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Background: Most people with alcohol or opioid use disorders (AUD or OUD) are not diagnosed or treated for these conditions in primary care. This study takes a critical step toward quantifying service gaps and directing improvement efforts for AUD and OUD by using electronic health record (EHR) data from diverse primary care organizations to quantify the extent to which AUD and OUD are underdiagnosed and undertreated in primary care practices.Methods: We extracted and integrated diagnosis, medication, and behavioral health visit data from the EHRs of 21 primary care clinics within four independent healthcare organizations representing community health centers and rural hospital-associated clinics in the Pacific Northwest United States. Rates of documented AUD and OUD diagnoses, pharmacological treatments, and behavioral health visits were evaluated over a two-year period (2015-2016).Results: Out of 47,502 adult primary care patients, 1476 (3.1%) had documented AUD; of these, 115 (7.8%) had orders for AUD medications and 271 (18.4%) had at least one documented visit with a non-physician behavioral health specialist. Only 402 (0.8%) patients had documented OUD, and of these, 107 (26.6%) received OUD medications and 119 (29.6%) had at least one documented visit with a non-physician behavioral health specialist. Rates of AUD diagnosis and AUD and OUD medications were higher in clinics that had co-located non-physician behavioral health specialists.Conclusions: AUD and OUD are underdiagnosed and undertreated within a sample of independent primary care organizations serving mostly rural patients. Primary care organizations likely need service models, technologies, and workforces, including non-physician behavioral health specialists, to improve capacities to diagnose and treat AUD and OUD. [ABSTRACT FROM AUTHOR]

Abstinence self-efficacy, coping skills, and therapeutic alliance are hypothesized mechanisms of behavioral change (MOBCs) in cognitive-behavioral therapy (CBT) for alcohol use disorder (AUD). However, little is known about when these hypothesized MOBCs change during treatment or in relation to the initiation of abstinence from alcohol, which the current study investigated. Patient-reported abstinence self-efficacy, drinking-related coping skills, and therapeutic alliance were measured at every session throughout a 12-session clinical trial that previously showed equivalent drinking reductions in female-specific individual- and group-based CBT for AUD. Participants (N = 121 women) were classified into subgroups based on whether and when they first initiated 14 days of continuous abstinence from alcohol during treatment. Interrupted time-series analyses evaluated the magnitude and timing of change in MOBC variables in relation to the initiation of abstinence. All three MOBC measures showed gradual improvements throughout treatment (within-subjects d = 0.03 to 0.09 change per week). Participants who initiated abstinence during treatment experienced additional sudden improvements in abstinence self-efficacy (d = 0.47) and coping skills (d = 0.27), but not therapeutic alliance (d = -0.02), the same week they initiated abstinence. Participants who were already abstinent when treatment started maintained higher abstinence self-efficacy and coping skills, but not therapeutic alliance, throughout treatment compared to participants who never initiated abstinence. Initiating abstinence may help facilitate improvements in abstinence self-efficacy and drinking-related coping skills. Clinicians may help patients anticipate when and how much these variables are expected to improve during treatment and encourage initiation of abstinence to potentially help facilitate improvements in abstinence self-efficacy and coping skills. [ABSTRACT FROM AUTHOR]

Most existing measures of persecutory ideation (PI) rely on infrequent in-person visits, and this limits their ability to assess rapid changes or real-world functioning. Mobile health (mHealth) technology may address these limitations. Little is known about passively sensed behavioral indicators associated with PI. In the current study, sixty-two participants with schizophrenia spectrum disorders completed momentary assessments of PI on a smartphone that also passively collected behavioral data for one year. Results suggested that PI was prevalent (n = 50, 82% of sample) but had infrequent incidence (25.2% of EMA responses). PI was also associated with changes in several passively sensed variables, including decreases in distance traveled (M kilometers = −1.20, SD = 18.88), time spent in a vehicle (M minutes = −4.15, SD = 49.59), length of outgoing phone calls (M minutes = −0.79, SD = 13.13), time spent proximal to human speech (M minutes = −6.26, SD = 153.03), and an increase in time sitting still (M minutes = 4.04, SD = 94.69). The present study suggests changes associated with PI may be detectable by passive sensors, including reductions in moving or traveling, and time spent around others or in self-initiated phone conversations. These constructs might constitute risk for PI. [ABSTRACT FROM AUTHOR]

Introduction: Structural equation modeling (SEM) is a multivariate data analytic technique used in many domains of addictive behaviors research. SEM results are usually summarized and communicated through statistical tables and path diagrams, which emphasize path coefficients and global fit without showing specific quantitative values of data points that underlie the model results. Data visualization methods are often absent in SEM research, which may limit the quality and impact of SEM research by reducing data transparency, obscuring unexpected data anomalies and unmodeled heterogeneity, and inhibiting the communication of SEM research findings to research stakeholders who do not have advanced statistical training in SEM.Methods and Results: In this report, we show how data visualization methods can address these limitations and improve the quality of SEM-based addictive behaviors research. We first introduce SEM and data visualization methodologies and differentiate data visualizations from model visualizations that are commonly used in SEM, such as path diagrams. We then discuss ways researchers may utilize data visualization in SEM research, including by obtaining estimates of latent variables and by visualizing multivariate relations in two-dimensional figures. R syntax is provided to help others generate data visualizations for several types of effects commonly modeled in SEM, including correlation, regression, moderation, and simple mediation.Discussion: The techniques outlined here may help spur the use of data visualization in SEM-based addictive behaviors research. Using data visualization in SEM may enhance methodological transparency and improve communication of research findings. [ABSTRACT FROM AUTHOR]

Providers' adherence in the delivery of behavioral interventions for substance use disorders is not fixed, but instead can vary across sessions, providers, and intervention sites. This variability can substantially impact the quality of intervention that clients receive. However, there has been limited work to systematically evaluate the extent to which substance use intervention adherence varies from session-to-session, provider-to-provider, and site-to-site. The present study quantifies the extent to which adherence to Motivational Interviewing (MI) for alcohol and drug use varies across sessions, providers, and intervention sites and compares the extent of this variability across three common MI research contexts that evaluate MI efficacy, MI effectiveness, and MI training. Independent raters coded intervention adherence to MI from 1275 sessions delivered by 216 providers at 15 intervention sites. Multilevel models indicated that 57%-94% of the variance in MI adherence was attributable to variability between sessions (i.e., within providers), while smaller proportions of variance were attributable to variability between providers (3%-26%) and between intervention sites (0.1%-28%). MI adherence was typically lowest and most variable within contexts evaluating MI training (i.e., where MI was not protocol-guided and delivered by community treatment providers) and, conversely, adherence was typically highest and least variable in contexts evaluating MI efficacy and effectiveness (i.e., where MI was highly protocolized and delivered by trained therapists). These results suggest that MI adherence in efficacy and effectiveness trials may be substantially different from that obtained in community treatment settings, where adherence is likely to be far more heterogeneous. [ABSTRACT FROM AUTHOR]

Background: Methadone is one of the most utilized treatments for opioid use disorder. However, requirements for observing methadone dosing can impose barriers to patients and increase risk for respiratory illness transmission (e.g., COVID-19). Video observation of methadone dosing at home could allow opioid treatment programs (OTPs) to offer more take-home doses while ensuring patient safety through remote observation of ingestion.Methods: Between April and August 2020, a clinical pilot program of video observation of methadone take-home dosing via smartphone was conducted within a multisite OTP agency. Participating patients completed a COVID-19 symptom screener and submitted video recordings of themselves ingesting all methadone take-home doses. Patients who followed these procedures for a two-week trial period could continue participating in the full pilot program and potentially receive more take-home doses. This retrospective observational study characterizes patient engagement and compares clinical outcomes with matched controls.Results: Of 44 patients who initiated the two-week trial, 33 (75 %) were successful and continued participating in the full pilot program. Twenty full pilot participants (61 %) received increased take-home doses. Full pilot participants had more days with observed dosing over a 60-day period than matched controls (mean = 53.2 vs. 16.6 days, respectively). Clinical outcomes were similar between pilot participants and matched controls.Conclusions: Video observation of methadone take-home dosing implemented during the COVID-19 pandemic was feasible. This model has the potential to enhance safety by increasing rates of observed methadone dosing and reducing infection risks and barriers associated with relying solely on face-to-face observation of methadone dosing. [ABSTRACT FROM AUTHOR]

Motivational interviewing (MI) is an efficacious treatment for substance use disorders and other problem behaviors. Studies on MI fidelity and mechanisms of change typically use human raters to code therapy sessions, which requires considerable time, training, and financial costs. Natural language processing techniques have recently been utilized for coding MI sessions using machine learning techniques, rather than human coders, and preliminary results have suggested these methods hold promise. The current study extends this previous work by introducing two natural language processing models for automatically coding MI sessions via computer. The two models differ in the way they semantically represent session content, utilizing either 1) simple discrete sentence features (DSF model) and 2) more complex recursive neural networks (RNN model). Utterance- and session-level predictions from these models were compared to ratings provided by human coders using a large sample of MI sessions (N=341 sessions; 78,977 clinician and client talk turns) from 6 MI studies. Results show that the DSF model generally had slightly better performance compared to the RNN model. The DSF model had "good" or higher utterance-level agreement with human coders (Cohen's kappa>0.60) for open and closed questions, affirm, giving information, and follow/neutral (all therapist codes); considerably higher agreement was obtained for session-level indices, and many estimates were competitive with human-to-human agreement. However, there was poor agreement for client change talk, client sustain talk, and therapist MI-inconsistent behaviors. Natural language processing methods provide accurate representations of human derived behavioral codes and could offer substantial improvements to the efficiency and scale in which MI mechanisms of change research and fidelity monitoring are conducted. [ABSTRACT FROM AUTHOR]

Background: The validity of the alcohol dependence syndrome has been supported. The question of whether different measures of the construct are comparable across studies and patient subgroups has not been examined. This study examined the alcohol dependence construct across four diverse large-scale treatment samples using integrative data analysis (IDA).Method: We utilized existing data (n=4393) from the COMBINE Study, Project MATCH, the Relapse Replication and Extension Project (RREP), and the United Kingdom Alcohol Treatment Trial (UKATT). We focused on four measures of alcohol dependence: the Alcohol Dependence Scale (COMBINE and RREP), Alcohol Use Inventory (MATCH), the Leeds Dependence Questionnaire (UKATT), and the Diagnostic and Statistical Manual of Mental Disorders (COMBINE and MATCH). Moderated nonlinear factor analysis was used to create a measure of alcohol dependence severity that was moderated by study membership, gender, age, and marital status.Results: A commensurate measure of alcohol dependence severity was successfully created using 20 items available in four studies. We identified differential item functioning by study membership, age, gender, and/or marital status for 12 of the 20 items, indicating specific patient subgroups who responded differently to items based on their underlying dependence severity.Conclusions: Alcohol dependence severity is a single unidimensional construct that is comparable across studies. The use of IDA provided a strong test of the validity of the alcohol dependence syndrome and clues as to how some items used to measure dependence severity may be more or less central to the construct for some patients. [ABSTRACT FROM AUTHOR]

Background: How the vitamin K oxidoreductase (VKORC1) supports vitamin K-dependent protein carboxylation is poorly understood. Results: VKORC1 multimers efficiently perform both reactions that reduce vitamin K, and the inactive monomer in wild type mutant heteromers suppresses reduction. Conclusion: VKORC1 fully reduces vitamin K required for carboxylation. Significance: Multimers are important inVKORC1mechanism and wild type mutant heteromers impact patients with warfarin resistance. [ABSTRACT FROM AUTHOR]

The γ-glutamyl carboxylase converts Glu to carboxylated Glu (Gla) to activate a large number of vitamin K-dependent proteins with diverse functions, and this broad physiological impact makes it critical to understand the mechanism of carboxylation. Gla formation is thought to occur in two independent steps (i.e. Glu deprotonation to form a carbanion that then reacts with CO2), based on previous studies showing unresponsiveness of Glu deprotonation to CO2. However, our recent studies on the kinetic properties of a variant enzyme (H160A) showing impaired Glu deprotonation prompted a reevaluation of this model. Glu deprotonation monitored by tritium release from the glutamyl γ-carbon was dependent upon CO2, and a proportional increase in both tritium release and Gla formation occurred over a range of CO2 concentrations. This discrepancy with the earlier studies using microsomes is probably due to the known accessibility of microsomal carboxylase to water, which reprotonates the carbanion. In contrast, tritium incorporation experiments with purified carboxylase showed very little carbanion reprotonation and consequently revealed the dependence of Glu deprotonation on CO2. Cyanide stimulated Glu deprotonation and carbanion reprotonation to the same extent in wild type enzyme but not in the H160A variant. Glu deprotonation that depends upon CO2 but that also occurs when water or cyanide are present strongly suggests a concerted mechanism facilitated by His-160 in which an electrophile accepts the negative charge on the developing carbanion. This revised mechanism provides important insight into how the carboxylase catalyzes the reaction by avoiding the formation of a high energy discrete carbanion. [ABSTRACT FROM AUTHOR]

Leptospirosis is an emerging infectious disease whose pathology includes a hemorrhagic response, and sequencing of the Leptospira interrogans genome revealed an ortholog of the vitamin K-dependent (VKD) carboxylase as one of several hemostatic proteins present in the bacterium. Until now, the VKD carboxylase was known to be present only in the animal kingdom (i.e. metazoans that include mammals, fish, snails, and insects), and this restricted distribution and high sequence similarity between metazoan and Leptospira orthologs strongly suggests that Leptospira acquired the VKD carboxylase by horizontal gene transfer. In metazoans, the VKD carboxylase is bifunctional, acting as an epoxidase that oxygenates vitamin K to a strong base and a carboxylase that uses the base to carboxylate Glu residues in VKD proteins, rendering them active in hemostasis and other physiologies. In contrast, the Leptospira ortholog showed epoxidase but not detectable carboxylase activity and divergence in a region of identity in all known metazoan VKD carboxylases that is important to Glu interaction. Furthermore, although the mammalian carboxylase is regulated so that vitamin K epoxidation does not occur unless Glu substrate is present, the Leptospira VKD epoxidase showed unfettered epoxidation in the absence of Glu substrate. Finally, human VKD protein orthologs were not detected in the L. interrogans genome. The combined data, then, suggest that Leptospira exapted the metazoan VKD carboxylase for some use other than VKD protein carboxylation, such as using the strong vitamin K base to drive a new reaction or to promote oxidative damage or depleting vitamin K to indirectly inhibit host VKD protein carboxylation. [ABSTRACT FROM AUTHOR]

Young adult frequent cannabis use has increased in prevalence and some frequent users have problems reducing their use. A strong link between momentary craving and subsequent use behaviors among individuals with problematic cannabis use has been reported in the literature, including young adults. In treatment contexts, interventions based on associative learning and reinforcement aim to reduce the prevalence of problematic substance use by altering the association between craving and use by increasing craving management skills such as mindfulness and reducing unhelpful responding such as avoidance or suppression. However, this model has not been tested among young adult cannabis users. The current study examined the influence of trait and state craving management strategies (mindfulness, coping style, experiential avoidance, and craving beliefs) on the link between momentary craving and use, using ecological momentary assessment in a sample of young adults with problematic use interested in reducing their use. Results demonstrated that two craving management constructs were associated with use: non-reactivity (p = 0.02) and non-judgment (p < 0.01). Interactions with momentary craving were observed for two constructs: non-judgmentalness (p = 0.02) and craving beliefs (p < 0.01). Findings suggest that treatments that increase non-reactivity and non-judgmentalness may reduce the occurrence of cannabis use for young adults contemplating reduction during an important period of biopsychosocial development by mitigating the impact of craving or directly reducing use. Additionally, negative beliefs about craving may serve a protective function during acute periods of elevation in momentary craving, an unexpected finding deserving further investigation. [ABSTRACT FROM AUTHOR]

Background: Patients with a substance use disorder (SUD) often present with co-occurring chronic conditions in primary care. Despite the high co-occurrence of chronic medical conditions and SUD, little is known about whether chronic condition outcomes or related service utilization in primary care varies between patients with versus without documented SUDs. This study examined whether having a SUD influenced the use of primary care services and common chronic condition outcomes for patients with diabetes, hypertension, and obesity.Methods: A longitudinal cohort observational study examined electronic health record data from 21 primary care clinics in Washington and Idaho to examine differences in service utilization and clinical outcomes for diabetes, hypertension, and obesity in patients with and without a documented SUD diagnosis. Differences between patients with and without documented SUD diagnoses were compared over a three-year window for clinical outcome measures, including hemoglobin A1c, systolic and diastolic blood pressure, and body mass index, as well as service outcome measures, including number of encounters with primary care and co-located behavioral health providers, and orders for prescription opioids. Adult patients (N = 10,175) diagnosed with diabetes, hypertension, or obesity before the end of 2014, and who had ≥2 visits across a three-year window including at least one visit in 2014 (baseline) and at least one visit occurring 12 months or longer after the 2014 visit (follow-up) were examined.Results: Patients with SUD diagnoses and co-occurring chronic conditions were seen by providers more frequently than patients without SUD diagnoses (p's < 0.05), and patients with SUD diagnoses were more likely to be prescribed opioid medications. Chronic condition outcomes were no different for patients with versus without SUD diagnoses.Discussion: Despite the higher visit rates to providers in primary care, a majority of patients with SUD diagnoses and chronic medical conditions in primary care did not get seen by co-located behavioral health providers, who can potentially provide and support evidence informed care for both SUD and chronic conditions. Patients with chronic medical conditions also were more likely to get prescribed opioids if they had an SUD diagnosis. Care pathway innovations for SUDs that include greater utilization of evidence-informed co-treatment of SUDs and chronic conditions within primary care settings may be necessary for improving care overall for patients with comorbid SUDs and chronic conditions. [ABSTRACT FROM AUTHOR]

Objectives: To test group-based Female-Specific Cognitive Behavioral Therapy (G-FS-CBT) for women with Alcohol Use Disorder (AUD) against an individual Female-Specific Cognitive Behavioral Therapy (I-FS-CBT). This aims of this paper are to describe G-FS-CBT development, content, feasibility, acceptability, group process, engagement in treatment, and within- and post-treatment outcomes.Methods: Women with AUD (n=155) were randomly assigned to 12 manual-guided sessions of G-FS-CBT or I-FS-CBT; 138 women attended at least one treatment session.Results: Women in G-FS-CBT attended fewer sessions (M=7.6) than women in I-FS-CBT (M=9.7; p<.001). Women in both conditions reported high satisfaction with the treatments. Independent coders rated high fidelity of delivery of both G-FS-CBT and I-FS-CBT. Therapeutic alliance with the therapist was high in both conditions, with I-FS-CBT being slightly but significantly higher than G-FS-CBT. In the first six weeks of treatment, women in both treatment conditions significantly reduced their percent drinking days (PDD) and percent heavy days drinking (PHD) by equivalent amounts, maintained through the rest of treatment and the 12month follow up with no treatment condition effects. Women reported significant improvement in all but one of the secondary outcomes during treatment; gains made during treatment in depression, anxiety, autonomy, and interpersonal problems were maintained during the follow-up period, while gains made during treatment in use of coping skills, self-efficacy for abstinence, self-care, and sociotropy deteriorated over follow up but remained improved compared to baseline.Conclusions: Findings support the feasibility, acceptability, and efficacy of a group format for female-specific CBT for AUD, a new 12-session, single gender, community friendly, group therapy with programming specifically for women. Similar, positive outcomes for individual and group treatment formats were found for drinking, mood, coping skills, self-confidence, interpersonal functioning, and self-care. [ABSTRACT FROM AUTHOR]

The vitamin K oxidoreductase (VKOR) reduces vitamin K to support the carboxylation and consequent activation of vitamin K-dependent proteins, but the mechanism of reduction is poorly understood. VKOR is an integral membrane protein that reduces vitamin K using membrane-embedded thiols (Cys-132 and Cys-135), which become oxidized with concomitant VKOR inactivation. VKOR is subsequently reactivated by an unknown redox protein that is currently thought to act directly on the Cys132-Cys135 residues. However, VKOR contains evolutionarily conserved Cys residues (Cys-43 and Cys-51) that reside in a loop outside of the membrane, raising the question of whether they mediate electron transfer from a redox protein to Cys-132/Cys-135. To assess a possible role, the activities of mutants with Ala substituted for Cys (C43A and C51A) were analyzed in intact membranes using reductants that were either membrane-permeable or -impermeable. Both reductants resulted in wild type VKOR reduction of vitamin K epoxide; however, the C43A and C51A mutants only showed activity with the membrane-permeant reductant. We obtained similar results when testing the ability of wild type and mutant VKORs to support carboxylation, using intact membranes from cells coexpressing VKOR and carboxylase. These results indicate a role for Cys-43 and Cys-51 in catalysis, suggesting a relay mechanism in which a redox protein transfers electrons to these loop residues, which in turn reduce the membrane-embedded Cys132-Cys135 disulfide bond to activate VKOR. The results have implications for the mechanism of warfarin resistance, the topology of VKOR in the membrane, and the interaction of VKOR with the carboxylase. [ABSTRACT FROM AUTHOR]

The high prevalence of opioid use among justice-involved adults make jails an exceptional setting to initiate opioid use disorder (OUD) treatment, but optimal strategies for delivering these interventions are still not well understood. The objective of this study was to conduct a randomized controlled trial to assess the effectiveness of extended-release naltrexone (XR-NTX, Vivitrol®; Alkermes Inc) alone or in conjunction with patient navigation (XR-NTX + PN) for jail inmates with OUD. We randomized a sample of 135 sentenced jail inmates with moderate to severe OUD to (1) XR-NTX only; (2) XR-NTX + PN; or (3) enhanced treatment-as-usual (ETAU) with drug education, each initiated prior to release from jail. We scheduled follow-up data assessments at 1, 3, 6, and 12 months post-release. Primary outcomes were opioid use (based on Timeline Followback Interview and Addiction Severity Index) and meeting CIDI DSM-5 criteria for OUD 6 months postrelease. We also measured treatment adherence, HIV risk, and recidivism. XR-NTX participants received a mean of 2.26 of 7 possible injections compared to XR-NTX + PN participants, who received a mean of 2.93 injections (Cohen's d = 0.33, 95% CI: -0.09 to 0.74). Thirty-six percent of patients in XR-NTX + PN attended at least one postrelease PN session. We found no significant differences by study condition six months after release from jail for the primary outcomes of any opioid use (ETAU: 17%, XR-NTX: 16%, XR-NTX + PN: 29%) and past 30-day OUD (ETAU: 8%, XR-NTX: 11%, XR-NTX + PN: 10%). Secondary outcomes of rearrest and HIV risk also were similar across groups, with the exception of lower sex-related HIV risk among those in the XR-NTX condition at 12 months. This study did not show superior outcomes of XR-NTX or XR-NTX + PN with regard to opioid use or recidivism outcomes, relative to ETAU. It did, however, highlight the difficulties with adherence to XR-NTX and PN interventions in OUD patients initiating treatment in jail. [ABSTRACT FROM AUTHOR]

Co-occurring substance use disorders (SUDs) are common among people with opioid use disorder (OUD) and known to hinder receipt of medications for OUD (MOUD). It is important to understand how MOUD care implemented outside of SUD specialty settings impacts access for patients with co-occurring SUDs. The Veterans Health Administration's (VA) Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative was implemented in primary care, mental health, and pain clinics in 18 VA facilities, and was found to increase MOUD receipt. This study assessed the SCOUTT initiative's impact among patients with and without co-occurring SUDs. This study used a controlled interrupted time series design. We extracted electronic health record data for patients with OUD with visits in SCOUTT intervention or matched comparison clinics during the post-implementation year (9/1/2018–8/31/2019). We examined the monthly proportion of patients who received MOUD in SCOUTT intervention or comparison clinics (primary care, mental health, and pain clinics), or in a VA SUD specialty clinic (where patients may have been referred), during the pre- and post-implementation years. Segmented logistic regression models estimated pre-post changes in outcomes (immediate level change from the final month of the pre-implementation period to the first month of the post-implementation period, change in trend/slope) in intervention vs. comparison facilities, adjusting for patient characteristics and pre-implementation trends. We stratified analyses by the presence of co-occurring SUDs. Among patients without co-occurring SUDs, the pre-post trend/slope change in MOUD received in SCOUTT intervention or comparison clinics was greater in intervention vs. comparison facilities (adjusted odds ratio [aOR]: 1.06, 95% confidence interval [CI]: 1.02–1.10), and the immediate increase in MOUD received in SUD clinics was greater in intervention vs. comparison facilities (aOR: 1.12, 95% CI: 1.02–1.22). These changes did not significantly differ in intervention vs. comparison facilities among patients with co-occurring SUDs. The SCOUTT initiative may have increased MOUD receipt primarily among patients without co-occurring SUDs. Focusing on increasing MOUD receipt for patients with co-occurring SUDs may improve the overall effectiveness of MOUD implementation efforts. • SCOUTT implemented MOUD in VA primary care, mental health, and pain clinics. • We examined SCOUTT's impact among patients with and without co-occurring SUD. • SCOUTT may have increased MOUD for patients without, but not with, co-occurring SUD. • MOUD implementation efforts should increase focus on patients with co-occurring SUD. [ABSTRACT FROM AUTHOR]

Objective: Alcohol Behavioral Couple Therapy (ABCT) is an efficacious alcohol treatment. The purpose of the study was to describe patient and partner language and therapist behavior during therapy sessions and test a proposed causal model linking active ingredients of ABCT as measured by therapist behaviors, hypothesized mechanisms of behavior change as measured by in-session patient and partner language, and alcohol use outcomes.Method: Data came from couples in four ABCT clinical trials (N = 188; 86 males, 102 females, and their partners). Patient and partner verbal behaviors in session one and a mid-treatment session were coded using the System for Coding Couples' Interactions in Therapy-Alcohol. Therapist behavior was coded using the Couples Treatment Integrity Rating System. Percent days abstinent was calculated from daily drinking data for the first and second half of treatment and six months post-treatment.Results: Therapists delivered an adequate level of the ABCT interventions during treatment. During treatment, couples increased positive behaviors, talked less about drinking, and decreased their amount of motivational language. Therapist behaviors did not predict patient or partner behaviors during treatment or drinking outcomes. Partner advice in the first session predicted poorer drinking outcomes. At mid-treatment, patient behaviors as a block, and specific behaviors of contemptuousness toward their partner and sustain talk, predicted poorer drinking outcomes.Conclusions: During ABCT, patients decrease their drinking, and patient and partner behaviors change in predicted ways. Partner advice, patient contemptuousness, and patient sustain talk predicted poorer outcomes. Analyses of within-session verbal behavior did not support the hypothesized mechanisms for change for ABCT. [ABSTRACT FROM AUTHOR]

Opioid use disorder (OUD) contributes to rising morbidity and mortality. Life-saving OUD treatments can be provided in primary care but most patients with OUD don't receive treatment. Comorbid depression and other conditions complicate OUD management, especially in primary care. The MI-CARE trial is a pragmatic randomized encouragement (Zelen) trial testing whether offering collaborative care (CC) to patients with OUD and clinically-significant depressive symptoms increases OUD medication treatment with buprenorphine and improves depression outcomes compared to usual care. Adult primary care patients with OUD and depressive symptoms (n ≥ 800) from two statewide health systems: Kaiser Permanente Washington and Indiana University Health are identified with computer algorithms from electronic Health record (EHR) data and automatically enrolled. A random sub-sample (50%) of eligible patients is offered the MI-CARE intervention: a 12-month nurse-driven CC intervention that includes motivational interviewing and behavioral activation. The remaining 50% of the study cohort comprise the usual care comparison group and is never contacted. The primary outcome is days of buprenorphine treatment provided during the intervention period. The powered secondary outcome is change in Patient Health Questionnaire (PHQ)-9 depression scores. Both outcomes are obtained from secondary electronic healthcare sources and compared in "intent-to-treat" analyses. MI-CARE addresses the need for rigorous encouragement trials to evaluate benefits of offering CC to generalizable samples of patients with OUD and mental health conditions identified from EHRs, as they would be in practice, and comparing outcomes to usual primary care. We describe the design and implementation of the trial, currently underway. Trial Registration: ClinicalTrials.gov Identifier: NCT05122676. Clinical trial registration date: November 17, 2021. [ABSTRACT FROM AUTHOR]

This study examined variability in Motivational Interviewing (MI) integrity among 15 providers for three years following training. Data come from an effectiveness trial in which providers were trained to deliver brief single-session MI interventions. Each session was audio-recorded and coded for MI integrity using the Motivational Interviewing Treatment Integrity (MITI) 3.1.1 rating system. Within-provider variation in MI integrity was large, especially for behavior count scores (e.g., open questions, complex reflections) and only slightly smaller for global session scores of MI Spirit and Empathy. Within-provider variability was in most cases larger than between-provider variability and there was no evidence that providers improved appreciably over time. These findings raise concerns about the quality of MI being delivered in large-scale implementation efforts and have implications for the monitoring and training of higher quality MI. [ABSTRACT FROM AUTHOR]

A characteristic feature of classic pseudoxanthoma elasticum (PXE), an autosomal recessive disorder caused by mutations in the ABCC6 gene, is aberrant mineralization of connective tissues, particularly the elastic fibers. Here, we report a family with PXE-like cutaneous features in association with multiple coagulation factor deficiency, an autosomal recessive disorder associated with GGCX mutations. The proband and her sister, both with severe skin findings with extensive mineralization, were compound heterozygotes for missense mutations in the GGCX gene, which were shown to result in reduced γ-glutamyl carboxylase activity and in undercarboxylation of matrix gla protein. The proband's mother and aunt, also manifesting with PXE-like skin changes, were heterozygous carriers of a missense mutation (p.V255M) in GGCX and a null mutation (p.R1141X) in the ABCC6 gene, suggesting digenic nature of their skin findings. Thus, reduced γ-glutamyl carboxylase activity in individuals either compound heterozygous for a missense mutation in GGCX or with haploinsufficiency in GGCX in combination with heterozygosity for ABCC6 gene expression results in aberrant mineralization of skin leading to PXE-like phenotype. These findings expand the molecular basis of PXE-like phenotypes, and suggest a role for multiple genetic factors in pathologic tissue mineralization in general.Journal of Investigative Dermatology (2009) 129, 553–563; doi:10.1038/jid.2008.271; published online 18 September 2008 [ABSTRACT FROM AUTHOR]