Publications by authors named "Edward Bernstein"

54 Publications

Shorter outpatient wait-times for buprenorphine are associated with linkage to care post-hospital discharge.

Drug Alcohol Depend 2021 Jul 20;224:108703. Epub 2021 Apr 20.

Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA, 02118, USA.

Background: Inpatient addiction consult services (ACS) lower barriers to accessing medications for opioid use disorder (MOUD), however not every patient recommended for MOUD links to outpatient care. We hypothesized that fewer days between discharge date and outpatient appointment date was associated with improved linkage to buprenorphine treatment among patients evaluated by an ACS.

Methods: We extracted appointment and demographic data from electronic medical records and conducted retrospective chart review of adults diagnosed with opioid use disorder (OUD) evaluated by an ACS in Boston, MA between July 2015 and August 2017. These patients were initiated on or recommended buprenorphine treatment on discharge and provided follow-up appointment at our hospital post-discharge. Multivariable logistic regression assessed whether arrival to the appointment post-discharge was associated with shorter wait-times (0-1 vs. 2+ days).

Results: In total, 142 patients were included. Among patients who had wait-times of 0-1 day, 63 % arrived to their appointment compared to wait-times of 2 or more days (42 %). There were no significant differences between groups based on age, gender, distance of residence from the hospital, insurance status, co-occurring alcohol use disorder diagnosis, or discharge with buprenorphine prescription. After adjusting for covariates, patients with 0-1 day of wait-time had 2.6 times the odds of arriving to their appointment [95 % CI 1.3-5.5] compared to patients who had 2+ days of wait-time.

Conclusion: For hospitalized patients with OUD evaluated for initiating MOUD, same- and next-day appointments are associated with increased odds of linkage to outpatient MOUD care post-discharge compared to waiting two or more days.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108703DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180499PMC
July 2021

A randomized clinical trial of a theory-based fentanyl overdose education and fentanyl test strip distribution intervention to reduce rates of opioid overdose: study protocol for a randomized controlled trial.

Trials 2020 Nov 26;21(1):976. Epub 2020 Nov 26.

Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA.

Background: Opioid overdose deaths involving synthetic opioids, particularly illicitly manufactured fentanyl, remain a substantial public health concern in North America. Responses to overdose events (e.g., administration of naloxone and rescue breathing) are effective at reducing mortality; however, more interventions are needed to prevent overdoses involving illicitly manufactured fentanyl. This study protocol aims to evaluate the effectiveness of a behavior change intervention that incorporates individual counseling, practical training in fentanyl test strip use, and distribution of fentanyl test strips for take-home use among people who use drugs.

Methods: Residents of Rhode Island aged 18-65 years who report recent substance use (including prescription pills obtained from the street; heroin, powder cocaine, crack cocaine, methamphetamine; or any drug by injection) (n = 500) will be recruited through advertisements and targeted street-based outreach into a two-arm randomized clinical trial with 12 months of post-randomization follow-up. Eligible participants will be randomized (1:1) to receive either the RAPIDS intervention (i.e., fentanyl-specific overdose education, behavior change motivational interviewing (MI) sessions focused on using fentanyl test strips to reduce overdose risk, fentanyl test strip training, and distribution of fentanyl test strips for personal use) or standard overdose education as control. Participants will attend MI booster sessions (intervention) or attention-matched control sessions at 1, 2, and 3 months post-randomization. All participants will be offered naloxone at enrolment. The primary outcome is a composite measure of self-reported overdose in the previous month at 6- and/or 12-month follow-up visit. Secondary outcome measures include administratively linked data regarding fatal (post-mortem investigation) and non-fatal (hospitalization or emergency medical service utilization) overdoses.

Discussion: If the RAPIDS intervention is found to be effective, its brief MI and fentanyl test strip training components could be easily incorporated into existing community-based overdose prevention programming to help reduce the rates of fentanyl-related opioid overdose.

Trial Registration: ClinicalTrials.gov NCT04372238 . Registered on 01 May 2020.
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http://dx.doi.org/10.1186/s13063-020-04898-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690169PMC
November 2020

Appointment wait-times and arrival for patients at a low-barrier access addiction clinic.

J Subst Abuse Treat 2020 07 22;114:108011. Epub 2020 Apr 22.

Department of Medicine, Boston University School of Medicine and Boston Medical Center, United States of America.

Introduction: Same-day or next-day access to outpatient medication for addiction treatment (MAT) for both alcohol and opioid use disorders may facilitate sustained treatment with evidence-based therapies for substance use disorders (SUD). This study evaluates the association between appointment wait-times and odds of arrival to appointment for patients seeking outpatient MAT.

Methods: The study sample consisted of patients who scheduled an appointment with a low-barrier access addiction clinic between August 1, 2016, and July 31, 2017. The outcome of interest was the status of the appointment as a dichotomous variable: arrive or no-show/cancel. The primary independent variable (wait-time) was the number of overnights between the date a patient scheduled a clinic appointment and the date of service, categorized as 0 days, 1 day, and 2+ days. We conducted bivariable and multivariable logistic regressions to calculate unadjusted and adjusted odds ratios for arrival. Multivariable analyses were adjusted for gender, age, distance of residence from the clinic, and insurance type.

Results: Our analysis included 657 patients, of whom 410 (62%) arrived to their first appointment. Among the 657 patients, 47% (308) were scheduled the same day (0 days) and 82% (252) of them were seen, 23% (151) waited 1 day (next-day) and 53% (80) of them were seen, and 30% (198) waited 2+ days and 39% (78) of them were seen. Patients were more likely to be seen when they had a same-day (OR 6.9 [95% CI 4.6-10.4]; AOR 7.5 [4.9-11.4]) or next-day (OR 1.7 [1.1-2.7]; AOR 1.7 [1.1-2.6]) appointment compared to waiting 2+ days.

Conclusion: Patients seeking MAT through a clinic that schedules same-day and next-day appointments for treatment are more likely to attend addiction appointments compared to patients who wait longer. Clinics should strive to reduce wait-times for patients seeking MAT.
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http://dx.doi.org/10.1016/j.jsat.2020.108011DOI Listing
July 2020

Feasibility of a Brief Intervention to Facilitate Advance Care Planning Conversations for Patients with Life-Limiting Illness in the Emergency Department.

J Palliat Med 2021 01 1;24(1):31-39. Epub 2020 Jun 1.

Department of Emergency Medicine and Brigham and Women's Hospital, Boston, Massachusetts, USA.

Advance care planning (ACP) conversations are an important intervention to provide care consistent with patient goals near the end of life. The emergency department (ED) could serve as an important time and location for these conversations. To determine the feasibility of an ED-based, brief negotiated interview (BNI) to stimulate ACP conversations among seriously ill older adults. We conducted a pre/postintervention study in the ED of an urban, tertiary care, academic medical center. From November 2017 to May 2019, we prospectively enrolled adults ≥65 years of age with serious illness. Trained clinicians conducted the intervention. We measured patients' ACP engagement at baseline and follow-up (3 ± 1 weeks) and reviewed electronic medical record documentation of ACP (e.g., medical order for life-sustaining treatment [MOLST]). We enrolled 51 patients (mean age = 71; SD 12), 41% were female, and 51% of patients had metastatic cancer. Median duration of the intervention was 11.8 minutes; few (6%) of the interventions were interrupted. We completed follow-up for 61% of participants. Patients' self-reported ACP engagement increased from 3.0 to 3.7 out of 5 after the intervention ( < 0.01). Electronic documentation of health care proxy forms increased (75%-94%,  = 48) as did MOLST (0%-19%,  = 48) during the six months after the ED visit. A novel, ED-based, BNI intervention to stimulate ACP conversations for seriously ill older adults is feasible and may improve ACP engagement and documentation.
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http://dx.doi.org/10.1089/jpm.2020.0067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7757694PMC
January 2021

Suspected involvement of fentanyl in prior overdoses and engagement in harm reduction practices among young adults who use drugs.

Subst Abus 2019 17;40(4):519-526. Epub 2019 Jun 17.

Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA.

From 2011 to 2016, the United States has experienced a 55% increase in overall overdose deaths and a 260% increase in fatal fentanyl-related overdoses. Increasing engagement in harm reduction practices is essential to reducing the rate of fentanyl-related overdoses. This study sought to examine the uptake of harm reduction practices among young adults who reported recent drug use and who were recruited for a study to assess the utility and acceptability of rapid fentanyl test strips. Between May and October 2017, 93 young adults who reported drug use in the past 30 days were recruited through word of mouth, Internet advertising, and public canvasing. Participants completed an interviewer-administered survey that assessed participants' sociodemographic and behavioral characteristics, suspected fentanyl exposure, and overdose history. We assessed harm reduction practices and other correlates associated with experiencing a suspected fentanyl-related overdose. Of 93 eligible participants, 36% ( = 34) reported ever having experienced an overdose, among whom 53% ( = 18) suspected having experienced a fentanyl-related overdose. Participants who had ever experienced a fentanyl-related overdose were more likely to keep naloxone nearby when using drugs compared with those who had never experienced an overdose and those who had experienced an overdose that they did not suspect was related to fentanyl ( < .001). Additionally, experiencing a suspected fentanyl-related overdose was associated with having previously administered naloxone to someone else experiencing an overdose ( < .001). Those who had experienced a suspected fentanyl-related overdose were more likely to carry and administer naloxone. Future overdose prevention interventions should involve persons who have experienced a suspected fentanyl overdose and/or responded to an overdose in order to develop harm reduction programs that meet the needs of those at risk of an overdose.
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http://dx.doi.org/10.1080/08897077.2019.1616245DOI Listing
August 2020

Preparing Mexican-Origin Community Health Advocates (Promotores) to Conduct SBIRT for Problem Drinking in the Emergency Room.

Pedagogy Health Promot 2018 Dec 2;4(4):247-253. Epub 2018 Feb 2.

Professor, Emergency Medicine. Boston, University School of Medicine, Boston, MA.

Community Health Advocates (CHAs), known as in Spanish-speaking communities, are an important resource for the mobilization, empowerment, and the delivery of health education messages in Hispanic/Latino communities. This article focuses on understanding cultural, didactic, and logistical aspects of preparing CHAs to become competent to perform a brief intervention and referral to treatment (SBIRT) in the emergency room (ER). The CHAs training emphasizes making connections with Mexican-origin young adults aged 18-30, and capitalizing on a teachable moment to effect change in alcohol consumption and negative outcomes associated with alcohol use. We outline a CHA recruitment, content/methods training, and the analysis of advantages and challenges presented by the delivery of an intervention by CHAs.
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http://dx.doi.org/10.1177/2373379918756425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6432642PMC
December 2018

Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities.

Ann Emerg Med 2019 08 13;74(2):276-284. Epub 2019 Feb 13.

Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA; Department of Medicine, Division of Palliative Medicine, Brigham and Women's Hospital, Boston, MA.

During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique "teachable moment" to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.
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http://dx.doi.org/10.1016/j.annemergmed.2019.01.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6714052PMC
August 2019

Empower Seriously Ill Older Adults to Formulate Their Goals for Medical Care in the Emergency Department.

J Palliat Med 2019 03 12;22(3):267-273. Epub 2018 Nov 12.

3 Serious Illness Care Program, Ariadne Labs , Boston, Massachusetts.

Background: Most seriously ill older adults visit the emergency department (ED) near the end of life, yet no feasible method exists to empower them to formulate their care goals in this setting.

Objective: To develop an intervention to empower seriously ill older adults to formulate their future care goals in the ED.

Design: Prospective intervention development study.

Setting: In a single, urban, academic ED, we refined the prototype intervention with ED clinicians and patient advisors. We tested the intervention for its acceptability in English-speaking patients ≥65 years old with serious illness or patients whose treating ED clinician answered "No" to the "surprise question" ("would not be surprised if died in the next 12 months"). We excluded patients with advance directives or whose treating ED clinician determined the patient to be inappropriate.

Measurements: Our primary outcome was perceived acceptability of our intervention. Secondary outcomes included perceived main intent and stated attitude toward future care planning.

Results: We refined the intervention with 16 mock clinical encounters of ED clinicians and patient advisors. Then, we administered the refined intervention to 23 patients and conducted semistructured interviews afterward. Mean age of patients was 76 years, 65% were women, and 43% of patients had metastatic cancer. Most participants (n = 17) positively assessed our intervention, identified questions for their doctors, and reflected on how they feel about their future care.

Conclusion: An intervention to empower seriously ill older adults to understand the importance of future care planning in the ED was developed, and they found it acceptable.
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http://dx.doi.org/10.1089/jpm.2018.0360DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6391608PMC
March 2019

Use of rapid fentanyl test strips among young adults who use drugs.

Int J Drug Policy 2018 11 18;61:52-58. Epub 2018 Oct 18.

Department of Epidemiology, School of Public Health, Brown University, Providence, RI, USA. Electronic address:

Background: The overdose epidemic has been exacerbated by a dramatic increase in deaths involving illicitly manufactured fentanyl (IMF). Drug checking is a novel strategy to identify IMF in illicit drugs. We examined the uptake and acceptability of rapid fentanyl test strips among young adults.

Methods: From May to September 2017, we recruited 93 young adults in Rhode Island who reported injecting drugs or using heroin, cocaine, or illicitly obtained prescription pills in the past 30 days. Participants were asked to test either their urine after drug use (post-consumption) or a drug sample prior to use (pre-consumption) using rapid fentanyl test strips. After a questionnaire and a brief training, participants received ten strips for their personal use and were asked to return for a one-month follow-up visit, which assessed the uptake and acceptability of the rapid strips tests and the behavioral outcomes associated with receipt of a positive test.

Results: Of the 81 (87%) participants who returned for follow-up and who had complete data, the mean age was 27, 45 (56%) were male, and 37 (46%) were non-white. A total of 62 participants (77%) reported using at least one test strip. Of these, 31 (50%) received at least one positive result. A positive result was associated with older age, homelessness, heroin use, injection drug use, ever witnessing an overdose, and concern about overdose or drugs being laced with fentanyl (all p < 0.05). Receiving a positive result was significantly associated with reporting a positive change in overdose risk behavior between baseline and follow-up (p ≤  0.01). Among all participants, 79 (98%) reported confidence in their ability to use the test strips and 77 (95%) wanted to use them in the future.

Conclusions: Young adults reported high uptake and acceptability of fentanyl test strips to detect IMF in illicit drugs.
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http://dx.doi.org/10.1016/j.drugpo.2018.09.009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6701177PMC
November 2018

High willingness to use rapid fentanyl test strips among young adults who use drugs.

Harm Reduct J 2018 02 8;15(1). Epub 2018 Feb 8.

Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Box G-S-121-2, Providence, RI, 02912, USA.

Background: Synthetic opioid overdose mortality among young adults has risen more than 300% in the USA since 2013, primarily due to the contamination of heroin and other drugs with illicitly manufactured fentanyl. Rapid test strips, which can be used to detect the presence of fentanyl in drug samples (before use) or urine (after use), may help inform people about their exposure risk. The purpose of this study was to determine whether young adults who use drugs were willing to use rapid test strips as a harm reduction intervention to prevent overdose. We hypothesized that those who had ever overdosed would be more willing to use the test strips.

Methods: We recruited a convenience sample of young adults who use drugs in Rhode Island from May to September 2017. Eligible participants (aged 18 to 35 with past 30-day drug use) completed an interviewer-administered survey. The survey assessed participant's socio-demographic and behavioral characteristics, overdose risk, as well as suspected fentanyl exposure, and willingness to use take-home rapid test strips to detect fentanyl contamination in drugs or urine. Participants were then trained to use the test strips and were given ten to take home.

Results: Among 93 eligible participants, the mean age was 27 years (SD = 4.8), 56% (n = 52) of participants were male, and 56% (n = 52) were white. Over one third (n = 34, 37%) had a prior overdose. The vast majority (n = 86, 92%) of participants wanted to know if there was fentanyl in their drug supply prior to their use. Sixty-five (70%) participants reported concern that their drugs were contaminated with fentanyl. After the brief training, nearly all participants (n = 88, 95%) reported that they planned to use the test strips.

Conclusions: More than 90% of participants reported willingness to use rapid test strips regardless of having ever overdosed, suggesting that rapid fentanyl testing is an acceptable harm reduction intervention among young people who use drugs in Rhode Island. Study follow-up is ongoing to determine whether, how, and under what circumstances participants used the rapid test strips and if a positive result contributed to changes in overdose risk behavior.
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http://dx.doi.org/10.1186/s12954-018-0213-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5806485PMC
February 2018

Identifying Patients for Overdose Prevention With ICD-9 Classification in the Emergency Department, Massachusetts, 2013-2014.

Public Health Rep 2016 09 22;131(5):671-675. Epub 2016 Aug 22.

Boston University School of Public Health, Boston, MA, USA; Boston University School of Medicine, Boston, MA, USA.

The national rise in opioid overdose deaths signifies a need to integrate overdose prevention within healthcare delivery settings. The emergency department (ED) is an opportune location for such interventions. To effectively integrate prevention services, the target population must be clearly defined. We used ICD-9 discharge codes to establish and apply overdose risk categories to ED patients seen from January 1, 2013 to December 31, 2014 at an urban safety-net hospital in Massachusetts with the goal of informing ED-based naloxone rescue kit distribution programs. Of 96,419 patients, 4,468 (4.6%) were at increased risk of opioid overdose, defined by prior opioid overdose, misuse, or polysubstance misuse. A small proportion of those at risk were prescribed opioids on a separate occasion. Use of risk categories defined by ICD-9 codes identified a notable proportion of ED patients at risk for overdose, and provides a systematic means to prioritize and direct clinical overdose prevention efforts.
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http://dx.doi.org/10.1177/0033354916661981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5230809PMC
September 2016

Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment.

BMC Res Notes 2016 Oct 18;9(1):465. Epub 2016 Oct 18.

Boston University School of Public Health, 715 Albany Street, T3 W, Boston, MA, 02118, USA.

Background: The increase in opioid overdose deaths has become a national public health crisis. Naloxone is an important tool in opioid overdose prevention. Distribution of nasal naloxone has been found to be a feasible, and effective intervention in community settings and may have potential high applicability in the emergency department, which is often the initial point of care for persons at high risk of overdose. One safety net hospital introduced an innovative policy to offer take-home nasal naloxone via a standing order to ensure distribution to patients at risk for overdose. The aims of this study were to examine acceptance and uptake of the policy and assess facilitators and barriers to implementation.

Methods: After obtaining pre-post data on naloxone distribution, we conducted a qualitative study. The PARiHS framework steered development of the qualitative guide. We used theoretical sampling in order to include the range of types of emergency department staff (50 total). The constant comparative method was initially used to code the transcripts and identify themes; the themes that emerged from the coding were then mapped back to the evidence, context and facilitation constructs of the PARiHS framework.

Results: Acceptance of the policy was good but uptake was low. Primary themes related to facilitators included: real-world driven intervention with philosophical, clinician and leadership support; basic education and training efforts; availability of resources; and ability to leave the ED with the naloxone kit in hand. Barriers fell into five general categories: protocol and policy; workflow and logistical; patient-related; staff roles and responsibilities; and education and training.

Conclusions: The actual implementation of a new innovation in healthcare delivery is largely driven by factors beyond acceptance. Despite support and resources, implementation was challenging, with low uptake. While the potential of this innovation is unknown, understanding the experience is important to improve uptake in this setting and offer possible solutions for other facilities to address the opioid overdose crisis. Use of the PARiHS framework allowed us to recognize and understand key evidence, contextual and facilitation barriers to the successful implementation of the policy and to identify areas for improvement.
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http://dx.doi.org/10.1186/s13104-016-2268-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070095PMC
October 2016

Reaching Adolescents for Prevention: The Role of Pediatric Emergency Department Health Promotion Advocates.

Pediatr Emerg Care 2017 Apr;33(4):223-229

From the *Department of Community Health Sciences, Boston University School of Public Health; Departments of †Emergency Medicine and ‡Pediatrics, Boston University School of Medicine; and §Adolescent Substance Abuse Program, Boston Children's Hospital, Boston, MA.

Objectives: Almost 200,000 adolescents visit US emergency departments (EDs) yearly for conditions involving underage drinking but receive no follow-up referral. Other health risk behaviors resulting in sexually transmitted infections, car crashes, and assault-related injury are common among adolescents. A pediatric ED (PED) visit presents an opportunity to discuss and promote prevention. We report here on implementation of a new PED navigator/extender role, the Health Promotion Advocate (HPA).

Methods: Health Promotion Advocates surveyed patients to identify health risks, stresses, and needs. A positive screen triggered a brief conversation containing the following elements: permission to discuss risks/needs; exploration of context (a typical day in your life); brief feedback (information and norms); exploration of benefits and consequences of risk behaviors; assessment of readiness to change; calling up assets, instilling hope; discussing challenges of change; negotiating a menu of options and prescription for change; referrals to primary care, community resources; and treatment services as indicated.

Results: During 2009-2013, HPAs screened 2149 PED patients aged 14 to 21 years and referred 834 for an array of services (eg, primary care, mental health, insurance, personal safety, human immunodeficiency virus testing, general education diploma (GED), employment, housing, and food pantries) to address reported health risks; 785 screened positive for at-risk substance use (53% female, 36% without primary care). Among them, 636 received a brief intervention; 546 were referred to specialized substance abuse treatment. Two case studies are presented to illustrate the engagement and referral process.

Conclusions: Health Promotion Advocates working as PED team members can extend PED services beyond the scope of the presenting complaint.
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http://dx.doi.org/10.1097/PEC.0000000000000662DOI Listing
April 2017

Differences by gender at twelve months in a brief intervention trial among Mexican-origin young adults in the emergency department.

J Ethn Subst Abuse 2017 Jan-Mar;16(1):91-108. Epub 2016 Jan 28.

d Alliance for Border Collaboratives , El Paso , Texas.

In this study, we investigate the role of gender in prevalence and consequences of binge drinking and brief intervention outcomes among Mexican-origin young adults aged 18-30 years at the U.S.-Mexico border. We conducted a secondary analysis, stratified by gender, from a randomized controlled trial of a brief motivational intervention in a hospital emergency department. Intervention effects for males included reductions in drinking frequency, binge drinking, and alcohol-related consequences. For females the intervention was associated with reduction in drinking frequency and binge drinking but did not have a significant effect on alcohol-related consequences. Results suggest a new direction for tailoring interventions to gender.
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http://dx.doi.org/10.1080/15332640.2015.1095667DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4733888PMC
October 2017

Emergency Department-based Opioid Harm Reduction: Moving Physicians From Willing to Doing.

Acad Emerg Med 2016 Apr 22;23(4):455-65. Epub 2016 Mar 22.

Department of Emergency Medicine, Boston Medical Center, Boston, MA.

Objectives: Develop and internally validate a survey tool to assess emergency department (ED) physician attitudes, clinical practice, and willingness to perform opiate harm reduction (OHR) interventions and to identify barriers and facilitators in translating willingness to action.

Methods: This study was an anonymous, Web-based survey based on the Theory of Planned Behavior of ED physicians at three tertiary referral centers. Construction and internal validation of scaled questions was assessed through principal component and Cronbach's alpha analyses. Stepwise linear regression was conducted to measure impact of physician knowledge, attitudes, confidence, and self-efficacy on willingness to perform OHR interventions including opioid overdose education; naloxone prescribing; and referral to naloxone, methadone, and syringe access programs.

Results: A total of 200 of 278 (71.9%) physicians completed the survey. Principal component analysis yielded five components: attitude, confidence, self-efficacy, professional impact factors, and personal impact factors. Overall, respondents were willing to perform OHR interventions, but few actually do. Willingness was correlated with attitude, confidence, and self-efficacy (R(2)  = 0.50); however, overall physicians lacked confidence (mean = 3.06 of 5, 95% confidence interval [CI] = 2.94 to 3.18]). Knowledge, time, training, and institutional support were all prohibitive barriers. Physicians reported that research evidence, professional organization recommendations, and opinions of ED leaders would strongly influence a change in their clinical practice to incorporate OHR interventions (mean = 4.25 of 5, 95% CI = 4.18 to 4.32).

Conclusions: Compared to prior studies, emergency medicine physicians had increased willingness to perform OHR interventions, but there remains a disparity between willingness and clinical practice. Influential factors that may move physicians from "willing" to "doing" include dissemination of supportive research evidence; professional organization endorsement; ED leadership opinion; and addressing time, knowledge, and institutional barriers.
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http://dx.doi.org/10.1111/acem.12910DOI Listing
April 2016

The remote brief intervention and referral to treatment model: Development, functionality, acceptability, and feasibility.

Drug Alcohol Depend 2015 Oct 23;155:236-42. Epub 2015 Jul 23.

Boston University School of Medicine, 77 Albany St., Boston, MA 02118, USA. Electronic address:

Background: Screening, brief intervention, and referral to treatment (SBIRT) is effective for reducing risky alcohol use across a variety of medical settings. However, most programs have been unsustainable because of cost and time demands. Telehealth may alleviate on-site clinician burden. This exploratory study examines the feasibility of a new Remote Brief Intervention and Referral to Treatment (R-BIRT) model.

Methods: Eligible emergency department (ED) patients were enrolled into one of five models. (1) Warm Handoff: clinician-facilitated phone call during ED visit. (2) Patient Direct: patient-initiated call during visit. (3) Electronic Referral: patient contacted by R-BIRT personnel post visit. (4) Patient Choice: choice of models 1-3. (5) Modified Patient Choice: choice of models 1-2, Electronic Referral offered if 1-2 were declined. Once connected, a health coach offered assessment, counseling, and referral to treatment. Follow up assessments were conducted at 1 and 3 months. Primary outcomes measured were acceptance, satisfaction, and completion rates.

Results: Of 125 eligible patients, 50 were enrolled, for an acceptance rate of 40%. Feedback and satisfaction ratings were generally positive. Completion rates were 58% overall, with patients enrolled into a model wherein the consultation occurred during the ED visit, as opposed to after the visit, much more likely to complete a consultation, 90% vs. 10%, χ(2) (4, N=50)=34.8, p<0.001.

Conclusions: The R-BIRT offers a feasible alternative to in-person alcohol SBIRT and should be studied further. The public health impact of having accessible, sustainable, evidence-based SBIRT for substance use across a range of medical settings could be considerable.
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http://dx.doi.org/10.1016/j.drugalcdep.2015.07.014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4624210PMC
October 2015

Brief Intervention in the Emergency Department Among Mexican-Origin Young Adults at the US-Mexico Border: Outcomes of a Randomized Controlled Clinical Trial Using Promotores.

Alcohol Alcohol 2016 Mar 4;51(2):154-63. Epub 2015 Aug 4.

Alliance of Border Collaboratives, El Paso, TX, USA.

Aims: A randomized controlled trial of brief intervention (BI), for drinking and related problems, using peer health promotion advocates (promotores), was conducted among at-risk and alcohol-dependent Mexican-origin young adult emergency department (ED) patients, aged 18-30.

Methods: Six hundred and ninety-eight patients were randomized to: screened only (n = 78), assessed (n = 310) and intervention (n = 310). Primary outcomes were at-risk drinking and Rapid Alcohol Problems Screen (RAPS4) scores. Secondary outcomes were drinking days per week, drinks per drinking day, maximum drinks in a day and negative consequences of drinking.

Results: At 3- and 12-month follow-up the intervention condition showed significantly lower values or trends on all outcome variables compared to the assessed condition, with the exception of the RAPS4 score; e.g. at-risk drinking days dropped from 2.9 to 1.7 at 3 months for the assessed condition and from 3.2 to 1.2 for the intervention condition. Using random effects modeling controlling for demographics and baseline values, the intervention condition showed significantly greater improvement in all consumption measures at 12 months, but not in the RAPS4 or negative consequences of drinking. Improvements in outcomes were significantly more evident for non-injured patients, those reporting drinking prior to the event, and those lower on risk taking disposition.

Conclusions: At 12-month follow-up this study demonstrated significantly improved drinking outcomes for Mexican-origin young adults in the ED who received a BI delivered by promotores compared to those who did not.

Trial Register: ClinicalTrials.gov.

Clinical Trial Registration Number: NCT02056535.
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http://dx.doi.org/10.1093/alcalc/agv084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755550PMC
March 2016

Readiness to Change and to Accept Help and Drinking Outcomes in Young Adults of Mexican Origin.

J Stud Alcohol Drugs 2015 Jul;76(4):602-6

Alliance of Border Collaboratives, El Paso, Texas.

Objective: The purpose of this study was to assess whether readiness to change drinking (RCD) and readiness to accept help (RAH) improve short- and longer term drinking outcomes.

Method: Data from a randomized controlled trial of screening and brief intervention (SBI) conducted in a U.S. emergency department at the U.S.-Mexico border are reported. A total of 620 at-risk and dependent Mexican-origin drinkers (56% male), ages 18-30, received either an assessment only or intervention (SBI). Drinking outcomes included drinking days per week, average and maximum drinks per drinking day, heavy drinking (5+ drinks) days per week, and negative consequences. Random effects longitudinal models predicted baseline, 3-month, and 12-month drinking outcomes from baseline RCD and RAH. Models tested if (a) outcomes were significantly reduced at follow-ups and (b) differential reduction occurred by RCD, RAH, and post-intervention changes in readiness among those receiving SBI.

Results: For both study groups, outcomes improved from baseline to each follow-up across RCD and RAH status. RCD was not associated with differential improvement in outcomes for either group. In the SBI group, those RAH reported larger reductions at 3 months in average and maximum quantity than those not RAH but did not differ from those not RAH at 12-month outcomes. Among the SBI group, changing from not ready to ready (RTC or RAH) post-intervention was not associated with greater reductions in drinking compared with remaining not ready or ready post-intervention.

Conclusions: Baseline RCD is not associated with drinking outcomes. Baseline RAH may facilitate greater reductions in drinking for those receiving SBI and should be further examined as a possible mediator of SBI effects for young adults of Mexican origin.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4495078PMC
http://dx.doi.org/10.15288/jsad.2015.76.602DOI Listing
July 2015

Opioid education and nasal naloxone rescue kits in the emergency department.

West J Emerg Med 2015 May 1;16(3):381-4. Epub 2015 Apr 1.

Boston University School of Medicine, Boston Medical Center, Department of Emergency Medicine, Boston, Massachusetts ; Boston University School of Public Health, Department of Community Health Sciences, Boston, Massachusetts.

Introduction: Emergency departments (EDs) may be high-yield venues to address opioid deaths with education on both overdose prevention and appropriate actions in a witnessed overdose. In addition, the ED has the potential to equip patients with nasal naloxone kits as part of this effort. We evaluated the feasibility of an ED-based overdose prevention program and described the overdose risk knowledge, opioid use, overdoses, and overdose responses among participants who received overdose education and naloxone rescue kits (OEN) and participants who received overdose education only (OE).

Methods: Program participants were surveyed by telephone after their ED visit about their substance use, overdose risk knowledge, history of witnessed and personal overdoses, and actions in a witnessed overdose including use of naloxone.

Results: A total of 415 ED patients received OE or OEN between January 1, 2011 and February 28, 2012. Among those, 51 (12%) completed the survey; 37 (73%) of those received a naloxone kit, and 14 (27%) received OE only. Past 30-day opioid use was reported by 35% OEN and 36% OE, and an overdose was reported by 19% OEN and 29% OE. Among 53% (27/51) of participants who witnessed another individual experiencing an overdose, 95% OEN and 88% OE stayed with victim, 74% OEN and 38% OE called 911, 26% OEN and 25% OE performed rescue breathing, and 32% OEN (n=6) used a naloxone kit to reverse the overdose. We did not detect statistically significant differences between OEN and OE-only groups in opioid use, overdose or response to a witnessed overdose.

Conclusion: This is the first study to demonstrate the feasibility of ED-based opioid overdose prevention education and naloxone distribution to trained laypersons, patients and their social network. The program reached a high-risk population that commonly witnessed overdoses and that called for help and used naloxone, when available, to rescue people. While the study was retrospective with a low response rate, it provides preliminary data for larger, prospective studies of ED-based overdose prevention programs.
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http://dx.doi.org/10.5811/westjem.2015.2.24909DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4427207PMC
May 2015

Smoking Is Associated with Increased Risk of Binge Drinking in a Young Adult Hispanic Population at the US-Mexico Border.

Subst Abus 2015 ;36(3):318-24

a Texas Tech University Health Science Center , El Paso , Texas , USA.

Background: This study examines factors related to general health and health behavior, including smoking, that may be associated with binge drinking, drinking "at risk," and potential for alcohol use disorder among young adults of Mexican ancestry.

Methods: A total of 2191 young adult emergency department (ED) patients (18-30 years) of Mexican ancestry in a public hospital proximate to the US-Mexico border completed health surveys while they were waiting to be treated, including questions on general health, drinking, smoking, and drug use.

Results: Thirty-seven percent of the study participants reported binge drinking, 38% were "at-risk" alcohol users (above National Institute on Alcohol Abuse and Alcoholism guidelines), and 22% were Rapid Alcohol Problem Screen (RAPS) positive (indicating potential for alcohol use disorder). Smoking was reported by 31%, marijuana use by 16%, and other drug use by 9%. Multiple variable models revealed that smoking was the strongest factor associated with binge drinking. Those who smoked were 3.1 (P < .0001) times more likely to binge drink. Other factors independently associated with binge drinking were age 22-25 years (odds ratio [OR] = 1.5, P = .003), male gender (OR = 1.5, P = .0001), and ED visit for injury (OR = 1.4, P = .007).

Conclusions: There is a strong association of smoking and binge drinking. Study findings suggest that brief interventions designed to reduce preventable health risks for young Hispanics should include discussion of both binge drinking and smoking behaviors.
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http://dx.doi.org/10.1080/08897077.2014.987945DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4461552PMC
November 2016

The association of injury with substance use disorder among women of reproductive age: an opportunity to address a major contributor to recurrent preventable emergency department visits?

Acad Emerg Med 2014 Dec;21(12):1459-68

Boston University School of Public Health, Boston, MA.

Objectives: Substance use disorder (SUD) among women of reproductive age is a complex public health problem affecting a diverse spectrum of women and their families, with potential consequences across generations. The goals of this study were 1) to describe and compare the prevalence of patterns of injury requiring emergency department (ED) visits among SUD-positive and SUD-negative women and 2) among SUD-positive women, to investigate the association of specific categories of injury with type of substance used.

Methods: This study was a secondary analysis of a large, multisource health care utilization data set developed to analyze SUD prevalence, and health and substance abuse treatment outcomes, for women of reproductive age in Massachusetts, 2002 through 2008. Sources for this linked data set included diagnostic codes for ED, inpatient, and outpatient stay discharges; SUD facility treatment records; and vital records for women and for their neonates.

Results: Injury data (ICD-9-CM E-codes) were available for 127,227 SUD-positive women. Almost two-thirds of SUD-positive women had any type of injury, compared to 44.8% of SUD-negative women. The mean (±SD) number of events also differed (2.27 ± 4.1 for SUD-positive women vs. 0.73 ± 1.3 for SUD-negative women, p < 0.0001). For four specific injury types, the proportion injured was almost double for SUD-positive women (49.3% vs 23.4%), and the mean (±SD) number of events was more than double (0.72 ± 0.9 vs. 0.26 ± 0.5, p < 0.0001). The numbers and proportions of motor vehicle incidents and falls were significantly higher in SUD-positive women (22.5% vs. 12.5% and 26.6% vs. 11.0%, respectively), but the greatest differences were in self-inflicted injury (11.5% vs. 0.8%; mean ± SD events = 0.19 ± 0.9 vs. 0.009 ± 0.2, p < 0.0001) and purposefully inflicted injury (11.5% vs 1.9%, mean ± SD events = 0.18 ± 0.1 vs. 0.02 ± 0.2, p < 0.0001). In each of the injury categories that we examined, injury rates among SUD-positive women were lowest for alcohol disorders only and highest for alcohol and drug disorders combined. Among 33,600 women identified as using opioids, 2,132 (6.3%) presented to the ED with overdose. Multiple overdose visits were common (mean ± SD = 3.67 ± 6.70 visits). After adjustment for sociodemographic characteristics, psychiatric history, and complex/chronic illness, SUD remained a significant risk factor for all types of injury, but for the suicide/self-inflicted injury category, psychiatric history was by far the stronger predictor.

Conclusions: The presence of SUD increases the likelihood that women in the 15- to 49-year age group will present to the ED with injury. Conversely, women with injury may be more likely to be involved in alcohol abuse or other substance use. The high rates of injury that we identified among women with SUD suggest the utility of including a brief, validated screen for substance use as part of an ED injury treatment protocol and referring injured women for assessment and/or treatment when scores indicate the likelihood of SUD.
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http://dx.doi.org/10.1111/acem.12548DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4330107PMC
December 2014

A research agenda for gender and substance use disorders in the emergency department.

Acad Emerg Med 2014 Dec 1;21(12):1438-46. Epub 2014 Dec 1.

Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI.

For many years, gender differences have been recognized as important factors in the etiology, pathophysiology, comorbidities, and treatment needs and outcomes associated with the use of alcohol, drugs, and tobacco. However, little is known about how these gender-specific differences affect ED utilization; responses to ED-based interventions; needs for substance use treatment and barriers to accessing care among patients in the ED; or outcomes after an alcohol-, drug-, or tobacco-related visit. As part of the 2014 Academic Emergency Medicine consensus conference on "Gender-Specific Research in Emergency Care: Investigate, Understand and Translate How Gender Affects Patient Outcomes," a breakout group convened to generate a research agenda on priority questions related to substance use disorders.
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http://dx.doi.org/10.1111/acem.12534DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4318812PMC
December 2014

Age and sharing of needle injection equipment in a cohort of Massachusetts injection drug users: an observational study.

Addict Sci Clin Pract 2013 Dec 13;8:20. Epub 2013 Dec 13.

Department of Epidemiology, Harvard School of Public Health, 677 Huntington Ave,, Boston MA, USA.

Background: Hepatitis C infection (HCV) among individuals aged 15-24 years has increased in Massachusetts, likely due to injection drug use. The prevalence of injection equipment sharing (sharing) and its association with age was examined in a cohort of out-of-treatment Massachusetts substance users.

Methods: This analysis included baseline data from a behavioral intervention with substance users. Younger and older (<25 versus ≥ 25 years) injection drug users were compared on demographic characteristics, substance use practices, including factors present during the most recent sharing event ("event-level factors"), and HCV testing history.

Results: Sharing was reported by 41% of the 484 individuals who reported injection drug use in the past 30 days. Prevalence of sharing varied by age (50% <25 years old versus 38% ≥ 25 years, p=0.02). In a multivariable logistic regression model younger versus older individuals had twice the odds of sharing (95% CI=1.26, 3.19). During their most recent sharing event, fewer younger individuals than older had their own drugs available (50% versus 75%, p<0.001); other injection event-level factors did not vary by age. In the presence of PTSD, history of exchanging sex for money, or not being US born, prevalence of sharing by older users was higher and was similar to that of younger users, such that there was no association between age and sharing.

Conclusions: In this cohort of injection drug users, younger age was associated with higher prevalence of sharing, but only in the absence of certain stressors. Harm reduction efforts might benefit from intervening on mental health and other stressors in addition to substance use. Study findings suggest a particular need to address the dangers of sharing with young individuals initiating injection drug use.
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http://dx.doi.org/10.1186/1940-0640-8-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3880095PMC
December 2013

Qualitative analysis of cocaine and heroin users' main partner sex-risk behavior: is safety in love safety in health?

Addict Sci Clin Pract 2013 Apr 23;8:10. Epub 2013 Apr 23.

Boston University School of Medicine, Boston, MA, USA.

Background: In 2009, 27% of the 48,100 estimated new cases of HIV were attributed to heterosexual contact with an infected or at-risk person. Sexually active adults are less likely to use condoms in relationships with main partners than with non-regular partners, despite general knowledge that condom use reduces HIV transmission.

Methods: The purpose of this secondary qualitative analysis was to explore and contextualize perceptions of main partnerships, HIV risk, and attitudes toward condom use within main partner relationships among a subsample of intervention-arm cocaine- and/or heroin-using patients enrolled in a negative trial of brief motivational intervention to reduce the incidence of sexually transmitted disease and unsafe sexual behaviors. The open-ended portion of these interview audiotapes consisted of questions about perceptions of risk and attitudes about condom use with main partners. Enrollees were aged 18-54, English or Spanish speaking, and included in this analysis only if they reported having a main partner. We identified codes and elaborated important themes through a standard inductive three step coding process, using HyperRESEARCH™ software.

Results: Among 48 interviewees, 65% were male, half were non-Hispanic white, over 60% were 20-39 years of age, 58% had intravenous drug use (IDU), and 8% were HIV-positive. Participants defined respect, support, trust, and shared child-rearing responsibility as the most valued components of main partner relationships. Condom use was viewed occasionally as a positive means of showing respect with main partners but more often as a sign of disrespect and a barrier to intimacy and affection. Enrollees appraised their partners' HIV risk in terms of perceptions of physical health, cleanliness, and sexual and HIV testing history. They based decisions regarding condom use mainly on perceived faithfulness, length of involvement, availability of condoms, and pregnancy desirability.

Conclusions: Risk appraisal was commonly based on appearance and subjective factors, and condom use with main sexual partners was described most often as a demonstration of lack of trust and intimacy.

Trial Registration: NCT01379599.
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http://dx.doi.org/10.1186/1940-0640-8-10DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698184PMC
April 2013

Long-term follow-up after voluntary human immunodeficiency virus/sexually transmitted infection counseling, point-of-service testing, and referral to substance abuse treatment from the emergency department.

Acad Emerg Med 2012 Apr;19(4):386-95

Department of Emergency Medicine, Boston University School of Medicine, Boston Medical Center, MA, USA.

Objectives: Public health initiatives have lowered human immunodeficiency virus (HIV) transmission risk associated with injection drug use in the United States, making sexual risk behaviors a greater source of transmission. Strategies are therefore needed to reduce these risk behaviors among all emergency department (ED) patients who use drugs, regardless of route of administration. Although recent articles have focused on the opportunity for early HIV detection and treatment through an array of ED screening and testing strategies, the effect of voluntary HIV testing and brief counseling (VT/C) on the sexual behaviors of out-of-treatment drug users over time has not yet been reported.

Methods: From November 2004 to May 2008, the study screened 46,208 urban ED patients aged 18 to 54 years; 2,148 (4.6%) reported cocaine or heroin use within 30 days, 1,538 met eligibility criteria (Drug Abuse Severity Test [DAST] scores ≥3 and were either English- or Spanish-speaking), and 1,030 were enrolled. These data were obtained in the course of a randomized, controlled trial (Project SAFE) of a brief motivational intervention focused on reducing risky sexual behaviors. Although the intervention itself did not demonstrate any differential effect on the number or percentage of unprotected sexual acts, both control and intervention group participants received baseline VT/C and referral for drug treatment as part of the study protocol. This study is a report of a secondary analysis of cohort data to describe changes in sexual behaviors over time among drug users after the VT/C and referral.

Results: The mean (±SD) age of enrollees was 35.8 (±8.4) years; 67% were male, 39% were non-Hispanic black or African American, 41% were white non-Hispanic, and 19% were Hispanic. Half injected drugs, and 53% met criteria for posttraumatic stress disorder (PTSD). At baseline testing, 8.8% were HIV-positive on enzyme-linked immunosorbent assay. Follow-ups were conducted at 6 and 12 months, with an attrition rate of 22%. Known HIV-positive patients accounted for 84 of 1,030 cases (8.1%), and 13 new cases were discovered: 7 of 946 at were discovered at the baseline contact (0.74%), 2 of 655 were discovered at 6 months (0.3%), and 4 of 706 (0.57%) were discovered at the 12-month contact. Twelve of the 13 returned for confirmatory testing and were actively enrolled in our infectious disease clinic. For all partners, there was a reduction in the percentage of unprotected sex acts over time (p < 0.0001), with decreases at 6 months versus baseline (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.60 to 0.83), sustained at 12 months versus baseline (OR = 0.69, 95% CI = 0.58 to 0.82). For the outcome of percentage of sex acts while high, there was also a significant reduction over time (p < 0.0001), with a drop-off at 6 months versus baseline (OR = 0.31, 95% CI = 0.25 to 0.37) that was sustained at 12 months (OR vs. baseline 0.25, 95% CI = 0.20 to 0.30). In an adjusted model, male sex, older age, and HIV positivity predicted significant declines over time in the likelihood of unprotected sexual acts. Older age and higher baseline drug severity predicted significant decreases over time in the likelihood of sex acts while high.

Conclusions: Voluntary testing and counseling for HIV or sexually transmitted infections, accompanied by referral to drug treatment, for this population of ED cocaine and heroin users was associated with reduction in unprotected sex acts and fewer sex acts while high.
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http://dx.doi.org/10.1111/j.1553-2712.2012.01314.xDOI Listing
April 2012

The impact of a brief motivational intervention on unprotected sex and sex while high among drug-positive emergency department patients who receive STI/HIV VC/T and drug treatment referral as standard of care.

AIDS Behav 2012 Jul;16(5):1203-16

Department of Emergency Medicine, Boston University School of Medicine, Boston Medical Center, 1 Boston Medical Center Place (Dowling 1), Boston, MA 02118, USA.

This randomized, controlled trial, conducted among out-of-treatment heroin/cocaine users at an emergency department visit, tests the impact on sexual risk of adding brief motivational intervention (B-MI) to point-of-service testing, counseling and drug treatment referral. 1,030 enrollees aged 18-54 received either voluntary counseling/testing (VC/T) with drug treatment referral, or VC/T, referral, and B-MI, delivered by an outreach worker. We measured number and proportion of non-protected sex acts (last 30 days) at 6 and 12 months (n = 802). At baseline, 70% of past-30-days sex acts were non-protected; 35% of sex acts occurred while high; 64% of sexual acts involved main, 24% casual and 12% transactional sex partners; 1.7% tested positive for an STI, and 8.8% for HIV. At six or 12 month follow-up, 20 enrollees tested positive for Chlamydia and/or Gonorrhea, and 6 enrollees HIV sero-converted. Self-reported high-risk behaviors declined in both groups with no significant between-group differences in behaviors or STI/HIV incidence.
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http://dx.doi.org/10.1007/s10461-012-0134-0DOI Listing
July 2012

Feasibility of chronic disease patient navigation in an urban primary care practice.

J Ambul Care Manage 2012 Jan-Mar;35(1):38-49

Women's Health Unit, Section of General Internal Medicine, Evans Department of Medicine and Women's Health Interdisciplinary Research Center, Boston University School of Medicine, Boston, MA 02118, USA.

The purpose of this study was to evaluate the feasibility of incorporating chronic disease navigation using lay health care workers trained in motivational interviewing (MI) into an existing mammography navigation program. Primary-care patient navigators implemented MI-based telephone conversations around mammography, smoking, depression, and obesity. We conducted a small-scale demonstration, using mixed methods to assess patient outcomes and provider satisfaction. One hundred nine patients participated. Ninety-four percent scheduled and 73% completed a mammography appointment. Seventy-one percent agreed to schedule a primary care appointment and 54% completed that appointment. Patients and providers responded positively. Incorporating telephone-based chronic disease navigation supported by MI into existing disease-specific navigation is efficacious and acceptable to those enrolled.
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http://dx.doi.org/10.1097/JAC.0b013e31822cbd7cDOI Listing
April 2012

Mechanisms of change in control group drinking in clinical trials of brief alcohol intervention: implications for bias toward the null.

Drug Alcohol Rev 2010 Sep;29(5):498-507

Department of Community Health Sciences, Boston University School of Public Health, Boston, MA 02118, USA.

Issues: Reductions in control group consumption over time that are possibly related to research design affect the impact of brief alcohol interventions (BAI) in clinical settings.

Approach: We conducted a systematic review to identify research design factors that may contribute to control group change, strategies to limit these effects and implications for researchers. Studies with control group n > 30 were selected if they published baseline and outcome consumption data, conducted trials in clinical settings in Anglophone countries and did not censor gender or age.

Key Findings: Among 38 studies cited in 20 reviews through October 2009, 16 met criteria (n = 31-370). In 54%, controls received alcohol specific handouts, advice and/or referral. Both the number and depth of assessments were highly variable. The percentage change in consumption ranged from-0.10 to-0.84 (mean-0.32), and effect size from 0.04 to 0.70 (mean 0.37). Published data were insufficient for meta-analysis.

Implications: Researchers should consider strategies to reduce the impact of research design factors, such as procedures to enhance sample diversity, blind subjects to study purpose to limit social desirability bias, reduce the number and depth of instruments (assessment reactivity), and finally, analytic techniques to decrease the impact of outliers and regression to the mean.

Conclusions: This review identifies problems with retrospective analysis of predictors of control group change, and underscores the need to design prospective studies to permit identification, quantification and adjustment for potential sources of bias in BAI trials.
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http://dx.doi.org/10.1111/j.1465-3362.2010.00174.xDOI Listing
September 2010