This randomized study examined the efficacy of motivational interviewing (MI) to reduce substance use among adults with depression in outpatient psychiatry. The sample consisted of 104 participants ages 18 and over who reported hazardous drinking (three drinks or more per occasion), illegal drug use or misuse of prescription drugs in the prior 30days, and who scored ≥15 on the Beck Depression Inventory–II (BDI-II). Participants were randomized to receive either three sessions of MI or printed literature about alcohol and drug use risks, as an adjunct to usual outpatient depression care, and completed telephone follow-up interviews at 3 and 6months (93 and 99% of the baseline sample, respectively). Among participants reporting any hazardous drinking at baseline (n=73), MI-treated participants were less likely than controls to report hazardous drinking at 3months (60.0 vs. 81.8%, p=.043). MI is a promising intervention to reduce hazardous drinking among depression patients.
Depression; Hazardous drinking; Cannabis; Motivational interviewing
Chronic opioid therapy (COT) is associated with various adverse outcomes, especially at higher doses, yet little is known about predictors of sustained higher-dose COT. This study aimed to ascertain, among higher-dose COT patients, the association of patient-perceived pros and cons of opioids with continued higher-dose use 1 year later.
Patients (N = 1229) in 2 large health plans prescribed ≥ 50 mg morphine-equivalent dose (MED) per day for chronic non-cancer pain completed a survey assessing opioid benefits and harms. The Prescribed Opioid Difficulties Scale questionnaire assessed psychosocial problems, concerns, benefits, and side effects related to opioid use. Logistic regression models estimated the associations of the reported benefits and problems with higher-dose continuation (≥ 50 mg MED/d) versus dose reduction (< 50 mg MED/d) 1 year later.
Over 80% of participants continued higher-dose opioid use at 1 year, regardless of reported problems, concerns, side effects, pain reduction, or perceived helpfulness. Higher scores on the Prescribed Opioid Difficulties Scale Problems subscale (odds ratio = 0.79, 95% confidence interval, 0.68–0.92) and Concerns subscale (odds ratio = 0.76, 95% confidence interval, 0.65–0.90) were negatively associated with higher-dose use 1 year later. Other baseline measures (opioid helpfulness, reduction in pain, number of side effects, and side effect bothersomeness) were not significantly associated with continued higher-dose use.
The large majority of patients continued using higher-dose opioids regardless of baseline characteristics. These findings suggest the difficulty of reducing opioid dose among chronic higher-dose opioid users.
opioid; chronic; continuation; discontinuation; chronic opioid therapy; benefits; aversive effects; side effects; pain reduction; dosing; problems; concerns
This study examines the association between twelve-step participation and outcomes over seven years among 419 adolescent substance use patients with and without psychiatric comorbidities. Although level of participation decreased over time for both groups, co-morbid adolescents participated in twelve-step groups at comparable or higher levels across time points. Results from mixed-effects logistic regression models indicated that for both groups, twelve-step participation was associated with both alcohol and drug abstinence at follow-ups, increasing the likelihood of either by at least three times. Findings highlight the potential benefits of twelve-step participation in maintaining long-term recovery for adolescents with and without psychiatric disorders.
long-term outcomes; adolescents; psychiatric comorbidity; twelve-step participation
Chronic opioid therapy has increased dramatically, as have complications related to prescription opioids. Little is known about the problems and concerns attributed to opioids by patients receiving different opioid doses.
We surveyed 1883 patients who were receiving chronic opioid therapy for chronic non-cancer pain. Opioid regimen characteristics were ascertained from electronic pharmacy records. Patient-reported opioid-related problems and concerns were measured using the Prescription Opioid Difficulties Scale. Depression was assessed with the Patient Health Questionnaire.
Patients prescribed higher opioid doses reported modestly higher pain intensity and pain impact. After adjustment, patients on higher doses attributed higher levels of psychosocial problems and control concerns to prescribed opioids (p<.0001). They also had higher levels of depression and were more likely to meet criteria for clinical depression. Over 60% of patients receiving 120+ mg daily (morphine equivalent) were clinically depressed, a 2.6-fold higher risk (95% CI of 1.5 to 4.4) than patients on low dose regimens (< 20 mg daily).
Higher opioid doses were associated with somewhat higher pain severity and higher levels of patient-reported opioid-related psychosocial problems, control concerns, and depression. These findings may result from patient selection for high dose therapy or problems caused by higher dose opioids.
Opioid; Dosage; Chronic Pain; Depression; Addiction
Substance use (SU) problems are common among adolescents, a serious health risk for them and a major public health problem, but are inadequately addressed in most pediatric health care settings. Primary care offers an excellent context for SU assessment and treatment for adolescents and their families, offering better access and a less stigmatized environment for receiving treatment than specialty programs. This paper examines the literature on the integration of substance use treatment with adolescent health care, focusing on 2 areas: Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Emergency Departments and Primary Care, and School- and College-Based Health Centers.
Substance use; Adolescent; Pediatric; Psychiatric disorders; Behavioral health; Comorbidity; Screening, brief intervention, and referral to treatment; SBIRT; Alcohol; Drug; Emergency departments; Primary care; School-based health centers; SBHC; Health care; Integration; Assessment; Treatment
Chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) is characterized by both high rates of patient-initiated discontinuation and by perceived helpfulness among those who sustain opioid use. This study examines predictors of the desire to cut down or stop opioid therapy among patients receiving COT who report that opioids are helpful for relieving pain.
We conducted a cross-sectional survey of 1737 selected patients receiving COT for CNCP who perceived opioids to be helpful in relieving their pain. Ambivalence about opioid use was assessed by agreement/disagreement with a statement indicating that they would like to stop or cut down use of prescribed opioid medications. Depression was measured with the 8-item Patient Health Questionnaire.
A high percentage (43.3%) of survey respondents who found opioids helpful also reported the desire to stop or cut down opioids. Half of these patients reporting the desire to stop or cut down were clinically depressed, compared to a third of those not wanting to stop or cut down, a highly significant difference after controlling for covariates (p<0.0001). The group wanting to stop or cut down opioid use also reported significantly higher levels of opioid-related psychosocial problems and opioid control concerns.
There are high rates of ambivalence about opioid use among COT recipients who consider opioids helpful for pain relief. Depressed patients are more likely to be ambivalent about use of prescribed opioids. Eliciting patient ambivalence may be helpful in patients who are not benefiting from long-term opioid use as an initial step towards consideration of discontinuation.
chronic opioid therapy; chronic non-cancer pain; depression
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?
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.
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.
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.
Remission; Abstinence; Longitudinal; Treatment
Despite considerable research, relationships among gender, alcohol consumption, and health remain controversial, due to potential confounding by health-related attitudes and practices associated with drinking, measurement challenges, and marked gender differences in drinking. We examined gender/alcohol consumption differences in health-related attitudes and practices, and evaluated how these factors affected relationships among gender, alcohol consumption, and health status.
A stratified random sample of adult health-plan members completed a mail survey, yielding 7884 respondents (2995 male/4889 female). Using MANCOVAs and adjusting for health-related attitudes, values, and practices, we examined gender differences in relationships between alcohol consumption and health.
More frequent heavy drinking was associated with worse health-related attitudes and values, worse feelings about visiting the doctor, and worse health-related practices. Relationships between health-related practices and alcohol use differed by gender, and daily or almost daily heavy drinking was associated with significantly lower physical and mental health for women compared to men. Drinking status (lifelong abstainers, former drinkers, and level of regular alcohol consumption) was related to health status and vitality, even after adjusting for health-related attitudes, values, and practices. Relationships did not differ by gender. Former drinkers reported lower physical and mental health status than either lifelong abstainers or current drinkers.
Drinking status is independently related to physical health, mental health, and vitality, even after controlling for the health-related attitudes, values, and practices expected to confound these relationships. Among current drinkers, women who engage in very frequent heavy drinking have worse physical and mental health than their male counterparts.
Alcohol Drinking; Gender; Health Status; Health Behaviors; Health-related Attitudes
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.
Alcoholics Anonymous; 12-step groups; latent class growth analysis; trajectories analysis; alcohol and drug outcomes
The treatment of alcohol and other drugs is now more commonly framed in terms of a chronic condition which requires ongoing monitoring. A model which includes continuing access to health care may optimize outcomes. Most studies of chronic care models have not included health care and have only examined short term effects.
The sample (n = 783) included consecutive admissions in ten public and private alcohol and other drug (AOD) treatment programs followed over seven years. The outcome was remission which was defined as alcohol and drug abstinence or non-problem use.
In the private sample, receiving health care services predicted remission across the seven years; however this did not occur in the public sample. More patients in the public treatment sample received AOD treatment readmissions each year, while more of those in the private sector received psychiatric and general health visits. Except for drug problem severity, there were no other clinical differences between the samples. There were no differences in the proportions of patients in the two sectors who received the full spectrum of chronic care services. In the final models, 12-step participation was markedly significant for both samples.
Models of chronic care for substance use need to consider differences between private and public treatment and should take into account that individuals may not always have access, or avail themselves of services that may optimize long-term outcomes.
alcohol; chronic care; longitudinal; treatment services
Chronic diseases and injuries are elevated among people with substance use problems/dependence, yet heavier drinkers use fewer routine and preventive health services than non-drinkers and moderate drinkers, while former drinkers and abstainers use more than moderate drinkers. Researchers hypothesize that drinking clusters with attitudes and practices that produce better health among moderate drinkers and that heavy drinkers avoid doctors until becoming ill, subsequently quitting and using more services. Gender differences in alcohol consumption, health-related attitudes, practices, and prevention-services use may affect these relationships.
A stratified random sample of health-plan members (7884; 2995 males, 4889 females) completed a mail survey that was linked to 24 months of health-plan records. Data were used to examine relationships between alcohol use, gender, health-related attitudes/practices, health, and prevention-service use.
Controlling for attitudes, practices, and health, female lifelong abstainers and former drinkers were less likely to have mammograms; individuals with alcohol use disorders and positive AUDIT scores were less likely to obtain influenza vaccinations. AUDIT-positive women were less likely to undergo colorectal screening than AUDIT-positive men. Consistent predictors of prevention-services use were: self-report of having a primary care provider (positive); disliking visiting the doctor (negative); smoking cigarettes (negative), and higher BMI (negative).
When factors associated with drinking are controlled, patterns of alcohol consumption have limited effects on preventive service use. Individuals with stigmatized behaviors (e.g., hazardous/harmful drinking, smoking, or high BMIs) are less likely to receive care. Making care experiences positive and carefully addressing stigmatized health practices could increase preventive service use.
Alcohol Drinking; Preventive Care; Gender; Health Status; Health Behaviors; Health-related Attitudes
Inability to predict most health services use and costs using demographics and health status suggests that other factors affect use, including attitudes and practices that influence health and willingness to seek care. Alcohol consumption has generated interest because heavy, chronic consumption causes adverse health consequences, acute consumption increases injury, and moderate drinking is linked to better health while hazardous drinking and alcohol-related problems are stigmatized and may affect willingness to seek care.
A stratified random sample of health-plan members completed a mail survey, yielding 7884 respondents (2995 male/4889 female). We linked survey data to 24 months of health-plan records to examine relationships between alcohol use, gender, health-related attitudes, practices, health, and service use. In-depth interviews with a stratified 150-respondent subsample explored individuals’ reasons for seeking or avoiding care.
Quantitative results suggest health-related practices and attitudes predict subsequent service use. Consistent predictors of care were having quit drinking, current at-risk consumption, cigarette smoking, higher BMI, disliking visiting doctors, and strong religious/spiritual beliefs. Qualitative analyses suggest embarrassment and shame are strong motivators for avoiding care.
Although models included numerous health, functional status, attitudinal and behavioral predictors, variance explained was similar to previous reports, suggesting more complex relationships than expected. Qualitative analyses suggest several potential predictive factors not typically measured in service-use studies: embarrassment and shame, fear, faith that the body will heal, expectations about likelihood of becoming seriously ill, disliking the care process, the need to understand health problems, and the effects of self-assessments of health-related functional limitations.
Alcohol Drinking; Health Services Utilization; Gender; Health Status; Health Behavior; Health-related Attitudes
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.
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.
Longitudinal observational study.
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.
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.
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.
continuing care; cost; primary care; longitudinal study
To examine associations between drinking patterns, medical conditions, and behavioral health risks among older adults.
Analyses compared survey participants (health plan members ages 65 to 90, N = 6662) who drank moderately to those who drank over recommended limits or did not drink.
Overlimit drinking was associated with smoking; not trying to eat low-fat foods (in men), and lower BMI (in women). Predictors of not drinking during the prior 12 months included ethnicity, lower education, worse self-reported health, diabetes and heart problems.
Significant relationships exist between health and alcohol consumption patterns, which vary by gender.
older adults; alcohol; behavioral health risks; obesity; gender; ethnicity
This study examined routine computerized screening for alcohol and drug use of men and women seeking outpatient psychiatric services (excluding chemical dependency treatment) and prevalence based on electronic medical records of consecutive admissions.
The sample of 422 patients, ages 18–91, completed a self-administered questionnaire. Measures included 30-day, one-year, and lifetime substance use and alcohol-related problems.
Seventy-five percent of patients completed electronic intakes during the study period. Prior-month alcohol use was reported by 90 men (70%) and 180 women (62%). Of these patients, heavy drinking (five or more drinks on one occasion) was reported by 37 men (41%) and 41 women (23%). Prior-month cannabis use was reported by 17 men (13%) and 32 women (11%).
Computerized intake systems that include alcohol and drug screening can be integrated into outpatient psychiatric settings. Heavy drinking and use of nonprescribed drugs are commonly reported, which provides an important intervention opportunity.
This study examines twelve-step attendance trajectories over seven years, factors associated with the trajectories, and relationships between the trajectories and long-term substance use outcomes among adolescents entering outpatient substance use treatment in a private, non-profit integrated managed care health plan.
Longitudinal observational study.
Four Kaiser Permanente Northern California substance use treatment programs.
391 adolescents entering treatment between 2000 and 2002 who completed at least one follow-up interview in year one, and at least one during years three to seven, after treatment entry.
Alcohol and drug use, twelve-step meeting attendance and activity involvement, and post-treatment medical service utilization.
Semiparametric group-based modeling identified three distinct twelve-step attendance trajectory groups over seven years: low/no attendance (60%), early but not continued (26%), and continued (14%). There were lower proportions of males and of adolescents with prior substance use treatment experience in the low/no attendance group (p=0.019 and p=0.003, respectively). In addition, those in the low/no attendance group had lower perception on circumstances, motivation and readiness for treatment at baseline (p=0.023). Multivariate logistic generalized estimating equation analyses found that those in the continued group were more likely to be abstinent from both alcohol and drugs during follow-ups than those in the low/no attendance group (OR=2.40, p=0.003 and OR=1.96, p=0.026, respectively). However, no differences in long-term outcomes were found between those in the other two groups.
Robust connection with twelve-step groups appears to be associated with better long-term outcomes among adolescents with substance use disorders.
long-term outcomes; adolescents; twelve-step attendance trajectories; continuing care
This study contrasts community health and social service providers’ views on alcohol vs. other drug abuse. A probability sample of 457 social work and other providers from a county’s public and private medical and mental health clinics, welfare and criminal justice systems, and substance abuse programs, as well as clergy, private therapists, and physicians were interviewed. For both alcohol and drug problems, providers thought only of severe dysfunctions, which suggest that less severe forms of these problems may evade detection. In addition, drug problems were viewed as more harmful than alcohol problems, which may result in providers minimizing alcohol problems.
Alcohol and drug problems; providers’ views; attitudes; definitions
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.