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1.  Genetic Contributors to Variation in Alcohol Consumption Vary by Race/Ethnicity in a Large Multi-Ethnic Genome-wide Association Study 
Molecular psychiatry  2017;22(9):1359-1367.
Alcohol consumption is a complex trait determined by both genetic and environmental factors, and is correlated with the risk of alcohol use disorders. While a small number of genetic loci have been reported to be associated with variation in alcohol consumption, genetic factors are estimated to explain about half of the variance in alcohol consumption, suggesting that additional loci remain to be discovered. We conducted a genome-wide association study (GWAS) of alcohol consumption in the large Genetic Epidemiology Research in Adult Health and Aging (GERA) cohort, in four race/ethnicity groups: non-Hispanic Whites, Hispanic/Latinos, East Asians, and African Americans. We examined two statistically independent phenotypes reflecting subjects’ alcohol consumption during the past year, based on self-reported information: any alcohol intake (drinker/non-drinker status), and the regular quantity of drinks consumed per week (drinks/week) among drinkers. We assessed these two alcohol consumption phenotypes in each race/ethnicity group, and in a combined trans-ethnic meta-analysis comprising a total of 86 627 individuals. We observed the strongest association between the previously-reported single nucleotide polymorphism (SNP) rs671 in ALDH2 and alcohol drinker status (OR=0.40, p=2.28×10−72) in East Asians, and also an effect on drinks/week (beta=−0.17, p=5.42×10−4) in the same group. We also observed a genome-wide significant association in non-Hispanic Whites between the previously-reported SNP rs1229984 in ADH1B and both alcohol consumption phenotypes (OR=0.79, p=2.47×10−20 for drinker status and beta=−0.19, p=1.91×10−35 for drinks/week), which replicated in Hispanic/Latinos (OR=0.72, p=4.35×10−7 and beta=−0.21, p=2.58×10−6, respectively). While prior studies reported effects of ADH1B and ALDH2 on lifetime measures, such as risk of alcohol dependence, our study adds further evidence of the effect of the same genes on a cross-sectional measure of average drinking. Our trans-ethnic meta-analysis confirmed recent findings implicating the KLB and GCKR loci in alcohol consumption, with strongest associations observed for rs7686419 (beta=−0.04, p=3.41×10−10 for drinks/week and OR=0.96, p=4.08×10−5 for drinker status), and rs4665985 (beta = 0.04, p=2.26×10−8 for drinks/week and OR=1.04, p=5.00×10−4 for drinker status), respectively. Finally, we also obtained confirmatory results extending previous findings implicating AUTS2, SGOL1, and SERPINC1 genes in alcohol consumption traits in non-Hispanic whites.
doi:10.1038/mp.2017.101
PMCID: PMC5568932  PMID: 28485404
2.  Proceedings of the 14th annual conference of INEBRIA 
Holloway, Aisha S. | Ferguson, Jennifer | Landale, Sarah | Cariola, Laura | Newbury-Birch, Dorothy | Flynn, Amy | Knight, John R. | Sherritt, Lon | Harris, Sion K. | O’Donnell, Amy J. | Kaner, Eileen | Hanratty, Barbara | Loree, Amy M. | Yonkers, Kimberly A. | Ondersma, Steven J. | Gilstead-Hayden, Kate | Martino, Steve | Adam, Angeline | Schwartz, Robert P. | Wu, Li-Tzy | Subramaniam, Geetha | Sharma, Gaurav | McNeely, Jennifer | Berman, Anne H. | Kolaas, Karoline | Petersén, Elisabeth | Bendtsen, Preben | Hedman, Erik | Linderoth, Catharina | Müssener, Ulrika | Sinadinovic, Kristina | Spak, Fredrik | Gremyr, Ida | Thurang, Anna | Mitchell, Ann M. | Finnell, Deborah | Savage, Christine L. | Mahmoud, Khadejah F. | Riordan, Benjamin C. | Conner, Tamlin S. | Flett, Jayde A. M. | Scarf, Damian | McRee, Bonnie | Vendetti, Janice | Gallucci, Karen Steinberg | Robaina, Kate | Clark, Brendan J. | Jones, Jacqueline | Reed, Kathryne D. | Hodapp, Rachel M. | Douglas, Ivor | Burnham, Ellen L. | Aagaard, Laura | Cook, Paul F. | Harris, Brett R. | Yu, Jiang | Wolff, Margaret | Rogers, Meighan | Barbosa, Carolina | Wedehase, Brendan J. | Dunlap, Laura J. | Mitchell, Shannon G. | Dusek, Kristi A. | Gryczynski, Jan | Kirk, Arethusa S. | Oros, Marla T. | Hosler, Colleen | O’Grady, Kevin E. | Brown, Barry S. | Angus, Colin | Sherborne, Sidney | Gillespie, Duncan | Meier, Petra | Brennan, Alan | de Vargas, Divane | Soares, Janaina | Castelblanco, Donna | Doran, Kelly M. | Wittman, Ian | Shelley, Donna | Rotrosen, John | Gelberg, Lillian | Edelman, E. Jennifer | Maisto, Stephen A. | Hansen, Nathan B. | Cutter, Christopher J. | Deng, Yanhong | Dziura, James | Fiellin, Lynn E. | O’Connor, Patrick G. | Bedimo, Roger | Gibert, Cynthia | Marconi, Vincent C. | Rimland, David | Rodriguez-Barradas, Maria C. | Simberkoff, Michael S. | Justice, Amy C. | Bryant, Kendall J. | Fiellin, David A. | Giles, Emma L. | Coulton, Simon | Deluca, Paolo | Drummond, Colin | Howel, Denise | McColl, Elaine | McGovern, Ruth | Scott, Stephanie | Stamp, Elaine | Sumnall, Harry | Vale, Luke | Alabani, Viviana | Atkinson, Amanda | Boniface, Sadie | Frankham, Jo | Gilvarry, Eilish | Hendrie, Nadine | Howe, Nicola | McGeechan, Grant J. | Ramsey, Amy | Stanley, Grant | Clephane, Justine | Gardiner, David | Holmes, John | Martin, Neil | Shevills, Colin | Soutar, Melanie | Chi, Felicia W. | Weisner, Constance | Ross, Thekla B. | Mertens, Jennifer | Sterling, Stacy A. | Shorter, Gillian W. | Heather, Nick | Bray, Jeremy | Cohen, Hildie A. | McPherson, Tracy L. | Adam, Cyrille | López-Pelayo, Hugo | Gual, Antoni | Segura-Garcia, Lidia | Colom, Joan | Ornelas, India J. | Doyle, Suzanne | Donovan, Dennis | Duran, Bonnie | Torres, Vanessa | Gaume, Jacques | Grazioli, Véronique | Fortini, Cristiana | Paroz, Sophie | Bertholet, Nicolas | Daeppen, Jean-Bernard | Satterfield, Jason M. | Gregorich, Steven | Alvarado, Nicholas J. | Muñoz, Ricardo | Kulieva, Gozel | Vijayaraghavan, Maya | Adam, Angéline | Cunningham, John A. | Díaz, Estela | Palacio-Vieira, Jorge | Godinho, Alexandra | Kushir, Vladyslav | O’Brien, Kimberly H. M. | Aguinaldo, Laika D. | Sellers, Christina M. | Spirito, Anthony | Chang, Grace | Blake-Lamb, Tiffany | LaFave, Lea R. Ayers | Thies, Kathleen M. | Pepin, Amy L. | Sprangers, Kara E. | Bradley, Martha | Jorgensen, Shasta | Catano, Nico A. | Murray, Adelaide R. | Schachter, Deborah | Andersen, Ronald M. | Rey, Guillermina Natera | Vahidi, Mani | Rico, Melvin W. | Baumeister, Sebastian E. | Johansson, Magnus | Sinadinovic, Christina | Hermansson, Ulric | Andreasson, Sven | O’Grady, Megan A. | Kapoor, Sandeep | Akkari, Cherine | Bernal, Camila | Pappacena, Kristen | Morley, Jeanne | Auerbach, Mark | Neighbors, Charles J. | Kwon, Nancy | Conigliaro, Joseph | Morgenstern, Jon | Magill, Molly | Apodaca, Timothy R. | Borsari, Brian | Hoadley, Ariel | Scott Tonigan, J. | Moyers, Theresa | Fitzgerald, Niamh M. | Schölin, Lisa | Barticevic, Nicolas | Zuzulich, Soledad | Poblete, Fernando | Norambuena, Pablo | Sacco, Paul | Ting, Laura | Beaulieu, Michele | Wallace, Paul George | Andrews, Matthew | Daley, Kate | Shenker, Don | Gallagher, Louise | Watson, Rod | Weaver, Tim | Bruguera, Pol | Oliveras, Clara | Gavotti, Carolina | Barrio, Pablo | Braddick, Fleur | Miquel, Laia | Suárez, Montse | Bruguera, Carla | Brown, Richard L. | Capell, Julie Whelan | Paul Moberg, D. | Maslowsky, Julie | Saunders, Laura A. | McCormack, Ryan P. | Scheidell, Joy | Gonzalez, Mirelis | Bauroth, Sabrina | Liu, Weiwei | Lindsay, Dawn L. | Lincoln, Piper | Hagle, Holly | Wallhed Finn, Sara | Hammarberg, Anders | Andréasson, Sven | King, Sarah E. | Vargo, Rachael | Kameg, Brayden N. | Acquavita, Shauna P. | Van Loon, Ruth Anne | Smith, Rachel | Brehm, Bonnie J. | Diers, Tiffiny | Kim, Karissa | Barker, Andrea | Jones, Ashley L. | Skinner, Asheley C. | Hinman, Agatha | Svikis, Dace S. | Thacker, Casey L. | Resnicow, Ken | Beatty, Jessica R. | Janisse, James | Puder, Karoline | Bakshi, Ann-Sofie | Milward, Joanna M. | Kimergard, Andreas | Garnett, Claire V. | Crane, David | Brown, Jamie | West, Robert | Michie, Susan | Rosendahl, Ingvar | Andersson, Claes | Gajecki, Mikael | Blankers, Matthijs | Donoghue, Kim | Lynch, Ellen | Maconochie, Ian | Phillips, Ceri | Pockett, Rhys | Phillips, Tom | Patton, R. | Russell, Ian | Strang, John | Stewart, Maureen T. | Quinn, Amity E. | Brolin, Mary | Evans, Brooke | Horgan, Constance M. | Liu, Junqing | McCree, Fern | Kanovsky, Doug | Oberlander, Tyler | Zhang, Huan | Hamlin, Ben | Saunders, Robert | Barton, Mary B. | Scholle, Sarah H. | Santora, Patricia | Bhatt, Chirag | Ahmed, Kazi | Hodgkin, Dominic | Gao, Wenwu | Merrick, Elizabeth L. | Drebing, Charles E. | Larson, Mary Jo | Sharma, Monica | Petry, Nancy M. | Saitz, Richard | Weisner, Constance M. | Young-Wolff, Kelly C. | Lu, Wendy Y. | Blosnich, John R. | Lehavot, Keren | Glass, Joseph E. | Williams, Emily C. | Bensley, Kara M. | Chan, Gary | Dombrowski, Julie | Fortney, John | Rubinsky, Anna D. | Lapham, Gwen T. | Forray, Ariadna | Olmstead, Todd A. | Gilstad-Hayden, Kathryn | Kershaw, Trace | Dillon, Pamela | Weaver, Michael F. | Grekin, Emily R. | Ellis, Jennifer D. | McGoron, Lucy | McGoron, Lucy
doi:10.1186/s13722-017-0087-8
PMCID: PMC5606215
3.  Methadone, Buprenorphine and Preferences for Opioid Agonist Treatment: A Qualitative Analysis 
Drug and alcohol dependence  2016;160:112-118.
Background
Patients and clinicians have begun to recognize the advantages and disadvantages of buprenorphine relative to methadone, but factors that influence choices between these two medications remain unclear. For example, we know little about how patients’ preferences and previous experiences influence treatment decisions. Understanding these issues may enhance treatment engagement and retention.
Methods
Adults with opioid dependence (n = 283) were recruited from two integrated health systems to participate in interviews focused on prior experiences with treatment for opioid dependence, knowledge of medication options, preferences for treatment, and experiences with treatment for chronic pain in the context of problems with opioids. Interviews were audio-recorded, transcribed verbatim, and coded using Atlas.ti.
Results
Our analysis revealed seven areas of consideration for opioid agonist treatment decision-making: 1) awareness of treatment options; 2) expectations and goals for duration of treatment and abstinence; 3) prior experience with buprenorphine or methadone; 4) need for accountability and structured support; 5) preference to avoid methadone clinics or associated stigma; 6) fear of continued addiction and perceived difficulty of withdrawal; and 7) pain control.
Conclusion
The availability of medication options increases the need for clear communication between clinicians and patients, for additional patient education about these medications, and for collaboration and patient influence over choices in treatment decision-making. Our results suggest that access to both methadone and buprenorphine will increase treatment options and patient choice and may enhance treatment adherence and outcomes.
doi:10.1016/j.drugalcdep.2015.12.031
PMCID: PMC4767611  PMID: 26796596
buprenorphine; methadone; opioid addiction; qualitative research
4.  Implementation of Screening, Brief Intervention, and Referral to Treatment for Adolescents in Pediatric Primary Care: A Cluster Randomized Trial 
JAMA pediatrics  2015;169(11):e153145.
Importance
Early intervention for substance use is critical to improving adolescent outcomes. Studies have found promising results for Screening, Brief Intervention, and Referral to Treatment (SBIRT), but little research has examined implementation.
Objective
To compare SBIRT implementation in pediatric primary care among trained pediatricians, pediatricians working in coordination with embedded behavioral health care practitioners (BHCPs), and usual care (UC).
Design, Setting, and Participants
The study is a 2-year (November 1,2011, through October 31, 2013), nonblinded, cluster randomized, hybrid implementation and effectiveness trial examining SBIRT implementation outcomes across 2 modalities of implementation and UC. Fifty-two pediatricians from a large general pediatrics clinic in an integrated health care system were randomized to 1 of 3 SBIRT implementation arms; patients aged 12 to 18 years were eligible.
Interventions
Two modes of SBIRT implementation, (1) pediatrician only (pediatricians trained to provide SBIRT) and (2) embedded BHCP (BHCP trained to provide SBIRT), and (3) UC.
Main Outcomes and Measures
Implementation of SBIRT (primary outcome), which included assessments, brief interventions, and referrals to specialty substance use and mental health treatment.
Results
The final sample included 1871 eligible patients among 47 pediatricians; health care professional characteristics did not differ across study arms. Patients in the pediatrician-only (adjusted odds ratio [AOR], 10.37; 95% CI, 5.45-19.74; P < .001) and the embedded BHCP (AOR, 18.09; 95% CI, 9.69-33.77; P < .001) arms had higher odds of receiving brief interventions compared with patients in the UC arm. Patients in the embedded BHCP arm were more likely to receive brief interventions compared with those in the pediatrician-only arm (AOR, 1.74; 95% CI, 1.31-2.31; P < .001). The embedded BHCP arm had lower odds of receiving a referral compared with the pediatrician-only (AOR, 0.58; 95% CI, 0.43-0.78; P < .001) and UC (AOR, 0.65; 95% CI, 0.48-0.89; P = .006) arms; odds of referrals did not differ between the pediatrician-only and UC arms.
Conclusions and Relevance
The intervention arms had better screening, assessment, and brief intervention rates than the UC arm. Patients in the pediatrician-only and UC arms had higher odds of being referred to specialty treatment than those in the embedded BHCP arm, suggesting lingering barriers to having pediatricians fully address substance use in primary care. Findings also highlight age and ethnic groups less likely to receive these important services.
Trial Registration
Clinicaltrials.gov Identifier: NCT02408952
doi:10.1001/jamapediatrics.2015.3145
PMCID: PMC4779618  PMID: 26523821
5.  Screening and Brief Intervention for Substance Misuse: Does It Reduce Aggression and HIV-Related Risk Behaviours? 
Purpose: To explore whether reducing substance misuse through a brief motivational intervention also reduces aggression and HIV risk behaviours.
Methods: Participants were enrolled in a randomized controlled trial in primary care if they screened positive for substance misuse. Substance misuse was assessed using the Alcohol, Smoking and Substance Involvement Screening Test; aggression, using a modified version of the Explicit Aggression Scale; and HIV risk, through a count of common risk behaviours. The intervention was received on the day of the baseline interview, with a 3-month follow-up.
Results: Participants who received the intervention were significantly more likely to reduce their alcohol use than those who did not; no effect was identified for other substances. In addition, participants who reduced substance misuse (whether as an effect of the intervention or not) also reduced aggression but not HIV risk behaviours.
Conclusions: Reducing substance misuse through any means reduces aggression; other interventions are needed for HIV risk reduction.
doi:10.1093/alcalc/agv007
PMCID: PMC4398989  PMID: 25731180
6.  Advising Depression Patients to Reduce Alcohol and Drug Use: Factors Associated With Provider Intervention in Outpatient Psychiatry 
Background and Objectives
Mental health clinicians have an important opportunity to help depression patients reduce co-occurring alcohol and drug use. This study examined demographic and clinical patient characteristics and service factors associated with receiving a recommendation to reduce alcohol and drug use from providers in a university-based outpatient psychiatry clinic.
Methods
The sample consisted of 97 participants ages 18 and older who reported hazardous drinking (≥3 drinks/occasion), illegal drug use (primarily cannabis) or misuse of prescription drugs, and who scored ≥15 on the Beck Depression Inventory-II (BDI-II). Participants were interviewed at intake and 6 months.
Results
At 6-month telephone interview, 30% of participants reported that a clinic provider had recommended that they reduce alcohol or drug use. In logistic regression, factors associated with receiving advice to reduce use included greater number of drinks consumed in the 30 days prior to intake (p = .035); and greater depression severity on the BDI-II (p = .096) and hazardous drinking at 6 months (p = .05).
Conclusions and Scientific Significance
While participants with greater alcohol intake and depression symptom severity were more likely to receive advice to reduce use, the low overall rate of recommendation to reduce use highlights the need to improve alcohol and drug use intervention among depression patients, and potentially to address alcohol and drug training and treatment implementation issues among mental health providers.
doi:10.1111/j.1521-0391.2014.12140.x
PMCID: PMC4752827  PMID: 25164533
7.  Physician versus non-physician delivery of alcohol screening, brief intervention and referral to treatment in adult primary care: the ADVISe cluster randomized controlled implementation trial 
Background
Unhealthy alcohol use is a major contributor to the global burden of disease and injury. The US Preventive Services Task Force has recommended alcohol screening and intervention in general medical settings since 2004. Yet less than one in six US adults report health care professionals discussing alcohol with them. Little is known about methods for increasing implementation; different staffing models may be related to implementation effectiveness. This implementation trial compared delivery of alcohol screening, brief intervention and referral to specialty treatment (SBIRT) by physicians versus non-physician providers receiving training, technical assistance, and feedback reports.
Methods
The study was a cluster randomized implementation trial (ADVISe [Alcohol Drinking as a Vital Sign]). Within a private, integrated health care system, 54 adult primary care clinics were stratified by medical center and randomly assigned in blocked groups of three to SBIRT by physicians (PCP arm) versus non-physician providers and medical assistants (NPP and MA arm), versus usual care (Control arm). NIH-recommended screening questions were added to the electronic health record (EHR) to facilitate SBIRT. We examined screening and brief intervention and referral rates by arm. We also examined patient-, physician-, and system-level factors affecting screening rates and, among those who screened positive, rates of brief intervention and referral to treatment.
Results
Screening rates were highest in the NPP and MA arm (51 %); followed by the PCP arm (9 %) and the Control arm (3.5 %). Screening increased over the 12 months after training in the NPP and MA arm but remained stable in the PCP arm. The PCP arm had higher brief intervention and referral rates (44 %) among patients screening positive than either the NPP and MA arm (3.4 %) or the Control arm (2.7 %). Higher ratio of MAs to physicians was related to higher screening rates in the NPP and MA arm and longer appointment times to screening and intervention rates in the PCP arm.
Conclusion
Findings suggest that time frames longer than 12 months may be required for full SBIRT implementation. Screening by MAs with intervention and referral by physicians as needed can be a feasible model for increasing the implementation of this critical and under-utilized preventive health service within currently predominant primary care models.
Trial registration: Clinical Trials NCT01135654
doi:10.1186/s13722-015-0047-0
PMCID: PMC4653951  PMID: 26585638
Alcohol screening; Brief intervention for alcohol misuse; Primary care; Unhealthy alcohol use; Cluster randomized trial; Implementation
8.  Significant Life Events and Their Impact on Alcohol and Drug Use: A Qualitative Study 
Journal of psychoactive drugs  2014;46(5):450-459.
This study used a life-course perspective to identify and understand life events related to long-term alcohol and other drug (AOD) use trajectories across the life span. Using a purposive sample, we conducted semi-structured telephone interviews with 48 participants (n=30 abstinent and 18 non-abstinent) from a longitudinal study of AOD outcomes 15 years following outpatient AOD treatment. A content analysis was conducted using ATLAS.ti software to identify events and salient themes. Caregiving for an ill or dependent family member was related to better AOD outcomes by reinforcing abstinence and reduced drinking, and contributing to alcohol cessation in most individuals who cited caregiving as a pivotal event. Grandparenting and parenting an adult child were motivational for sustaining abstinence and reduced drinking. Findings were mixed on death of a loved one which was related to abstinence in some and relapse in others. Redemption and mutual fulfillment as caregivers, reconciliations with adult children, and legacy-building as grandparents were themes associated with maintaining abstinence and reduced drinking. AOD treatment has the opportunity to employ motivational interventions for relapse prevention that address the meaning and life-long reach of intimate relationships for individuals and their AOD use across the life span.
doi:10.1080/02791072.2014.962715
PMCID: PMC4294766  PMID: 25364998
life events; life course; substance use; qualitative; caregiving; relationships
9.  Effectiveness of Nurse-Practitioner-Delivered Brief Motivational Intervention for Young Adult Alcohol and Drug Use in Primary Care in South Africa: A Randomized Clinical Trial 
Aims: To assess the effectiveness of brief motivational intervention for alcohol and drug use in young adult primary care patients in a low-income population and country. Methods: A randomized controlled trial in a public-sector clinic in Delft, a township in the Western Cape, South Africa recruited 403 patients who were randomized to either single-session, nurse practitioner-delivered Brief Motivational Intervention plus referral list or usual care plus referral list, and followed up at 3 months. Results: Although rates of at-risk alcohol use and drug use did not differ by treatment arm at follow-up, patients assigned to the Brief Motivational Intervention had significantly reduced scores on ASSIST (Alcohol, Smoking and Substance Involvement Screening Test) for alcohol—the most prevalent substance. Conclusion: Brief Motivational Intervention may be effective at reducing at-risk alcohol use in the short term among low-income young adult primary care patients; additional research is needed to examine long-term outcomes.
doi:10.1093/alcalc/agu030
PMCID: PMC4060738  PMID: 24899076
10.  Comparison of Health Care Needs of Child Family Members of Adults with Alcohol or Drug Dependence Versus Adults with Asthma or Diabetes 
Objective
To compare the health problems, preventive care utilization, and medical costs of child family members (CFMs) of adults diagnosed with alcohol or drug dependence (AODD) to CFMs of adults diagnosed with diabetes or asthma.
Methods
Child family members of adults diagnosed with AODD between 2002 and 2005 and CFMs of matched adults diagnosed with diabetes or asthma were followed up to 7 years after diagnosis of the index adult. Logistic regression was used to determine whether the CFMs of AODD adults were more likely to be diagnosed with medical conditions, or get preventive care, than the CFMs of adults with asthma or diabetes. Children’s health services use was compared using multivariate models.
Results
In Year 5 after index date, CFMs of adults with AODD were more likely to be diagnosed with depression and AODD than CFMs of adults with asthma or diabetes and were less likely to be diagnosed with asthma, otitis media, and pneumonia than CFMs of adults with asthma. CFMs of AODD adults were less likely than CFMs of adult asthmatic patients to have annual well-child visits. CFMs of AODD adults had similar mean annual total health care costs to CFMs of adults with asthma but higher total costs ($159/yr higher, confidence interval, $56–$253) than CFMs of adult diabetic patients. CFMs of adults with AODD had higher emergency department, higher outpatient alcohol and drug program, higher outpatient psychiatry, and lower primary care costs than CFMs of either adult asthmatic patients or diabetic patients.
Conclusion
Children in families with an alcohol- or drug-dependent adult have unique patterns of health conditions, and differences in the types of health services used, compared to children in families with an adult asthmatic or diabetic family member. However, overall cost and utilization for health care services is similar or only somewhat higher. This is the first study of its kind, and the results have implications for the reduction of parental alcohol or drug dependence stigma by health care providers, clearly an important issue in this era of health reform.
doi:10.1097/DBP.0000000000000049
PMCID: PMC4123818  PMID: 24799266
alcohol; drug; costs; family
11.  Does age at first treatment episode make a difference in outcomes over 11 years? 
This study examines the associations between age at first substance use treatment entry and trajectory of outcomes over 11 years. We found significant differences in individual and treatment characteristics between adult intakes first treated during young adulthood (25 years or younger) and those first treated at an older age. Compared to their first treated older age counterparts matched on demographics and dependence type, those who entered first treatment during young adulthood had on average an earlier onset for substance use but a shorter duration between first substance use and first treatment entry; they also had worse alcohol and other drug outcomes 11 years post treatment entry. While subsequent substance use treatment and 12-step meeting attendance are important for both age groups in maintaining positive outcomes, relationships varied by age group. Findings underline the importance of different continuing care management strategies for those entering first treatment at different developmental stages.
doi:10.1016/j.jsat.2013.12.003
PMCID: PMC3940137  PMID: 24462221
substance use treatment; outcome trajectories; young adulthood; life course
12.  Alcohol and drug treatment involvement, 12-step attendance and abstinence: 9-year cross-lagged analysis of adults in an integrated health plan 
This study explored causal relationships between post-treatment 12-step attendance and abstinence at multiple data waves and examined indirect paths leading from treatment initiation to abstinence 9-years later. Adults (n=1945) seeking help for alcohol or drug use disorders from integrated healthcare organization outpatient treatment programs were followed at 1-, 5-, 7- and 9- years. Path modeling with cross-lagged partial regression coefficients was used to test causal relationships. Cross-lagged paths indicated greater 12-step attendance during years 1 and 5 were casually related to past-30-day abstinence at years 5 and 7 respectfully, suggesting 12-step attendance leads to abstinence (but not vice versa) well into the post-treatment period. Some gender differences were found in these relationships. Three significant time-lagged, indirect paths emerged linking treatment duration to year-9 abstinence. Conclusions are discussed in the context of other studies using longitudinal designs. For outpatient clients, results reinforce the value of lengthier treatment duration and 12-step attendance in year 1.
doi:10.1016/j.jsat.2013.10.015
PMCID: PMC3943492  PMID: 24342024
Path model; longitudinal data; alcohol and drug treatment; 12-step attendance; managed care
13.  “The chief of the services is very enthusiastic about it”: A qualitative study of the adoption of buprenorphine for opioid addiction treatment 
Qualified physicians may prescribe buprenorphine to treat opioid dependence, but medication use remains controversial. We examined adoption of buprenorphine in two not-for-profit integrated health plans, over time, completing 101 semi-structured interviews with clinicians and clinician-administrators from primary and specialty care. Transcripts were reviewed, coded, and analyzed. A strong leader championing the new treatment was critical for adoption in both health plans. Once clinicians began using buprenorphine, patients’ and other clinicians’ experiences affected decisions more than did the champion. With experience, protocols developed to manage unsuccessful patients and changed to support maintenance rather than detoxification. Diffusion outside addiction and mental health settings was nonexistent; primary care clinicians cited scope-of-practice issues and referred patients to specialty care. With greater diffusion came questions about long-term use and safety. Recognizing how implementation processes develop may suggest where, when, and how to best expend resources to increase adoption of such treatments.
doi:10.1016/j.jsat.2013.09.002
PMCID: PMC3897203  PMID: 24268947
Diffusion of technology; buprenorphine; opioid addiction; qualitative research; medication adoption; implementation research
14.  Posttreatment Low-Risk Drinking as a Predictor of Future Drinking and Problem Outcomes Among Individuals with Alcohol Use Disorders 
Background
Treatment for alcohol disorders has traditionally been abstinence-oriented, but evaluating the merits of a low-risk drinking outcome as part of a primary treatment endpoint is a timely issue given new pertinent regulatory guidelines. This study explores a posttreatment low-risk drinking outcome as a predictor of future drinking and problem severity outcomes among individuals with alcohol use disorders in a large private, not for profit, integrated care health plan.
Methods
Study participants include adults with alcohol use disorders at 6 months (N = 995) from 2 large randomized studies. Logistic regression models were used to explore the relationship between past 30-day drinker status at 6 months posttreatment (abstinent [66%], low-risk drinking [14%] defined as nonabstinence and no days of 5+ drinking, and heavy drinking [20%] defined as 1 or more days of 5 + drinking) and 12-month outcomes, including drinking status and Addiction Severity Index measures of medical, psychiatric, family/social, and employment severity, controlling for baseline covariates.
Results
Compared to heavy drinkers, abstinent individuals and low-risk drinkers at 6 months were more likely to be abstinent or low-risk drinkers at 12 months (adj. ORs = 16.7 and 3.4, respectively; p < 0.0001); though, the benefit of abstinence was much greater than that of low-risk drinking. Compared to heavy drinkers, abstinent and low-risk drinkers were similarly associated with lower 12-month psychiatric severity (adj. ORs = 1.8 and 2.2, respectively, p < 0.01) and family/social problem severity (adj. OR = 2.2; p < 0.01). While abstinent individuals had lower 12-month employment severity than heavy drinkers (adj. OR = 1.9; p < 0.01), low-risk drinkers did not differ from heavy drinkers. The drinking groups did not differ on 12-month medical problem severity.
Conclusions
Compared to heavy drinkers, low-risk drinkers did as well as abstinent individuals for many of the outcomes important to health and addiction policy. Thus, an endpoint that allows low-risk drinking may be tenable for individuals undergoing alcohol specialty treatment.
doi:10.1111/j.1530-0277.2012.01908.x
PMCID: PMC4114217  PMID: 22827502
Low-Risk Drinking; Drinking Outcomes; Social Functioning; Alcohol
15.  Costs of care for persons with opioid dependence in commercial integrated health systems 
Background
When used in general medical practices, buprenorphine is an effective treatment for opioid dependence, yet little is known about how use of buprenorphine affects the utilization and cost of health care in commercial health systems.
Methods
The objective of this retrospective cohort study was to examine how buprenorphine affects patterns of medical care, addiction medicine services, and costs from the health system perspective. Individuals with two or more opioid-dependence diagnoses per year, in two large health systems (System A: n = 1836; System B: n = 4204) over the time span 2007–2008 were included. Propensity scores were used to help adjust for group differences.
Results
Patients receiving buprenorphine plus addiction counseling had significantly lower total health care costs than patients with little or no addiction treatment (mean health care costs with buprenorphine treatment = $13,578; vs. mean health care costs with no addiction treatment = $31,055; p < .0001), while those receiving buprenorphine plus addiction counseling and those with addiction counseling only did not differ significantly in total health care costs (mean costs with counseling only: $17,017; p = .5897). In comparison to patients receiving buprenorphine plus counseling, those with little or no addiction treatment had significantly greater use of primary care (p < .001), other medical visits (p = .001), and emergency services (p = .020). Patients with counseling only (compared to patients with buprenorphine plus counseling) used less inpatient detoxification (p < .001), and had significantly more PC visits (p = .001), other medical visits (p = .005), and mental health visits (p = .002).
Conclusions
Buprenorphine is a viable alternative to other treatment approaches for opioid dependence in commercial integrated health systems, with total costs of health care similar to abstinence-based counseling. Patients with buprenorphine plus counseling had reduced use of general medical services compared to the alternatives.
doi:10.1186/1940-0640-9-16
PMCID: PMC4142137  PMID: 25123823
Substance abuse; Cost analysis; Health care utilization; Commercial health insurance; Parity
16.  Ten-year stability of remission in private alcohol and drug outpatient treatment: Non-problem users versus abstainers 
Drug and alcohol dependence  2012;125(0):67-74.
Background
This study examined stability of remission in patients who were abstainers and non-problem users at 1-year after entering private, outpatient alcohol and drug treatment. We examined: (a) How does risk of relapse change over time? (b) What was the risk of relapse for non-problem users versus abstainers? (c) What individual, treatment, and extra-treatment characteristics predicted time to relapse, and did these differ by non-problem use versus abstinence?
Methods
The sample consisted of 684 adults in remission (i.e., abstainers or non-problem users) 1 year following treatment intake. Participants were interviewed at intake, and 1, 5, 7, 9, and 11 years after intake. We used discrete-time survival analysis to examine when relapse is most likely to occur and predictors of relapse.
Results
Relapse was most likely at 5-year, and least likely at 11-year follow-up. Non-problem users had twice the odds of relapse compared to abstainers. Younger individuals and those with fewer 12-step meetings and shorter index treatment had higher odds of relapse than others. We found no significant interactions between non-problem use and the other covariates suggesting that significant predictors of outcome did not differ for non-problem users.
Conclusions
Non-problem use is not an optimal 1-year outcome for those in an abstinence-oriented, heterogeneous substance use treatment program. Future research should examine whether these results are found in harm reduction treatment and self-help models, or in those with less severe problems. Results suggest treatment retention and 12-step participation are prognostic markers of long-term positive outcomes for those achieving remission at 1 year.
doi:10.1016/j.drugalcdep.2012.03.020
PMCID: PMC3644563  PMID: 22542217
Remission; Abstinence; Longitudinal; Treatment
17.  Do 12-step meeting attendance trajectories over 9 years predict abstinence? 
This study grouped treatment-seeking individuals (n=1825) by common patterns of 12-step attendance using 5 waves of data (75% interviewed year-9) to isolate unique characteristics and use-related outcomes distinguishing each class profile. The high class reported the highest attendance and abstention. The descending class reported high baseline alcohol severity, long treatment episodes, and high initial attendance and abstinence; but by year-5 their attendance and abstinence dropped. The early-drop class, which started with high attendance and abstinence but with low problem severity, reported no attendance after year 1. The rising class, with fairly high alcohol and psychiatric severity throughout, reported initially low attendance, followed by increasing attendance paralleling their abstention. Last, the low and no classes, which reported low problem-severity and very low/no attendance, had the lowest abstention. Female gender and high alcohol severity predicted attendance all years. Consistent with a sustained benefit for 12-step exposure, abstinence patterns aligned much like attendance profiles.
doi:10.1016/j.jsat.2011.10.004
PMCID: PMC3320672  PMID: 22206631
Alcoholics Anonymous; 12-step groups; latent class growth analysis; trajectories analysis; alcohol and drug outcomes
18.  The role of continuing care on 9-year cost trajectories of patients with intakes into an outpatient alcohol and drug treatment program 
Medical Care  2012;50(6):540-546.
Background
The importance of a continuing care approach for substance use disorders (SUDs) is increasingly recognized. Our prior research found that a Continuing Care model for SUDs that incorporates three components (regular primary care, and specialty SUD and psychiatric treatment as needed) is beneficial to long-term remission. The study builds on this work to examine the cost implications of this model.
Objectives
To examine associations between receiving Continuing Care and subsequent healthcare costs over 9 years among adults entering outpatient SUD treatment in a private non-profit, integrated managed care health plan. We also compare the results to a similar analysis of a demographically matched control group without SUD’s.
Study Design
Longitudinal observational study.
Measures
Measures collected over 9 years include demographic characteristics, self-reported alcohol and drug use and Addiction Severity Index, and health care utilization and cost data from health plan databases.
Results
Within the treatment sample, SUD patients receiving all components of Continuing Care had lower costs than those receiving fewer components. Compared to the demographically matched non-SUD controls, those not receiving Continuing Care had significantly higher inpatient costs (excess cost=$65.79/member-month; p < .01) over 9 years, while no difference was found between those receiving Continuing Care and controls.
Conclusions
Although a causal link cannot be established between receiving Continuing Care and reduced long-term costs in this observational study, findings reinforce the importance of access to health care and development of interventions that optimize patients receiving those services and that may reduce costs to health systems.
doi:10.1097/MLR.0b013e318245a66b
PMCID: PMC3354333  PMID: 22584889
continuing care; cost; primary care; longitudinal study
20.  Continuing Care and Long-Term Substance Use Outcomes in Managed Care: Early Evidence for a Primary Care–Based Model 
Objectives
How best to provide ongoing services to patients with substance use disorders to sustain long-term recovery is a significant clinical and policy question that has not been adequately addressed. Analyzing nine years of prospective data for 991 adults who entered substance abuse treatment in a private, nonprofit managed care health plan, this study aimed to examine the components of a continuing care model (primary care, specialty substance abuse treatment, and psychiatric services) and their combined effect on outcomes over nine years after treatment entry.
Methods
In a longitudinal observational study, follow-up measures included self-reported alcohol and drug use, Addiction Severity Index scores, and service utilization data extracted from the health plan databases. Remission, defined as abstinence or non-problematic use, was the outcome measure.
Results
A mixed-effects logistic random intercept model controlling for time and other covariates found that yearly primary care, and specialty care based on need as measured at the prior time point, were positively associated with remission over time. Persons receiving continuing care (defined as having yearly primary care and specialty substance abuse treatment and psychiatric services when needed) had twice the odds of achieving remission at follow-ups (p<.001) as those without.
Conclusions
Continuing care that included both primary care and specialty care management to support ongoing monitoring, self-care, and treatment as needed was important for long-term recovery of patients with substance use disorders.
doi:10.1176/appi.ps.62.10.1194
PMCID: PMC3242696  PMID: 21969646
21.  Stopping smoking during first year of substance use treatment predicted 9-year alcohol and drug treatment outcomes 
Drug and alcohol dependence  2010;114(2-3):110-118.
This study examined the association between stopping smoking at 1 year after substance use treatment intake and long-term substance use outcomes. Nine years of prospective data from 1,185 adults (39% female) in substance use treatment at a private health care setting were analyzed by multivariate logistic generalized estimating equation models. At 1 year, 14.1% of 716 participants who smoked cigarettes at intake reported stopping smoking, and 10.7% of the 469 non-smokers at intake reported smoking. After adjusting for sociodemographics, substance use severity and diagnosis at intake, length of stay in treatment, and substance use status at 1 year, those who stopped smoking at 1 year were more likely to be past-year abstinent from drugs, or in past-year remission of drugs and alcohol combined, at follow-ups than those who continued to smoke (OR = 2.4, 95% CI: 1.2 – 4.7 and OR = 1.6, 95% CI: 1.1 – 2.4, respectively). Stopping smoking at 1 year also predicted past-year alcohol abstinence through 9 years after intake among those with drug-only dependence (OR = 2.4, 95% CI: 1.2 – 4.5). We found no association between past-year alcohol abstinence and change in smoking status at 1 year for those with alcohol dependence or other substance use diagnoses when controlling for alcohol use status at 1 year. Stopping smoking during the first year after substance use treatment intake predicted better long-term substance use outcomes through 9 years after intake. Findings support promoting smoking cessation among smoking clients in substance use treatment.
doi:10.1016/j.drugalcdep.2010.09.008
PMCID: PMC3062692  PMID: 21050681
longitudinal data; tobacco; alcohol; substance use; treatment
22.  Addiction treatment ultimatums and U.S. health reform: A case study 
AIMS
Increased access to health care, including addiction treatment, has long been a goal of health reform in the U.S. An unanswered question is whether reform will change the way people get to addiction treatment; when treatment is easily accessible, do individuals self-refer, or do they still enter treatment via ultimatums, and if so, from which sources? To begin examining this, we used a single case study of a U.S. health plan that provides access similar to that called for in health reform.
METHOD
Using a case study method of data from studies conducted in a large, private non-profit, integrated managed care health plan which includes addiction services, we examined the prevalence and source of ultimatums to enter treatment, and the characteristics of those receiving them. The plan is highly representative of changes to U.S. health care and other countries due to health reform.
RESULTS
Many individuals entering addiction treatment had received an ultimatum stemming from employment, legal, medical, and family sources. Having more employment problems, an occupation with public safety concerns, being older, male, and ethnicity predicted an employment ultimatum. Higher legal problem severity predicted a legal ultimatum. More men (and younger people) had family ultimatums, and more women (and older people) had medical ultimatums. Being younger, male, married, having higher employment and family problem severity, and being drug or combined drug/alcohol dependent rather than dependent on alcohol-only predicted an ultimatum from one’s family. On the whole, an ultimatum from one source was not related to having one from another source. Those most likely to receive ultimatums from multiple sources were women, those separated/divorced, and those having higher psychiatric and legal problem severity.
CONCLUSIONS
Even in an insured population with good access to addiction treatment, individuals often receive ultimatums to enter treatment rather than being self-referred. Understanding the treatment entry process, and how it is affected by health care systems, could benefit from international and other comparative research.
PMCID: PMC3225963  PMID: 22135620
alcohol and drug treatment systems; treatment entry; coercion
23.  The time is now: missed opportunities to address patient needs in community clinics in Cape Town, South Africa 
Summary
OBJECTIVE
To investigate the prevalence and correlates of missed opportunities for addressing reproductive and mental health needs during patients’ visits to primary healthcare facilities.
METHODS
We selected a random sample of participants from 14 of the 49 clinics in Cape Town’s public health sector using stratified, cluster random sampling (n = 2618). Participants were screened to identify those at risk for unsafe sexual behaviour and a mental disorder (specifically substance use, depression, anxiety, and suicide). Information pertaining to whether or not respondents were asked about these issues during clinic visits during the previous year was elicited. The rates and correlates of missed opportunities for providing reproductive and mental health interventions were calculated.
RESULTS
The criteria of a strict definition of a missed opportunity for reproductive or mental health care information were fulfilled by 25% of the sample, while 46% met criteria for a looser definition. After adjusting for the effects of other variables in the model, men and Coloured respondents were more likely to have satisfied the definition of a missed opportunity for an intervention, while having completed high school and having children increased the likelihood of receiving an intervention.
CONCLUSION
Consultations with primary healthcare providers in which these issues are not discussed may represent missed opportunities. Persons presenting for routine care can be counselled, screened and, if required, treated. Interventions are needed at the patient, provider, and community levels to increase the opportunities to provide reproductive and mental health care to patients during routine visits.
doi:10.1111/j.1365-3156.2010.02606.x
PMCID: PMC2954234  PMID: 20667052
missed opportunities; primary care; South Africa
24.  Individuals Receiving Addiction Treatment: Are Medical Costs of their Family Members Reduced? 
Addiction (Abingdon, England)  2010;105(7):1226-1234.
Aims
To examine whether alcohol and other drug (AOD) treatment of the individual with AOD disorders is related to reduced medical costs of family members.
Methods
Using Kaiser Permanente Northern California administrative databases we matched AOD treatment patients with health plan members without AOD disorders on age, gender, and utilization criteria; we identified family members of each group. We measured abstinence at 1-year post-intake and examined health care costs per member-month of family members of AOD patients and of controls through 5 years post-intake. We used generalized estimating equation methods to examine differences in average medical cost per member-month for each year, between family members of abstinent and non-abstinent AOD patients and control family members. We used multilevel models to examine the 4-year trajectories of cost subsequent to measuring abstinence status, controlling for pre-intake cost, age, gender and family size.
Results
AOD patients’ family members had significantly higher costs and more psychiatric and medical conditions than control family members in the pre-treatment year. At 2-5 years post-intake, each year family members of AOD patients who were abstinent at 1 year had similar average per member-month medical costs as control family members (e.g., difference at year 5=$2.63; p>.82), whereas average per member-month costs of family members of non-abstinent patients were higher (e.g., difference at year 5=$35.59; p=.06). Family members of AOD patients who were not abstinent at 1 year, had a trajectory of increasing medical cost (slope=$10.32; p=.03) relative to control family members.
Conclusions
Successful AOD treatment is related to medical cost reductions for family members; these reductions may be considered a proxy for improved health.
doi:10.1111/j.1360-0443.2010.02947.x
PMCID: PMC2907442  PMID: 20491730
family health; cost analysis; alcoholism and addictive behavior; substance abuse
25.  Integrating Primary Medical Care With Addiction Treatment 
Context
The prevalence of medical disorders is high among substance abuse patients, yet medical services are seldom provided in coordination with substance abuse treatment.
Objective
To examine differences in treatment outcomes and costs between integrated and independent models of medical and substance abuse care as well as the effect of integrated care in a subgroup of patients with substance abuse–related medical conditions (SAMCs).
Design
Randomized controlled trial conducted between April 1997 and December 1998.
Setting and Patients
Adult men and women (n=592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif.
Interventions
Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n=285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n=307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available.
Main Outcome Measures
Abstinence outcomes, treatment utilization, and costs 6 months after randomization.
Results
Both groups showed improvement on all drug and alcohol measures. Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P=.18). For patients without SAMCs, there were also no differences in abstinence rates (integrated care, 66% vs independent care, 73%; P=.23) and there was a slight but nonsignificant trend of higher costs for the integrated care group ($367.96 vs $324.09, P=.19). However, patients with SAMCs (n=341) were more likely to be abstinent in the integrated care group than the independent care group (69% vs 55%, P=.006; odds ratio [OR], 1.90; 95% confidence interval [CI], 1.22-2.97). This was true for both those with medical (OR, 3.38; 95% CI, 1.68-6.80) and psychiatric (OR, 2.10; 95% CI, 1.04-4.25) SAMCs. Patients with SAMCs had a slight but nonsignificant trend of higher costs in the integrated care group ($470.81 vs $427.95, P=.14). The incremental cost-effectiveness ratio per additional abstinent patient with an SAMC in the integrated care group was $1581.
Conclusions
Individuals with SAMCs benefit from integrated medical and substance abuse treatment, and such an approach can be cost-effective. These findings are relevant given the high prevalence and cost of medical conditions among substance abuse patients, new developments in medications for addiction, and recent legislation on parity of substance abuse with other medical benefits.
PMCID: PMC3056510  PMID: 11594896

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