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Background Veterans with substance use problems have rates of partner and non-partner violence that typically exceed the general population. Sleep problems may exacerbate violence and maintain addictive behaviors in non-veterans, but requires study in veterans. Therefore, we examine the interrelationships between substance use, insomnia, and violence in veterans. Methods Veterans (N = 762) screened for a randomized controlled trial at veterans affairs mental health and substance use clinics. Participants completed modified Conflict Tactics Scales to quantify past-year violence and the Insomnia Symptom Questionnaire to assess sleep disturbance. We evaluated associations between substance use and sleep in predicting the target of aggression (partner or non-partner) and degree of violence (aggression or injury) using binomial logistic regressions. Results Half of participants endorsed symptoms suggestive of insomnia, 23.2% endorsed physical aggression toward partners (PA-P) and 33.9% non-partners (PA-NP), and 9.7% endorsed physical injury of partners (PI-P) and 17.6% of non-partners (PI-NP). Regressions revealed significant models for PA-P, PA-NP, and PI-NP, whereas the PI-P model was not significant. PA-P was higher among non-Caucasian race and older veterans. PA-NP was more common in those with insomnia and increased with frequency of cocaine use. Insomnia moderated the relationship between cocaine use and PA-NP; there was a weaker relationship between cocaine use and PA-NP in those with insomnia. PI-NP was more common with higher frequency of alcohol and cocaine use, and in those with insomnia. Conclusions This study finds sleep disturbances are meaningful predictors of violence among veterans with differential relationships with aggression severity, victims, and substance use concurrence.

BACKGROUND AND AIMS: Despite their high comorbidity, the effects of brief interventions (BI) to reduce cannabis use, alcohol use, and anxiety symptoms have received little empirical attention. The aims of this study were to examine whether a therapist-delivered BI (TBI) or computer-guided BI (CBI) to address drug use, alcohol consumption (when relevant) and HIV risk behaviors, relative to enhanced usual care (EUC), was associated with reductions in parallel trajectories of alcohol use, cannabis use, and anxiety symptoms, and whether demographic characteristics moderated reductions over time. DESIGN: Latent growth curve modeling was used to examine joint trajectories of alcohol use, cannabis use, and anxiety symptoms assessed at 3-, 6-, and 12-months after baseline enrollment. SETTING: Hurley Medical Center Emergency Department (ED) in Flint, Michigan, USA. PARTICIPANTS: The sample was 780 drug-using adults (18–60 years old; 56% female; 44% White) randomly assigned to receive either a TBI, CBI, or EUC through the HealthiER You study. INTERVENTIONS AND COMPARATOR: ED-delivered TBI and CBIs involved touchscreen-delivered and audio-assisted content. The TBI was administered by a Master’s-level therapist, whereas the CBI was self-administered using a virtual health counselor. EUC included a review of health resources brochures in the ED. MEASUREMENTS: Assessments of alcohol use (10-item Alcohol Use Disorders Identification Test), cannabis use (past 30-day frequency) and anxiety symptoms (Brief Symptom Inventory-18) occurred at baseline, and 3-, 6-, and 12-month follow-up. FINDINGS: TBI, relative to EUC, was associated with significant reductions in cannabis use (B=−.49, SE=.20, p

OBJECTIVE: To examine the efficacious components of a computer-delivered brief intervention (CBI) for reducing marijuana use among adults presenting to a low-income urban emergency department (ED), which a prior report found to decrease marijuana use at a 6-month follow-up. METHOD: Participants were 237 ED patients reporting recent drug use (46% male; 54% African-American; mean age, 30.7) who were randomized to receive a CBI consisting of an interactive program guided by a virtual health counselor. The primary outcome was past 30-day marijuana use at 6-month follow-up assessed using the Timeline Follow-Back (TLFB). Intervention components related to change in marijuana use at 6 month follow-up examined in the current study included participant responses to items within five CBI domains that were rooted in motivational interviewing: goals for change, strengths, evoking-change (concerns about use and benefits of change), challenges, and tools for change. RESULTS: The evoking-change domain was related to significant reductions in marijuana use at 6 months (B=−2.91, SE=1.10, p

Physical aggression (towards partners or non-partners) is common among patients in treatment for substance use disorders (SUDs), including among Veteran samples; however, few treatment programs provide adjunct intervention approaches targeting reduction or prevention of aggression. The primary objectives of this comparative efficacy study were to examine the impact of adjunct aggression interventions delivered during treatment on aggression and substance use outcomes, including: a) an acute treatment phase 6-session integrated Motivational Interviewing-Cognitive Behavioral Treatment intervention (MI-CBT) for aggression and substance use prevention, b) MI-CBT plus a 12-week telephone-based Continuing Care (MI-CBT + CC) intervention, and c) an acute phase single session control condition [including some discussion of violence prevention and local violence prevention resources (Enhanced Treatment as Usual (E-TAU))]. Participants (N = 180; 165 males and 15 females) were Veterans with SUD problems and past-year severe aggression who were randomized to one of three conditions: MI-CBT, MI-CBT + CC, or E-TAU. Primary 12-month outcomes included physical aggression and injury to partners, non-partners, and total aggression (collapsing across partner and non-partner relationships). Substance use outcomes included heavy drinking, marijuana use, cocaine use, and overall illicit substance use. Due to low representation in the sample (n = 4 women in each group at follow-up), women were excluded from primary analyses. According to unadjusted analyses of male participants, all groups showed similar significant declines in aggression over time, with the MI-CBT and MI-CBT + CC groups showing significant reductions in more substance use outcomes (heavy drinking, cocaine use, overall illicit drug use) than the E-TAU group. The only significant group x time interaction was for partner physical aggression by men (those in the MI-CBT + CC group showed a significantly greater decrease from baseline to follow-up). Also, neither the MI-CBT nor MI-CBT + CC groups reported any injuring of partners during the follow-up. For heavy drinking, cocaine, marijuana and overall illicit drug use, there were significant reductions over time, but no group by time interaction effects. The findings illustrate significant reductions in aggression and substance use over time for those involved in VA SUD treatment, and a potential modest benefit of additional integrated treatment approaches (MI-CBT, MI-CBT + CC) on reducing aggression. Future studies should examine dissemination efforts in the VA, cost-effectiveness, and moderators of outcome.

The shift from a multiaxial system of diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) brought forth the discontinuation of the Global Assessment of Functioning (GAF). DSM-5 proposes the use of a more reliable method for assessing and describing disability, the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). The WHODAS 2.0 is widely-used within the Department of Veterans Affairs (VA) and the Veterans Benefits Administration to guide clinical decision making and assist in decisions pertaining to financial compensation. While the WHODAS 2.0 purports to be well-validated for adults cross-culturally in clinical and non-clinical samples, research is limited pertaining to the factor structure of the WHODAS 2.0 in non-compensation seeking U.S. Veteran populations. This study evaluated the factor structure of the WHODAS 2.0 in a sample of 464 Veterans receiving VA mental healthcare. Exploratory and confirmatory factor analyses of the WHODAS 2.0 data were conducted. Analyses confirmed the hardiness of the WHODAS 2.0 for use with Veterans. However, exploratory analyses pointed to several items that may reduce the functioning of the questionnaire in clinical Veteran samples. Exploratory and confirmatory analyses indicated better model fit can be achieved.

Importance Chronic pain is common in those with substance use disorders (SUDs) and predicts poorer addiction treatment outcomes. A critical challenge for addiction treatment is to develop effective methods to improve pain-related and substance use-related outcomes for those in treatment for SUDs. Objective To examine the efficacy of an integrated behavioral pain management intervention (Improving Pain During Addiction Treatment [ImPAT]) for men and women with SUDs to treat pain, functioning, and substance use. Design, setting, and participants In this randomized clinical trial, 8 sessions of ImPAT were compared with 8 sessions of a supportive psychoeducational control (SPC) condition for adults with pain treated at a large residential SUD treatment program. Follow-up occurred at 3, 6, and 12 months postbaseline. A total of 1372 adults were screened, including 960 men and 412 women, and 510 adults were randomized, including 264 men and 246 women. The goal was to recruit approximately equal numbers of men and women to examine results separately in men and women. A total of 470 of 510 participants (92.2%) completed at least 1 follow-up assessment. Data were collected from October 3, 2011, to January 14, 2016. Data were analyzed from February 1, 2016, to May 1, 2020. Interventions ImPAT focused on how a psychosocial model of pain was associated with functioning and relapse prevention and provides skills to manage pain. SPC served as the active control condition and involved discussions of topics like nutrition and the course of addiction, which were intended to be relevant to the patient population and to have face validity but be distinct from the content of ImPAT. Main outcomes and measurements The primary outcomes were pain intensity, pain-related functioning, and behavioral pain tolerance at 12 months. Secondary outcomes were frequency of alcohol and drug use over 12 months. Results Of the 510 included participants, the mean (SD) age was 34.8 (10.3) years. A total of 133 men and 122 women were assigned to ImPAT, and a total of 131 men and 124 women were assigned to the SPC condition. Over 12 months of follow-up, randomization to the ImPAT intervention was associated with higher tolerance of pain among men, higher by a mean score of 0.11 (95% CI, 0.03 to 0.18; P = .004; Cohen d = 0.40) at 3 months and by 0.07 (95% CI, -0.01 to 0.19; P = .11; Cohen d = 0.25) at 12 months. Women receiving the ImPAT intervention experienced a reduction in pain intensity from 3 to 12 months, while women receiving the SPC condition experienced an increase in pain intensity, resulting in lower pain in the ImPAT condition by a mean score of 0.58 (95% CI, -0.07 to 1.22; P = .08; Cohen d = -0.22) at 12 months. No differences were found between the ImPAT and SPC conditions on alcohol or drug use. Conclusions and relevance Behavioral pain management is not typically included in addiction treatment, but the present results indicate that this type of intervention was associated with better pain-related outcomes, including pain tolerance in men and pain intensity in women. Improvements in substance use-related outcomes beyond that achieved by treatment as usual were not observed. Treatment programs should consider providing psychosocial pain management services to augment standard addiction treatment. Trial registration ClinicalTrials.gov Identifier: NCT01372267.

Individuals seeking substance use treatment who have one or more co-occurring mental health problems tend to have lower treatment engagement, higher rates of attrition, and poorer treatment outcomes. Readiness to change (RTC) is an integral construct in the recovery process, with higher RTC associated with improved treatment outcomes. However, the impact of psychiatric symptoms on RTC is not fully understood, especially among specialty subpopulations, such as military Veterans. Therefore, the aim of the present study was to examine the associations of mental health problems with RTC in a sample of Veterans initiating outpatient substance use treatment. The present sample was comprised of 278 Veterans (12% women, Mage = 48.22, SD = 14.06) who completed self-report intake measures assessing past month substance use frequency, substance-related consequences, symptoms of insomnia, depression, and anxiety, and importance and confidence to change one's substance use. Four separate canonical correlation analyses focusing on RTC alcohol, opioid, cannabis, and nicotine use were conducted. Veterans' inclusion in each analysis was not mutually exclusive. Results indicated that greater depression, anxiety, consequences, and frequency of alcohol use corresponded with greater importance to change alcohol use. Likewise, greater depression, anxiety, and insomnia symptoms along with frequency of use and consequences related to greater importance and confidence to change one's opioid use. In contrast, greater anxiety, depression, insomnia, and frequency of use were associated with less confidence in one's ability to change cannabis use. None of these variables were related to one's RTC nicotine use. Findings highlight the importance of assessing mental health problems at outset of substance use treatment, as they may be an indication of RTC and could be used as a catalyst to advance Veterans forward in the process of behavior change.

This study examines alcohol consumption, anxiety, trait mindfulness, and physical and sexual dating violence aggression (PDV and SDV) among 735 emerging adults (18-25 years) in an urban emergency department. Of the total sample, 27.2% perpetrated PDV and 16.5% perpetrated SDV. Alcohol was positively associated with PDV/SDV. Anxiety was positively associated with PDV. Mindfulness was negatively associated with PDV/SDV. Interaction analyses revealed women had lower PDV with higher nonjudgment facet of mindfulness. Higher act aware was associated with lower PDV regardless of high versus low alcohol. Findings indicate different contributing factors among perpetrators of PDV/SDV; some factors may be attenuated by mindfulness.

BACKGROUND: Reducing underage drinking is a public health priority given increased risk for injury and other consequences. Emergency department (ED) visits offer a potential “teachable moment” to initiate interventions among youth engaged in risky drinking. Given mixed findings for alcohol brief interventions (BIs), this paper examined baseline markers of BI response in order to inform future interventions. METHOD: We conducted secondary analyses of data from a randomized controlled trial of an alcohol BI delivered to youth in an ED. Among 475 participants (M(age)=18.6, SD=1.4; 48.7% Female, 78.6% White/Caucasian) receiving a computer or therapist BI, we examined baseline characteristics (i.e., demographic, substance use, mood, risk/protective factors, and readiness to change) that predicted positive intervention response (i.e., BI responder) at 3-month follow-up using AUDIT-C scores (cut offs: < 3 for ages 14–17; < 4 for ages 18–20). RESULTS: Mediated logistic regression analysis (controlling for demographics) showed that greater readiness to change at baseline was positively related to BI response and baseline alcohol consumption was negatively related to BI response. Having a mentor was indirectly related to BI response via baseline alcohol consumption. Baseline readiness to change and alcohol consumption mediated the association between positive peer influences and BI response, whereas readiness to change mediated the relation between depression and BI response. CONCLUSION: Findings suggest that BI response is influenced by protective social factors, such as positive peers and mentors, and depression, via alcohol severity indicators (i.e., readiness to change, consumption), thus providing clues to enhancing the content and dose of early interventions.

Individuals with a substance use disorder (SUD) diagnosis are more than twice as likely to smoke cigarettes as the general population. Emerging research has suggested that treating a substance use disorder simultaneously with tobacco use leads to a higher rate of treatment success for both substances. Despite this, substance use treatment protocols tend not to focus on tobacco use; in fact, traditional substance use treatments often discourage patients from attempting to quit smoking. One rationale is that patients may not be motivated to quit smoking. In the current study, data from veterans enrolled in outpatient treatment for a SUD were examined to assess for general characteristics of smokers as compared to non-smokers as well as to examine motivation to quit smoking. Baseline (i.e., pre-treatment) data from 277 Veterans were used. Charts of smokers in the SUD clinic (SUDC) were reviewed to assess how smoking is handled by SUDC providers, and if smokers attempt cessation. Of 277, 163 (59%) SUDC patients reported that they currently smoke cigarettes (M=16.3 cigarettes per day, SD=11.1). Smokers in the clinic reported greater general impairment than nonsmokers on the Short Index of Problems, F(1248)=8.9, p=0.003, as well as greater specific impairment: Physical Problems, F(1258)=13.5, p=0.000; Interpersonal Problems, F(1262)=5.6, p=0.019; Intrapersonal Problems, F(1260)=6.5, p=0.011, and Social Responsibility, F(1262)=14.7, p=0.000. Smokers in the sample were marginally more anxious than their non-smoking counterparts as measured by the GAD-7, F(1254)=4.6, p=0.053, though they were not significantly more depressed (p=0.19). On a 1-10 scale, smokers reported moderate levels of importance (M=5.4, SD=3.1), readiness (M=5.6, SD=3.2), and confidence (M=5.0, SD=3.0) regarding quitting smoking. Review of smokers' medical records reveal that while SUDC providers assess tobacco use at intake (90%) and offer treatment (86.5%), a substantially small portion of smokers attempt cessation (41.1%) while enrolled in SUDC. Moreover, no patients were enrolled in smoking-specific behavioral interventions while in SUDC, though 78 patients did obtain nicotine replacement or another smoking cessation medication (41% were prescribed by a SUDC provider). Contrary to the belief that treatment-seeking substance users are not motivated to quit smoking, these preliminary analyses demonstrate that Veterans were at least contemplating quitting smoking while they were enrolled in substance use treatment. Further, there is evidence that cigarette smokers have greater impairment caused by substance use, suggesting that this subgroup is of particular high need. Specific treatment recommendations are discussed, including how behavioral health providers in SUD clinics may be better able to capitalize on patients' moderate motivation to quit at intake.

Alcohol brief interventions (BIs) for youth are efficacious, but effect sizes found have been modest. This article presents secondary data analyses from a randomized controlled trial of motivational interviewing-based (MI) alcohol BIs among youth in an emergency department, examining within-session predictors of alcohol outcomes at 3 months among those receiving BIs.Risky drinkers (ages 14-20) received either a computer BI (n = 277) or therapist BI (n = 278). Within-session measures were obtained via computer metrics (therapist and computer BIs) and coding of audiotapes (therapist BI only). Parallel structural equation models examined direct and indirect effects of BI components on 3-month alcohol consumption and consequences, with posttest precursors of behavior change (e.g., importance, readiness, and intentions) as potential mediators. Components examined included reasons to avoid or reduce drinking, strengths, strategies for change, benefits of change, and leisure activities (computer BI only), and MI global ratings and MI-adherent behaviors (therapist BI only).For both BIs, greater number of strategies directly predicted greater posttest scores, with posttest scores mediating the relationship between strategies and alcohol consumption at 3 months. Greater number of strengths directly predicted fewer alcohol-related consequences at 3 months for both BIs; however, strengths also indirectly predicted greater consumption, mediated by posttest scores. Greater number of reasons to avoid or reduce drinking directly predicted greater alcohol consumption for the therapist BI only.These findings suggest ways to optimize the content and efficacy of alcohol BIs. Reviews of strategies such as refusal skills, protective behavioral strategies, and coping with negative affect may be particularly salient for reducing alcohol misuse.

Background Increasing rates of cannabis use among emerging adults is a growing public health problem. Intensive longitudinal data can provide information on proximal motives for cannabis use, which can inform interventions to reduce use among emerging adults. Method As part of a larger longitudinal study, patients aged 18–25 years (N = 95) recruited from an urban Emergency Department completed daily text message assessments of risk behaviors for 28 days, including daily cannabis quantity and motives. Using a mixed effects linear regression model, we examined the relationships between daily quantity of cannabis consumed and motives (i.e., enhancement, social, conformity, coping, and expansion). Results Participants were, on average, 22.0 years old (SD = 2.2); 48.4% were male, 45.3% were African American, and 56.8% received public assistance. Results from the multi-level analysis (clustering day within individual), controlling for gender, race, and receipt of public assistance, indicated daily use of cannabis use for enhancement (β = 0.27), coping (β = 0.15), and/or social motives (β = 0.34) was significantly associated with higher quantities of daily cannabis use; whereas expansion and conformity motives were not. Conclusions Daily data show that emerging adults who use cannabis for enhancement, social, and coping motives reported using greater quantities of cannabis. Future research should examine more comprehensive cannabis motives (e.g., boredom, social anxiety, sleep) and test tailored interventions focusing on alternative cognitive/behavioral strategies to address cannabis motives.

Aims To examine efficacy of drug brief interventions (BIs) among adults presenting to a low-income urban emergency department (ED). Design Randomized controlled trial on drug use outcomes at 3, 6 and 12 months. Participants were assigned to (1) computer-delivered BI (Computer BI), (2) therapist-delivered, computer-guided BI (Therapist BI) or (3) enhanced usual care (EUC-ED) for drug-using adults. Participants were re-randomized after the 3-month assessment to either adapted motivational enhancement therapy (AMET) booster or enhanced usual care booster (EUC-B). Setting Patients recruited from low-income urban emergency departments (ED) in Flint, Michigan, USA. Participants A total of 780 ED patients reporting recent drug use, 44% males, mean age = 31 years. Interventions Computer BI consisted of an interactive program guided by a virtual health counselor. Therapist BI included computer guidance. The EUC-ED conditions included review of community health and HIV prevention resources. The BIs and boosters were based on motivational interviewing, focusing on reduction of drug use and HIV risk behaviors. Measurements Primary outcome was past 90 days using drugs at 6 and 12 months and secondary outcomes were weighted drug-days and days of marijuana use. Findings Percentage changes in mean days used any drug from baseline to 12 months were: Computer BI + EUC-B: –10.9%, P = 0.0844; Therapist BI + EUC-B: –26.7%, P = 0.0041, for EUC-ED + EUC-B: –20.9, P = 0.0011. In adjusted analyses, there was no significant interaction between ED intervention and booster AMET for primary and secondary outcomes. Compared with EUC-ED, Therapist BI reduced number of days using any drug [95% confidence interval (CI) = −0.41, −0.07, P = 0.0422] and weighted drug-days (95% CI = –0.41, −0.08, P = 0.0283). Both Therapist and Computer BI had significantly fewer number of days using marijuana compared to EUC-ED (Therapist BI: 95% CI = –0.42, −0.06, P = 0.0104, Computer BI: 95% CI = –0.34, −0.01, P = 0.0406). Booster effects were not significant. Conclusions An emergency department-based motivational brief intervention, delivered by a therapist and guided by computer, appears to reduce drug use among adults seeking emergency department care compared with enhanced usual care.

Risk factors of violence perpetration in veterans include substance use and posttraumatic stress disorder (PTSD); however, it is unknown whether these factors are associated with greater risk for partner or non-partner violence. This study investigated the associations between probable PTSD, heavy drinking, marijuana use, cocaine use, and partner and non-partner violence perpetration.Self-report questionnaires assessing past-year partner and non-partner aggression (CTS2) as well as past-month substance use (SAOM), probable PTSD (PCL-C), and probable depression (PHQ-9) were administered to 810 substance using veterans entering VA mental health treatment.In bivariate analyses, probable PTSD in substance using veterans was associated with violence perpetration (partner physical, χThe results provide evidence that probable PTSD, heavy drinking, and cocaine use are associated with increased risk of non-partner violence perpetration in substance using veterans. These results underscore the importance of screening for PTSD symptoms and violence perpetration towards non-partners in substance using veterans presenting for treatment.

Pretreatment interventions have documented efficacy for reducing initial therapy refusal and early therapy departure. However, these interventions have not been well-studied in diagnostically diverse patient populations or within Veterans Affairs (VA) health care settings. We designed a manualized 4-session group cognitive-behavioral therapy-based pretreatment intervention (PTI) for a diagnostically diverse population of Veterans referred for psychotherapy in a general mental health clinic (MHC) in a large VA hospital. Retrospective record review was used to collect patient data over a period of 6 months after their completion of the PTI. A sample of 50 Veterans who were referred for care at the MHC prior to the implementation of the PTI was used for comparison (NoPTI). Two hundred sixty-six Veterans participated in the PTI. Veterans who participated in the PTI were equally as likely to attend at least one psychotherapy session as NoPTI Veterans, but had more individual and group therapy sessions during the 6-month therapy tracking period. PTI participants were also less likely to have a psychiatric hospitalization during the 6-month therapy tracking period. Study findings suggest that PTIs are a good fit to a VA general mental health setting and effective in bolstering therapy attendance. Limitations and future directions are discussed. (PsycINFO Database Record

Objective: This study examined patterns of violence victimization and aggression in both intimate partner and non-partner relationships among veterans, and used latent profile analysis to identify subtypes of violence involvement. Methods: Participants were 841 substance use treatment-seeking veterans (94% male) from a large VA Medical Center who completed screening measures for a randomized controlled trial. Self-report measures were: substance use, legal problems, depression, and violence involvement. Results: Past year violence involvement, including both intimate partner (IPV) and non-partner (NPV) were common in the sample; although NPV occurred at somewhat higher rates. When including either IPV or NPV aggression or victimization, over 48% reported involvement with physical violence, 31% with violence involving injury and 86% with psychological aggression. Latent profile analysis including both aggression and victimization in partner and non-partner relationships indicated a four profile solution: no-low violence (NLV, n = 701), predominantly IPV (n = 35), predominantly NPV (n = 83), and high general violence (HGV, n = 22). Multinomial logistic regression analyses revealed that compared to the no-low violence group, the remaining three groups differed in demographics, depressive symptoms, alcohol and other drug use, and legal involvement. Individuals within each profile had different patterns of substance use and legal involvement with the participants with an HGV profile reporting the most legal problems. Conclusions: IPV and NPV are relatively common among veterans seeking substance use treatment. Characteristics of violence and associated substance use, mental health, and legal difficulties may be useful in considering how to tailor substance use and mental health services.

BACKGROUND Violent injury is the leading cause of death among urban youth. Emergency department (ED) visits represent an opportunity to deliver a brief intervention (BI) to reduce violence among youth seeking medical care in high-risk communities. OBJECTIVE The objective was to determine the efficacy of a universally applied BI addressing violence behaviors among youth presenting to an urban ED. METHODS ED youth (14 to 20 years old) seeking medical or injury-related care in a Level I ED (October 2011-March 2015) and screening positive for a home address within the intervention or comparison neighborhood of a larger youth violence project were enrolled in this quasi-experimental study. Based on home address, participants were assigned to receive either the 30-minute therapist-delivered BI (Project Sync) or a resource brochure (enhanced usual care [EUC] condition). The Project Sync BI combined motivational interviewing and cognitive skills training, including a review of participant goals, tailored feedback, decisional balance exercises, role-playing exercises, and linkage to community resources. Participants completed validated survey measures at baseline and a 2-month follow-up assessment. Main outcome measures included self-report of physical victimization, aggression, and self-efficacy to avoid fighting. Poisson and zero-inflated Poisson regression analyses analyzed the effects of the BI, compared to the EUC condition, on primary outcomes. RESULTS A total of 409 eligible youth (82% participation) were enrolled and assigned to receive either the BI (n = 263) or the EUC condition (n = 146). Two-month follow-up was 91% (n = 373). There were no significant baseline differences between study conditions. Among the entire sample, mean (±SD) age was 17.7 (±1.9) years, 60% were female, 93% were African American, and 79% reported receipt of public assistance. Of participants, 9% presented for a violent injury, 9% reported recent firearm carriage, 20% reported recent alcohol use, and 39% reported recent marijuana use. Compared with the EUC group, participants in the therapist BI group showed self-reported reductions in frequency of violent aggression (therapist, -46.8%; EUC, -36.9%; incident rate ratio [IRR] = 0.87; 95% confidence interval [CI] = 0.76 to 0.99) and increased self-efficacy for avoiding fighting (therapist, +7.2%; EUC, -1.3%; IRR = 1.09; 95% CI = 1.02 to 1.15). No significant changes were noted for victimization. CONCLUSIONS Among youth seeking ED care in a high-risk community, a brief, universally applied BI shows promise in increased self-efficacy for avoiding fighting and a decrease in the frequency of violent aggression.

While the relationship between underage drinking and injury has been well established, few studies have examined whether presenting for an acute injury moderates the efficacy of a brief intervention (BI) on alcohol misuse.Patients (aged 14-20 years) in the emergency department screening positive for risky drinking (Alcohol Use Disorders Identification Test-Consumption score) completed a baseline assessment, were randomized to conditions (a standalone computer-delivered BI [n = 277], a therapist-delivered BI [n = 278], or a control condition [n = 281]), and completed a 3-month follow-up. This secondary analysis of Project U-Connect examined regression models (controlling for baseline values) to examine the main effects of injury and the interaction effects of injury by BI condition on alcohol consumption and consequences.Among 836 youth enrolled in the randomized controlled trial (mean age, 18.6 years; 51.6% were male; 79.4% were white), 303 (36.2%) had a primary complaint of intentional or unintentional injury. At baseline, injured patients were more likely to be male (p0.001) and have higher alcohol consumption (p0.01), but were less likely to misuse prescription drugs (p = 0.02) than those presenting for medical reasons. Regression models (controlling for baseline values) demonstrated that injury presentation predicted greater alcohol consumption prior to a BI. The computer BI was more effective at reducing alcohol consequences among those presenting with injury than those presenting for other reasons. Injury did not affect the efficacy of the computer BI on alcohol consumption, and injury did not affect the efficacy of the therapist BI on alcohol outcomes.A therapist or computer BI reduced alcohol consumption and consequences among risky drinkers regardless of reason for emergency department presentation highlighting the opportunity to reach a broad array of youth. Although the therapist BI was not moderated by injury presentation, the computer BI was particularly effective at reducing alcohol consequences among those presenting with injury at 3-month follow-up.Therapeutic/care management study, level III.

Background and Aims Chronic pain is difficult to treat in individuals with substance use disorders and, when not resolved, can have a negative impact on substance use disorder treatment outcomes. This study tested the efficacy of a psychosocial pain management intervention, ImPAT (improving pain during addiction treatment), that combines pain management with content related to managing pain without substance use. Design Single-site, parallel-groups randomized controlled trial comparing ImPAT to a supportive psychoeducational control (SPC) condition; follow-up assessments occurred at 3, 6 and 12 months. Setting The Ann Arbor VA Substance Use Disorder treatment program, USA. Participants Veterans Health Administration patients {n = 129; mean [standard deviation (SD)], age = 51.7 (9.5); 115 of 129 (89%) male; ImPAT (n = 65); SPC (n = 64)}. Intervention ImPAT combines principles of cognitive–behavioral therapy and acceptance-based approaches to pain management with content related to avoiding the use of substances as a coping mechanism for pain. The SPC used a psychoeducational attention control treatment for alcoholism modified to cover other substances in addition to alcohol. Measurements Primary: Pain intensity over 12 months; secondary: pain-related functioning, frequency of alcohol and drug use over 12 months. Findings Primary: randomization to the ImPAT intervention versus SPC predicted significantly lower pain intensity {β [standard error (SE)] = −0.71 (0.29); 95% confidence interval (CI) = −1.29, −0.12}; secondary: relative to the SPC condition, those who received ImPAT also reported improved pain-related functioning [β (SE) = 0.27 (0.11); 95% CI = 0.05, 0.49] and lower frequency of alcohol consumption [β (SE) = −0.77; 95% CI = −1.34, −0.20]. No differences were found between conditions on frequency of drug use over follow-up. Conclusions For adults with pain who are enrolled in addictions treatment, receipt of a psychological pain management intervention (improving pain during addiction treatment) reduced pain and alcohol use and improves pain-related functioning over 12 months relative to a matched-attention control condition.

OBJECTIVES: With this study, we examined secondary outcomes of an emergency department (ED)–based brief intervention (BI) on dating violence perpetration and victimization and depression symptoms over 3, 6, and 12 months. METHODS: ED patients (14–20 years) were screened for risk drinking. Patients who received positive screen results were randomly assigned to a computer BI (n = 277), therapist BI (n = 278), or control condition (n = 281). After the 3-month assessment, participants were randomly assigned to receive the post-ED BI or control condition. BIs were used to address alcohol consumption and consequences (eg, dating violence and depression symptoms) by using motivational interviewing. RESULTS: A total of 836 patients were enrolled in the randomized controlled trial of 4389 patients screened and 1054 who reported risky drinking. Regression models were used to examine longitudinal effects of the alcohol BI on dating violence perpetration, dating violence victimization, and depression symptoms. The therapist BI resulted in a significant reduction of dating violence perpetration up to 12 months (incidence rate ratio [IRR] = 0.53; 95% confidence interval [CI]: 0.37–0.77) and depression symptoms up to 3 months (IRR = 0.85; 95% CI: 0.72–1.00) after the intervention. Computer BI resulted in a reduction of dating violence perpetration (IRR = 0.52; 95% CI: 0.35–0.76) and depression symptoms (IRR = 0.78; 95% CI: 0.66–0.94) 6 months postintervention. Post-ED BIs were associated with lower perpetration at 12 months and lower victimization at 6 and 12 months, irrespective of BI intervention randomization at baseline; however, they did not affect depression symptoms. CONCLUSIONS: A single-session ED BI revealed previously to show promise in reducing underage drinking also demonstrates promise in preventing dating violence perpetration and depression symptoms. These technology-enhanced BIs could be particularly helpful given the potential for more efficient resource usage and ease of future implementation.

Background The primary aim of this study was to examine the efficacy of two motivational interviewing-based alcohol brief interventions (BIs) among adults presenting to an emergency department (ED). The secondary aim was to evaluate moderators of intervention effects. Methods Participants were 750 ED patients reporting recent alcohol misuse. Participants were randomly assigned to: 1) computer-delivered BI (Computer BI), 2) therapist-delivered BI with computer guidance (Therapist BI-CG), or 3) control. The BIs focused on reduction of alcohol use and risk behaviors. The outcome measure was trajectories of alcohol consumption (measured by the AUDIT-C) across baseline, 3-, 6- and 12-month follow-up assessments, analyzed using latent growth curve modeling. Moderation of intervention effect by gender, age, and baseline alcohol use disorder severity was examined. Results Across the full sample (40% males, mean age = 35.8, SD = 12.3), there was an overall reduction in alcohol consumption across 12 months. The main effects of the Therapist and Computer BI were not significant relative to control. Moderation analysis revealed that the impact of Therapist BI-CG, relative to control, was greater on reductions in alcohol consumption in participants with moderate to severe symptoms of alcohol use disorder compared to those with mild symptoms. The effect of the Computer BI on alcohol use, relative to control, was greater among younger participants compared to older participants. Conclusions While no overall effect was shown, ED-based Therapist BI-CG with computer guidance may be effective among patients with moderate-severe drinking patterns, whereas Computer BIs may be more effective for younger participants.

Objective Violence is a salient concern among veterans, yet relationships between psychiatric comorbidity, social networks, and aggression are poorly understood. We examined associations between biopsychosocial factors (substance use, posttraumatic stress disorder [PTSD], and social network behaviors) with aggression. Method We recruited veterans endorsing past-year aggression and substance use (N = 180) from Department of Veterans Affairs outpatient treatment clinics. Main and interaction effects between probable PTSD, substance use, social network violence and substance use, and veteran violence were examined with negative binomial regressions-specifically, physical aggression toward a relationship partner (PA-P), physical injury of a partner (PI-P), physical aggression toward nonpartners (PA-NP), and physical injury of nonpartners (PI-NP). Results Alcohol use yielded consistent main effects. PTSD and social network violence demonstrated main effects for PA-NP and PI-NP. PTSD and social network violence interacted to predict PA-P such that social network violence appeared salient only in the context of PTSD. PTSD was associated with PI-P, PA-NP, and PI-NP in social network substance use models. In the PA-P model including social network substance use, veterans with PTSD reported greater PA-P in the context of greater social network substance use, whereas veterans without PTSD endorsed PA-P concurrent with greater alcohol frequency. For PI-P, PTSD interacted with alcohol to predict a greater likelihood of partner injury in the context of social network substance use. Conclusions Investigated variables demonstrated unique associations within the context of specific relationships and the severity of behaviors. Overall, the findings underscore the importance of biopsychosocial models for understanding veteran violence. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Background: Daily process research can help distinguish causal relationships between substance use and sexual risk behaviors in high-risk groups, such as urban emerging adults. We employed text messaging to assess 18–25 year-olds’ daily substance use and sexual risk behaviors over 28 days. We describe the implementation of this method, attitudes regarding the daily surveys, and correlates of survey completion.Method: We recruited 111 emerging adults from an urban Emergency Department in a resource-limited area who reported recent drug use and unprotected sex (Mage=22.0; 53.2% female; 45.1% African American; 43.2% receiving public assistance).Results: Respondents completed M = 18.0 (SD = 8.7) of 28 daily surveys (27 items each). Participants completing a 1-month follow-up found the surveys not at all/only a little annoying (90.3%) and were comfortable with questions about drugs/alcohol (97.9%) and sex (94.6%). Completion was higher on weekdays versus weekends, and earlier in the study. Daily survey...

OBJECTIVES: This study examined the efficacy of emergency department (ED)-based brief interventions (BIs), delivered by a computer or therapist, with and without a post-ED session, on alcohol consumption and consequences over 12 months. METHODS: Patients (ages 14–20 years) screening positive for risky drinking were randomized to: BI (n = 277), therapist BI (n = 278), or control (n = 281). After the 3-month follow-up, participants were randomized to receive a post-ED BI session or control. Incorporating motivational interviewing, the BIs addressed alcohol consumption and consequences, including driving under the influence (DUI), and alcohol-related injury, as well as other concomitant drug use. The computer BI was an offline, Facebook-styled program. RESULTS: Among 4389 patients screened, 1054 patients reported risky drinking and 836 were enrolled in the randomized controlled trial. Regression models examined the main effects of the intervention conditions (versus control) and the interaction effects (ED condition × post-ED condition) on primary outcomes. The therapist and computer BIs significantly reduced consumption at 3 months, consequences at 3 and 12 months, and prescription drug use at 12 months; the computer BI reduced the frequency of DUI at 12 months; and the therapist BI reduced the frequency of alcohol-related injury at 12 months. The post-ED session reduced alcohol consequences at 6 months, benefiting those who had not received a BI in the ED. CONCLUSIONS: A single-session BI, delivered by a computer or therapist in the ED, shows promise for underage drinkers. Findings for the fully automated stand-alone computer BI are particularly appealing given the ease of future implementation.

Substance misuse is prevalent among veterans entering the criminal justice system, and is related to recidivism. Research demonstrates that trauma exposure and posttraumatic stress (PTS) symptoms, which commonly co-occur with substance misuse, also increase the risk of legal involvement and recidivism. However, it is unclear whether the associations between trauma, PTS symptoms and violent and nonviolent crime may be conflated by substance use. The aim of the present study was to understand the association between PTS symptoms and criminal justice involvement (both violent and nonviolent crime) among substance-using veterans seeking Veterans Affairs (VA) specialty mental health care after accounting for substance use frequency and demographics including age, gender, and ethnicity. Further, this study examined whether specific clusters of PTS were associated with violent and nonviolent veteran offending. Participants included 697 veterans (52 women) aged 21 to 75 (M = 47.49, SD = 13.51) with a history of trauma exposure. Veterans self-reported past-month PTS symptoms, substance use, and lifetime legal charges. Logistic regression results indicated total PTS symptoms were associated with violent, but not nonviolent charges, above and beyond age, sex, race, cocaine use, and heavy alcohol use. Intrusion symptoms, in particular, were associated with violent charges. Results highlight the utility of examining PTS as a multifaceted construct and have implications for the assessment and treatment needs of justice-involved veterans. For example, the findings suggest that treatment needs appear to differ for those reporting violent or nonviolent offending, with a greater need for assessing and treating PTS for those involved with violent crime. (PsycINFO Database Record

Purpose Suicide is well known to be a leading cause of death among American youth, and interventions aimed at the reduction of such have been extensively researched. Less investigated, has been the potential protective nature of mindfulness and mindful behaviours such as observing, describing, awareness of inner experience, nonjudgment, and nonreactivity, against suicidal ideation. Methods Emerging adults (EAs; 18–25 years old) recruited from an urban emergency department (ED) completed a self-administered computer survey asking about depressive symptoms, trait mindfulness, and demographics. Logistic regressions were conducted in order to examine the relationships between suicidal ideation and mindfulness, depression, and demographic characteristics. Results The final sample, including 776 EAs, identified as 63% Male, 58% African American, and an average age of 21.5. Those with higher levels of overall mindfulness were less likely to have suicidal ideation (OR 0.96, 95% CI 0.93–0.99). In addition, those with a college education were less likely (OR 0.40, 95% CI 0.16–0.94), and those identified as African American (OR 2.3, 95% CI 1.0–4.9) and with depression (OR 1.8, 95% CI 1.5–2.7) more likely to contemplate suicide. When facets of mindfulness were examined, only nonjudgment was found to be related to a reduction in suicidal ideation (OR 0.90, 95% CI 0.82–0.98). Again, college was related to reduced risk (OR 0.40, 95% CI 0.14–0.89), and depression increased (OR 2.0, 95% CI 1.7–2.4) risk of suicidal ideation. Conclusions Findings indicate that overall mindfulness, and specifically the mindful behaviour of nonjudgment, led to a reduction in suicidal ideation. Having a college education also reduced suicidal ideation. Contributions Future interventions aimed at the reduction of suicidal ideation should consider including mindfulness, particularly in EAs, for whom the development of mindfulness could be particularly helpful in their ongoing brain development.

Purpose Digital dating violence (DDV) is an issue of concern with increases in technology use among emerging adults (EA). Despite this surge, predictors of DDV perpetration remain understudied, particularly among non-college EAs. This study examines the relationship between DDV perpetration, trait mindfulness, dating partner residence, receipt of public assistance, and demographic characteristics among at-risk EAs. The evaluation of correlates of DDV perpetration will inform the development of effective treatment interventions. Methods EAs (n=775) ages 18–25 years treated in the emergency department (ED) for any reason completed a self-administered computerised survey. Ordinary least squares linear regression with a Poisson distribution was conducted to examine associations between DDV perpetration and trait mindfulness, dating partner residence, receipt of public assistance, and demographic characteristics. Results Thirty-seven percent of the sample was comprised of women, 43% received public assistance, and 25% lived with a dating partner. The majority of the sample identified as Black (61%), while the remaining as Caucasian (39%). Analyses indicated that higher levels of trait mindfulness were associated with lower levels of DDV perpetration (I²=−0.06, p Conclusions These findings indicate that lower levels of trait mindfulness, living with a partner and receiving public assistance (likely indicative of economic stressors) were associated with more DDV perpetration. Interventions aimed at reducing DDV perpetration should give special attention to these characteristics. Contributions This work is part of a growing body of research aimed at developing evidenced-based interventions for DDV perpetration. The identification of correlates of DDV perpetration will contribute to the development of more effective interventions to mitigate this type of aggression.

Purpose Dating violence (DV) is a significant public health concern with serious consequences. Rates of DV are high among youth treated in Emergency Departments (EDs). More research is needed to understand the association between DV aggression (physical DV with and without injury to partner; psychological DV) and its correlates (e.g., mindfulness, technology use, mental health, service utilisation). Methods Participants included emerging adults (EAs; 18–25 years) treated in an urban ED who completed a self-administered computer survey. Multinomial logistic regressions were conducted for physical DV (PDV) with/without injury and PDV with/without psychological DV (PsDV), and included mindfulness, alcohol consumption, cell phone use, anxiety and demographics. Results The sample included 746 EAs (37% Female, 61% African American, average age 21.5 years). Compared to those with no PDV, those with PDV/no injury had lower mindfulness (OR=0.97, 95% CI:0.95–0.99), more alcohol OR=1.14, 95% CI:1.06–1.23), more anxiety OR=1.06, 95% CI:1.02–1.11), and more cell phone use (OR=2.25, 95% CI:1.06–4.77). Participants with PDV/injury and those with PDV/PsDV had lower mindfulness (OR=0.95, 95%, CI:0.92–0.98; OR=0.96, 95% CI:0.94–0.99), more alcohol (OR=1.15, 95% CI:1.05–1.27; OR=1.18, 95% CI:1.09–1.29), and more anxiety (OR=1.08, 95% CI:1.02–1.14; OR=1.10, 95% CI:1.05–1.16). Participants reporting PDV/no PsDV reported lower mindfulness (OR=0.93, 95% CI:0.89–0.98) and more alcohol consumption (OR=1.19, 95% CI:1.04–1.38). Those with DV were no more likely to have received treatment then those without. Conclusions Mindfulness, alcohol, and anxiety are significant factors in PDV regardless of partner injury or concurrent PsDV. Those reporting DV are just as likely to use cell phones as those with no DV. They are also no more likely to have received mental health or substance use treatment. Contributions This research suggests: 1) potential for mindfulness-based interventions to reduce DV; 2) technology-enhanced interventions are a viable approach; 3) interventions are needed because perpetrators are no more likely to have received treatment.

This study examined patterns of violence victimization and aggression in both intimate partner and nonpartner relationships among U.S. military veterans using latent profile analysis to identify subtypes of violence involvement.Participants were 839 substance use treatment-seeking veterans (93% male) from a large Veterans Affairs Medical Center who completed screening measures for a randomized controlled trial.Past-year violence involvement, including both intimate partner violence (IPV) and nonpartner violence (NPV), was common in the sample, although NPV occurred at somewhat higher rates. When we included either IPV or NPV aggression or victimization, more than 40% reported involvement with physical violence, 30% with violence involving injury, and 86% with psychological aggression. Latent profile analysis including both aggression and victimization in partner and nonpartner relationships indicated a four-profile solution: no/low violence (NLV; n = 377), predominantly IPV (n = 219), predominantly NPV (n = 134), and high general violence (HGV; n = 109). Multinomial logistic regression analyses revealed that, compared with the NLV group, the remaining three groups differed in age, cocaine use, posttraumatic stress disorder (PTSD) symptoms, and legal involvement. Legal issues appeared to differentiate the profiles most, with the predominantly NPV and HGV profiles reporting more instances of driving under the influence and the HGV profile reporting legal problems related to aggression.IPV and NPV are fairly common among veterans seeking substance use treatment. The clinical characteristics of violence profiles indicate that cocaine use, PTSD symptoms, and legal involvement are treatment needs that vary with violence profile and may be useful for clinical decision making.

Background Gambling is relatively under-assessed in Veterans Affairs (VA) substance use disorder (SUD) treatment settings, yet shared characteristics with substance addiction suggest the importance of understanding how gambling behaviors present in Veterans seeking SUD care. Method We evaluated substance use, mental health, and violence-related correlates of past 30-day gambling among 833 Veterans (93% male, M age 48 years, 72% Caucasian) seeking treatment in VA outpatient mental health and SUD clinics who completed screening for a randomized clinical trial. Results A total of 288 (35%) Veterans reported past 30-day gambling. Among those who gambled, 79% had cravings/urges to gamble, whereas between 20%–27% of gamblers reported perceived relationship, legal, and daily life problems related to gambling, as well as difficulty controlling gambling. A logistic regression analysis revealed that age, recent binge-drinking, and non-partner physical aggression were associated with recent gambling. Conclusions Gambling was associated with binge-drinking and non-partner physical aggression, supporting potential shared characteristics among these behaviors such as impulsivity and risk-taking, which may complicate SUD treatment engagement and effectiveness. Findings support the need to screen for gambling in the VA, and to adapt treatments to include gambling as a potential behavioral target or relapse trigger, particularly among heavy drinking patients.

Purpose: Demographics, mental illness, substance use, and prior family violence are associated with perpetration of intimate partner violence (IPV) among male patient populations as well as court-based and community samples. However, few studies have identified health services use and physical symptoms associated with IPV perpetration among men. This study assesses the prevalence of IPV perpetration in a nationally representative sample of men and examines the associations of IPV perpetration with demographics, health services use, physical symptoms, mental illness, substance abuse, and prior family violence. Methods: Data from the 2001 to 2003 National Comorbidity Survey–Replication was used to assess the prevalence of IPV perpetration among adult men. Bivariate and multivariate logistic regression determined associations of IPV perpetration with demographics, health services use, physical symptoms, mental health diagnoses, substance abuse/dependence, and prior family violence. Results: The prevalence of male IPV perpetration is 19.2%. Physical symptoms from irritable bowel syndrome (odds ratio [OR] 2.61; 95% confidence interval [CI], 1.17–5.84) and insomnia (OR, 1.33; 95% CI, 1.04–1.71), as well as substance abuse/dependence (OR, 1.76; 95% CI, 1.09–2.85), were correlates of IPV perpetration in multivariate logistic regression analyses controlling for demographics and health services use. When prior family violence was added to the multivariate logistic regression model, only childhood family violence victimization (OR, 1.99; 95% CI, 1.21–3.28) and witnessing childhood family violence (OR, 2.02; 95% CI, 1.17–3.49) were associated with IPV perpetration. Conclusions: Nearly 1 in 5 men in the United States reported lifetime IPV perpetration toward their current intimate partner. Physical symptoms from irritable bowel syndrome and insomnia, substance use disorders, and prior family violence are associated with IPV perpetration by men. Understanding these associations may aid primary care physicians in identifying male patients who perpetrate IPV.

BACKGROUND AND OBJECTIVE: Effective violence interventions are not widely implemented, and there is little information about the cost of violence interventions. Our goal is to report the cost of a brief intervention delivered in the emergency department that reduces violence among 14- to 18-year-olds. METHODS: Primary outcomes were total costs of implementation and the cost per violent event or violence consequence averted. We used primary and secondary data sources to derive the costs to implement a brief motivational interviewing intervention and to identify the number of self-reported violent events (eg, severe peer aggression, peer victimization) or violence consequences averted. One-way and multi-way sensitivity analyses were performed. RESULTS: Total fixed and variable annual costs were estimated at $71 784. If implemented, 4208 violent events or consequences could be prevented, costing $17.06 per event or consequence averted. Multi-way sensitivity analysis accounting for variable intervention efficacy and different cost estimates resulted in a range of $3.63 to $54.96 per event or consequence averted. CONCLUSIONS: Our estimates show that the cost to prevent an episode of youth violence or its consequences is less than the cost of placing an intravenous line and should not present a significant barrier to implementation.

AIMS: To examine the efficacy of a brief intervention delivered by a therapist (TBI) or a computer (CBI), in preventing cannabis use among adolescents in urban primary care clinics. DESIGN: A randomized controlled trial comparing: CBI and TBI versus control. SETTING: Urban primary care clinics in the United States. PARTICIPANTS: Research staff recruited 714 adolescents (ages 12-18) who reported no lifetime cannabis use on a screening survey for this study, which included a baseline survey, randomization (stratified by gender and grade) to conditions (control; CBI; TBI), and 3, 6, and 12 month assessments. MEASUREMENTS: Using an intent to treat approach, primary outcomes were cannabis use (any, frequency); secondary outcomes included frequency of other drug use, severity of alcohol use, and frequency of delinquency (among 85% completing follow-ups). FINDINGS: Compared with controls, CBI participants had significantly lower rates of any cannabis use over 12 months (24.2%, 16.8%, respectively, p CONCLUSIONS: Among adolescents in urban primary care in the United States, a computer brief intervention appeared to prevent and reduce cannabis use. Both computer and therapist delivered brief interventions appeared to have small effects in reducing other risk behaviors, but these dissipated over time. Language: en

Background Dating violence (DV) has emerged as a major concern among youth with links to substance use, injuries, and death. The emergency department (ED) provides an opportunity for violence screening and prevention interventions. Additional data are needed regarding antecedents of DV versus non-dating violence (NDV; e.g., acquaintance, stranger) to develop ED-based violence interventions for youth. Methods Participants were 575 patients screening positive for past 6-month drug use in an urban ED who completed timeline follow-back aggression modules at baseline and 6- and 12-months, indicating event-specific antecedents of violence. Multi-level logistic regressions using event-level data, nested by individual and time (i.e. baseline, 6- and 12-month assessment intervals), were used to examine antecedents of DV vs. NDV. Post-hoc analyses examined substance use × reasons and gender interactions. Results Prescription sedative/opioid misuse was more likely to be reported prior to DV whereas alcohol only, and co-ingested alcohol and marijuana only, were more likely to be reported prior to NDV. Reasons for DV included: “personal belongings”, “angry/bad mood,” “jealousy,” “drunk/high on drugs” and “arguing about sex”. Reasons for NDV included: “rumors,” “retaliation,” “personal space” and “aid (someone) due to physical attack”. Substance use before/during conflicts and reasons for conflicts were both uniquely associated with DV versus NDV. Two gender interactions were found. Conclusions ED based interventions for urban youth need to be tailored by gender, substance use (alcohol, cocaine, sedatives), reasons for violence, and type of violence (DV vs. NDV).

BACKGROUND: Dating violence (DV) among youth is an important public health problem. This study examined reasons for physical DV and the association between substance use and youth DV using daily calendar-based analyses among at-risk urban youth. METHODS: Patients (aged 14-24) presenting to an urban Emergency Department (ED) for a violent injury and a proportionally selected comparison sample of non-violently injured youth who screened positive for substance use in the past 6 months (n=599) were enrolled in this study. Multi-level, multinomial regressions were conducted using daily-level substance use data from Time Line Follow Back (TLFB) responses and physical DV data that were obtained by coding Time Line Follow Back - Aggression Module responses for the 30 days prior to visiting the ED. RESULTS: The two most commonly reported reasons for physical dating aggression and victimization, across sexes, were "jealousy/rumors" or "angry/bad mood." Multi-level multinomial regression models, adjusting for clustering within individual participants, showed that among females, cocaine use and sedative/opiate use were associated with severe dating victimization and alcohol use was associated with severe dating aggression. CONCLUSIONS: Use of TLFB data offers a unique opportunity to understand daily-level factors associated with specific incidents of DV in more detail. This study provides novel data regarding reasons for DV and the relationship between daily substance use and DV among urban youth, with alcohol, cocaine, and sedative/opiate use being associated with various types of DV. ED based DV interventions should be tailored to address youths' reasons for DV as well as reducing their substance use. Language: en

Many individuals with substance use disorders (SUDs) have been victims of violence and individuals with SUDs often exhibit coping skills deficits. The extent to which coping skills relate to victimization is unknown. This study evaluated the relationships between physical assault victimization types (i.e., only partner victimization, only nonpartner victimization, or both partner and nonpartner victimization) and emotion-focused, problem-focused, and avoidant coping among individuals in residential SUD treatment. More frequent use of problem-focused coping was associated with reduced odds of being victimized by partners and nonpartners and more frequent use of avoidant coping was associated with increased odds of victimization across both partners and nonpartners. These results highlight the potential value of assessing violence across relationship types and bolstering adaptive coping among individuals with SUDs.

The purpose of this study was to identify overlap and violence types between peer and dating aggression and victimization using latent class analysis (LCA) among a sample of aggressive adolescents with a history of alcohol use and to identify risk and protective factors associated with each violence class.From September 2006 to September 2009, a systematic sample of patients (14-18 years old) seeking care in an urban emergency department were approached. Adolescents reporting any past-year alcohol use and aggression completed a survey using validated measures including types of violence (severe and moderate aggression, severe and moderate victimization with both peers and dating partners). Using LCA, violence classes were identified; correlates of membership in each LCA class were determined.Among this sample (n = 694), LCA identified three classes described as (a) peer aggression (PA) (52.2%), (b) peer aggression + peer victimization (PAPV) (18.6%), and (c) multiple domains of violence (MDV) (29.3%). Compared with those in the PA class, those in the PAPV class were more likely to be male, report injury in a fight, and have delinquent peers. Compared with the PA class, those in the MDV class were more likely to be female, African American, report injury in a fight, carry a weapon, experience negative consequences from alcohol use, and have delinquent peers and more family conflict. Compared with the PAPV class, those in the MDV class were likely to be female, African American, receive public assistance, carry a weapon, experience negative consequences from alcohol use, and use marijuana.There is extensive overlap of victimization and aggression in both peer and dating relationships. Also, those with high rates of violence across relationships have increased alcohol misuse and marijuana use. Thus, violence-prevention efforts should consider addressing concomitant substance use.

Pain-related problems frequently complicate substance use disorder (SUD) course and prognosis. However, it is unclear if the negative outcomes associated with co-occurring pain are due to its link with greater SUD severity, disruption of SUD treatment processes, or connection to a third psychological process. The current study modeled the longitudinal effects of pain during a 4-week intensive outpatient treatment (IOP) on SUD symptoms and limited psychological flexibility (PF), a common feature of psychological well being that is commonly restricted in both SUD and pain patients. After controlling for initial severity of SUD symptoms, current pain level at treatment intake moderated change in a sub-component of PF, values commitment, but not SUD symptoms during the IOP. During the treatment, pain level also limited improvement in PF but not self-reported SUD symptoms. Targeting additional increases in psychological flexibility surrounding commitment to values during SUD treatment may help improve outcomes among patients who began treatment with significant pain symptoms.

Psychiatric symptoms, somatic problems, and co-occurring substance use have been associated with medical marijuana consumption among civilian patients with substance use disorders. It is possible that these factors may impact Veterans' ability to engage in or adhere to mental health and substance use disorder treatment. Therefore, we examined whether psychiatric functioning, substance use, and somatic problems were associated with medical marijuana use among Veterans receiving substance use disorder and/or mental health treatment. Participants (n=841) completed screening measures for a randomized controlled trial and 67 (8%) reported that they had a current medical marijuana card. Most of these participants (78%) reported using marijuana to treat severe/chronic pain. Significant bivariate differences revealed that, compared to participants without a medical marijuana card, those with a card were more likely to be in a middle income bracket, unemployed, and they had a significantly higher number of recent days of marijuana use, synthetic marijuana use, and using sedatives prescribed to them. Additionally, a significantly higher proportion of participants with a medical marijuana card scored above the clinical cutoff for posttraumatic stress disorder (PTSD) symptoms, had significantly higher severity of sleep-related problems, and reported a higher level of pain. These findings highlight the co-occurrence of substance use, PTSD symptoms, sleep-related problems, and chronic pain among Veterans who use medical marijuana. Future research should investigate the inter-relationships among medical marijuana use and other clinical issues (e.g., PTSD symptoms, sleep, pain) over time, and potential implications of medical marijuana use on treatment engagement and response.

The current study examined the application of resilience theory to adolescent gambling using Latent Class Analysis (LCA) to establish subtypes of adolescent gamblers and to explore risk and promotive factors associated with gambling group membership. Participants were a diverse sample of 249 adolescents ages 14 to 18 (30.1 % female, 59.4 % African American) presenting to an inner-city emergency department (ED) who reported having gambled at least once in the previous year. Two classes of gamblers were identified and distinguished based on the probability of endorsing gambling consequences: high consequence gamblers (class 1) and low consequence gamblers (class 2). Despite similar profiles on gambling frequency and largest amount gambled, high consequence gamblers (accounting for 37.8% of current gamblers) were more likely than low consequence gamblers to gamble more than planned, feel bad about their gambling, have arguments with friends and family about gambling and to borrow to pay back money lost while gambling. Compared to the low consequence group, high consequence gamblers were more likely to use marijuana, consume alcohol, engage in peer and dating violence and delinquency, and to report negative peer influences. Low consequence gamblers had higher levels of parental monitoring. Individuals in the high consequence group had higher scores on the risk, and lower scores on the promotive, factor index and Risk × Promotive Factor Index scores predicted gambling group membership. These findings support a risk-protective model of resilience and indicate that promotive factors buffer against high consequence gambling in the context of risk.

BACKGROUND AND OBJECTIVES: Emergency department (ED) visits present an opportunity to deliver brief interventions (BIs) to reduce violence and alcohol misuse among urban adolescents at risk for future injury. Previous analyses demonstrated that a BI resulted in reductions in violence and alcohol consequences up to 6 months. This article describes findings examining the efficacy of BIs on peer violence and alcohol misuse at 12 months. METHODS: Patients (14–18 years of age) at an ED reporting past year alcohol use and aggression were enrolled in the randomized control trial, which included computerized assessment, random assignment to control group or BI delivered by a computer or therapist assisted by a computer. The main outcome measures (at baseline and 12 months) included violence (peer aggression, peer victimization, violence-related consequences) and alcohol (alcohol misuse, binge drinking, alcohol-related consequences). RESULTS: A total of 3338 adolescents were screened (88% participation). Of those, 726 screened positive for violence and alcohol use and were randomly selected; 84% completed 12-month follow-up. In comparison with the control group, the therapist assisted by a computer group showed significant reductions in peer aggression (P < .01) and peer victimization (P < .05) at 12 months. BI and control groups did not differ on alcohol-related variables at 12 months. CONCLUSIONS: Evaluation of the SafERteens intervention 1 year after an ED visit provides support for the efficacy of computer-assisted therapist brief intervention for reducing peer violence.

Purpose In this study, we describe the characteristics of adolescents with mental health problems among those presenting to primary care clinics in urban areas. Methods The sample included 1,076 adolescents aged 12–18 years who presented to federally qualified community health clinics in urban cities in the Midwest. Bivariate and multivariate logistic regression analyses were conducted to examine the associations between having a mental health problem with demographic characteristics, health-related variables, and other risk and promotive factors. We also examined the use of health services and involvement in activities among those with mental health problems. Results Approximately 14% of adolescents screened positive for a mental health problem; among those with a mental health problem, 42.8% received mental health services in the past 3 months. In the multivariate logistic regression analysis, adolescents who were female, with poorer grades, fair to poor self-reported health, using drugs, and lower parental monitoring were more likely to have a mental health problem. In bivariate analyses, adolescents with mental health problems were less likely to participate in school activities and community activities and more likely to use emergency room services. Conclusions Adolescents with mental health problems were more likely to have several other difficulties including poor grades, poor self-rated health, drug/alcohol use, and sexual activity. This study highlights the importance of screening youth with multidimensional needs and referring them to the appropriate services.

Introduction: Violence is a leading cause of morbidity and mortality among patients seeking care in urban emergency departments (EDs). Few studies have examined the relationship between substance use and violence among ED patients with substance use disorders. The urban ED is a critical location for intervening with patients with substance use disorders and violence. This study examined correlates of violence by patients with substance use disorders.Method: For this cross-sectional study, 1215 patients (64.7% males, average age 34.1 years, SD = 10.58) in an ED, with substance use disorder, completed Substance Abuse Outcome Module (Smith et al., 1996, Psychiatric outcomes module: Substance Abuse Outcomes Module (SOAM). Baltimore, MD: Williams & Wilkins), Addiction Severity Index (McLellan et al., 2006, The Addiction Severity Index at 25: Origins, contributions and transitions. American Journal on Addictions, 15(2), 113–124), Conflict Tactics Scale (Straus, 1979, Measuring intrafamily conflict and violence:...

This study sought to compare patterns of alcohol use between male veterans and nonveterans.Data came from the 2004 Behavioral Risk Factor Surveillance System, a U.S. national telephone survey using stratified random sampling. Outcomes were 30-day alcohol use, binge drinking (5+ drinks on one occasion), and heavy drinking (2+ drinks per day). Age-stratified weighted regression analyses compared men who were veterans (n = 36,874) to those who were not (n = 77,056), and veterans who used Veterans Health Administration (VHA) services in the past year (n = 7,606) to veterans who did not, adjusting for potential confounders.Veterans aged 41 to 60 were less likely to binge drink (adjusted odds ratio [AOR] = 0.8) and veterans aged 61 to 70 were more likely to drink heavily compared to same-age men without military experience (AOR = 1.7). There were no significant differences in binge or heavy drinking for other age groups. Among veterans aged 51 to 60, those who used VHA services were more likely to report binge drinking than those who did not (AOR = 1.4).Male veterans generally have similar patterns of alcohol use as men without a history of military service, but the elevated alcohol use of specific groups of veterans merits concern.

The present study examined the association between a diagnosis of an alcohol use disorder or a drug use disorder and death by homicide over the course of 6 years.This was a cohort study that included all patients seen for medical treatment by the Veterans Health Administration during fiscal year (FY) 2001. Treatment records were used to identify all patients with a diagnosis of a substance use disorder in FY01 (n = 3,942,932). The National Death Index data provided information on the timing and cause of death between FY02 and the end of 2007. Analyses examined the association between substance use disorders and the time to homicide, after controlling for age and gender.Veterans Health Administration patients who were diagnosed with an alcohol use disorder were more likely to die by homicide than those without a substance use disorder (hazard ratio [HR] = 3.3, 95% CI [2.6,4.1]). This finding also was true for those with drug use disorders (HR = 4.3, 95% CI [3.4, 5.4]) and for those with both an alcohol use disorder and a drug use disorder (HR = 4.6, 95% CI [3.9, 5.4]), compared with those without a substance use disorder.In this observational study of veterans, a diagnosis of a substance use disorder was significantly associated with death by homicide. Alcohol and drug treatment programs may have an important role to play in reducing the burden of homicide as a public health problem.

Background and aims Prescription opioid overdose is a significant public health problem. Interventions to prevent overdose risk behaviors among high-risk patients are lacking. This study examined the impact of a motivational intervention to reduce opioid misuse and overdose risk behaviors. Methods This study was a pilot randomized controlled trial set in a single emergency department (ED) in which, 204 adult, English-speaking patients seeking care who reported prescription opioid misuse during the prior 3 months were recruited. Patients were randomized to either the intervention, a 30-minute motivational interviewing-based session delivered by a therapist plus educational enhanced usual care (EUC), or EUC alone. Participants completed self-reported surveys at baseline and 6 months post-baseline (87% retention rate) to measure the primary outcomes of overdose risk behaviors and the secondary outcome of non-medical opioid use. Findings Participants in the intervention condition reported significantly lower levels of overdose risk behaviors (incidence rate ratio [IRR] = 0.72, 95% CI: 0.59–0.87; 40.5% reduction in mean vs. 14.7%) and lower levels of non-medical opioid use (IRR = 0.81, 95% CI: 0.70–0.92; 50.0% reduction in mean vs. 39.5%) at follow-up compared to the EUC condition. Conclusions This study represents the first clinical trial of a behavioral intervention to reduce overdose risk. Results indicate that this single motivational enhancement session reduced prescription opioid overdose risk behaviors, including opioid misuse, among adult patients in the ED.

Objectives: Adolescents with a history of peer assault are known to report high rates of other risky behaviors. The characteristics of adolescents seeking care in the ED for acute assault-related injury are less well established. This knowledge deficit is particularly noticeable for adolescent female victims of peer assault. This study’s objectives were: 1) to characterize the demographics and risk behaviors of youths presenting to the emergency department (ED) with acute assault-related injury and 2) to compare assaulted youths’ demographic characteristics, past experiences with violence, and other risk behaviors by sex. Methods: A systematic sample of adolescents (ages 14 to 18 years) presenting to an urban ED with acute assault-related injury (excluding dating violence, sexual assault, and child abuse) was recruited. Consenting participants self-administered a computerized survey about demographics, history of peer and dating aggression, and theoretical correlates of violence (e.g., alcohol and other drug use, depressive symptoms, weapon carriage). Multivariate logistic regression was performed to identify factors that were differentially associated with presentation to the ED for acute assault-related injury for females versus males. Results: Of 3,338 adolescents completing a screening survey during the 36-month study period, 197 had presented to the ED with acute assault-related injuries; seven of these were excluded from this study due to being victims of dating violence. Most ( n= 179, 94.2%) of these 190 acutely assaulted participants were discharged home. The majority reported a history of past-year peer aggression ( n= 160, 84.2%) and past-year violent injury ( n= 106, 55.8%). Similar rates of past-year peer aggression, past-year violent injury, alcohol use, and weapon carriage were observed for adolescent males and females presenting with acute assault-related injury. Males and females also reported similar age, race, socioeconomic status, and education levels. Compared to males, females were less likely to report living with a parent (odds ratio [OR] = 0.25, 95% confidence interval [CI] = 0.08 to 0.84) and were more likely to report depressive symptoms (OR = 2.59, 95% CI = 1.23 to 5.48) and past-year dating aggression (OR = 2.23, 95% CI = 1.04 to 4.82). Conclusions: Male and female adolescents with acute assault-related injuries were very similar. Both reported extremely high rates of past year peer violence, assault-related injury, and substance use. The greater prevalence of some risk factors among adolescent females, such as depressive symptoms, dating aggression, and independent living status, should be further investigated.

The inner city Emergency Department (ED) provides a window of opportunity for screening for alcohol and other drug misuse and substance use disorders (SUDs), in order to facilitate linkage for individuals who are in need of services targeting such issues. The majority of prior work in this area has focused on alcohol use. This study used latent class analyses to characterize substance use/SUDs among adults presenting to the ED for medical complaints or injuries. Participants (n = 14,557; 77% participation; 45% male; 54% African–American) completed a computerized survey assessing demographics, health functioning, and substance use/SUDs. Although injured patients were significantly more likely to use tobacco, alcohol, and marijuana, and were more likely to have an alcohol use disorder, presenting complaint was not related to other drug use/diagnoses. Five latent classes were identified: (1) low users/SUDs (65.9%) (2) binge drinkers (24.3%), (3) marijuana users/SUD (3.5%), (4) cocaine users/SUD (2.9%), and (5) poly-drug users (3.3%). Compared to class 1, participants in the other classes were younger, male, without health insurance, with poor mental health functioning, tobacco users, and had prior substance use treatment. African–Americans were most likely to be in classes 3 or 4 and employed participants were most likely to be in class 2. In comparison to class 1, classes 2 and 3 reported better physical health; class 2 was more likely to present for injury whereas class 5 was more likely to present for a medical complaint. ED-based screening and interventions approaches need to address the co-occurrence of alcohol, illicit drug, and psychoactive prescription drug use.

Background: The U.S. prevalence of misuse of prescription opioid analgesics has increased substantially over the past decade but research on the factors influencing misuse of these medications remains preliminary. In the literature on alcohol, marijuana and stimulants, substance-related expectancies have been found to predict level of substance use. A similar line of research is needed to better understand reasons for misusing pain medications. Methods: This study utilized a sample of adults presenting to a large residential addictions treatment program (N = 351). Participants were administered a new instrument, the Pain Medication Expectancy Questionnaire (PMEQ) as well as questions about current alcohol, illegal drug and pain medication misuse. Exploratory factor analysis was used to determine underlying factors of the PMEQ. Results: Results of the factor analysis supported a three-factor solution focusing on pleasure/social enhancement, pain reduction and negative experience reduction. In general, greater perceived expectancy of the positive effects of Prescription Opiate Analgesics (POAs) in all three domains were correlated with greater frequency of substance use and poorer mental health functioning. Expectancies directly related to the pain-reducing properties of POAs were also related to greater pain and poorer physical functioning. Conclusions: This new measure of pain medication expectancies had sound psychometric properties and the resulting factors were associated with other clinically important aspects of patient functioning. The results highlight the need to assess for and address perceptions related to pain medication use in patients presenting to addictions treatment. Published by Elsevier Ireland Ltd.