Implementing Motivational Interviewing for Substance Misuse on Medical Inpatient Units: a Randomized Controlled Trial
General medical hospitals provide care for a disproportionate share of patients who misuse substances. Hospitalization provides a unique opportunity to identify and motivate patients to address their substance misuse.
To determine the effectiveness of three strategies for implementing motivational interviewing for substance misuse with general medical inpatients.
Type 3 hybrid effectiveness-implementation randomized controlled trial (Clinical Trials.gov: NCT01825057).
Thirty-eight providers (physicians, physician assistants, nurses) from 13 general medical inpatient services, and 1173 of their patients admitted to an academically affiliated acute care hospital.
Implementation strategies included (1) a continuing medical education workshop on detection of substance misuse and provision of a motivational interview; (2) workshop plus bedside supervision (apprenticeship condition); and (3) a workshop plus ability to place a medical order for an interview from a consultation-liaison service (consult condition).
Primary outcomes were the percentage of study-eligible patients who received an interview for substance misuse and the integrity (adherence, competence) of the interviews. The secondary outcome was the percent of patient statements within the interviews that indicated motivation for reducing substance misuse.
20.5% of patients in the consult condition received an interview, compared to 0.8% (Hedge’s g = 1.49) and 3.0% (Hedge’s g = 1.26) in the respective workshop only and apprenticeship conditions (p < 0.001). Motivational interviews in the consult condition were performed with more fundamental motivational interviewing adherence and competence than the other conditions. Most statements made by patients during the interviews favored reducing substance misuse, with no differences between conditions.
Providers’ ability to place an order to have experts from the consultation-liaison service deliver a motivational interview was a more effective implementation strategy than a workshop or apprenticeship method for ensuring motivational interviewing is available to medical inpatients who misuse substances.
KEY WORDSbehavioral science consultation implementation research substance abuse
The authors wish to thank the medical providers at the medical hospital where the study was conducted. We also would like to thank Victor Morris, Will Cushing, Jose Salvana, and Scott Sussman for the work they have done in support of the project. Finally, we want to acknowledge our research staff (Rebecca Aldi, Monica Canning-Ball, Heather Howell, Jessica Katon, Ashley McCaherty, and Jonathan Ryan) for their efforts to implement this trial with integrity.
The National Institute on Drug Abuse funded the study (R01 DA034243). The content of this manuscript solely reflects the authors’ views and not those of the funding agency or the authors’ institutional affiliates.
Compliance with Ethical Standards
The Yale University Human Investigation Committee approved the study (ClinicalTrials.gov (NCT01825057). We screened interested providers and obtained written informed consent alongside baseline assessments. Research assistants (RAs) screened and obtained written informed consent from eligible and interested patients.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
- 1.Stein MD, O’Sullivan PS, Ellis P, Perrin H, Wartenberg A. Utilization of medical services by drug users in detoxification. J Subst Abus 1993;10:187–93.Google Scholar
- 2.Richmond RL, Bell AP, Rollnick S, Heather BBN. Screening for smokers in four Sydney teaching hospitals. J Cardiovasc Risk 1995;2:199–203.Google Scholar
- 3.Katz A, Goldberg D, Smith J, Trick WE. Tobacco, alcohol, and drug use among hospital patients: concurrent use and willingness to change. J Hosp Med 2008;3:370–5.Google Scholar
- 5.Santora PB, Hutton HE. Longitudinal trends in hospital admissions with co-occurring alcohol/drug diagnoses, 1994–2002. J Subst Abus Treat 2008;35:1–12.Google Scholar
- 7.Smothers BA, Yahr HT, Sinclair MD. Prevalence of current DSM-IV alcohol use disorders in short-stay, general hospital admissions, United States. Arch Intern Med 1994;163:713–9.Google Scholar
- 9.Stinson FS, Grant BF, Dawson DA, Ruan WJ, Huang B, Saha T. Comorbidity between DSM–IV alcohol and specific drug use disorders in the United States: results from the National Epidemiologic Survey on alcohol and related conditions. Alcohol Drug Dep 2005;80:105–16.Google Scholar
- 12.Miller WR, Rollnick S. Motivational Interviewing: Helping People Change Third Edition. New York: Guilford Press; 2013.Google Scholar
- 14.Lundahl BW, Kunz C, Brownell C., Tollefson D, Burke B. Meta-analysis of motivational interviewing: twenty five years of empirical studies. Res Soc Work Pract 2010;20:137–60.Google Scholar
- 15.Magill M, Gaume J, Apodaca TR, Walthers J, Mastroleo NR, Borsari B et al. The technical hypothesis of motivational interviewing: A meta-analysis of MI’s key causal model. J Consult Clin Psychol 2014;82:873–83.Google Scholar
- 17.Soderlund LL, Madson MB, Rubak S, Nilsen P. A systematic review of motivational interviewing training for general health care practititoners. Pat Educ Counsel 2011;84:16–26.Google Scholar
- 21.Rogers E. Diffusion of Innovations (5th Ed). New York: Free Press; 2003.Google Scholar
- 24.Davis D. Does CME work? An analysis of the effect of educational activities on physician performance or health care outcomes. Int J Psychiatric Med 1998;28:21–39.Google Scholar
- 25.Walters ST, Matson SA, Baer, JS, Ziedonis DM. Effectiveness of workshop training for psychosocial addiction treatments: A systematic review. J Subst Abus Treat 2005;29:283−93.Google Scholar
- 26.de Roten Y, Zimmermann G, Ortega D, Delpland J. Meta-analysis of the effects of MI training on clinician behavior. J Subst Abus Treat 2013;45:155–62.Google Scholar
- 43.Urbaniak GC, Plous S. Research Randomizer (Version 4.0) [Computer software]. 2013. Retrieved on June 22, 2013, from http://www.randomizer.org/
- 46.Sheehan D, Lecrubier Y, Janavs J, Knapp E, Weiller E. Mini International Neuropsychiatric Interview (MINI). University of South Florida , Tampa; 1996.Google Scholar
- 50.Miller WR, Moyers TB, Ernst D, Amrhein P: Manual for the Motivational Interviewing Skills Code (MISC) v. 2.1. 2008. http://casaa.unm.edu/download/misc.pdf. Accessed 26 June 2019.
- 51.Ball SA, Bachrach K, DeCarlo J, et al. Characteristics, beliefs, and practices of community clinicians trained to provide manual-guided therapy for substance abusers. J Subst Abus Treat 2002;23:309–18.Google Scholar
- 53.McLellan AT, Kushner H, Metzger D, et al.: The fifth edition of the Addiction Severity Index. J Subst Abus Treat 1992;9:199–213.Google Scholar
- 55.Ware J, Kosinski M, Keller S: A 12-Item Short-Form Health Survey: Construction of scales and preliminary tests of reliability and validity. Med Care 1996;34:220–33.Google Scholar
- 57.Imel ZE, Baer JS, Martino S, Ball SA, Carroll KM. Mutual influence in therapist competence and adherence to motivational enhancement therapy. Drug Alcohol Depend 2011;15:229–36.Google Scholar
- 58.Cicchetti DV. Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess 1994;6:284–90.Google Scholar
- 62.Ronan MV, Herzig SJ. Hospitalizations related to opioid abuse/dependence and associated serious infections increased sharply, 2002-12. Health Aff 2016;35:832–7.Google Scholar
- 64.Trowbridge P, Weinstein ZM, Kerensky T, et al. Addiction consultation services-linking hospitalized patients to outpatient addiction treatment. J Subst Abus Treat 2017;79:1–5.Google Scholar
- 68.Rollnick S, Miller W, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York: Guilford Press, 2008.Google Scholar
- 71.Dorsey S, Pullmann MD, Kerns SEU, Jungbluth N, Meza R, Thompson K, et al. The juggling act of supervision in community mental health: Implications for supporting evidence-based treatment. Adm Policy Ment Health Ment Health Serv Res 2017;44:838–52.Google Scholar