Implementing Motivational Interviewing for Substance Misuse on Medical Inpatient Units: a Randomized Controlled Trial
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BACKGROUND: 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. OBJECTIVE: To determine the effectiveness of three strategies for implementing motivational interviewing for substance misuse with general medical inpatients. DESIGN: Type 3 hybrid effectiveness-implementation randomized controlled trial (Clinical Trials.gov: NCT01825057). PARTICIPANTS: 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. INTERVENTIONS: 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). MAIN MEASURES: 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. KEY RESULTS: 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 Prior Presentations This work was presented at the International Conference for Motivational Interviewing in June 2017, the Annual Conference on the Science of Dissemination and Implementation in Health Conference in December 2017, and the VA Implementation Research Group Cyberseminar Series in March 2018. Received December 14, 2018 Revised May 28, 2019 Accepted July 11, 2019
favored reducing substance misuse, with no differences between conditions. CONCLUSIONS: 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. TRIAL REGISTRY: NCT01825057 KEY WORDS: behavioral science; consultation; implementation research; substance abuse. J Gen Intern Med DOI: 10.1007/s11606-019-05257-3 © Society of General Internal Medicine (This is a U.S. government work and not under copyright protection in the U.S.; foreign copyright protection may apply) 2019
INTRODUCTION
Acute medical hospitalizations involve a disproportionate share of patients who misuse substances1–9 and ca
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