A team approach to systematic behavioral screening and intervention.

OBJECTIVES: Unhealthy behaviors are responsible for most chronic disease, ample healthcare costs, and around 40% of deaths. This study assessed patient satisfaction and behavioral outcomes for a program that enables healthcare settings to deliver evidence-based, cost-saving behavioral screening and intervention (BSI) services, as recommended by the US Preventive Services Task Force and others. STUDY DESIGN: Pre-post program evaluation. METHODS: Thirty-one diverse primary care clinics and 2 other sites participated. Over 110,000 patients completed multibehavioral screening questionnaires. Those with positive alcohol or drug screens met with dedicated, on-site health educators for further assessment, and then received either reinforcement, brief intervention, or referral. Over 300 patients completed satisfaction questionnaires during year 3 of the program. A pseudo-randomly selected group of 675 patients participated in a 6-month follow-up telephone interview. In addition, for a short time in a pilot project at 3 clinics, 29 patients received depression screening, collaborative care, and behavioral activation, and 22 completed a 3-month follow-up telephone interview. RESULTS: Mean patient satisfaction scores for all services exceeded 4.2 on a 5-point scale. Over 6 months, binge drinking episodes declined by over 20% for most subgroups. Recent marijuana use decreased by 15%. Depression symptom scores decreased by 55%. CONCLUSIONS: With intensive training and ongoing support, cost-efficient paraprofessionals can deliver effective alcohol, drug, and depression screening and intervention services in busy healthcare settings. The approach holds promise for systematically addressing on a population-wide basis a variety of important behavioral health determinants and reducing related healthcare costs.

Randomized-controlled trial of a telephone and mail intervention for alcohol use disorders: three-month drinking outcomes.

BACKGROUND: Alcohol screening, brief intervention, and referral to specialized treatment (ASBIR) reduce drinking and related harms. Unanswered questions are how to manage nondependent patients with poor response to brief interventions, how to manage dependent patients who do not obtain treatment, and how to ensure population-wide delivery of ASBIR. Telephone-administered counseling may provide answers. METHODS: We conducted a 12-month randomized controlled trial of a telephone and mail intervention for non-treatment-seeking primary care patients with alcohol use disorders. We enrolled 897 subjects after systematic screening in 18 primary care clinic waiting rooms in and around Madison and Milwaukee, Wisconsin, and subsequent telephone-administered diagnostic interviews. Experimental subjects received up to six sessions of protocol-driven telephone counseling based on principles of motivational interviewing and stages of readiness to change. Control subjects received a pamphlet on healthy lifestyles. The paper reports on 3-month drinking outcomes for men and women with alcohol abuse and dependence. RESULTS: Male experimental subjects (N=199) manifested a 30.6% decline in risky drinking days, compared with a 8.3% decline in controls (N=201, p<0.001). The total consumption declined by 17.3% compared with 12.9% by controls (p=0.001). Female experimental subjects (N=246) manifested a 17.2% decrease in risky drinking days compared with an 11.5% decrease by controls (N=251; p=NS) and a 13.9% decline in total consumption compared with 11.0% by controls (p=NS). Greater numbers of telephone counseling sessions were associated with greater declines in drinking. CONCLUSION: Following systematic screening, a six-session telephone and mail intervention is more effective than a pamphlet in reducing drinking at 3 months for non-treatment-seeking men with alcohol abuse and dependence. An intervention effect of the enrollment procedures may have obscured further intervention effectiveness. Telephone counseling shows promise for non-treatment-seeking primary care patients with alcohol use disorders.

Pharmacoepidemiology of potential alcohol-prescription drug interactions among primary care patients with alcohol-use disorders.

OBJECTIVE: To report on the proportion of individuals with alcohol-use disorders who take prescription medications that could interact with alcohol and on the proportion who recall advice to avoid alcohol with their medications. DESIGN: Secondary analysis of a randomized controlled trial of telephone counseling. SETTING: 18 primary care practices in south-central and southeastern Wisconsin. PATIENTS: 897 adults with alcohol-use disorders as identified by systematic survey. INTERVENTION: Telephone and mail survey. MAIN OUTCOME MEASURES: Patient-reported prescription medication use, potential for alcohol-drug interactions according to DrugDex, and patient-reported receipt of advice not to take alcohol with their medications. RESULTS: Of the 869 patients who provided usable information on prescription medication use, 348 (40.0%) were taking medications with alcohol interactions or proscriptions; the most frequently reported were bupropion, selective serotonin reuptake inhibitors, and various acetaminophen-containing compounds. Slightly more than 20% of patients were taking medications with moderate to severe alcohol interactions; over one-third of these 184 patients did not recall advice to avoid alcohol. CONCLUSION: Practitioners who prescribe or dispense medications may need to enhance their efforts to advise patients about alcohol-drug interactions. Prescribing and dispensing medications that interact with alcohol present opportunities to administer alcohol screens and interventions.

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.

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.