Training and fidelity monitoring of behavioral interventions in multi-site addictions research.

AIMS: Methods for the training and fidelity monitoring of behavioral interventions in multi-site addictions research are reviewed, including five published studies and seven ongoing studies sponsored by the National Institute on Drug Abuse-funded Clinical Trials Network. METHODS: Methods are categorized and reviewed consistent with a technology model of treatment delivery. Topics include: therapist selection, training, certification, and supervision; selection, training, and certification of supervisors; scales and processes used for monitoring of the quality of treatment; and processes followed to provide new training for replacement staff once trials have begun. RESULTS: The review reveals both a wide array of procedures and emerging standards for multi-site trials. Methodological weakness was observed with respect to limited empirical support for many adherence scales, little or no evaluation of supervisory processes, and no evaluation of re-training practices. CONCLUSIONS: Methods used in multi-site trials are important not only to ensure validity of those trials, but also to inform the wider dissemination of empirically based treatment into community agencies. Studies examining noted weaknesses are needed. Training and fidelity models that delegate responsibility to participating sites appear most relevant for establishing best practices for dissemination of behavioral interventions. The effectiveness of these distributed training and supervision models should be subjected to empirical study at a level of rigor comparable to the evaluation of their corresponding treatments.

Interdisciplinary benefits in Project MAINSTREAM: a promising health professions educational model to address global substance abuse.

Our purpose was to evaluate the interdisciplinary aspects of Project MAINSTREAM, a faculty development program that trained 39 competitively selected health professional tutors in substance abuse education. Mid-career faculty fellows (tutors) from 14 different health professions across the US dedicated 20% of their academic time for two years to Project MAINSTREAM. Teams of three fellows carried out curricular enhancement and service-learning field project requirements in mentored Interdisciplinary Faculty Learning Groups (IFLGs). Formative and summative evaluations were conducted via written questionnaires and confidential telephone interviews. The importance of interdisciplinary education was rated positively (mean of 3.57 on 1 - 5 scale). Using 18 parameters, fellows preferred interdisciplinary over single disciplinary teaching (means ranged from 3.40 - 4.86), and reported high levels of benefit from their interdisciplinary collaborations (means ranged from 3.53 - 4.56). Fellows reported that interdisciplinary educational collaborations were feasible (3.31) at their home institutions. The majority (63%) said that their trainees, colleagues, supervisors and institutions valued interdisciplinary training either "highly" or "somewhat", but 22% did not value it. The fellows identified scheduling conflicts (3.46), and lack of faculty rewards (3.46) such as pay or credit toward promotion, as two barriers that they encountered.

Effects of motivational interviewing training on mental health therapist behavior.

This study examined the effectiveness of training community mental health therapists in motivational interviewing (MI) adapted to treat clients with co-occurring disorders. Ten therapists with high caseloads of culturally diverse clients in two different community mental health settings fulfilled all study requirements. MI training consisted of a two-day didactic and experiential workshop followed by eight biweekly small group supervision (coaching) sessions. Using an interrupted time series design, 156 randomly selected therapy sessions involving 28 clients were coded for assessment of therapist fidelity to MI at multiple points in time, both pre- and post-training. Employing hierarchical linear modeling analysis, significant improvement in MI skill was observed after training on five of six key therapist ratings, and on the sole client rating (client change talk) that was examined. Importantly, the present study demonstrates training-related proficiency in motivational interviewing using: (a) a representative sample of mental health therapists from the community; (b) a protocol emphasizing adherence to a mental health treatment regimen as well as management of substance use behavior for clients with co-occurring disorders; (c) repeated random observations of therapy sessions; (d) measurement of training-related changes in clinician skills and self motivational statements by clients. Findings of this effectiveness study compared favorably with efficacy literature on MI training.

Creating change agents: a national substance abuse education project.

OBJECTIVE: This study evaluated the effects of a national interdisciplinary faculty development program, Project MAINSTREAM, on creating curriculum enhancement in health professional education. METHOD: Thirty-nine faculty completed a two-year, part-time fellowship program featuring interdisciplinary collaboration, mentoring, training meetings, and Internet-based instructional materials. The main vehicle for curricular change was a required collaborative education project to develop trainees' core competencies in substance abuse prevention services. RESULTS: Fellows used a variety of approaches to implement 123 curricula and provide 66,995 hours of training to 10,170 trainees. Ninety percent of the training hours occurred in required courses, a potential indication of sustainability. Fellows indicated that a majority of the offerings would be sustained beyond the fellowship. CONCLUSION: Project MAINSTREAM shows promise as a model for achieving durable curriculum change in response to the public health crisis associated with a workforce untrained to deliver substance abuse services.

Interdisciplinary service-learning substance abuse projects: processes and outcomes.

The purpose of this paper is to describe the development and implementation of community-based, service-learning field projects by 30 health professional faculty fellows of Project MAINSTREAM, a faculty development program on substance abuse. The fellows worked together for two years in 10 Interdisciplinary Faculty Learning Groups (IFLGs), which consisted of three academics of different disciplines. The ten projects are viewed within the context of service- learning and are based on a balance between the provision of services to the community and furthering the learning objectives of Project MAINSTREAM.

Reinforcement of counseling attendance and alcohol abstinence in a community-based dual-diagnosis treatment program: a feasibility study.

This study evaluated the effectiveness of a community-based contingency management (CM) protocol reinforcing punctual dual-diagnosis group counseling attendance and negative breath alcohol levels. Participants were 20 dual-diagnosis patients. The A-B-A within-subjects reversal design included a 4-week baseline phase (BL), a 12-week CM intervention, and a 4-week return-to-baseline phase (R-BL). Group counseling was provided twice weekly, with breath tests before each session. CM attendance rates were significantly higher (65%+-28%) than BL (45%+-32%, p<.05) and remained elevated in the R-BL phase (68%+-29%). Despite clinical reports of frequent intoxication, during the study all breath test results were negative, regardless of study phase. Thus, no contingency effect on alcohol use could be determined. Results suggest that CM interventions can be effective in increasing attendance in a community treatment program for the dually diagnosed.

Integrating medical and substance abuse treatment for addicts living with HIV/AIDS: evidence-based nursing practice model.

Forty-five active substance abusers with HIV/AIDS voluntarily participated in a substance abuse treatment research study with interviews at intake, 6 months and 12 months. These participants were engaged in treatment for a minimum of 45 days and a maximum of 90 days. The study used a nursing model of care, The Personalized Nursing LIGHT model, to integrate treatment for HIV/AIDS with substance abuse treatment. The LIGHT model seeks to enhance patient well being directly and thereby to support interventions that decrease substance use and improve management of chronic disease. The substance abuse treatment team included a nurse who used the LIGHT model and coordinated an integrated care protocol. The nurse accompanied clients on visits to their physicians for HIV treatment and facilitated the integration of medical recommendations with the substance abuse treatment. Six-month posttest data were gathered on all 45 participants and 12-month posttest interviews were accomplished with 29 of them. At 6 months, 78% of the respondents (35/45) reported no drug use in the past 30 days, and, at 12 months, 79% (23/29) were drug free for the past month. Significant decreases from intake to 6 months were detected on Addiction Severity Index (ASI) composite scores for drug use (p < 0.01), alcohol use (p < 0.04), medical severity (p < 0.02), psychiatric severity (p < 0.01), legal problems (p < 0.04), and employment difficulty (p < 0.01). Improvement of 6-month drug use composite scores was related significantly to treatment duration (R = 0.42; p < 0.01). Significant decreases in ASI measures of drug use (p < 0.01), alcohol use (p < 0.01), employment difficulty (p < 0.01), and family/social problems (p < 0.01) also occurred at 12 months. Well being, as measured by a Global Well Being Index, was found to improve significantly at 6 months (p < 0.02) and 12 months (p < 0.07). Concurrently, significant improvement was observed on Medical Outcomes Study-36-Item Short-Form Health Survey (SF-36) measures of general health and health functioning. These changes were noted at 6 months in the general health (p < 0.02), mental health (p < 0.01), social functioning (p < 0.01), role/emotional status (p < 0.04), and vitality (p < 0.01) subscales. At 12 months, the social functioning (p < 0.01) subscale responses were further decreased.

Injection drug use in North America.

Injection drug use of psychotropic agents for nontherapeutic purposes is associated with some of the most pernicious infectious diseases seen in the United States. There is an inextricable link between infection, injection drug use (IDU) and other risk behaviors, especially those related to sexual activity. A number of national surveys now provide excellent databases to track the breadth, scope and impact of IDU across the United States. The prevalence of heroin use has increased over the past decade with larger numbers of users presenting for treatment of drug use disorders. A host of serious infections can result from IDU. Prevention and early intervention with evidence-based harm-reduction strategies are crucial to reducing and eliminating these odious consequences.

Brief Intervention in Hazardous Drinking: An Important Adjunct to Medical School ATOD Curriculum.

Most medical school alcohol, tobacco and other drug (ATOD) curricula emphasize the diagnosis and treatment of alcohol abuse and dependence, even though a significant amount of alcohol-related morbidity and mortality is associated with the hazardous use of alcohol. An increased emphasis on screening for hazardous drinking and the use of early intervention has been shown to be effective in reducing heavy drinking in the primary care setting. This paper describes a family medicine clerkship seminar on clinical preventive medicine that focuses on tobacco and alcohol use. Results indicate that students learn that brief intervention counseling can influence patient behavior and plan to continue to use it in future patient encounters. However, the low number of students electing to intervene in hazardous drinking suggests that more curricular time is needed to overcome student resistance to addressing the alcohol use patterns of their patients.