. control; aIRR: 1.02, 95% CI: 0.85-1.23, P = .82 for MOTIV vs. control). There was no significant impact on drug-related problems at 6-month follow-up (aIRR: 1.12, 95% CI: 0.69-1.82, P = .66 and aIRR: 1.46, 95% CI: 0.89-2.38, P = .27 for BNI vs. control and MOTIV vs. control, respectively). Results were similar at 6 weeks.

Conclusions: Brief intervention has no apparent impact on marijuana use or drug-related problems among primary care patients with frequent marijuana use identified by screening.
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http://dx.doi.org/10.1080/08897077.2015.1075932DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4826635PMC
January 2018