U.S. veterans' experiences and factors associated with use of a smartphone application to self-manage unhealthy alcohol use.

Unhealthy alcohol use is common among Operations Enduring and Iraqi Freedom (OEF/OIF) veterans, yet barriers discourage treatment-seeking. Mobile applications (apps) that deliver alcohol interventions have potential to address these barriers and increase treatment receipt. Few studies have qualitatively assessed users' experiences with apps to manage alcohol use. We assessed OEF/OIF veterans' experiences with Step Away, an app to reduce alcohol-related risks, to identify factors that may influence engagement. This single-arm pilot study recruited OEF/OIF veterans with positive alcohol screens nationwide using mail/telephone. Veterans aged 18-55 who exceeded drinking guidelines and owned an iPhone were eligible. Twenty-one (16 men, 5 women) of 55 participants completed interviews. Interviews were analyzed using thematic analysis. Participants found Step Away easy to use, although setup was time consuming. Participants reported increased awareness of alcohol use, highlighting daily assessment, weekly feedback, goal setting, and high-risk notification features as helpful and associated awareness with an intent to decrease use. Participants described Step Away as informative, with over half reporting they would use it outside of the study and most recommending it. Suggestions for improvement included greater personalization and control over features. Step Away features appear to influence engagement and increase users' awareness about alcohol consumed and factors associated with drinking, as well as intent to change. Assessment, feedback, and customization features of apps may facilitate app engagement. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

A randomized clinical trial evaluating the impact of counselor training and patient feedback on substance use disorder patients' sexual risk behavior.

INTRODUCTION: High risk sex-such as sex with multiple partners, condomless sex, or transactional or commercial sex-is a risk factor in individuals with substance use disorders (SUDs). SUD treatment can reduce sexual risk behavior, but interventions to reduce such behavior in this context have not been consistently effective. This study sought to determine if the impact of treatment on sexual risk behavior can be increased. METHODS: In a nested 2 × 2 factorial repeated measures design, we examined outcomes of two interventions: training for counselors in talking to patients about sexual risk; and availability to both counselors and patients of a personalized feedback report based on patient self-report of sexual behavior. Counselors received either a brief, information-based, Basic Training, or a multi-session, skills-based Enhanced Training. Their patients completed an audio-assisted computerized assessment of sexual behavior and received either No Feedback or a Personalized Feedback Report (PFR). Four hundred seventy six patients participated. Patient follow-up occurred 3- and 6-months postbaseline. Primary patient outcome measures were Number of Unsafe Sex Occasions (USO) and whether patients reported talking about sex in counseling sessions (Discussed Sex), both in the past 90 days. Secondary outcomes included Number of Sexual Partners, Sex Under the Influence of Substances, and Perceived Condom Barriers. RESULTS: Patients of Enhanced-condition counselors compared to those of Basic-condition counselors were more likely to report talking about sex with their counselor at 6-month follow-up. Personalized feedback also increased the likelihood of reporting counselor discussions at 6-month follow-up. Neither the training nor the feedback condition affected USO, Number of Partners, or Sex Under the Influence. DISCUSSION: We discuss why these two interventions apparently altered counselor-patient communication about sexual risk behavior without affecting the behavior itself.

Usability and Acceptability of a Mobile App for the Self-Management of Alcohol Misuse Among Veterans (Step Away): Pilot Cohort Study.

BACKGROUND: Alcohol misuse is common among Operation Enduring Freedom and Operation Iraqi Freedom veterans, yet barriers limit treatment participation. Mobile apps hold promise as means to deliver alcohol interventions to veterans who prefer to remain anonymous, have little time for conventional treatments, or live too far away to attend treatment in person. OBJECTIVE: This pilot study evaluated the usability and acceptability of Step Away, a mobile app designed to reduce alcohol-related risks, and explored pre-post changes on alcohol use, psychological distress, and quality of life. METHODS: This single-arm pilot study recruited Operation Enduring Freedom and Operation Iraqi Freedom veterans aged 18 to 55 years who exceeded National Institute on Alcohol Abuse and Alcoholism drinking guidelines and owned an iPhone. Enrolled veterans (N=55) completed baseline and 1-, 3-, and 6-month assessments. The System Usability Scale (scaled 1-100, ≥70 indicating acceptable usability) assessed the effectiveness, efficiency, and satisfaction dimensions of usability, while a single item (scaled 1-9) measured the attractiveness of 10 screenshots. Learnability was assessed by app use during week 1. App engagement (proportion of participants using Step Away, episodes of use, and minutes per episode per week) over 6 months measured acceptability. Secondary outcomes included pre-post change on heavy drinking days (men: ≥5 drinks per day; women: ≥4 drinks per day) and Short Inventory of Problems-Revised, Kessler-10, and brief World Health Organization Quality of Life Questionnaire scores. RESULTS: Among the 55 veterans enrolled in the study, the mean age was 37.4 (SD 7.6), 16% (9/55) were women, 82% (45/55) were White, and 82% (45/55) had an alcohol use disorder. Step Away was used by 96% (53/55) of participants in week 1, 55% (30/55) in week 4, and 36% (20/55) in week 24. Step Away use averaged 55.1 minutes (SD 57.6) in week 1 and <15 minutes per week in weeks 2 through 24. Mean System Usability Scale scores were 69.3 (SD 19.7) and 71.9 (SD 15.8) at 1 and 3 months, respectively. Median attractiveness scores ranged from 5 to 8, with lower ratings for text-laden screens. Heavy drinking days decreased from 29.4% (95% CI 23.4%-35.4%) at baseline to 16.2% (95% CI 9.9%-22.4%) at 6 months (P<.001). Likewise, over 6 months, Short Inventory of Problems-Revised scores decreased from 6.3 (95% CI 5.1-7.5) to 3.6 (95% CI 2.4-4.9) (P<.001) and Kessler-10 scores decreased from 18.8 (95% CI 17.4-20.1) to 17.3 (95% CI 15.8-18.7) (P=.046). Changes were not detected on quality of life scores. CONCLUSIONS: Operation Enduring Freedom and Operation Iraqi Freedom veterans found the usability of Step Away to be acceptable and engaged in the app over the 6-month study. Reductions were seen in heavy drinking days, alcohol-related problems, and Kessler-10 scores. A larger randomized trial is warranted to confirm our findings.

Virtual Standardized Patients vs Academic Training for Learning Motivational Interviewing Skills in the US Department of Veterans Affairs and the US Military: A Randomized Trial.

Importance: Despite the need for effective and scalable training in motivational interviewing (MI) that includes posttraining coaching and feedback, limited evidence exists regarding the effectiveness of using virtual (computerized) standardized patients (VSPs) in such training. Objective: To evaluate the efficacy of training with a VSP on the acquisition and maintenance of MI skills compared with traditional academic study. Design, Setting, and Participants: This study was a 2-group, parallel-training randomized trial of 120 volunteer health care professionals recruited from a Department of Veterans Affairs and Department of Defense medical facility. Motivational interviewing skill was coded by external experts blinded to training group and skill assessment time points. Data were collected from October 17, 2016, to August 12, 2019. Interventions: After a computer course on MI, participants trained during two 45-minute sessions separated by 3 months. The 2 randomized training conditions included a branching storyline VSP, which provided MI skill rehearsal with immediate and summative feedback, and a control condition, which included academic study of content from the computerized MI course. Main Outcomes and Measures: Measurement of MI skill was based on recorded conversations with human standardized patients, assessed using the Motivational Interviewing Treatment Integrity 4.2.1 coding system, measured at baseline, after training, and after additional training in the randomized condition 3 months later. Results: A total of 120 volunteers (83 [69%] women), with a mean (SD) of 13.6 (10.3) years of health care experience, participated in the study; 61 were randomized to receive the intervention, and 59 were randomized to the control group. Those assigned to VSP training had significantly greater posttraining improvement in technical global scores (0.23; 95% CI, 0.03-0.44; P = .02), relational global scores (0.57; 95% CI, 0.33-0.81; P = .001), and the reflection-to-question ratio (0.23; 95% CI, 0.15-0.31; P = .001). Differences were maintained after the 3-month additional training session, with more improvements achieved after the 3-month training for the VSP trainees on the reflection-to- question ratio (0.15; 95% CI, 0.07-0.24; P = .001). Conclusions and Relevance: This randomized trial demonstrated a successful transfer of training from a VSP to human standardized patients. The VSP MI skill outcomes were better than those achieved with academic study and were maintained over time. Virtual standardized patients have the potential to facilitate dissemination of MI and may be useful for training in other evidence-based skills and treatments. Trial Registration: ClinicalTrials.gov Identifier: NCT04558060.

Increasing substance use disorder counselors' self-efficacy and skills in talking to patients about sex and HIV risk: A randomized training trial.

BACKGROUND: People with substance use disorder (SUD) experience increased risk for HIV, Hepatitis C, and sexually transmitted illnesses via risky sex. This high-risk population would benefit from sexual risk reduction interventions integrated into SUD treatment. However, many SUD counselors report lack of skill or confidence in addressing sexual risk with patients. METHODS: This study was part of a larger nested 2 × 2 factorial repeated measures design, which compared two levels of counselor training (Basic-2 h versus Enhanced-10 h plus ongoing coaching). We determined whether counselors receiving Enhanced training addressing their motivation, confidence and skills (a) increased knowledge about sexual issues; (b) increased self-efficacy to discuss sex with patients; and (c) improved skills in discussing sex as part of SUD treatment, compared with those receiving shorter information-based training. Counselors providing individual therapy at two opioid treatment programs (OTP) and two psychosocial outpatient programs in the United States were eligible. Randomization occurred after Basic training. Measures included self-report (self-efficacy and knowledge) and blinded coding of standardized patient interviews (skill). RESULTS: Counselors receiving Enhanced training (n = 28) showed significant improvements compared to their Basic training counterparts (n = 32) in self-efficacy, use of reflections, and use of decision-making and communication strategies with standardized patients. These improvements were maintained from post-training to 3-month follow-up. No adverse effects of study participation were reported. CONCLUSIONS: Results suggest that counselors can improve their knowledge, self-efficacy and skill related to sexual risk conversations with patients based on modest skills-based training.

Counselor turnover in substance use disorder treatment research: Observations from one multisite trial.

Background: Counselor workforce turnover is a critical area of concern for substance use disorder (SUD) treatment providers and researchers. To facilitate the adoption and implementation of innovative treatments, attention must be paid to how SUD treatment workforce issues affect the implementation of clinical effectiveness research. Multiple variables have been shown to relate to turnover, yet reasons that are specific to conducting research have not been systematically assessed. Methods: In a randomized clinical trial testing a sexual risk reduction counselor training intervention, 69 counselors at 4 outpatient SUD treatment sites (2 opioid treatment programs [OTPs], 2 psychosocial) were enrolled and randomized to 1 of 2 training conditions (Standard vs. Enhanced). Study counselor and agency turnover rates were calculated. Agency context and policies that impacted research participation were examined. Results: Study turnover rates for enrolled counselors were substantial, ranging from 33% to 74% over approximately a 2-year active study period. Study counselor turnover was significantly greater at outpatient psychosocial programs versus OTPs. Counselor turnover did not differ due to demographic or training condition assignment. Leaving agency employment was the most typical reason for study counselor turnover. Conclusions: This secondary analysis used data from a multisite study with frontline counselors to provide a qualitative description of challenges faced when conducting effectiveness research in SUD treatment settings. That counselors may be both subjects and deliverers of the interventions studied in clinical trials, with implications for differential impact on study implementation, is highlighted. We offer suggestions for researchers seeking to implement effectiveness research in SUD clinical service settings.

Feasibility of a care management approach for complex substance use disorders and high acute services utilization.

Although care management approaches have potential to improve clinical outcomes and reduce healthcare costs, little is known about the feasibility of these interventions in patients with complex substance use disorders (SUDs), which are characterized by psychosocial, psychological and/or medical needs and high acute healthcare utilization. We assessed the feasibility of recruitment, treatment engagement, compliance with follow-up assessments, and patients' use of a care management model (CMM) at one medical center. This pilot study enrolled patients with complex SUDs and high healthcare utilization in a prospective, 1-year open trial of a CMM adapted for specific needs of this patient population. Patients completed baseline assessment, monthly assessments of treatment progress and follow-up assessments at 6- and 12-months. Patients' use of CMM services were abstracted from medical records. Of 33 eligible patients approached, 23 (69.6%) men enrolled in the study. Approximately 59.1% of patients attended a CMM visit in ≥8 of 12 months enrolled. Patients completed monthly assessments in 4.9 (SD = 3.1) of 12 months enrolled, and 68.2% and 41.0% completed 6- and 12-month follow-up assessments, respectively. The most common CMM service delivered was care coordination/case management, followed by supportive counseling, motivational interviewing, and medication management. Recruitment and engagement results suggest that use of CMM for complex SUDs and high healthcare utilization is feasible. More robust outreach services may be needed to increase engagement among those who did not engage or lost contact with the CMM team. Additional research is needed to evaluate if CMM enhances retention, improves outcomes and reduces acute healthcare utilization of patients with complex SUDs.

High inpatient utilization among Veterans Health Administration patients with substance-use disorders and co-occurring mental health conditions.

BACKGROUND: Substance-use disorders (SUDs) are common and costly conditions. Understanding high inpatient utilization (HIU) among patients with SUD can inform the development of treatment approaches designed to reduce healthcare expenditures and improve service quality. OBJECTIVES: To examine the prevalence, type, and predictors of HIU among patients with SUD and co-occurring mental health conditions. METHODS: Service utilization and demographic and clinical variables were extracted from a national sample of Veterans Health Administration (VA) patients with SUD-only [n = 148,960 (98.3% male)], SUD plus serious mental illness ([i.e. schizophrenia- and/or bipolar-spectrum disorders; SUD/SMI; n = 75,913 (91.6% male)], and SUD plus other mental illness [SUD/MI; n = 245,675 (94.6% male)]. Regression models were used to examine HIU during a follow-up year. RESULTS: Prevalence of HIU among the SUD-only group was 6.2% (95% confidence interval (CI): 6.1%-6.3%) compared with 22.7% (95% CI: 22.4%-23.0%) and 9.7% (95% CI: 9.6%-9.8%) among the SUD/SMI and SUD/MI groups, respectively. Patients with SUD/MI represented nearly half of the HIU sample. Primary type of inpatient service use varied by comorbidity: SUD-only = medicine; SUD/SMI = psychiatric; SUD/MI similar use of psychiatric, SUD-related, and medicine. Predictors of HIU were generally similar across groups: older age, unmarried, homelessness, suicide risk, pain diagnosis, alcohol/opioid/sedative-use disorders, and prior-year emergency department/inpatient utilization. CONCLUSIONS: Substantial reductions in HIU among an SUD population will likely require treatment approaches that target patients with less-severe mental health conditions in addition to SMI. Cross-service collaborations (e.g., integration of medical providers in SUD care) and interventions designed to target issues and/or conditions that lead to HIU (e.g., homeless care services) may be critical to reducing HIU in this population.

Patients' perspectives on care management services for complex substance use disorders.

Although care management approaches have potential to improve clinical outcomes and reduce high health care costs of patients with complex substance use disorders, characterized by high psychosocial, psychological, and/or medical needs and high acute health care utilization, little is known about patients' perspectives or experiences with these interventions. The objectives of this study were to identify barriers and facilitators to patient engagement in care management services for complex substance use disorders from patients' perspectives. This pilot study invited 22 men with complex substance use disorders and high health care utilization who were enrolled in a 1-year open trial of a Care Management Model to complete semi-structured interviews at 1- and 3-months post-baseline. Interviews were recorded, transcribed, and analyzed using template analysis. Five themes related to engagement were identified: barriers to conventional substance use disorder treatment, facilitators of care management services, patient-provider relationship, patient-related factors, and enhancements to a Care Management Model. Results highlighted the importance of the patient-provider relationship, individual visits with providers, flexible and personalized treatment, and a focus on recovery over abstinence in promoting patient engagement in care management services. Results also highlighted a need for increased outreach and assistance with housing and transit to treatment. Patients' perspectives support key elements of the care management services that are designed to facilitate patient engagement and suggest the need for additional outreach and assistance with obtaining shelter and transportation. Additional research is needed to evaluate if care management approaches enhance retention, improve outcomes, and reduce health care utilization of patients with complex and chronic substance use disorders.

Are there secondary effects on marijuana use from brief alcohol interventions for college students?

OBJECTIVE: This study examined whether brief motivational interventions (BMIs) designed for reducing heavy drinking among college students have secondary effects on reducing marijuana use. METHOD: The data came from Project INTEGRATE, which combined data from 24 independent trials of BMIs and other individual-focused interventions designed to reduce heavy drinking and related problems among college students. We analyzed data from 10 samples across nine studies that used random assignment of participants into either a BMI or a control group and assessed marijuana use outcomes (N = 6,768; 41.5% men; 73.2% White; 57.7% first-year students; 19.2% current marijuana users at baseline). We derived three marijuana use groups within studies by cross-tabulating baseline and follow-up data: Nonusers, Reducers, and Stayers/Increasers. RESULTS: Peto's one-step odds ratio analyses for meta-analysis revealed no significant intervention effects on marijuana use at either short-term (1-3 month) or long-term (6-12 month) follow-up. Subsequent exploratory analyses showed that those who reduced drinking were more likely to be a marijuana Reducer or Nonuser, compared with a Stayer/Increaser, at both follow-ups. CONCLUSIONS: The BMIs to reduce heavy drinking evaluated in this study did not reduce marijuana use. However, our exploratory results suggest that if we can develop interventions for college students that effectively reduce drinking, we may also reduce their marijuana use. Furthermore, as recreational use of marijuana becomes legal or decriminalized and marijuana becomes more readily available, it may be necessary to develop interventions specifically targeting marijuana use among college students.

Evaluating therapist adherence in motivational interviewing by comparing performance with standardized and real patients.

OBJECTIVE: The goal of measuring therapist adherence is to determine whether a therapist can perform a given treatment. Yet, the evaluation of therapist behaviors in most clinical trials is limited. Typically, randomized trials have few therapists and minimize therapist variability through training and supervision. Furthermore, therapist adherence is confounded with uncontrolled differences in patients across therapists. Consequently, the extent to which adherence measures capture differences in actual therapist adherence versus other sources of variance is unclear. METHOD: We estimated intra-class correlations (ICCs) for therapist adherence in sessions with real and standardized patients (RPs and SPs), using ratings from a motivational interviewing (MI) dissemination trial (Baer et al., 2009) in which 189 therapists recorded 826 sessions with both patient types. We also examined the correlations of therapist adherence between SP and RP sessions, and the reliability of therapist level adherence scores with generalizability coefficients (GCs). RESULTS: ICCs for therapist adherence were generally large (average ICC for SPs = .44; average ICC for RPs = .40), meaning that a given therapist's adherence scores were quite similar across sessions. Both ICCs and GCs were larger for SP sessions compared to RPs on global measures of MI adherence, such as Empathy and MI Spirit. Correlations between therapist adherence with real and standardized patients were moderate to large on 3 of 5 adherence measures. CONCLUSION: Differences in therapist-level adherence ratings were substantial, and standardized patients have promise as tools to evaluate therapist behavior.

Early adolescent substance use as a risk factor for developing conduct disorder and depression symptoms.

OBJECTIVE: Conduct disorder and depression symptoms are well-established risk factors for substance use during adolescence. However, few investigations have examined whether early substance use increases adolescents' risk of developing conduct disorder/depression symptoms. METHOD: Using the Developmental Pathways Project sample of 521 middle school students (51.6% male), we tested whether substance use (indicated by alcohol and marijuana use, and use-related impairment) in 8th and 9th grade increased risk of conduct disorder and depression symptoms in 9th and 12th grade over and above prior symptoms. We examined whether associations between substance use and conduct disorder/depression symptoms were consistent across self- or parent-reported symptoms and whether associations were moderated by gender. RESULTS: Analyses indicated that, over and above prior symptoms, elevated substance use in 8th grade predicted elevated conduct disorder symptoms in 9th grade, and substance use in 9th grade predicted conduct disorder symptoms in 12th grade. In contrast, substance use failed to predict later depression symptoms independent of prior symptoms. These findings were consistent across self- and parent-reported conduct disorder/depression symptoms. With one exception (association between substance use in 8th grade and self-reported conduct disorder symptoms in 9th grade), relations between early substance use and later conduct disorder symptoms did not differ between boys and girls. CONCLUSIONS: Study findings underscore the unique contribution of substance use during early adolescence to the development of conduct disorder symptoms by late adolescence.

The association of therapist empathy and synchrony in vocally encoded arousal.

Empathy is a critical ingredient in motivational interviewing (MI) and in psychotherapy generally. It is typically defined as the ability to experience and understand the feelings of another. Basic science indicates that empathy is related to the development of synchrony in dyads. However, in clinical research, empathy has proved difficult to operationalize and measure, and has mostly relied on the felt sense of observers, clients, or therapists. We extracted estimates of therapist and standardized patient (SP) vocally encoded arousal (mean fundamental frequency; mean f0) in 89 MI sessions with high and low empathy ratings from independent observers. We hypothesized (a) therapist and SP mean f0 would be correlated and (b) the correlation of therapist and SP mean f0 would be greater in sessions with high empathy as compared with low. On the basis of a multivariate mixed model, the correlation between therapist and SP mean f0 was large (r = .71) and close to 0 in randomly assigned therapist-SP dyads (r = -.08). The association was higher in sessions with high empathy ratings (r = .80) than in sessions with low ratings (r = .36). There was strong evidence for vocal synchrony in clinical dyads as well as for the association of synchrony with empathy ratings, illustrating the relevance of basic psychological processes to clinical interactions. These findings provide initial evidence for an objective and nonobtrusive method for assessing therapist performance. Novel indicators of therapist empathy may have implications for the study of MI process as well as the training of therapists generally. (PsycINFO Database Record (c) 2014 APA, all rights reserved).

Callous-unemotional traits and conduct disorder symptoms as prospective risk factors for adolescent sexual activity.

Conduct disorder (CD) has been shown to increase risk for adolescent sexual activity and pregnancy. Despite increasing evidence underscoring callous-unemotional (CU) traits as a marker for youth with CD prone to especially poor outcomes, researchers have yet to explore whether CU traits confer additional risk of early sexual intercourse, unprotected sex, and pregnancy. The Developmental Pathways Project sample, including 471 ethnically diverse 6th-grade boys and girls followed into 12th grade, was used to examine whether CU traits and CD symptoms in 6th grade uniquely and/or synergistically predicted having sexual intercourse by age 13 as well as unprotected sex and pregnancy by 12th grade. Parent-rated CU traits and CD symptoms interacted to predict young adolescents having sexual intercourse, such that youth with elevated CU traits and CD symptoms in 6th grade were more likely to reporting having sex by age 13 than those with low CU traits and/or low CD symptoms. Elevated CD symptoms, but not CU traits, uniquely increased risk of pregnancy by 12th grade. Neither CU traits nor CD symptoms predicted engagement in unprotected sex in 12th grade. Our findings indicate that adolescents with conduct problems and CU traits are especially at risk for early sexual intercourse. Conversely, elevated CU traits do not appear to increase risk of unprotected sex or pregnancy among young adolescents with conduct problems. Research is needed to replicate these findings and to explore mechanisms underlying the association between CU traits, CD symptoms, and early adolescent sexual activity.

Callous-unemotional traits as unique prospective risk factors for substance use in early adolescent boys and girls.

Youth with elevated conduct disorder (CD) symptoms who also have callous-unemotional (CU) traits exhibit more antisocial behavior than youth without CU traits. However, evidence regarding whether CU traits increase risk of substance use over and above CD symptoms, and whether these associations differ for boys and girls, is scarce. Using the Developmental Pathways Project sample of 521 middle school students, we examined whether adolescent- and parent-reported CU traits measured in 6th grade prospectively predicted the onset and recurrence of substance use and use-related impairment by 9th grade. We also examined the degree to which CU traits uniquely predicted substance use and impairment over and above CD symptoms, as well as whether gender moderated these associations. Results indicated that adolescent-reported CU traits increased the likelihood of substance use and impairment onset and recurrence by 9th grade. Analyses revealed that CD symptoms accounted for prospective associations between adolescent-reported CU and substance use, but gender moderated these associations. Boys with elevated CU traits and CD symptoms were not more likely to report alcohol use onset or recurrence, but they were at highest risk of recurrent marijuana use, use of both alcohol and marijuana, and use-related impairment by 9th grade. Girls with low CU traits and high CD symptoms were most likely to report onset and recurrent use of alcohol, as well as recurrent marijuana use, use of both substances and impairment. Study findings highlight the importance of accounting for CD symptoms and gender when examining links between CU traits and substance use in early adolescence.

Prevalence, predictors, and service utilization of patients with recurrent use of Veterans Affairs substance use disorder specialty care.

Although substance use disorders (SUDs) are chronic conditions for many patients, the prevalence, predictors, and health care utilization patterns of those who reenter SUD specialty care are understudied. We identified 1,640 patients who initiated SUD specialty care at 1 Veterans Affairs (VA) medical center and categorized them, using their subsequent 24 and prior 60 months receipt of VA SUD care, as index episode only (35.7%, 33.5-38.1), index and prior episode(s) (24.6%, 22.5-22.7), and index and postindex episodes (39.6%, 37.3-42.0). Compared with the index episode-only group, the postindex episode(s) group had modestly higher percentages of men, divorced/separated, and alcohol use, cocaine use, bipolar disorder, and psychotic disorders. Patients with postindex episodes averaged 2 times more postindex emergency visits and mental health hospitalizations than patients with an index only episode. Results document the prevalence, overall health care utilization, and limited predictability of SUD treatment reentry and support development of new models of care for these complex patients.

Computer Assessment of Simulated Patient Interviews (CASPI): psychometric properties of a web-based system for the assessment of motivational interviewing skills.

OBJECTIVE: Benefits of empirically supported interventions hinge on clinician skill, particularly for motivational interviewing (MI). Existing MI skill assessments are limited with respect to validity (e.g., self-report) and practicality (e.g., coding session tapes). To address these limitations, we developed and evaluated two versions of a web-based assessment of MI skills, the Computer Assessment of Simulated Patient Interviews (CASPI). METHOD: Ninety-six counselors from the community and 24 members of the Motivational Interviewing Network of Trainers (MINT) completed the CASPI (N = 120), in which they verbally responded via microphones to video clips comprising three 9-item vignettes. Three coders used an emergent coding scheme, which was compared with alternative MI skills measures. RESULTS: CASPI demonstrated excellent internal consistency when averaging across two or three vignettes (α's = .86-.89). Intraclass correlations were above .40 for most items. Confirmatory factor analyses supported a correlated three-factor model: MI-consistent, resistance-engendering, and global change talk orientation rating. Means and factor loadings were invariant across forms (i.e., the two alternative versions of CASPI), and factor loadings were invariant across subgroup (i.e., community counselor or MINT member). Test-retest reliability was good for MI-consistent and resistance-engendering scores (r = .74 and .80, respectively) but low for change talk orientation (r = .29) unless coder was taken into account (r = .69). CASPI showed excellent construct and criterion-related validity. CONCLUSIONS: CASPI represents a promising method of assessing MI skills. Future studies are needed to establish its performance in real-world contexts.

Mutual influence in therapist competence and adherence to motivational enhancement therapy.

Although psychotherapy involves the interaction of client and therapist, mutual influence is not typically considered as a source of variability in therapist adherence and competence in providing treatments assessed in clinical trials. We examined variability in therapist adherence and competence in Motivational Enhancement Therapy (MET) both within and between caseloads in a large multi-site clinical trial. Three-level multilevel models (repeated measures, nested within clients, nested with therapists) indicated significant variability both within and between therapists. There was as much and sometimes more variability in MET adherence and competence within therapist caseloads than between therapists. Variability in MET adherence and competence within caseloads was not consistently associated with client severity of addiction at baseline. However, client motivation at the beginning of the session and days of use during treatment were consistent predictors of therapist adherence and competence. Results raise questions about the nature of therapist adherence and competence in treatment protocols. Accordingly, future analysis of clinical trials should consider the role of mutual influence in measures of therapist performance.

Associations of housing status with substance abuse treatment and service use outcomes among veterans.

OBJECTIVE: This secondary analysis evaluated the prevalence and stability of homelessness over one year among veterans entering substance abuse treatment and explored associations among housing status, treatment outcomes, and Veterans Affairs (VA) service utilization. METHODS: Participants in a trial of on-site primary care for veterans entering substance abuse treatment (N=622) were placed in four groups based on housing status: housed at baseline and final follow-up (41%), homeless at baseline and final follow-up (27%), housed at baseline but homeless at final follow-up (8%), and homeless at baseline but housed at final follow-up (24%). Groups were compared on treatment retention, changes in Addiction Severity Index (ASI) composite scores, and VA service utilization and costs. RESULTS: Treatment retention and changes in ASI alcohol composites did not differ between groups. Compared with scores in the consistently housed group, the ASI drug composites improved less over time in the consistently homeless group (p=.031) and the ASI psychiatric composites improved less in the group housed at baseline and homeless at final follow-up (p=.019). All homeless groups were more likely than the consistently housed group to have inpatient admissions and incurred higher total treatment costs. The consistently homeless group was more likely to use emergency care than the consistently housed group. CONCLUSIONS: Homelessness affects substance abuse treatment outcomes and costs. Interventions are needed to reduce homelessness among veterans entering substance abuse treatment.