To examine the role of family environment and peer networks in abstinence outcomes for adolescents 1 year after intake to alcohol and other drug (AOD) treatment.
Survey of 419 adolescents 13 to 18 years of age at consecutive intakes to AOD treatment programs at four sites of a large health system, with telephone follow-up survey 1 year after intake.
Examined association of 1-year abstinence with baseline characteristics. Using logistic regression, we examined characteristics predicting 1-year abstinence and predicting having fewer than four substance-using friends at 1 year.
We found that family environment scores related to family conflict, limit setting, and positive family experiences, were not related to abstinence outcomes, but peer networks were related. Adolescents with fewer (less than four) AOD-using friends were more likely to be abstinent than those with four or more AOD-using friends (65% vs. 41%, p = .0002). Having fewer than four AOD-using friends at intake predicted abstinence at 1 year (odds ratio [OR] = 2.904, p = .0002) and also predicted having fewer than four AOD-using friends at 1 year (OR = 2.557, p = 0.0007).
Although family environment is an important factor in the development of AOD problems in adolescents, it did not play a significant role in treatment success. The quality of adolescent peer networks did independently predict positive outcomes.
For physicians, advanced practice registered nurses, and other primary and behavioral care providers who screen and care for adolescents with AOD and other behavioral problems, our finding suggest the importance of focusing on improving the quality of their peer networks.
Adolescent substance use; treatment outcomes; peer networks; family environment
Taking opioids with other central nervous system (CNS) depressants can increase risk of oversedation and respiratory depression. We used telephone survey and electronic health care data to assess the prevalence of, and risk factors for, concurrent use of alcohol and/or sedatives among 1848 integrated care plan members who were prescribed chronic opioid therapy (COT) for chronic non-cancer pain. Concurrent sedative use was defined by receiving sedatives for 45+ days of the 90 days preceding the interview; concurrent alcohol use was defined by consuming 2+ drinks within 2 hours of taking an opioid in the prior 2 weeks. Some analyses were stratified by substance use disorder (SUD) history (alcohol or drug). Among subjects with no SUD history, 29% concurrently used sedatives vs. 39% of those with a SUD history. Rates of concurrent alcohol use were similar (12 to 13%) in the two substance use disorder strata. Predictors of concurrent sedative use included SUD history, female gender, depression, and taking opioids at higher doses and for more than one pain condition. Male gender was the only predictor of concurrent alcohol use. Concurrent use of CNS depressants was common among this sample of COT users regardless of substance use disorder status.
Chronic opioid therapy; alcohol; sedatives; concurrent; substance use disorder
Health services research is a multidisciplinary field that examines ways to organize, manage, finance, and deliver high-quality care. This specialty within substance abuse research developed from policy analyses and needs assessments that shaped federal policy and promoted system development in the 1970s. After the authorization of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA), patient information systems supported studies of treatment processes and outcomes. Health services research grew substantially in the 1990s when NIAAA and NIDA moved into the National Institutes of Health and legislation allocated 15% of their research portfolio to services research. The next decade will emphasize research on quality of care, adoption and use of evidence-based practices (including medication), financing reforms and integration of substance abuse treatment with primary care and mental health services.
To examine changes in use of prescription opioids for the management of chronic non-cancer pain in HIV-infected patients and to identify patient characteristics associated with long-term use.
Long-term prescription opioid use (i.e. 120+ days supply or 10+ prescriptions during a year) was assessed between 1997 and 2005 among 6,939 HIV-infected Kaiser Permanente members and HIV-uninfected persons in the general health plan memberships.
In 2005, 8% of HIV+ individuals had prevalent long-term opioid use, more than double the prevalence among HIV-uninfected individuals. However, the large increases in use from 1997 to 2005 in the general population were not observed for HIV-infected individuals. The strongest associations with prevalent use among HIV-infected individuals were female gender with a prevalence ratio [PR] of 1.8 (95% CI=1.3, 2.5); Charlson comorbidity score of 2 or more (compared with a score of 0) with a PR of 1.9 (95% CI=1.4, 2.8); injection drug use history with a PR of 1.8 (95% CI=1.3, 2.6); substance use disorders with a PR of 1.8 (95% CI=1.3, 2.5). CD4, HIV RNA, and AIDS diagnoses were associated with prevalent opioid use early in the antiretroviral therapy era (1997), but not in 2005.
Long-term opioid use for chronic pain has remained stable over time for HIV patients, while use increased in the general population. The prevalence of prescribed opioids in HIV patients was highest for certain subgroups, including women, and those with a comorbidity and substance abuse history.
HIV/AIDS; chronic pain; prescription opioids; substance use disorders
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.
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.
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.
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.
Alcohol and drug use and related problems may compromise depression treatment, and older adults may be especially at risk for poor outcomes. However, alcohol and drug use among older adults have not been studied in settings in which depression treatment is provided. This study examined the prevalence and clinical and demographic correlates of alcohol and drug use and misuse of prescription drugs among adults with depression seeking outpatient psychiatric care (excluding chemical dependency treatment).
The sample included 154 older adults (age 60 years and older who scored ≥10 on the Beck Depression Inventory-II [BDI-II] at intake). Participants also completed alcohol and drug use questions and the Short Michigan Alcohol Screening Test.
Recent alcohol and drug use, heavy episodic drinking, and history of alcohol-related problems were common. Alcohol use in the prior 30 days was reported by 53% of men and 50% of women. Cannabis use in the prior 30 days was reported by 12% of men and 4% of women; and misuse of sedatives in the prior 30 days was reported by 16% of men and 9% of women. In exact logistic regression, higher BDI-II score was associated with cannabis use (odds ratio = 15.8, 95% confidence interval = 2.0-734.0, exact p = 0.003).
Older adults with depression are likely to present for treatment with a range of concurrent alcohol and drug use patterns, including cannabis use and misuse of prescription medication. Clinicians should evaluate depressed patients for substance use and related problems and consider appropriate interventions.
Depression; alcohol; cannabis; prescription drug misuse
Some expert guidelines recommend time-scheduled opioid dosing over pain-contingent dosing for patients receiving chronic opioid therapy (COT). The premise is that time-scheduled dosing results in more stable opioid blood levels and better pain relief, fewer side effects, less reinforcement of pain behaviors, and lower addiction risk. We report results of a survey of 1781 patients receiving COT for chronic non-cancer pain, in which 967 reported time-scheduled opioid dosing only and 325 reported pain-contingent opioid dosing only. Opioid-related problems and concerns were assessed with the Prescribed Opioids Difficulties Scale. We hypothesized that respondents using time-scheduled opioid dosing would report significantly fewer problems and concerns than those using pain-contingent dosing. Patients receiving time-scheduled dosing received substantially higher average daily opioid doses than those using pain-contingent dosing (97.2 vs. 37.2 milligrams average daily dose morphine equivalents, p<.0001). Contrary to expectation, time-scheduled opioid dosing was associated with higher levels of patient opioid control concerns than pain-contingent dosing (6.2 vs. 4.8, p=.008), after adjusting for patient and drug regimen differences. Opioid-related psychosocial problems were somewhat greater among patients using time-scheduled dosing, but this difference was non-significant after controlling for patient and drug regimen differences (5.9 versus 5.0, p=.14). Time-scheduled dosing typically involved higher dosage levels and was associated with higher levels of patient concerns about opioid use. Controlled comparative effectiveness research is needed to assess benefits and risks of time-scheduled opioid dosing relative to pain-contingent opioid dosing among COT patients in ambulatory care.
Opioids; Chronic pain; Chronic opioid therapy; Adverse effects
This study examined alcohol use patterns among men and women with depression seeking outpatient psychiatric treatment, including factors associated with recent heavy episodic drinking and motivation to reduce alcohol consumption.
The sample consisted of 1183 patients ages 18 and over who completed a self-administered, computerized intake questionnaire and who scored ≥ 10 on the Beck Depression Inventory-II (BDI-II). Additional measures included current and past alcohol questions based on the Addiction Severity Index, heavy episodic drinking (≥ 5 drinks on one or more occasions in the past year), alcohol-related problems on the Short Michigan Alcoholism Screening Test (SMAST), and motivation to reduce drinking using the Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES).
Among those who consumed any alcohol in the past year (73.9% of the sample), heavy episodic drinking in the past year was reported by 47.5% of men and 32.5% of women. In logistic regression, prior-year heavy episodic drinking was associated with younger age (p=.011), male gender (p=.001) and cigarette smoking (p=.002). Among patients reporting heavy episodic drinking, motivation to reduce alcohol consumption was associated with older age (p=.008), greater usual quantity of alcohol consumed (p<.001), and higher SMAST score (p<.001).
In contrast to prior clinical studies, we examined sub-diagnostic alcohol use and related problems among psychiatric outpatients with depression. Patients reporting greater drinking quantities and alcohol-related problems also express more motivation to reduce drinking, providing intervention opportunities for mental health providers that should not be overlooked.
depression; alcohol; hazardous drinking; prevalence; motivation
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.
longitudinal data; tobacco; alcohol; substance use; treatment
This paper describes characteristics of opioid use episodes for non-cancer pain and defines thresholds for the transition into Defacto Long-term Opioid Therapy.
CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult members of two health plans serving over one-percent of the U.S. population. Opioid use episodes beginning in 1997–2005 were classified as Acute, Episodic, Long-term/Lower Dose, or Long-term/Higher Dose.
Defacto Long-term Opioid Therapy was defined by opioid use episodes lasting longer than 90 days with at least 10 prescriptions and/or at least 120 days supply dispensed. Long-term/Higher Dose episodes (<1.5% of all episodes) were characterized by daily or near daily use, a mean duration of about 1000 days, and an average daily dose of about 55 milligrams. They accounted for more than half the total morphine equivalents dispensed from 1997–2006. Short-acting, less potent opioids (e.g. hydrocodone with acetaminophen) were by far the most commonly prescribed medications for acute, episodic and long-term episodes. Long-acting (sustained-release) opioids were the predominately prescribed medication in a minority of long-term episodes (6–12%).
Defacto Long-term Opioid Therapy was characterized by considerable diversity in medications, dosage, and frequency of use. Long-term opioid therapy may evolve from acute or episodic use in the absence of an agreed upon treatment plan. Defined thresholds for Defacto Long-term Opioid Therapy provide a possible check point for physicians and health plans to ensure that patients receiving opioid medications long-term are managed according to a treatment plan that is documented and monitored.
Opioids; Epidemiology; Chronic Pain; Methods; Episodes
To report trends and characteristics of long-term opioid use for non-cancer pain.
CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult enrollees of two health plans serving over one-percent of the US population. Using automated data, we constructed episodes of opioid use between 1997 and 2005. We estimated age-sex standardized rates of opioid use episodes beginning in each year (incident) and on-going in each year (prevalent), and the percent change in rates annualized (PCA) over the 9 year period. Long-term episodes were defined as > 90 days with 120+ days supply or 10+ opioid prescriptions in a given year.
Over the study period, incident long-term use increased from 8.5 to 12.1 per 1,000 at Group Health (GH) (6.0% PCA), and 6.3 to 8.6 per 1,000 at Kaiser Permanente of Northern California (KPNC) (5.5% PCA). Prevalent long-term use doubled from 23.9 to 46.8 per 1,000 at GH (8.5% PCA), and 21.5 to 39.2 per 1,000 at KPNC (8.1% PCA). Non-Schedule II opioids were the most commonly used opioid among patients engaged in long-term opioid therapy, particularly at KPNC. Long-term use of Schedule II opioids also increased substantially at both health plans. Among prevalent long-term users in 2005, 28.6% at GH and 30.2% at KPNC were also regular users of sedative hypnotics.
Long-term opioid therapy for non-cancer pain is increasingly prevalent, but the benefits and risks associated with such therapy are inadequately understood. Concurrent use of opioids and sedative-hypnotics was unexpectedly common and deserves further study.
pain; opioids; trends; analgesic
We examined the association between substance use (SU) disorder and mortality among HIV-infected patients in a large, private medical care program.
In a retrospective cohort design, HIV-infected patients (≥14 years old) from a large health plan (Northern California) were studied to examine mortality associated with diagnosis of SU dependence or abuse over an 11-year period.
At study entry or during follow-up, 2,279 (25%) of 9,178 HIV-infected patients had received a diagnosis of SU disorder. Diagnoses were categorized as alcohol dependence/abuse only, illicit drugs only, or both. Cause of death differed by the category of SU diagnosis. Mortality rates ranged from 35.5 deaths per 1,000 person-years in patients with an SU disorder to 17.5 deaths among patients without an SU disorder. Regression results indicated mortality risk was significantly higher in all categories of SU disorder compared to no SU diagnosis (hazard ratios ranging from 1.65 to 1.67) after adjustment for SU treatment and confounders.
A diagnosis of SU dependence/abuse is associated with higher mortality among HIV-infected patients for whom access to medical services is not a significant factor.
HIV; Mortality; Substance Dependence and Abuse
In 2010, the Washington Circle convened a meeting, supported by the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA), for a multidisciplinary group of experts to focus on the research gaps in performance measures for substance use disorders. This article presents recommendations in three areas: development of new performance measures; methodological and other considerations in using performance measures; and implementation research focused on using performance measures for accountability and quality improvement.
Performance measures; Research agenda; Process; Outcome; Structure; Electronic health records
The growth curve modeling (GCM) technique has been widely adopted in longitudinal studies to investigate progression over time. The simplest growth profile involves two growth factors, initial status (intercept) and growth trajectory (slope). Conventionally, all repeated measures of outcome are included as components of the growth profile, and the first measure is used to reflect the initial status. Selection of the initial status, however, can greatly influence study findings, especially for randomized trials. In this article, we propose an alternative GCM approach involving only post-intervention measures in the growth profile and treating the first wave after intervention as the initial status. We discuss and empirically illustrate how choices of initial status may influence study conclusions in addressing research questions in randomized trials using two longitudinal studies. Data from two randomized trials are used to illustrate that the alternative GCM approach proposed in this article offers better model fitting and more meaningful results.
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.
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.
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.
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.
alcohol and drug treatment systems; treatment entry; coercion
We examined the associations between psychiatric diagnoses, substance use disorders, health services, and mortality among 9751 HIV-infected patients (≥14 years old) in a large, private medical care program, in a retrospective cohort design over a 12-year period. All study data were extracted from computerized clinical and administrative databases. Results showed that 25.4% (n = 2472) of the 9751 study subjects had received a psychiatric diagnosis (81.1% had major depression, 17.1% had panic disorder, 14.2% had bipolar disorder, and 8.1% had anorexia/bulimia); and 25.5% (n = 2489) had been diagnosed with substance use disorder; 1180 (12.1%) patients had received both psychiatric and substance diagnoses. In comparison to patients with neither a psychiatric diagnosis nor a SU diagnosis, the highest risk of death was found among patients with dual psychiatric and substance use diagnoses who had no psychiatric treatment visits and no substance treatment (relative hazards [RH] = 4.17, 95% confidence interval [CI] = 2.35 to 7.40). Among dually diagnosed patients, receiving psychiatric and/or substance use disorder treatment somewhat reduced the risk of death compared to patients with neither diagnosis. The lowest risks of death were observed among patients with a single diagnosis who had received corresponding treatment. Our study findings suggest that screening for psychiatric and substance problems at the initiation and during the course of HIV/AIDS treatment and providing psychiatric and substance use disorder treatment may extend life for these vulnerable patients.
To investigate the prevalence and correlates of missed opportunities for addressing reproductive and mental health needs during patients’ visits to primary healthcare facilities.
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.
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.
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.
missed opportunities; primary care; South Africa
Individuals who have both substance use disorders and mental health problems have poorer treatment outcomes. This study examines the relationship of service utilization and 12-step participation to outcomes at 1 and 5 years for patients treated in one of two integrated service delivery systems: the Department of Veterans Affairs (VA) system and a health maintenance organization (HMO).
Subsamples from each system were selected using multiple criteria indicating severity of mental health problems at admission to substance use disorder treatment (VA = 401; HMO = 331). Separate and multiple-group structural equation model analyses used baseline characteristics, service use, and 12-step participation as predictors of substance use and mental health outcomes at 1 and 5 years following admission.
Substance use and related problems showed stability across time, however, these relationships were stronger among VA patients. More continuing care substance use outpatient visits were associated with reductions in mental health symptoms in both groups, whereas receipt of outpatient mental health services was associated with more severe psychological symptoms. Participation in 12-step groups had a stronger effect on reducing cocaine use among VA patients, whereas it had a stronger effect on reducing alcohol use among HMO patients. More outpatient psychological services had a stronger effect on reducing alcohol use among HMO patients.
Common findings across these two systems demonstrate the persistence of substance use and related psychological problems, but also show that continuing care services and participation in 12-step groups are associated with better outcomes in both systems.
substance use disorder treatment; mental health services; continuing care; 12-step/self-help groups; longitudinal outcomes
To examine whether alcohol and other drug (AOD) treatment of the individual with AOD disorders is related to reduced medical costs of family members.
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.
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.
Successful AOD treatment is related to medical cost reductions for family members; these reductions may be considered a proxy for improved health.
family health; cost analysis; alcoholism and addictive behavior; substance abuse
To review the research on economic and systemic barriers faced by adolescents needing treatment for alcohol and drug problems, particularly those with co-occurring conditions.
We reviewed the literature on adolescent access to alcohol and drug services, including early intervention, and integrated and specialty mental health treatment for those with co-occurring disorders, examining the role of health care systems, public policy (health reform), treatment financing and reimbursement systems (public and private), implementation of evidence-based practices, confidentiality practices, and treatment costs and cost/benefits.
Barriers to treatment, particularly integrated treatment, are largely rooted in our organizationally fragmented health care system, which encompasses public and private, carved-out and integrated systems, and different funding mechanisms (Medicaid versus block grants versus private insurance that include “high deductible” plans and other cost controls.) In both systems, carved-out programs de-link services from other mental health and general health care. Barriers are also rooted in disciplinary differences and weak clinical linkages between psychiatry, primary care and substance use, and in confidentiality policies that inhibit communication and coordination, while protecting patient privacy.
In this era of health care reform, we have the opportunity to increase access for adolescents and develop new models of integrated services for those with co-occurring conditions. We discuss opportunities for improving treatment access and implementation of evidence-based practices, examine implications of health reform and parity legislation for psychiatric and substance use treatment, and comment on key unanswered questions and future research opportunities.
adolescent; substance; psychiatric; co-occurring; barriers
We describe age and gender trends in long-term use of prescribed opioids for chronic noncancer pain in 2 large health plans.
Age- and gender-standardized incident (beginning in each year) and prevalent (ongoing) opioid use episodes were estimated with automated health care data from 1997 to 2005. Profiles of opioid use in 2005 by age and gender were also compared.
From 1997 to 2005, age–gender groups exhibited a total percentage increase ranging from 16% to 87% for incident long-term opioid use and from 61% to 135% for prevalent long-term opioid use. Women had higher opioid use than did men. Older women had the highest prevalence of long-term opioid use (8%–9% in 2005). Concurrent use of sedative-hypnotic drugs and opioids was common, particularly among women.
Risks and benefits of long-term opioid use are poorly understood, particularly among older adults. Increased surveillance of the safety of long-term opioid use is needed in community practice settings.
Opioids have been linked to increased risk of fractures, but little is known about how opioid dose affects fracture risk.
To assess whether risk of fracture increases with opioid dose among older patients initiating sustained use of opioids for chronic non-cancer pain.
A cohort study that uses Cox proportional hazards models to compare fracture risk among current opioid users vs. persons no longer using opioids.
Members of an integrated health care plan (N = 2,341) age 60 years and older who received 3+ opioid prescriptions within a 90-day period for chronic, non-cancer pain between 2000 and 2005.
Time-varying measures of opioid use and average daily dose in morphine equivalents were calculated from automated data. Fractures were identified from automated data and then validated through medical record review.
Compared with persons not currently using opioids, opioid use was associated with a trend towards increased fracture risk (1.28 (95% CI (0.99, 1.64 )). Higher dose opioid use (≥50 mg/day) was associated with a 9.95% annual fracture rate and a twofold increase in fracture risk (2.00 (95% CI (1.24, 3.24)). Of the fractures in the study cohort, 34% were of the hip or pelvis, and 37% were associated with inpatient care.
Higher doses (≥50 mg/day) of opioids for chronic non-cancer pain were associated with a 2.00 increase in risk of fracture confirmed by medical record review. Clinicians should consider fracture risk when prescribing higher-dose opioid therapy for older adults.
fracture; opioids; elderly; survival; chronic pain
The prevalence of medical disorders is high among substance abuse patients, yet medical services are seldom provided in coordination with substance abuse treatment.
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).
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.
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.
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.
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.
This study examined ethnic differences in accessing treatment for depression and substance use disorders (SUDs) among men and women in a large integrated health plan, and explored factors potentially contributing to health care disparities.
Participants were 22,543 members ages 20 to 65 who responded to health surveys in 2002 and 2005. Survey questions were linked to provider-assigned diagnoses, electronic medication, psychiatry, and chemical dependency program records.
Among women diagnosed with depression, Latinas (p < .01) and Asian-Americans (p < .001) were less likely than Whites to fill an antidepressant prescription. Among men diagnosed with depression, African Americans (p < .01) were less likely than Whites to do so. Among women diagnosed with an SUD, African Americans (p < .05) were less likely than Whites to have one or more chemical dependency program visits.
Results demonstrated ethnic differences in accessing depression and SUD treatment among patients diagnosed with these disorders, which persisted after controlling for education, income, having a regular health care provider and length of health plan enrollment. Findings highlight potential gender differences in ethnic disparities, lower antidepressant utilization among Asian Americans, and the effects of co-occurring disorders in accessing behavioral health care.
depression; substance use disorder (SUD); health care disparities; managed care
Research has identified a wide range of health conditions related to alcohol and drug use in studies conducted primarily in developed countries and in populations with severe alcohol and drug problems. Little is known about medical conditions in those with less severe alcohol and drug use in developing countries. We used WHO AUDIT and ASSIST screeners to identify hazardous drinking or drug use in public health clinics in Cape Town, South Africa, and included questions about doctor-diagnosed medical conditions. Using logistic regression we examined the relationship of medical conditions to hazardous alcohol, drug and tobacco use. Those with hazardous substance use had higher prevalence of many health conditions including tuberculosis. Hepatitis B, migraine, chronic bronchitis, and liver cirrhosis. Optimal treatment for some medical conditions may include treatment of underlying hazardous substance use, particularly use of drugs other than alcohol. In these populations, access to substance use treatment is limited and even brief interventions or advice may be useful.