Implementation of strength-based case management for opioid-dependent patients presenting in medical emergency departments: rationale and study design of a randomized trial.

BACKGROUND: As the USA grapples with an opioid epidemic, medical emergency departments (EDs) have become a critical setting for intervening with opioid-dependent patients. Brief interventions designed to bridge the gap from acute ED care to longer-term treatment have shown limited efficacy for this population. Strength-based case management (SBCM) has shown strong effects on treatment linkage among patients with substance use disorders in other healthcare settings. This study aimed to investigate whether SBCM is an effective model for linking opioid-dependent ED patients with addiction treatment and pharmacotherapy. Here, we describe the implementation and challenges of adapting SBCM for the ED (SBCM-ED). Study rationale, design, and baseline characteristics are also described. METHODS: This study compared the effects of SBCM-ED to screening, assessment, and referral alone (SAR) on treatment linkage, substance use, and functioning. We recruited participants from a public hospital in NYC. Working alliance between case managers and participants and the feasibility of SBCM implementation were evaluated. Baseline data from the randomized sample were analyzed for group equivalency. Outcomes analyses are forthcoming. RESULTS: Three hundred adult participants meeting DSM-IV criteria for opioid dependence were randomly assigned to either SBCM, in which they received a maximum of six case management sessions within 90 days of enrollment, or SAR, in which they received a comprehensive referral list and pamphlet outlining drug use consequences. No significant differences were found between groups at baseline on demographic or substance use characteristics. All SAR participants and 92.6% of SBCM-ED participants initiated their assigned intervention. Over half of SBCM-ED first sessions occurred in the ED on the day of enrollment. Case managers developed a strong working alliance with SBCM-ED participants after just one session. CONCLUSION: Interventions that exceed SBIRT were accepted by an opioid-dependent patient population seen in an urban medical ED. At the time of study funding, this trial was one of the first to focus specifically on this population in this challenging setting. The successful implementation of SBCM demonstrates its adaptability to the ED and may serve as a potential model for EDs seeking to adopt an intervention that overcomes the barrier between the ED encounter and more intensive treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT02586896 . Registered on 27 October 2015.

A Meta-Analysis of the Efficacy of Case Management for Substance Use Disorders: A Recovery Perspective.

Background: Case management is a client-centered approach to improve the coordination and continuity of service delivery, especially for persons with substance use disorders (SUD) and multiple and complex support needs. This intervention supports individuals by helping them identify needed services, facilitate linkage with services, and promote participation and retention in services. However, it is questionable whether case management is equally effective in promoting recovery and aspects of personal functioning. The objective was to conduct an updated meta-analysis and to assess whether case management was more effective than treatment as usual (TAU) among persons with SUD for improving treatment-related (e.g., successful linkage with and retention in treatment) as well as personal functioning outcomes (e.g., substance use). Methods: This meta-analysis focuses on randomized controlled trials (RCTs) that included persons with alcohol or drug use disorders and compared case management with TAU. To be eligible, interventions had to meet core case management functions as defined in the literature. We conducted searches of the following databases to May 2017: the Cochrane Drugs and Alcohol Specialized Register, CENTRAL, PubMed, Embase, CINAHL, and Web of Science. Also, reference lists of retrieved publications were scanned for relevant (un)published studies. Results: The overall effect size for case management compared to TAU across all outcome categories and moments was small and positive (SMD = 0.18, 95% CI 0.07-0.28), but statistically significant. Effects were considerably larger for treatment tasks (SMD = 0.33, 95% CI 0.18-0.48) than for personal functioning outcomes (SMD = 0.06, 95% CI -0.02 to 0.15). The largest effect sizes were found for retention in substance abuse treatment and linkage with substance abuse services. Moderator effects of case management models and conditions were assessed, but no significant differences were observed. Conclusions: The primary results from earlier meta-analyses were supported: case management is more effective than TAU conditions for improving outcomes, but this effect is significantly larger for treatment-related tasks than for personal functioning outcomes. Case management can be an important supplement to available services for improving linkage and retention, although further research is needed to assess its potential for supporting recovery from a longitudinal perspective.

Clarifying Parents' and Pediatricians' Views of Partnership.

PURPOSE: Given the importance of partnership in improving health care outcomes among children, there is a substantial need to understand better what partnership means to parents and physicians. The goal of this study was to develop a partnership survey that was based on parents' and pediatricians' opinions about the key concepts of partnership. METHODS: Parents of patients visiting an affluent suburban private practice and a federally qualified health center, and 2 groups of pediatricians, were asked to review 61 partnership concepts and identify those they considered as being important to partnership. RESULTS: Parents and pediatricians from both practices agreed that 42 (68.9%) of the concepts were important to partnership. Sixteen of these concepts were dropped because they were redundant. Parents from both the suburban practice and health center identified 5 (8.2%) concepts that they believed contributed to partnership. Seven (11.5%) concepts were viewed as important to parents and pediatricians from the suburban practice but not to parents from the health center. Significant socioeconomic differences between the 2 parent groups suggested factors that explained the differences between parent groups. CONCLUSION: The 38 concepts endorsed by parents and pediatricians provided a nuanced view of partnership and formed the Parent Pediatrician Partnership Survey.

The efficacy of case management with persons who have substance abuse problems: a three-level meta-analysis of outcomes.

OBJECTIVE: Case management has been widely used as an intervention in the treatment of substance abuse problems. Its effectiveness has been associated with over 450 outcomes, some consistent with case management's traditional functions of linking (treatment tasks) and others typical of treatment outcomes such as substance use (personal functioning). METHOD: Meta-analyses were conducted on 21 randomized clinical trials in which we compared the efficacy of case management with standard-of-care conditions and active interventions. Characteristics of case management-including targeted outcomes, case management model, location on the treatment continuum, and intervention quality-were treated as moderators, as were 2 study features, length of follow-up, and methodological quality. RESULTS: RESULTS showed that case management was efficacious across all targeted outcomes when compared with standard of care (δ = 0.15, SE = 0.037), although the overall effect was weak. There was a significant difference, F(1, 429) = 25.26, p < .0001, between case management's effect on treatment task outcomes such as linking with and staying in treatment (δ2 = .29, p = .001) and improving individuals' functioning of persons with substance abuse problems in areas such as substance use and HIV risk behaviors (δ1 = 0.06, p = .05). Moderator analyses demonstrated that (a) 4 case management models were more effective than standard of care in improving treatment task outcomes and (b) case management was effective either in or out of treatment. CONCLUSIONS: Our results demonstrate that case management is effective across a wide range of treatment task outcomes, but more limited in its effectiveness with personal functioning outcomes.

The role of jails in engaging PLWHA in care: from jail to community.

HIV testing in jails has provided public health officials with the opportunity to not only identify new cases of HIV but to also reestablish contact with previously diagnosed individuals, many of whom never entered care following diagnosis or entered care but then dropped out. The presence of inmates throughout the HIV/AIDS continuum of care suggests that jails can play a strategic role in engaging persons living with HIV and AIDS in care. In order to be successful in structuring HIV/AIDS programs in jails, health care and correctional officials will be well-served to: (1) understand the HIV/AIDS continuum of care from the standpoint of engagement interventions that promote participation; (2) be aware of jail, community, and prison interventions that promote engagement in care; (3) anticipate and plan for the unique barriers jails provide in implementing engagement interventions; and, (4) be creative in designing engagement interventions suitable for both newly and previously diagnosed individuals.

Longitudinal association of preference-weighted health-related quality of life measures and substance use disorder outcomes.

AIM: To examine the construct validity of generic preference-weighted health-related quality of life measures in a sample of patients with a substance use disorder (SUD). DESIGN: Longitudinal (baseline and 6-month follow-up) data from a research study that evaluated interventions to improve linkage and engagement with SUD treatment. SETTING: A central intake unit that referred patients to seven SUD treatment centers in a Midwestern US metropolitan area. PARTICIPANTS: A total of 495 individuals with a SUD. MEASUREMENTS: Participants completed two preference-weighted measures: the self-administered Quality of Well-Being scale (QWB-SA) and the standard gamble weighted Medical Outcomes Study SF-12 (SF-6D). They were also administered two clinical assessments: all seven domains of the Addiction Severity Index (ASI) and a symptom checklist based on the DSM-IV. Construct validity was determined via the relationships between disease-specific SUD and generic measures. FINDINGS: In unadjusted analyses, the QWB-SA and SF-6D change scores were correlated significantly with six ASI subscale change scores, but not with employment status. In adjusted repeated-measures analyses, three of seven ASI subscale scores were significant predictors of QWB-SA and 5/7 ASI subscale scores were significant predictors of SF-6D. Abstinence and problematic use at follow-up were significant predictors of QWB-SA and SF-6D. Effect sizes ranged from 0.352 to 0.400 for abstinence and -0.484 to -0.585 for problematic use. CONCLUSIONS: Generic preference-weighted health-related quality of life measures show moderate to good associations with substance-use specific measures and in certain circumstances can be used in their stead. This study provides further support for the use of the Quality of Well-Being scale and Medical Outcomes Study SF-12 in clinical and economic evaluations of substance use disorder interventions.

Development of the pretreatment readiness scale for substance abusers: modification of an existing motivation assessment.

The Texas Christian University-Treatment Motivation Assessment (TCU-TMA) was originally developed to assess motivation among in-treatment opiod users. Numerous studies of in-treatment substance abusers in a variety of settings have confirmed the three factors present in the scale, including Problem Recognition, Desire For Help, and Treatment Readiness. The goal of the present study was to examine the factor structure of the TCU-TMA in a sample of 367 pretreatment substance abusers assessed at a centralized intake unit who had not yet entered treatment. Exploratory and confirmatory factor analyses led to the development of the Pretreatment Readiness Scale (PRS) that, like the TCU-TMA, contained Problem Recognition and Treatment Readiness factors. Desire for Change replaced Desire for Help in the new scale and Treatment Reluctance indicated mixed feelings about entering treatment. The implications of these findings on developing interventions for the pretreatment group will be discussed.

The multidimensional structure of external barriers to substance abuse treatment and its invariance across gender, ethnicity, and age.

The goal of the present study was to identify the multidimensional factor structure of external barriers to substance abuse treatment and test its invariance across gender, ethnic, and age groups in a sample of 518 substance abusers assessed at a centralized intake unit. Exploratory (EFA) and confirmatory factor analyses (CFA) demonstrated a well-defined multidimensional factor structure of highly differentiated external barrier factors: time conflict, treatment accessibility, treatment entry difficulty, and financial problems. Furthermore, multi-group CFA tests were used to test equivalencies of the measurement and structural models. The statistical fit results supported the invariance of the ethnic groups. Although there were some gender and age differences in measurement and structural relations among the external barrier facets, the model fit indices results provided support for the invariance of both measurement and structural models. The findings suggest that it would be reasonable to consider the pattern of factor loadings and structure relations as invariant across gender, ethnic, and age groups.

Improving linkage with substance abuse treatment using brief case management and motivational interviewing.

BACKGROUND: Poor linkage with substance abuse treatment remains a problem, negating the benefits that can accrue to both substance abusers and the larger society. Numerous behavioral interventions have been tested to determine their potential role in improving linkage. METHODS: A randomized clinical trial of 678 substance abusers compared the linkage effect of two brief interventions with the referral standard of care (SOC) at a centralized intake unit (CIU). Interventions included five sessions of strengths-based case management (SBCM) or one session of motivational interviewing (MI). A priori hypotheses predicted that both interventions would be better than the standard of care in predicting linkage and that SBCM would be more effective than MI. We analyzed the effect of the two interventions on overall treatment linkage rates and by treatment modality. Logistic regression analysis examined predictors of treatment linkage for the sample and each group. RESULTS: Two hypotheses were confirmed in that SBCM (n=222) was effective in improving linkage compared to the SOC (n=230), 55.0% vs. 38.7% (p<.01). SBCM improved linkage more than MI (55.0% vs. 44.7%, p<.05). Motivational interviewing (n=226) was not significantly more effective in improving linkage than the standard of care (44.7% vs. 38.7%; p>.05). The three trial groups differed only slightly on the client characteristics that predicted linkage with treatment. CONCLUSIONS: The results of this study confirm a body of literature that supports the effectiveness of case management in improving linkage with treatment. The role of motivational interviewing in improving linkage was not supported. Results are discussed in the context of other case management and motivational interviewing linkage studies.

Brief strengths-based case management promotes entry into HIV medical care: results of the antiretroviral treatment access study-II.

OBJECTIVE: The Antiretroviral Treatment Access Study-II (ARTAS-II) evaluated a brief case management intervention delivered in health departments and community-based organizations (CBOs) to link recently diagnosed HIV-infected persons to medical care rapidly. METHODS: Recently diagnosed HIV-infected persons were recruited from 10 study sites across the United States during 2005 to 2006. The intervention consisted of up to 5 sessions with an ARTAS linkage case manager over a 90-day period. The outcome measure was whether or not the participant had seen an HIV medical care provider at least once within 6 months of enrollment. Multivariate logistic regression was used to identify significant predictors of receiving HIV medical care. RESULTS: Seventy-nine percent (497 of 626) of participants visited an HIV clinician at least once within the first 6 months. Participants who were older than 25 years of age, Hispanic, and stably housed; had not recently used noninjection drugs; had attended 2 or more sessions with the case manager; and were recruited at a study site that had HIV medical care colocated on its premises were all significantly more likely to have received HIV care. CONCLUSIONS: The ARTAS linkage case management intervention provides a model that health departments and CBOs can use to ensure that recently diagnosed HIV-infected persons attend an initial HIV care encounter.

Individual and system influences on waiting time for substance abuse treatment.

Waiting time is a contemporary reality of many drug abuse treatment programs, resulting in substantial problems for substance users and society. Individual and system factors that influence waiting time are diverse and may vary at different points in the treatment continuum. This study assessed waiting time preceding clinical assessment at a centralized intake unit and during the period after the assessment but before treatment entry. The present study included 577 substance abusers who were enrolled in a large clinical trial of two brief treatment interventions in a midsize metropolitan area in Ohio. Bivariate analyses identified individual and system factors that influenced preassessment and postassessment waiting time, as well as total wait to treatment services. Multivariate analyses demonstrated that longer wait time for an assessment is influenced by being court referred, less belief in having a substance abuse problem, and less desire for change. A shorter wait to actually enter treatment is predicted by having a case manager, being more ready for treatment, and having less severe employment and alcohol problems. The different influences present during the two waiting periods suggest that assessment and treatment programs need to implement system changes and entry enhancement interventions that are specific to the needs of substance abusers at each waiting period.

Understanding the working alliance between persons with substance abuse problems and strengths-based case managers.

A substantial body of literature has examined the importance of the working alliance in psychotherapy; few works have examined it in the context of case management Qualitative methods were used to examine how 26 persons with substance abuse problems perceived the working alliance with case managers who practice from the strengths perspective. Clients' narratives emphasized the personal qualities of the case manager and the nature of the client-case manager relationship. Their narratives also reflected two guiding principles of strengths-based case management: personal control over goal-setting, and an emphasis on strengths. Most clients concluded that a positive working alliance helped them to build trust, self-worth, and self-esteem.

Effectiveness of different models of case management for substance-abusing populations.

Case management has been implemented in substance abuse treatment to improve (cost-) effectiveness, but controversy exists about its potential to realize this objective. A systematic and comprehensive review of peer-reviewed articles (n = 48) published between 1993 and 2003 is presented, focusing on the effects of different models of case management among various substance-abusing populations. Results show that several studies have reported positive effects, but only some randomized and controlled trials have demonstrated the effectiveness of case management compared with other interventions. Longitudinal effects of this intervention remain unclear. Although no compelling evidence was found for the effectiveness of case management, some evidence is available about the (differential) effectiveness of intensive case management and assertive community treatment for homeless and dually-diagnosed substance abusers. Strengths-based and generalist case management have proven to be relatively effective for substance abusers in general. Most positive effects concern reduced use of inpatient services and increased utilization of community-based services, prolonged treatment retention, improved quality of life, and high client satisfaction. Outcomes concerning drug use and psychosocial functioning are less consistent, but seem to be mediated by retention in treatment and case management. Further research is required to learn more about the extent of the effects of this intervention, how long these are sustained and what specific elements cause particular outcomes.

Pathways of Substance Users Linking (Or Not) With Treatment.

This qualitative paper describes different pathways substance users experience as they decide whether to link to treatment or not after being assessed in a centralized intake unit in a Midwestern city. The narratives of 16 participants who did not link with treatment were compared with the narratives of 20 participants who did. Narratives from both groups described similar themes that were experienced differently. Nonlinkers were characterized by pretreatment abstinence, a negative experience with previous treatment, little previous engagement in a treatment career, and meaningful social support coming from AA. Linkers were more likely to continue using drugs before treatment entry, yet they described more readiness for treatment and were more engaged in a treatment career. The treatment careers approach provides a broader framework for understanding linkage versus nonlinkage to treatment.

The Multidimensional Structure of Internal Barriers to Substance Abuse Treatment and Its Invariance Across Gender, Ethnicity, and Age.

The goal of the present study was to identify the dimensions present in items representing internal barriers to substance abuse treatment and to test their invariance across gender, ethnic, and age groups. Twenty items from the Barriers to Treatment Inventory (BTI) were used to assess the structure and nature of the internal treatment barriers of 518 clients presenting to a central intake unit for a substance abuse assessment. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) revealed that a five factor model provided the best fit to the data. Internal treatment barriers were best described by five dimensions: absence of problem, negative social support, fear of treatment, privacy concerns, and committed lifestyle. Extending the confirmatory factor analysis to test multi-group invariance, there were some differences in measurement and structural relations among the internal barrier dimensions across gender, ethnic, and age groups. However, the lack of invariance was small and practically insubstantial. The findings led to the conclusion that the theoretical constructs measured by the five internal barrier dimensions are equivalent across important characteristics in this population.

A folk model of treatment readiness among drug users in Ohio.

Despite the benefits of substance abuse treatment, only a small proportion of drug users enter treatment. Understanding "readiness" is critical for engaging drug users in treatment and for involving them in the recovery process. This paper reports on ethnographic interviews conducted with 35 active drug users as they were entering treatment services, to describe how they perceive readiness for treatment. Drug users expressed readiness for treatment in terms reflective of twelve step programs, a folk model of treatment. A better understanding of drug users' perceptions can help to inform interventions designed to improve readiness for treatment.

Understanding treatment readiness in recently assessed, pre-treatment substance abusers.

The goal of this study was to more fully understand readiness for treatment in a pre-treatment sample of 446 substance abusers. Structural Equation Modeling (SEM) was used to: (1) examine the relationships between readiness factors identified in the Pre-Treatment Readiness Scale; and (2) identify the effects of predisposing, illness, and inhibiting determinants on the factors. As with in-treatment samples, Problem Recognition was found to influence Treatment Readiness, although through a different intervening factor, Desire for Change rather than Desire for Help. A fourth factor, Treatment Reluctance, was also influenced by the Desire for Change factor. Fixed characteristics such as age and gender had minimal influences on readiness factors, as did inhibiting characteristics that reflected recent functioning. Illness characteristics including drug severity and perceived treatment barriers had a more robust influence on readiness factors. This study provides an increased understanding of readiness for treatment among pre-treatment substance abusers and also supported the construct validity of the Pre-Treatment Readiness Scale.

Treatment barriers identified by substance abusers assessed at a centralized intake unit.

The 59-item Barriers to Treatment Inventory (BTI) was administered to 312 substance abusers at a centralized intake unit following assessment but before treatment entry to assess their views on barriers to treatment. Factor analysis identified 25 items in 7 well-defined latent constructs: Absence of Problem, Negative Social Support, Fear of Treatment, Privacy Concerns, Time Conflict, Poor Treatment Availability, and Admission Difficulty. The factorial structure of the barriers is consistent with the findings of other studies that asked substance abusers about barriers to treatment and is conceptually compatible with Andersen's model of health care utilization. Factors were moderately to highly correlated, suggesting that they interact with one another. Selected characteristics were generally not predictive of barrier factors. Overall, results indicate that the BTI has good content validity and is a reliable instrument for assessing barriers to drug treatment. The potential utility of the BTI in assessment settings is discussed.