Improve Substance Use Research Articles

Opportunities for Identifying and Addressing Unhealthy Substance Use in Rural Communities: A Commentary on Cucciare et al (2017).

Unhealthy substance use is a public health problem facing rural communities across the United States. Unfortunately, numerous challenges including stigma, perceived need for care, and perceived accessibility of substance use treatment serve as barriers to many rural adults using substances in obtaining the care they need. It is therefore important to examine whether accessing health care options other than substance use treatment is associated with improved substance use. In a recent study published in the American Journal of Drug and Alcohol Abuse, we explored whether use of outpatient medical care (OMC) was associated with reductions in substance use among rural stimulant users over a 3-year period. Overall, the results showed that, among rural adults using stimulants, those with at least one OMC visit had fewer days of alcohol, crack cocaine, and methamphetamine use over time. However, most participants reported not having any use of an OMC over the 3-year period, suggesting the need for identifying innovative opportunities to provide substance use help for persons living in rural settings. In this commentary, we discuss opportunities for detecting and addressing unhealthy substance use in retail clinics, via clergy and pharmacists.

Treating addiction with schema therapy and EMDR in women with co-occurring SUD and PTSD: A pilot study

ABSTRACTBackground: This study aimed to examine whether the combined use of schema therapy (ST) and Eye Movement Desensitization and Reprocessing (EMDR) can improve substance use disorder (SUD) outcomes in a sample of women with co-occurring SUD and posttraumatic stress disorder (PTSD). To our knowledge, no research has examined this question in a SUD-PTSD clinical sample.Methods: We proposed to 15 women with SUD/PTSD comorbidity a two-phase-protocol therapy: eight ST sessions associated with EMDR focused on reprocessing traumatic memory (phase A) and eight ST sessions associated with EMDR focused on reprocessing addictive memory (phase B). We evaluated addiction severity, alcohol craving, cannabis craving, PTSD symptoms, early maladaptive schemas (EMS) intensity and depressive symptoms before and after treatment.Results: Findings indicated that eight sessions of ST combined with EMDR focused on traumatic memories (phase A) reduced PTSD symptoms and the number of EMS. Findings on phase B showed a statistically significant decrease for addiction severity and depressive symptoms.Conclusions. This study supports the importance of providing integrative therapies for improving SUD outcomes. Overall, this study indicates that ST plus EMDR is an effective, rapid, thorough and enduring treatment for SUD-PTSD women.

Contingency management treatment in cocaine using methadone maintained patients with and without legal problems

BackgroundLegal difficulties and cocaine use are prevalent in methadone maintenance patients, and they are related to one another, as well as to poor response to methadone treatment. Contingency management (CM) is efficacious for decreasing cocaine use, but the relation of CM treatment to criminal activities has rarely been studied. MethodsThis study evaluated whether baseline legal problems are related to subsequent substance use and illegal activities for cocaine using methadone maintained patients and whether CM differentially improves outcomes depending on baseline legal problems. Using data from four randomized CM trials (N=323), we compared methadone maintained patients with legal problems at the start of study participation to those without initial legal problems. ResultsOverall, the addition of CM to standard methadone care improved substance use outcomes regardless of initial legal problems. Endorsement of legal problems within 30days of study initiation was associated with reduced proportion of negative samples submitted during the 12-week treatment period. A significant interaction effect of baseline legal problems and treatment condition was present for subsequent self-reports of illegal activities. Those with baseline legal problems who were assigned to CM had reduced self-reports of reengagement in illegal activity throughout a six month follow-up compared to their counterparts randomized to standard care. ConclusionsAdding CM to methadone treatment improves substance use outcomes and reduces subsequent illegal activity in cocaine-using methadone patients with legal problems.

To Improve Substance Use Disorder Prevention, Treatment and Recovery: Engage the Family

: Approximately 21 million people in the United States have a substance use disorder (SUD); the number of family members impacted by a loved one's SUD is exponentially greater. Affected family members of individuals with SUDs are at high risk for developing chronic medical and psychiatric health conditions, are high utilizers of the health care system, and have high health care expenditures. Family members play a central role in the lives of many individuals with SUDs; information given to family members can have a significant impact on persons with addiction and therefore the SUD treatment that an individual might receive. Evidence-based interventions targeting affected family members have been shown to: improve health outcomes for all family members, result in better addiction treatment outcomes, and prevent adolescent substance use. Despite mounting evidence, the health care system has been hesitant to engage families in a meaningful way. Health care providers should consider how implicit and explicit assumptions about the role of family members in SUD development, treatment, and recovery may contribute to this underlying reluctance. Antiquated policies and procedures that alienate family members should be modified (e.g., limiting phone access). Family members have a right to receive professional treatment and to be educated about the difference between mutual/peer support and evidence-based treatment options. Despite the potential for family members to move the needle on the country's current addiction crisis they remain an underutilized resource. A paradigm shift will be required to get the current SUD care continuum to adopt a family-centric model.

Inpatient Addiction Consultation for Hospitalized Patients Increases Post-Discharge Abstinence and Reduces Addiction Severity.

Alcohol and drug use results in substantial morbidity, mortality, and cost. Individuals with alcohol and drug use disorders are overrepresented in general medical settings. Hospital-based interventions offer an opportunity to engage with a vulnerable population that may not otherwise seek treatment. To determine whether inpatient addiction consultation improves substance use outcomes 1 month after discharge. Prospective quasi-experimental evaluation comparing 30-day post-discharge outcomes between participants who were and were not seen by an addiction consult team during hospitalization at an urban academic hospital. Three hundred ninety-nine hospitalized adults who screened as high risk for having an alcohol or drug use disorder or who were clinically identified by the primary nurse as having a substance use disorder. Addiction consultation from a multidisciplinary specialty team offering pharmacotherapy initiation, motivational counseling, treatment planning, and direct linkage to ongoing addiction treatment. Addiction Severity Index (ASI) composite score for alcohol and drug use and self-reported abstinence at 30 days post-discharge. Secondary outcomes included 90-day substance use measures and self-reported hospital and ED utilization. Among 265 participants with 30-day follow-up, a greater reduction in the ASI composite score for drug or alcohol use was seen in the intervention group than in the control group (mean ASI-alcohol decreased by 0.24 vs. 0.08, p<0.001; mean ASI-drug decreased by 0.05 vs. 0.02, p=0.003.) There was also a greater increase in the number of days of abstinence in the intervention group versus the control group (+12.7days vs. +5.6, p<0.001). The differences in ASI-alcohol, ASI-drug, and days abstinent all remained statistically significant after controlling for age, gender, employment status, smoking status, and baseline addiction severity (p=0.018, 0.018, and 0.02, respectively). In a sensitivity analysis, assuming that patients who were lost to follow-up had no change from baseline severity, the differences remained statistically significant. In a non-randomized cohort of medical inpatients, addiction consultation reduced addiction severity for alcohol and drug use and increased the number of days of abstinence in the first month after hospital discharge.

Amy Winehouse Foundation young persons’ substance use survey–pilot findings

IntroductionGovernment-funded research indicates the prevalence of substance use in this age group is decreasing. However, anecdotal evidence suggests otherwise.Previous surveys have been limited by:— difficulty recruiting schools;— the range of substances included;— paper surveys.ObjectivesTo determine whether a secure online survey method improves substance use prevalence data collection in school age adolescents.MethodAn online survey was created following literature review, and assessment of the reliability and validity of existing surveys. A comprehensive range of substances were included. A total of 750 students (11–16 yrs) from a mainstream school in Lancashire completed the survey during a supervised classroom session. Focus groups were conducted with students and teachers.ResultsNo technical problems were encountered and survey data was securely transferred to Excel allowing instant analysis.Teachers felt the survey would be unproblematic to administer independently and found the inclusion of substances such as legal highs, and energy drinks, especially relevant.Most students completed the survey within the session and reported a positive experience, although some difficulties understanding wording were mentioned. They felt an online survey improved confidentiality (and therefore honesty) and was easier to fill in. However, there was concern about teachers reading their responses.ConclusionsA secure online survey may be acceptable to both teachers and students, and enables the collection of hundreds of surveys in a short time period. It also improves analysis techniques.Further analysis of whether there is a teacher-versus-researcher supervision effect on the honesty of student responses is required.Disclosure of interestThe authors have not supplied their declaration of competing interest.

Barriers and facilitators to successful transition from long-term residential substance abuse treatment

Although residential substance abuse treatment has been shown to improve substance use and other outcomes, relapse is common. This qualitative study explores factors that hinder and help individuals during the transition from long-term residential substance abuse treatment to the community. Semi-structured interviews were conducted with 32 individuals from residential substance abuse treatment. Based on the socio-ecological model, barriers and facilitators to transition were identified across five levels: individual, interpersonal, organizational, community, and policy. The major results indicate that primary areas of intervention needed to improve outcomes for these high-risk individuals include access to stable housing and employment, aftercare services and positive support networks; expanded discharge planning services and transitional assistance; and funding to address gaps in service delivery and to meet individuals' basic needs. This study contributes to the literature by identifying transition barriers and facilitators from the perspectives of individuals in residential treatment, and by using the socio-ecological model to understand the complexity of this transition at multiple levels. Findings identify potential targets for enhanced support post-discharge from residential treatment.

Online learning improves substance use care in Kenya: Randomized control trial results and implications

Online learning improves substance use care in Kenya: Randomized control trial results and implications

Improving substance use prevention efforts with executive function training

BackgroundExecutive function (EF) includes emotional regulation, planning and decision-making, and behavioral impulse control. Improving youth substance use (SU) prevention by targeting EF poses challenges including determining whether specific sub-domains of EF are more associated with SU than others, whether EF is related to some types of SU more than others, and whether EF programs might be enhanced by inclusion of mindfulness training. MethodsData were drawn from two studies from the Pathways to Health project: a randomized controlled trial of 4th–6th graders and a cross-sectional pilot study of the relationship of EF to specific types of SU in a sample of 7th graders. Survey measures included assessment of the EF subdomains of inhibitory control (IC), emotional control, working memory, organization/planning, lifetime SU (tobacco and alcohol use), and mindfulness. Analyses included multivariate and multiple group path analysis. ResultsResults suggested that the EF sub-domain of IC was the strongest and most consistent predictor of SU, particularly cigarette and e-cigarette use, though emotional control was predictive of alcohol use among late-elementary school students. In the 7th grade sample, IC was predictive of alcohol, cigarette, and e-cigarette use only among students in the low 75% of mindfulness. ConclusionsFindings from the present studies suggest that improvements in SU prevention efforts may result from increased curricular emphasis on IC and its application to multiple substance use prevention, and systematically integrating mindfulness with EF skills training. Future research should examine whether EF–SU relationships vary across patterns of SU and types of measures used to assess EF.

Prevalence and Trajectories of Psychiatric Symptoms Among Sober Living House Residents

ABSTRACTObjective: Sober living houses are alcohol- and drug-free recovery residences that help individuals with substance use disorders maintain long-term abstinence. Given the prevalence of co-occurring mental disorders among individuals entering substance use treatment, it is likely that many such residents are also contending with psychiatric symptoms, and it is unclear how these symptoms may affect their sobriety. This study sought to describe the prevalence and trajectories of different types of symptoms among sober living house residents and examine how these symptoms affect substance use outcomes. Methods: Data for this study were collected as part of a larger study on outcomes among sober living house residents in Northern California. The current study examined data from 300 residents in two housing groups; residents were interviewed upon entry and re-interviewed at 6-, 12-, and 18-month follow-ups. Psychiatric symptoms were assessed using the Brief Symptom Inventory (BSI). General estimating equations tested changes in BSI global psychological distress and clinical symptom scales over time and examined the relationship between scale scores and substance use in longitudinal models controlling for demographics, length of stay, and psychiatric service utilization. Results: The average age of residents was 38.5 years (SD = 10.1) and they were mostly male (80%) and Caucasian (65%). Retention rates were high, with 90% (n = 269) participating in at least one follow-up interview. Overall psychological distress (Wald χ2 = 7.99, df = 3, p = .046), symptoms of depression (Wald χ2 = 13.57, df = 3, p = .004), and phobic anxiety (Wald χ2 = 7.89, df = 3, p = .048) significantly improved over time. In all models examining the relationship between BSI scale scores and substance use, rates of abstinence and days of use among those who reported using substances also improved over time. Overall distress (OR = 0.48, p < .001) as well as higher scores on the somatization (OR = 0.56, p < .001), depression (OR = 0.53, p < .001), hostility (OR = 0.71, p = .006), and phobic anxiety (OR = 0.74, p = .012) subscales were significantly associated with a decreased likelihood of abstinence. Symptoms of somatization (B = 0.092, SE = 0.029, p = .002) were associated with an increase in the number of days substances were used among those who reported use. Conclusions: Psychological symptoms among sober living house residents improve over time, but they are risk factors for relapse, suggesting that additional support provided to residents with psychiatric symptoms could improve substance use outcomes.

Respiratory sinus arrhythmia as a potential measure in substance use treatment--outcome studies.

Dysfunction of physiological regulation systems may underlie the disrupted emotional and self-regulatory processes among people with substance use disorder (SUD). This paper reviews evidence as to whether or not respiratory sinus arrhythmia (RSA), as a psychophysiological index of emotional regulation, could provide useful information in treatment-outcome research to provide insights into recovery processes. We reviewed the use of RSA in clinical research and studies on SUD treatment. Search terms for the review of RSA in clinical research included respiratory sinus arrhythmia, heart rate variability, vagal, cardiac vagal control, psychophysiology, intervention, treatment, mindfulness, mind-body, mental health, substance use, chemical dependence, regulation and emotion regulation. For the review of RSA in intervention studies, we included only those that provided adequate description of psychophysiological methods, and examined RSA in the context of an intervention study. RSA appears to be able to provide an index of self-regulatory capacity; however, it has been little used in either intervention or treatment research. Of the four intervention studies included in this review, all were mindfulness-based interventions. Two studies were with substance-using samples, and both showed pre-post increases in RSA and related improved substance use outcomes. Two of the three studies were randomized controlled trials (RCTs), and both showed significant increases in RSA in the experimental compared to comparison condition. Respiratory sinus arrhythmia may be a useful index of emotional regulation in people with substance use disorder, and a potential measure of underlying mechanisms for SUD treatment studies, particularly mindfulness-based interventions.

Sleep and Substance Use among US Adolescents, 1991-2014.

To examine associations between sleep and alcohol, amphetamine, cigarette, marijuana, and non-heroin narcotic use among US middle and high school students, trends in associations over time, and the comparative impact of select covariates on association strength. Data from the 1991-2014 nationally representative Monitoring the Future study of 8(th)-, 10(th)-, and 12(th)-grade US students were used to estimate standardized correlations between the frequency of getting at least 7 hours of sleep (7+ sleep) and substance use frequency while simultaneously regressing both outcomes on key covariate domains. As 7+ sleep frequency increased, substance use frequency significantly decreased and vice versa. Overall, association strength was inversely associated with grade. Associations were generally modest, varied across substances, and weakened over the historical period examined for 8(th)- and 10(th)- graders. Associations showed little variance by sex and racial/ethnic subgroups. Controlling for deviance, psychosocial and general health covariates significantly attenuated association strength. Among US secondary students, 7+ sleep/substance use associations were largely explained by individual deviance, psychosocial, and general health characteristics. Awareness and exploitation of these shared associations may be useful in improving substance use prevention and/or treatment efforts.

Interoceptive Awareness Is Important for Relapse Prevention: Perceptions of Women Who Received Mindful Body Awareness in Substance Use Disorder Treatment.

It is postulated that interventions aimed at facilitating interoceptive awareness (i.e., awareness of inner body sensations) may facilitate regulation and improve substance use disorder (SUD) treatment outcomes. The aim of the study was to better understand the role of interoceptive training in SUD treatment, an identified gap in the literature. On the basis of a National Institute on Drug Abuse (NIDA)-funded pilot randomized clinical trial that used a two-group repeated measures design to examine mindful awareness in body-oriented therapy (MABT) for women in SUD treatment, this study examined the experience of a subset of participants that received and completed MABT intervention in the larger original study. In a qualitative study using a single focus group, participants were asked to respond to multiple questions regarding their current use of interoceptive awareness skills, perceived benefit, learning processes, and suggestions for program development. Interpretive analysis was used to describe the themes that emerged from the focus group responses. Participants consistently used interoceptive awareness self-care skills learned in MABT. Interoceptive awareness training and daily practice were perceived as critical for emotional awareness, regulation, and relapse prevention. In addition, findings highlight the relevance of MABT educational strategies such as touch and individual delivery to teach interoceptive awareness and self-care skills for women in SUD treatment. These findings suggest the positive role of interoceptive awareness in promoting relapse prevention among women in SUD treatment, important for guiding future research, and program development for this population that apply across healthcare disciplines.

Prevalence and correlates of a lifetime cannabis use disorder among pregnant former tobacco smokers

BackgroundFollowing tobacco and alcohol, cannabis is the most commonly used substance during pregnancy. Given the high prevalence of concurrent cannabis and tobacco use as well as the health consequences associated with prenatal substance use, we sought to document the relative contributions of psychosocial and psychiatric factors commonly associated with cannabis use in predicting a lifetime cannabis use disorder (CUD) among women who had quit smoking tobacco as a result of pregnancy. MethodsPregnant former tobacco smokers (n=273) enrolled in a larger randomized controlled trial for postpartum tobacco relapse prevention completed semi-structured psychiatric interviews and self-reported demographic, pregnancy, health, psychosocial, and tobacco use factors during their third trimester of pregnancy. ResultsIn total, 14% (n=38) of women met criteria for a lifetime CUD. The strongest predictors of a lifetime CUD were a history of having multiple psychiatric disorders (OR=36.44; 95% CI=5.03–264.27; p<0.001) followed by a lifetime alcohol use disorder (OR=3.54; 95% CI=1.27–9.87; p<0.05). In addition, more frequent attempts to quit smoking tobacco (OR=1.12; 95% CI=1.01–1.25; p<0.05) and lower self-efficacy about weight management after quitting smoking tobacco (OR=0.78; 95% CI=0.62–0.97; p<0.05) also were significantly associated with a lifetime CUD. ConclusionsWomen with a history of both cannabis and tobacco dependence may represent a subset of women who need more specialized treatment during the perinatal period to improve substance use outcomes.

Pathways to rearrest among court mandated female substance use treatment patients.

Many women who experience substance dependence come into contact with the criminal justice system and are mandated by the court to enter treatment. Treatment is a viable option and can have many positive outcomes, but there remains significant room for improvement. This study was designed to identify key risk factors that can be addressed to improve substance use treatment outcomes for this population. The study sample consisted of (n) 381 women who were court mandated to enter substance use treatment. Multivariate path analyses were conducted to assess the associations between correlates of substance use treatment outcomes, risk for relapse, and rearrest. Women who displayed certain demographic risk factors (i.e., less educated and unmarried) and had greater levels of substance use severity prior to entering treatment experienced elevated risk for relapse. Consequently, women who relapsed were nearly three times (OR = 2.50, 95% CI = 1.26-4.93) as likely to be rearrested within 12 months of discharge from treatment compared to those who did not relapse. Certain risk factors contribute to relapse, which increases risk for rearrest. Services specifically tailored to women who were court mandated to enter treatment need to consider certain demographic risk factors, clinical substance use severity, and relapse prevention as key elements to minimize subsequent criminal offending.

A Systematic Review of Smoking Cessation Interventions for Adults in Substance Abuse Treatment or Recovery.

Introduction:The aim was to evaluate the effectiveness of smoking cessation interventions for patients with substance use disorders. The secondary aim was to evaluate impact on substance use treatment outcomes.Methods:Randomized controlled trials involving adult smokers, recently or currently receiving inpatient or outpatient treatment for substance use disorders were reviewed. Databases, grey literature, reference lists, and journals were searched for relevant studies between 1990 and August 2014. Two authors extracted data and assessed quality. The primary outcome was biochemically verified continuous abstinence from smoking at 6 or 12 months, secondary outcomes were biochemically verified 7-day point prevalence smoking abstinence (PPA) at 6 or 12 months and substance use outcomes. Heterogeneity between studies precluded pooled analyses of the data.Results:Seventeen of 847 publications were included. Five studies reported significant effects on smoking cessation: (1) nicotine patches improved continuous abstinence at 6 months; (2) nicotine gum improved continuous abstinence at 12 months; (3) counseling, contingency management and relapse prevention improved continuous abstinence at 6 and 12 months; (4) cognitive behavioral therapy, plus nicotine replacement therapy (NRT), improved PPA at 6 months; and (5) a combination of bupropion, NRT, counseling and contingency management improved PPA at 6 months. Two studies showed some evidence of improved substance use outcomes with the remaining eight studies measuring substance use outcomes showing no difference.Conclusions:NRT, behavioral support, and combination approaches appear to increase smoking abstinence in those treated for substance use disorders. Higher quality studies are required to strengthen the evidence base.

Implementation of Network for the Improvement of Addiction Treatment (NIATx) Processes in Substance Use Disorder Treatment Centers.

Internal process improvements embedded within the Network for Improvement of Addiction Treatment (NIATx) program are promising innovations for improving substance use disorder (SUD) treatment performance, such as engagement and retention. To date, few studies have examined the variables that may increase diffusion and implementation of NIATx innovations. This study investigates organizational characteristics associated with SUD treatment center utilization of NIATx process improvements in a sample of 458 treatment programs. Overall, 19% had utilized NIATx process improvements. After statistically controlling environmental factors, five organizational variables were associated with the likelihood that treatment centers used NIATx processes. Organization size, administrative intensity, membership in a provider association, and participation in National Institute on Drug Abuse's Clinical Trials Network were positively associated with the odds of utilizing NIATx processes, while the association for the level of slack resources was negative. The findings suggest that policies and related supportive efforts may be required to facilitate diffusion and implementation of NIATx processes to affect SUD treatment center performance and capacity.

Criminal Typology of Veterans Entering Substance Abuse Treatment

Criminal justice involvement among veterans is a critical and timely concern, yet little is known about criminal histories and clinical characteristics among veterans seeking treatment for substance use disorders (SUDs). The present study examined criminal typology, clinical characteristics, treatment utilization, and 12-step mutual-help group (MHG) participation among veterans (N=332) at intake to SUD treatment at the Department of Veterans Affairs (VA), and 6months and 1year post-intake. Cluster analysis yielded three types of criminal histories mild—(78.9%), moderate (13.6%), and severe (7.5%)—distinguished by type of offense, number of convictions, and number of months incarcerated. At intake, participants with mild criminal histories reported more alcohol problems and fewer legal and employment problems than participants with moderate and severe criminal histories. Participants with severe criminal histories were most likely to attend a 12-step MHG meeting in the year post-intake, but all groups had high attendance. When only participants who had attended at least one meeting in the year post-intake were compared, participants with mild criminal histories worked more steps and were more involved in 12-step practices. All groups improved between baseline and follow-up and did not differ at follow-ups on substance use or other clinical outcomes. Multiple regressions identified treatment utilization and MHG attendance, but not baseline criminal history, as significant predictors of improved substance use problem severity at follow-up. Outpatient treatment and 12-step MHG attendance appear to be important components of recovery for veterans with varying criminal histories. Clinicians in SUD treatment programs should screen for criminal histories at treatment intake to ensure appropriate treatment planning.

Online Interprofessional Education and Practice for Health Care Professionals Improves Substance Use Treatment Capacity

Online Interprofessional Education and Practice for Health Care Professionals Improves Substance Use Treatment Capacity

Examining vulnerability to smokeless tobacco use among adolescents and adults with major depressive disorder

Aims: Integration of behavioral health including substance use problems into primary care is an essential benefit that federally qualified health centers (FQHCs) will offer as part of the Affordable Care Act (ACA). This study explores FQHC primary care clinicians’ beliefs and behaviors in integrating drug use assessment and treatment into their practices with a screening, brief intervention and referral to treatment (SBIRT) protocol. Methods: We administered a 10-min questionnaire to 68 primary care clinicians of 5 FQHCs in Los Angeles. Results: Clinicians expressed limited confidence in their ability to deal with illicit drug use of their patients, scoring on average 3.31 on a five point Likert scale. Two-thirds reported assessing for drug use regularly ‘at every visit’ and/or ‘at annual visits’. Median response for how often they counsel regarding drug use (on a five point Likert Scale from ‘Never’ to ‘Always’), was 4 (‘Usually’). Regarding their perspectives on the best practical resource for addressing drug use in their clinics, 45.6% named primary care clinicians. A minority (29.4%) of clinicians had completed a clinical rotation dealing with substance use, and 27.2% reported that more than 10h of their trainingwas devoted to substance use problems. Having a substance use rotation was associated with greater confidence in SBIRT (p<0.01). More hours of substance use training was associated with greater confidence (p=0.01) and routinely addressing substance use in their patients (p=0.04). Conclusions:Our findings suggest that clinician confidence and practices in substance use care are not optimal, but are associated with increased substance use education. Further work should examine whether improving clinicians’ education/training at community health centers, improves substance use care practices. Financial support: This study is part of the UCLA Quit Using Drugs Intervention Trial (QUIT),which has been funded byNational Institute on Drug Abuse (R01DA022445). Dr. Anjani Reddy is a National Research Service Award Fellow.