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1.  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
2.  Alcohol, Cannabis, and Opioid Use Disorders, and Disease Burden in an Integrated Healthcare System 
Objectives
We examined prevalence of major medical conditions and extent of disease burden among patients with and without substance use disorders (SUDs) in an integrated healthcare system serving 3.8 million members.
Methods
Medical conditions and SUDs were extracted from electronic health records in 2010. Patients with SUDs (n = 45,461; alcohol, amphetamine, barbiturate, cocaine, hallucinogen, and opioid) and demographically matched patients without SUDs (n = 45,461) were compared on the prevalence of nineteen major medical conditions. Disease burden was measured as a function of 10-year mortality risk using the Charlson Comorbidity Index. P-values were adjusted using Hochberg's correction for multiple-inference testing within each medical condition category.
Results
The most frequently diagnosed SUDs in 2010 were alcohol (57.6%), cannabis (14.9%), and opioid (12.9%). Patients with these SUDs had higher prevalence of major medical conditions than non-SUD patients (alcohol use disorders—85.3% vs. 55.3%; cannabis use disorders—41.9% vs. 23.0%; and opioid use disorders—44.9% vs. 26.1%; all p < .001). Patients with these SUDs also had higher disease burden than non-SUD patients; patients with opioid use disorders (M = 0.48; SE = 1.46) had particularly high disease burden (M = 0.23; SE = 0.09), (p < .001).
Conclusions
Common SUDs, particularly opioid use disorders, are associated with substantial disease burden for privately insured individuals without significant impediments to care. This signals the need to explore the full impact SUDs have on the course and outcome of prevalent conditions and initiate enhanced service engagement strategies to improve disease burden.
doi:10.1097/ADM.0000000000000260
PMCID: PMC5291754  PMID: 27610582
Substance Use Disorder; Medical Comorbidity; Disease Burden; Behavioral Healthcare; Integrated Healthcare
3.  The role of hazardous drinking reductions in predicting depression and anxiety symptom improvement among psychiatry patients: A longitudinal study 
Journal of affective disorders  2016;206:169-173.
Background
Co-occurrence of depression, anxiety, and hazardous drinking is high in clinical samples. Hazardous drinking can worsen depression and anxiety symptoms (and vice versa), yet less is known about whether reductions in hazardous drinking improve symptom outcomes.
Methods
Three hundred and seven psychiatry outpatients were interviewed (baseline, 3-, 6-months) for hazardous drinking (drinking over recommended daily limits), depression (PHQ-9), and anxiety (GAD-7) as part of a hazardous drinking intervention trial. Longitudinal growth models tested associations between hazardous drinking and symptoms (and reciprocal effects between symptoms and hazardous drinking), adjusting for treatment effects.
Results
At baseline, participants had moderate anxiety (M=10.81; SD=10.82) and depressive symptoms (M=13.91; SD=5.58); 60.0% consumed alcohol at hazardous drinking levels. Over 6-months, participants’ anxiety (B=−3.03, p<.001) and depressive symptoms (B=−5.39, p<.001) improved. Continued hazardous drinking led to slower anxiety (B=0.09, p=.005) and depressive symptom (B=0.10, p=.004) improvement; reductions in hazardous drinking led to faster anxiety (B=−0.09, p=.010) and depressive (B=−0.10, p=.015) symptom improvement. Neither anxiety (B=0.07, p=.066) nor depressive (B=0.05, p=.071) symptoms were associated with hazardous drinking outcomes.
Limitations
Participants were psychiatry outpatients, limiting generalizability.
Conclusions
Reducing hazardous drinking can improve depression and anxiety symptoms but continued hazardous use slows recovery for psychiatry patients. Hazardous drinking-focused interventions may be helpful in promoting symptom improvement in clinical populations.
doi:10.1016/j.jad.2016.07.039
PMCID: PMC5077687  PMID: 27475887
Depression; Alcohol; Hazardous drinking; Anxiety
4.  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
6.  Prescription Opioid Registry Protocol in an Integrated Health System 
The American journal of managed care  2017;23(5):e146-e155.
Objective
To establish a prescription opioid registry protocol in a large health system and to describe algorithms to characterize persons using prescription opioids, opioid use episodes and concurrent use of sedative/hypnotics.
Study Design
Protocol development and retrospective cohort study.
Methods
Using Kaiser Permanente Northern California (KPNC) electronic health record data, we selected patients using prescription opioids in 2011. Opioid and sedative/hypnotic fills, and physical and psychiatric comorbidity diagnoses were extracted for years 2008 to 2014. Algorithms were developed to identify each patient’s daily opioid and sedative/hypnotic use, and morphine daily dose equivalent. Opioid episodes were classified as long-term, episodic, or acute. Logistic regression was used to predict characteristics associated with becoming a long-term opioid user.
Results
In 2011, 18% of KPNC adult members filled at least one opioid prescription. Among those patients, 25% used opioids long-term and their average duration of use was more than 4 years. Sedative/hypnotics were used by 76% of long-term users. Being over 80 years of age, white, living in a more deprived neighborhood, having a chronic pain diagnosis, and use of sedative/hypnotics were predictors of initiating long-term opioid use.
Conclusion
This study established a population-based opioid registry that is flexible, and can be used to address important questions of prescription opioid use. It will be used in future studies to answer a broad range of other critical public health issues relating to prescription opioid use.
PMCID: PMC5560074  PMID: 28810131
prescription opioids; long-term use; registry
7.  A key challenge for motivational interviewing: training in clinical practice 
Addiction (Abingdon, England)  2016;111(7):1154-1156.
Motivational interviewing (MI) has a strong evidence base supporting its clinical efficacy, yet provider fidelity is difficult to maintain over time, may be costly, and the effects of proficiency on client outcomes remain unknown. These issues need further research and may pose significant challenges to MI implementation in health care.
doi:10.1111/add.13182
PMCID: PMC4899270  PMID: 26929099
Fidelity; implementation; motivational interviewing; SBIRT; training
8.  A Randomized Clinical Trial of Motivational Interviewing to Reduce Alcohol and Drug Use among Patients with Depression 
Objective
This study examined the efficacy of Motivational Interviewing (MI) to reduce hazardous drinking and drug use among adults in treatment for depression.
Methods
Randomized controlled trial based in a large outpatient psychiatry program in an integrated health care system in Northern California. The sample consisted of 307 participants ages 18 and over who reported hazardous drinking, drug use (primarily cannabis) or misuse of prescription drugs in the prior 30 days, and who scored ≥ 5 on the Patient Health Questionnaire (PHQ-9). Participants were randomized to receive either 3 sessions of MI (one in person and two by phone) or printed literature about alcohol and drug use risks (control), as an adjunct to usual outpatient depression care. Measures included alcohol and drug use in the prior 30 days and PHQ-9 depression symptoms. Participants completed baseline in-person interviews and telephone follow-up interviews at 3 and 6 months (96% and 98% of the baseline sample, respectively). Electronic health records were used to measure usual care.
Results
At 6 months, MI was more effective than control in reducing rate of cannabis use (p=.037); and hazardous drinking (≥4 drinks in a day for women, ≥5 drinks in a day for men), (p= .060). In logistic regression, assignment to MI predicted lower cannabis use at 6 months (p= .016) after controlling for covariates. Depression improved in both conditions.
Conclusions
MI can be an effective intervention for cannabis use and hazardous drinking among patients with depression.
doi:10.1037/ccp0000096
PMCID: PMC4919182  PMID: 26985728
depression; alcohol; hazardous drinking; cannabis; motivational interviewing
9.  Specifying and Pilot Testing Quality Measures for the American Society of Addiction Medicine's Standards of Care 
Journal of addiction medicine  2016;10(3):148-155.
Objectives
In 2013, American Society of Addiction Medicine (ASAM) approved their Standards of Care for the Addiction Specialist Physician. Subsequently, an ASAM Performance Measures Panel identified and prioritized the standards to be operationalized into performance measures. The goal of this paper is to describe the process of operationalizing three of these standards into quality measures, and to present the initial measure specifications and results of pilot testing these measures in a large health care system. By presenting the process rather than just the end results, we hope to shed light on the measure development process in order to educate, as well as stimulate debate about the decisions that were made.
Methods
Each measure was decomposed into major concepts. Then each concept was operationalized using commonly available administrative data sources. Alternative specifications examined and sensitivity analyses were conducted to inform decisions that balanced accuracy, clinical nuance, and simplicity. Using data from the US Veterans Health Administration (VHA), overall performance and variation in performance across 119 VHA facilities were calculated.
Results
Three measures were operationalized and pilot tested: pharmacotherapy for alcohol use disorder, pharmacotherapy for opioid use disorder, and timely follow-up after medically managed withdrawal (aka detoxification). Each measure was calculable with available data, showed ample room for improvement (no ceiling effects) and wide facility-level variability.
Conclusions
Next steps include conducting feasibility and pilot testing in other health care systems and other contexts such as standalone addiction treatment programs, as well as to study the specification and predictive validity of these measures.
doi:10.1097/ADM.0000000000000203
PMCID: PMC5001552  PMID: 26933875
Quality Measurement; Standards of Care; Treatment Processes
10.  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
11.  Measures of Outcome for Stimulant Trials: ACTTION Recommendations and Research Agenda 
Background
The development and approval of an efficacious pharmacotherapy for stimulant use disorders has been limited by the lack of a meaningful indicator of treatment success, other than sustained abstinence.
Methods
In March, 2015, a meeting sponsored by Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) was convened to discuss the current state of the evidence regarding meaningful outcome measures in clinical trials for stimulant use disorders. Attendees included members of academia, funding and regulatory agencies, pharmaceutical companies, and healthcare organizations. The goal was to establish a research agenda for the development of a meaningful outcome measure that may be used as an endpoint in clinical trials for stimulant use disorders.
Results and Conclusions
Based on guidelines for the selection of clinical trial endpoints, the lessons learned from prior addiction clinical trials, and the process that led to identification of a meaningful indicator of treatment success for alcohol use disorders, several recommendations for future research were generated. These include a focus on the validation of patient reported outcome measures of functioning, the exploration of patterns of stimulant abstinence that may be associated with physical and/or psychosocial benefits, the role of urine testing for validating self-reported measures of stimulant abstinence, and the operational definitions for reduction-based measures in terms of frequency rather than quantity of stimulant use. These recommendations may be useful for secondary analyses of clinical trial data, and in the design of future clinical trials that may help establish a meaningful indicator of treatment success.
doi:10.1016/j.drugalcdep.2015.11.004
PMCID: PMC4698050  PMID: 26652899
Stimulant use disorders; Outcome measures; Clinical trials
12.  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
13.  Proceedings of the 13th annual conference of INEBRIA 
Watson, Rod | Morris, James | Isitt, John | Barrio, Pablo | Ortega, Lluisa | Gual, Antoni | Conner, Kenneth | Stecker, Tracy | Maisto, Stephen | Paroz, Sophie | Graap, Caroline | Grazioli, Véronique S | Daeppen, Jean-Bernard | Collins, Susan E | Bertholet, Nicolas | McNeely, Jennifer | Kushnir, Vlad | Cunningham, John A. | Crombie, Iain K | Cunningham, Kathryn B | Irvine, Linda | Williams, Brian | Sniehotta, Falko F | Norrie, John | Melson, Ambrose | Jones, Claire | Briggs, Andrew | Rice, Peter | Achison, Marcus | McKenzie, Andrew | Dimova, Elena | Slane, Peter W | Grazioli, Véronique S. | Collins, Susan E. | Paroz, Sophie | Graap, Caroline | Daeppen, Jean-Bernard | Baggio, Stéphanie | Dupuis, Marc | Studer, Joseph | Gmel, Gerhard | Magill, Molly | Grazioli, Véronique S. | Tait, Robert J. | Teoh, Lucinda | Kelty, Erin | Geelhoed, Elizabeth | Mountain, David | Hulse, Gary K. | Renko, Elina | Mitchell, Shannon G. | Lounsbury, David | Li, Zhi | Schwartz, Robert P. | Gryczynski, Jan | Kirk, Arethusa S. | Oros, Marla | Hosler, Colleen | Dusek, Kristi | Brown, Barry S. | Finnell, Deborah S. | Holloway, Aisha | Wu, Li-Tzy | Subramaniam, Geetha | Sharma, Gaurav | Wallhed Finn, Sara | Andreasson, Sven | Dvorak, Robert D. | Kramer, Matthew P. | Stevenson, Brittany L. | Sargent, Emily M. | Kilwein, Tess M. | Harris, Sion K. | Sherritt, Lon | Copelas, Sarah | Knight, John R. | Mdege, Noreen D | McCambridge, Jim | Bischof, Gallus | Bischof, Anja | Freyer-Adam, Jennis | Rumpf, Hans-Juergen | Fitzgerald, Niamh | Schölin, Lisa | Toner, Paul | Böhnke, Jan R. | Veach, Laura J. | Currin, Olivia | Dongre, Leigh Z. | Miller, Preston R. | White, Elizabeth | Williams, Emily C. | Lapham, Gwen T. | Bobb, Jennifer J. | Rubinsky, Anna D. | Catz, Sheryl L. | Shortreed, Susan | Bensley, Kara M. | Bradley, Katharine A. | Milward, Joanna | Deluca, Paolo | Khadjesari, Zarnie | Watson, Rod | Fincham-Campbell, Stephanie | Drummond, Colin | Angus, Kathryn | Bauld, Linda | Baumann, Sophie | Haberecht, Katja | Schnuerer, Inga | Meyer, Christian | Rumpf, Hans-Jürgen | John, Ulrich | Gaertner, Beate | Barrault-Couchouron, Marion | Béracochéa, Marion | Allafort, Vincent | Barthélémy, Valérie | Bonnefoi, Hervé | Bussières, Emmanuel | Garguil, Véronique | Auriacombe, Marc | Saint-Jacques, Marianne | Dorval, Michel | M’Bailara, Katia | Segura-Garcia, Lidia | Ibañez-Martinez, Nuria | Mendive-Arbeloa, Juan Manuel | Anoro-Perminger, Manel | Diaz-Gallego, Pako | Piñar-Mateos, Mª Angeles | Colom-Farran, Joan | Deligianni, Marianthi | Yersin, Bertrand | Adam, Angeline | Weisner, Constance | Chi, Felicia | Lu, Wendy | Sterling, Stacy | Kraemer, Kevin L. | McGinnis, Kathleen A. | Fiellin, David A. | Skanderson, Melissa | Gordon, Adam J. | Robbins, Jonathan | Zickmund, Susan | Korthuis, P. Todd | Edelman, E. Jennifer | Hansen, Nathan B. | Cutter, Christopher J. | Dziura, James | Fiellin, Lynn E. | O’Connor, Patrick G. | Maisto, Stephen A. | Bedimo, Roger | Gilbert, Cynthia | Marconi, Vincent C. | Rimland, David | Rodriguez-Barradas, Maria | Simberkoff, Michael | Justice, Amy C. | Bryant, Kendall J. | Berman, Anne H | Shorter, Gillian W | Bray, Jeremy W | Barbosa, Carolina | Johansson, Magnus | Hester, Reid | Campbell, William | Souza Formigoni, Maria Lucia O. | Andrade, André Luzi Monezi | Sartes, Laisa Marcorela Andreoli | Sundström, Christopher | Eék, Niels | Kraepelien, Martin | Kaldo, Viktor | Fahlke, Claudia | Hernandez, Lynn | Becker, Sara J. | Jones, Richard N. | Graves, Hannah R. | Spirito, Anthony | Diestelkamp, Silke | Wartberg, Lutz | Arnaud, Nicolas | Thomasius, Rainer | Gaume, Jacques | Grazioli, Véronique | Fortini, Cristiana | Malan, Zelra | Mash, Bob | Everett-Murphy, Katherine | Grazioli, Véronique S. | Studer, Joseph | Mohler-Kuo, M. | Bertholet, Nicolas | Gmel, Gerhard | Doi, Lawrence | Cheyne, Helen | Jepson, Ruth | Luna, Vanesa | Echeverria, Leticia | Morales, Silvia | Barroso, Teresa | Abreu, Ângela | Aguiar, Cosma | Stewart, Duncan | Abreu, Angela | Brites, Riany M. | Jomar, Rafael | Marinho, Gerson | Parreira, Pedro | Seale, J. Paul | Johnson, J. Aaron | Henry, Dena | Chalmers, Sharon | Payne, Freida | Tuck, Linda | Morris, Akula | Gonçalves, Cátia | Besser, Bettina | Casajuana, Cristina | López-Pelayo, Hugo | Balcells, María Mercedes | Teixidó, Lídia | Miquel, Laia | Colom, Joan | Hepner, Kimberly A. | Hoggatt, Katherine. J. | Bogart, Andy | Paddock, Susan. M. | Hardoon, Sarah L | Petersen, Irene | Hamilton, Fiona L | Nazareth, Irwin | White, Ian R. | Marston, Louise | Wallace, Paul | Godfrey, Christine | Murray, Elizabeth | Sovinová, Hana | Csémy, Ladislav
doi:10.1186/s13722-016-0062-9
PMCID: PMC5032602  PMID: 27654147
14.  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
15.  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
16.  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
17.  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
18.  Predictors of Abstinence from Heavy Drinking During Treatment in COMBINE and External Validation in PREDICT 
Background
The goal of the current study was to use tree-based methods (Zhang and Singer, 2010) to identify predictors of abstinence from heavy drinking in COMBINE (Anton et al., 2006), the largest study of pharmacotherapy for alcoholism in the United States to date, and to validate these results in PREDICT (Mann et al., 2012), a parallel study conducted in Germany.
Methods
We compared a classification tree constructed according to purely statistical criteria to a tree constructed according to a combination of statistical criteria and clinical considerations for prediction of no heavy drinking during treatment in COMBINE. We considered over one-hundred baseline predictors. The tree approach was compared to logistic regression. The trees and a deterministic forest identified the most important predictors of no heavy drinking for direct testing in PREDICT.
Results
The tree built using both clinical and statistical considerations consisted of four splits based on consecutive days of abstinence (CDA) prior to randomization, age, family history of alcoholism (FHAlc) and confidence to resist drinking in response to withdrawal and urges. The tree based on statistical considerations with four splits also split on CDA and age but also on GGT level and drinking goal. Deterministic forest identified CDA, age and drinking goal as the most important predictors. Backward elimination logistic regression among the top 18 predictors identified in the deterministic forest analyses identified only age and CDA as significant main effects. Longer CDA and goal of complete abstinence were associated with better outcomes in both data sets.
Conclusions
The most reliable predictors of abstinence from heavy drinking were CDA and drinking goal. Trees provide binary decision rules and straightforward graphical representations for identification of subgroups based on response and may be easier to implement in clinical settings.
doi:10.1111/acer.12541
PMCID: PMC4397985  PMID: 25346505
alcohol dependence; clinical trial; classification tree; deterministic forest; logistic regression
19.  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
20.  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
21.  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
22.  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
23.  “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
25.  Factors Associated With Treatment Initiation for Psychiatric and Substance Use Disorders Among Persons With HIV 
Objective
Prior studies of individuals with HIV infection have found that accessing psychiatric and substance abuse treatment when needed can improve health and prolong life, yet little is known about factors associated with treatment initiation.
Methods
In a retrospective cohort design including individuals with HIV infection (≥14 years old) in an integrated health care system in Northern California, this study included 822 patients with a major psychiatric diagnosis and 1,624 with a substance use disorder diagnosis. Data were extracted from a regional HIV registry and computerized databases.
Results
Twenty-four percent (N=198) of study patients with psychiatric diagnoses and 15% (N=245) with substance abuse or dependence received one or more specialty care visits within 12 months of diagnosis. Among patients with a psychiatric diagnosis, significant predictors of visiting a psychiatry clinic included not having an AIDS diagnosis at baseline or before the study (p=.049), having a diagnosis of major depression (p=.013), having a diagnosis of bipolar disorder (p<.001), and receiving a psychiatric diagnosis in 1996 versus later years of the study (p<.01). Among patients with a substance use disorder, significant predictors of initiating substance abuse treatment included age <30 (p=.015) and being in the HIV transmission risk group of injection drug use (p<.001).
Conclusions
Clinical, diagnostic, and demographic factors were associated with specialty care treatment initiation in this sample of individuals with HIV infection and substance use or psychiatric disorders. Developing strategies to enhance treatment initiation has the potential to improve outcomes for individuals with HIV infection.
doi:10.1176/appi.ps.201200064
PMCID: PMC4030718  PMID: 23584606

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