Among patients receiving methadone maintenance treatment (MMT) for opioid dependence, receipt of unobserved dosing privileges (take homes) and adequate doses (i.e. ≥ 80mg) are each associated with improved addiction treatment outcomes, but the association with acute care hospitalization is unknown. We studied whether take-home dosing and adequate doses (i.e. ≥ 80 mg) were associated with decreased hospital admission among patients in a MMT program.
We reviewed daily electronic medical records of patients enrolled in one MMT program to determine receipt of take home doses, methadone dose ≥ 80mg and hospital admission date. Non-linear mixed effects logistic regression models were used to evaluate whether take home doses or dose ≥ 80mg on a given day were associated with hospital admission on the subsequent day. Covariates in adjusted models included age, gender, race/ethnicity, HIV status, medical illness, mental illness, and polysubstance use at program admission.
Subjects (n=138) had the following characteristics: mean age 43 years; 52% female; 17% HIV-infected; 32% medical illness; 40% mental illness; and 52% polysubstance use. During a mean follow-up of 20 months, 42 patients (30%) accounted for 80 hospitalizations. Receipt of take homes was associated with significantly lower odds of a hospital admission (AOR 0.26; 95%CI: 0.11-0.62), whereas methadone dose ≥ 80mg was not (AOR 1.01; 95% CI: 0.56-1.83).
Among MMT patients, receipt of take homes, but not dose of methadone, was associated with decreased hospital admission. Take home status may reflect not only patients’ improved addiction outcomes, but also reduced healthcare utilization.
Methadone maintenance treatment; dose; take home status; hospital admission
This paper assesses the associations between intimate partner violence (IPV) and STIs and sexual risks among HIV-positive female drinkers in St. Petersburg, Russia. Survey and STI data were analyzed from 285 women in HERMITAGE, a secondary prevention study with HIV-positive heavy drinkers. Logistic and Poisson regression analyses assessed associations of IPV with STI and risky sex. Most women (78%) experienced IPV and 19% were STI-positive; 15% sold sex. IPV was not significantly associated with STI, but was with selling sex (AOR=3.56, 95% CI=1.02–12.43). In conclusion, IPV is common and associated with sex trade involvement among Russian HIV-positive female drinkers.
Russia; sex work; substance use; HIV-positive; sexually transmitted infections (STI); intimate partner violence (IPV)
The study aim was to assess whether HCV was associated with painful symptoms among patients with HIV. Using data from a prospective cohort of HIV-infected adults with alcohol problems we assessed the effects of HCV on pain that interfered with daily living and painful symptoms (muscle/joint pain, headache and peripheral neuropathy). Exploratory analyses assessed whether depressive symptoms and inflammatory cytokines mediated the relationship between HCV and pain. HCV-infected participants (n=200) had higher odds of pain that interfered with daily living over time (adjusted odds ratio [AOR] 1.43; 95% CI 1.02 to 2.01; p=0.04) compared to those not infected with HCV. HIV/HCV co-infected participants had higher odds of muscle or joint pain (AOR 1.45; 95% CI 1.06 to 1.97; p=0.02) and headache (AOR 1.57; 95% CI: 1.18 to 2.07; p<0.01). The association between HCV and peripheral neuropathy did not reach statistical significance (AOR 1.33; 0.96 to 1.85; p=0.09). Depressive symptoms and inflammatory cytokines did not appear to mediate the relationship between HCV and pain. Adults with HIV who are also co-infected with HCV are more likely to experience pain that interfered with daily living, muscle or joint pain, and headaches compared to those not co-infected. Research is needed to explore the association between HCV infection and pain, and to determine whether HCV treatment is an effective intervention.
Pain; hepatitis C; cytokines; symptoms; peripheral neuropathy
A prospective cohort study to identify factors associated with receipt of substance abuse treatment (SAT) among adults with alcohol problems and HIV/AIDS. Data from the Human Immunodeficiency Virus-Longitudinal Interrelationships of Viruses and Ethanol (HIV-LIVE) study were analyzed. Generalized estimating equation logistic regression models were fit to identify factors associated with any service utilization. An alcohol dependence diagnosis had a negative association with SAT (adjusted odds ratio [AOR] = 0.36; 95% confidence interval [95% CI] = 0.19, 0.67), as did identifying as a sexual orientation other than heterosexual (AOR = 0.46; CI = 0.29, 0.72), and having social supports that use alcohol/drugs (AOR = 0.62; CI = 0.45, 0.83). Positive associations with SAT include: presence of hepatitis C antibody (AOR = 3.37; CI = 2.24, 5.06), physical or sexual abuse (AOR = 2.12; CI = 1.22, 3.69), social supports that help with sobriety (AOR = 1.92; CI = 1.28, 2.87), homelessness (AOR = 2.40; CI = 1.60, 3.62) drug dependence diagnosis (AOR = 2.64; CI = 1.88, 3.70), and clinically important depressive symptoms (AOR = 1.52, CI = 1.08, 2.15). While reassuring that factors indicating need for SAT among people with HIV and alcohol problems (e.g. drug dependence) are associated with receipt, non-need factors (e.g. sexual orientation, age) that should not decrease likelihood of receipt of treatment were identified.
Substance abuse; treatment; addiction; HIV/AIDS; alcohol
Despite the value of 12-step meetings, few studies have examined factors associated with attendance among those living with HIV/AIDS, such as the impact of HIV disease severity and demographics.
This study examines predisposing characteristics, enabling resources and need on attendance at Alcoholic Anonymous (AA) and Narcotics Anonymous (NA) meetings among those living with HIV/AIDS and alcohol problems.
Secondary analysis of prospective data from the HIV-Longitudinal Interrelationships of Viruses and Ethanol study, a cohort of 400 adults living with HIV/AIDS and alcohol problems. Factors associated with AA/NA attendance were identified using the Anderson model for vulnerable populations. Generalized estimating equation logistic regression models were fit to identify factors associated with self-reported AA/NA attendance.
At study entry, subjects were 75% male, 12% met diagnostic criteria for alcohol dependence, 43% had drug dependence and 56% reported attending one or more AA/NA meetings (past six months). In the adjusted model, female gender negatively associated with attendance, as were social support systems that use alcohol and/or drugs, while presence of HCV antibody, drug dependence diagnosis, and homelessness associated with higher odds of attendance.
Non-substance abuse related barriers to AA/NA group attendance exist for those living with HIV/AIDS, including females and social support systems that use alcohol and/or drugs. Positive associations of homelessness, HCV infection and current drug dependence were identified. These findings provide implications for policy makers and treatment professionals who wish to encourage attendance at 12-step meetings for those living with HIV/AIDS and alcohol or other substance use problems.
HIV-infection; alcohol addiction disorder; substance-related disorders; 12 step groups; HIV/AIDS
Despite the vast literature examining disparities in medical care, little is known about racial/ethnic and mental health disparities in sexual health care. The objective of this study was to assess disparities in safe sex counseling and resultant behavior among a patient population at risk of negative sexual health outcomes.
We conducted a cross-sectional analysis among a sample of substance dependent men and women in a metropolitan area in the United States. Multiple logistic regression models were used to explore the relationship between race/ethnicity (non-Hispanic black; Hispanic; non-Hispanic white) and three indicators of mental illness (moderately severe to severe depression; any manic episodes; ≥3 psychotic symptoms) with two self-reported outcomes: receipt of safe sex counseling from a primary care physician and having practiced safer sex because of counseling.
Among 275 substance-dependent adults, approximately 71% (195/275) reported ever being counseled by their regular doctor about safe sex. Among these 195 subjects, 76% (149/195) reported practicing safer sex because of this advice. Blacks (adjusted odds ratio (AOR): 2.71; 95% confidence interval (CI): 1.36,5.42) and those reporting manic episodes (AOR: 2.41; 95% CI: 1.26,4.60) had higher odds of safe sex counseling. Neither race/ethnicity nor any indicator of mental illness was significantly associated with practicing safer sex because of counseling.
Those with past manic episodes reported more safe sex counseling, which is appropriate given that hypersexuality is a known symptom of mania. Black patients reported more safe sex counseling than white patients, despite controlling for sexual risk. One potential explanation is that counseling was conducted based on assumptions about sexual risk behaviors and patient race. There were no significant disparities in self-reported safer sex practices because of counseling, suggesting that increased counseling did not differentially affect safe sex behavior for black patients and those with manic episodes. Exploring the basis of how patient characteristics can influence counseling and resultant behavior merits further exploration to help reduce disparities in safe sex counseling and outcomes.
Counseling; Disparities; Sexual behavior; Stereotyping
Female sex workers (FSWs) are the group at greatest risk for human immunodeficiency virus (HIV) infection in India. Women and girls trafficked (ie, forced or coerced) into sex work are thought to be at even greater risk because of high exposure to violence and unprotected sex, particularly during the early months of sex work, that is, at initiation. Surveys were completed with HIV-infected FSWs (n = 211) recruited from an HIV-related service organization in Mumbai, India. Approximately 2 in 5 participants (41.7%) reported being forced or coerced into sex work. During the first month in sex work, such FSWs had higher odds of sexual violence (adjusted odds ratio [AOR], 3.1; 95% confidence interval [CI], 1.6–6.1), ≥7 clients per day (AOR, 3.3; 1.8–6.1), no use of condoms (AOR, 3.8, 2.1–7.1), and frequent alcohol use (AOR, 1.9; 1.0–3.4) than HIV-infected FSWs not entering involuntarily. Those trafficked into sex work were also at higher odds for alcohol use at first sex work episode (AOR, 2.2; 95% CI, 1.2–4.0). These results suggest that having been trafficked into sex work is prevalent among this population and that such FSWs may face high levels of sexual violence, alcohol use, and exposure to HIV infection in the first month of sex work. Findings call into question harm reduction approaches to HIV prevention that rely primarily on FSW autonomy.
Unhealthy alcohol use (the spectrum of risky use through dependence) is common in HIV-infected persons, yet it can interfere with HIV medication adherence, may lower CD4 cell count, and can cause hepatic injury. Carbohydrate-deficient transferrin (CDT), often measured as %CDT, can detect heavy drinking but whether it does in people with HIV is not well established.
We evaluated the operating characteristics of %CDT in HIV-infected adults using cross-sectional data from 300 HIV-infected adults with current or past alcohol problems. Past 30-day alcohol consumption was determined using the Timeline Followback, a validated structured recall questionnaire, as the reference standard. Sensitivity and specificity of %CDT (at manufacturer's cutoff point of 2.6%) for detecting both “at-risk” (≥four drinks per occasion or >seven drinks per week for women, ≥five drinks per occasion or >14 per week for men) and “heavy” drinking (≥ four drinks per day for women, ≥ five drinks per day for men on at least seven days) were calculated. Receiver operating characteristic (ROC) curves were estimated to summarize the diagnostic ability of %CDT for distinguishing “at risk” and “heavy” levels of drinking. Exploratory analyses that stratified by gender and viral hepatitis infection were performed.
Of 300 subjects, 103 reported current consumption at “at-risk” amounts, and 47 reported “heavy” amounts. For “at-risk” drinking, sensitivity of %CDT was 28% (95% confidence interval (CI) 19%, 37%), specificity 90% (95% CI 86%, 94%); area under the ROC curve (AUC) was 0.59. For “heavy” drinking, sensitivity was 36% (95% CI 22%, 50%), specificity 88% (95% CI 84%, 92%); AUC was 0.60.
Sensitivity appeared lower among women and those with viral hepatitis; specificity was similar across subgroups. Among HIV-infected adults, %CDT testing yielded good specificity, but poor sensitivity for detecting “at-risk” and “heavy” alcohol consumption, limiting its clinical utility for detecting unhealthy alcohol use in this population.
carbohydrate-deficient transferrin; CDT; alcohol; HIV
Little is known about how different types of substances affect oral health. Our objective was to examine the respective effects of alcohol, stimulants, opioids, and marijuana on oral health in substance-dependent persons. Using self-reported data from 563 substance-dependent individuals, we found that most reported unsatisfactory oral health, with their most recent dental visit more than 1 year ago. In multivariable logistic regressions, none of the substance types were significantly associated with oral health status. However, opioid use was significantly related to a worse overall oral health rating compared to 1 year ago. These findings highlight the poor oral health of individuals with substance dependence and the need to address declining oral health among opioid users. General health and specialty addiction care providers should be aware of oral health problems among these patients. In addition, engagement into addiction and medical care may be facilitated by addressing oral health concerns.
Oral health; Substance dependence; Dental care
The association between smoking and HIV disease progression has been examined in several studies; however, findings have been inconsistent. We examined the effect of recent cigarette smoking on CD4+ T cell count/µL (CD4 count) and HIV RNA concentration (HIV viral load [VL]) among two HIV-infected cohorts with alcohol problems in Massachusetts in the periods 1997–2001 and 2001–2006 using a prospective cohort design and linear mixed models. Smoking groups were defined as: minimal or non-smokers, light smokers, moderate smokers and heavy smokers. Age, alcohol use, injection drug use, depressive symptoms, gender, annual income, and antiretroviral therapy (ART) adherence were considered as potential confounders. Among 462 subjects, no significant differences in CD4 count or viral load were found between smoking groups. Using minimal or non-smokers as the reference group, the adjusted mean differences in CD4 count were: 8.2 (95% confidence interval (CI): −17.4, 33.8) for heavy smokers; −0.1 (95% CI: −25.4, 5.1) for moderate smokers; and −2.6 (95% CI: −28.3, 3.0) for light smokers. For log10 VL, the adjusted differences were: 0.03 (95% CI: −0.12, 0.17) for heavy smokers; −0.06 (95% CI: −0.20, 0.08) for moderate smokers; and 0.14 (95% CI −0.01, 0.28) for light smokers. This study did not find an association between smoking cigarettes and HIV disease progression as measured by CD4 cell count and VL.
Cigarette Smoking; CD4+ T cells; Viral Load; HIV
Structural equation models (SEMs) provide a general framework for analyzing mediated longitudinal data. However when interest is in the total effect (i.e. direct plus indirect) of a predictor on the binary outcome, alternative statistical techniques such as non-linear mixed models (NLMM) may be preferable, particularly if specific causal pathways are not hypothesized or specialized SEM software is not readily available. The purpose of this paper is to evaluate the performance of the NLMM in a setting where the SEM is presumed optimal.
We performed a simulation study to assess the performance of NLMMs relative to SEMs with respect to bias, coverage probability, and power in the analysis of mediated binary longitudinal outcomes. Both logistic and probit models were evaluated. Models were also applied to data from a longitudinal study assessing the impact of alcohol consumption on HIV disease progression.
For the logistic model, the NLMM adequately estimated the total effect of a repeated predictor on the repeated binary outcome and were similar to the SEM across a variety of scenarios evaluating sample size, effect size, and distributions of direct vs. indirect effects. For the probit model, the NLMM adequately estimated the total effect of the repeated predictor, however, the probit SEM overestimated effects.
Both logistic and probit NLMMs performed well relative to corresponding SEMs with respect to bias, coverage probability and power. In addition, in the probit setting, the NLMM may produce better estimates of the total effect than the probit SEM, which appeared to overestimate effects.
To understand patterns of alcohol consumption and baseline factors associated with favorable drinking patterns among HIV-infected patients.
We studied drinking patterns among HIV-infected patients with current or past alcohol problems. We assessed drinking status in 6 month intervals. Based on National Institute on Alcohol Abuse and Alcoholism guidelines a favorable drinking pattern was defined as not drinking risky amounts at each assessment or decreased drinking over time. All other patterns were defined as unfavorable. Logistic regression models were used to identify baseline factors associated with a favorable pattern.
Among 358 subjects, 54% had a favorable drinking pattern with 44% not drinking risky amounts at every assessment, and 11% decreasing consumption over time. Of the 46% with an unfavorable pattern, 4% drank risky amounts each time, 5% increased, and 37% both decreased and increased consumption over time. Current alcohol dependence and recent marijuana use were negatively associated with a favorable pattern, while older age and female gender, and having a primary HIV risk factor of injection drug use were positively associated with a favorable pattern.
Many HIV-infected adults with alcohol problems have favorable drinking patterns over time, and alcohol consumption patterns are not necessarily constant. Identifying HIV-infected adults with a pattern of risky drinking may require repeated assessments of alcohol consumption.
Alcohol; HIV; drinking patterns
Chronic medical diseases require regular and longitudinal care and self-management for effective treatment. When chronic diseases include substance use disorders, care and treatment of both the medical and addiction disorders may affect access to care and the ability to focus on both conditions. The objective of this paper is to evaluate the association between the presence of chronic medical disease and recent addiction treatment utilization among adults with substance dependence.
Cross-sectional secondary data analysis of self-reported baseline data from alcohol and/or drug-dependent adults enrolled in a randomized clinical trial of a disease management program for substance dependence in primary care. The main independent variable was chronic medical disease status, categorized using the Katz Comorbidity Score as none, single condition of lower severity, or higher severity (multiple conditions or single higher severity condition), based on comorbidity scores determined from self-report. Asthma was also examined in secondary analyses. The primary outcome was any self-reported addiction treatment utilization (excluding detoxification) in the 3 months prior to study entry, including receipt of any addiction-focused counseling or addiction medication from any healthcare provider. Logistic regression models were adjusted for sociodemographics, type of substance dependence, recruitment site, current smoking, and recent anxiety severity.
Of 563 subjects, 184 (33%) reported any chronic disease (20% low severity; 13% higher severity) and 111 (20%) reported asthma; 157 (28%) reported any addiction treatment utilization in the past 3 months. In multivariate regression analyses, no significant effect was detected for chronic disease on addiction treatment utilization (adjusted odds ratio [AOR] 0.88 lower severity vs. none, 95% confidence interval (CI): 0.60, 1.28; AOR 1.29 higher severity vs. none, 95% CI: 0.89, 1.88) nor for asthma.
In this cohort of alcohol and drug dependent persons, there was no significant effect of chronic medical disease on recent addiction treatment utilization. Chronic disease may not hinder or facilitate connection to addiction treatment.
addiction; substance abuse; substance abuse; treatment; medical care; chronic disease
Prevalence of unhealthy alcohol use among medical inpatients is high.
To characterize the course and outcomes of unhealthy alcohol use, and factors associated with these outcomes.
Prospective cohort study.
A total of 287 medical inpatients with unhealthy alcohol use.
At baseline and 12 months later, consumption and alcohol-related consequences were assessed. The outcome of interest was a favorable drinking outcome at 12 months (abstinence or drinking “moderate” amounts without consequences). The independent variables evaluated included demographics, physical/sexual abuse, drug use, depressive symptoms, alcohol dependence, commitment to change (Taking Action), spending time with heavy-drinking friends and receipt of alcohol treatment (after hospitalization). Adjusted regression models were used to evaluate factors associated with a favorable outcome.
Thirty-three percent had a favorable drinking outcome 1 year later. Not spending time with heavy-drinking friends [adjusted odds ratio (AOR) 2.14, 95% CI: 1.14–4.00] and receipt of alcohol treatment [AOR (95% CI): 2.16(1.20–3.87)] were associated with a favorable outcome. Compared to the first quartile (lowest level) of Taking Action, subjects in the second, third and highest quartiles had higher odds of a favorable outcome [AOR (95% CI): 3.65 (1.47, 9.02), 3.39 (1.38, 8.31) and 6.76 (2.74, 16.67)].
Although most medical inpatients with unhealthy alcohol use continue drinking at-risk amounts and/or have alcohol-related consequences, one third are abstinent or drink “moderate” amounts without consequences 1 year later. Not spending time with heavy-drinking friends, receipt of alcohol treatment and commitment to change are associated with this favorable outcome. This can inform efforts to address unhealthy alcohol use among patients who often do not seek specialty treatment.
unhealthy alcohol use; medical inpatients; factors associated with drinking and consequences
The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not seek help for drug abuse and dependence, and SBI has proven efficacy for unhealthy alcohol use. On the other hand, the diversity of drugs of abuse and the high prevalence of abuse and dependence among those who use them raise concerns that drug SBI may have limited or no efficacy. Federal efforts to disseminate SBI for drug use are underway, and reimbursement codes to compensate clinicians for these activities have been developed. However, the discrepancies between science and policy developments underscore the need for evidence-based research regarding the efficacy of SBI for drug use. This article discusses the rationale for drug SBI and existing research on its potential to improve drug-use outcomes and makes the argument that randomized controlled trials to determine its efficacy are urgently needed to bridge the gap between research, policy, and clinical practice.
addiction; drug use; primary care; drug screening; brief intervention
Unprotected heterosexual transactional sex plays a central role in the spread of HIV in India. Given alcohol’s association with risky sex in other populations and alcohol’s role in HIV disease progression, we investigated patterns of alcohol use in HIV-infected female sex workers (FSWs) and HIV-infected male clients of FSWs in Mumbai. Analyses identified factors associated with heavy alcohol use and evaluated the relationship between alcohol use and risky sex. We surveyed 211 female and 205 male individuals; 80/211 FSWs (38%) and 127/205 male clients (62%) drank alcohol in the last 30 days. Among females, 32 and 11% drank heavily and were alcohol-dependent, respectively; among males the respective proportions were 44 and 29%. Men’s heavy alcohol use was significantly associated with inconsistent condom use over the last year (AOR 2.40, 95% CI 1.21–4.77, P = 0.01); a comparable association was not seen in women. These findings suggest a need to address alcohol use both to avoid the medical complications of its heavy use in this population and to mitigate inconsistent condom use, the latter issue possibly requiring gender specific approaches. Such efforts to reduce drinking will be an important dimension to secondary HIV prevention in India.
Alcohol; Transactional sex; HIV; Female sex workers
Unhealthy alcohol use is common in medical inpatients, and hospitalization has been hypothesized to serve as a “teachable moment” that could motivate patients to decrease drinking, but studies of hospital-based brief interventions have often not found decreases. Evaluating associations between physical health and subsequent drinking among medical inpatients with unhealthy alcohol use could inform refinement of hospital-based brief interventions by identifying an important foundation on which to build them. We tested associations between poor physical health and drinking after hospitalization and whether associations varied by alcohol dependence status and readiness to change.
Participants were medical inpatients who screened positive for unhealthy alcohol use and consented to participate in a randomized trial of brief intervention (n=341). Five measures of physical health were independent variables. Outcomes were abstinence and the number of heavy drinking days (HDDs) reported in the 30 days prior to interviews 3 months after hospitalization. Separate regression models were fit to evaluate each independent variable controlling for age, gender, randomization group, and baseline alcohol use. Interactions between each independent variable and alcohol dependence and readiness to change were tested. Stratified models were fit when significant interactions were identified.
Among all participants, measures of physical health were not significantly associated with either abstinence or number of HDDs at 3 months. Having an alcohol-attributable principal admitting diagnosis was significantly associated with fewer HDDs in patients who were non-dependent [adjusted incidence rate ratio (aIRR) 0.10, 95% CI 0.03 – 0.32] or who had low alcohol problem perception (aIRR 0.36, 95% CI 0.13 – 0.99) at hospital admission. No significant association between alcohol-attributable principal admitting diagnosis and number of HDDs was identified for participants with alcohol dependence or high problem perception.
Among medical inpatients with non-dependent unhealthy alcohol use and those who do not view their drinking as problematic, alcohol-attributable illness may catalyze decreased drinking. Brief interventions that highlight alcohol-related illness might be more successful.
Linear mixed models (LMMs) are frequently used to analyze longitudinal data. Although these models can be used to evaluate mediation, they do not directly model causal pathways. Structural equation models (SEMs) are an alternative technique that allows explicit modeling of mediation. The goal of this paper is to evaluate the performance of LMMs relative to SEMs in the analysis of mediated longitudinal data with time-dependent predictors and mediators. We simulated mediated longitudinal data from an SEM and specified delayed effects of the predictor. A variety of model specifications were assessed, and the LMMs and SEMs were evaluated with respect to bias, coverage probability, power, and Type I error. Models evaluated in the simulation were also applied to data from an observational cohort of HIV-infected individuals. We found that when carefully constructed, the LMM adequately models mediated exposure effects that change over time in the presence of mediation, even when the data arise from an SEM.
To assess whether smoke-free restaurant laws influence the progression from (1) never smoking to early experimentation and (2) early experimentation to established smoking.
A longitudinal, 4-year, 3-wave study of a representative sample of Massachusetts youth.
A total of 301 Massachusetts communities.
Study participants were 3834 Massachusetts youths aged 12 to 17 years at baseline, from January 2, 2001, to June 18, 2002, of whom 2791 (72.8%) were reinterviewed after 2 years (from January 30, 2003, to July 31, 2004) and 2217 (57.8%) were reinterviewed after 4 years (from February 16, 2005, to March 26, 2006). Wave 3 respondents were recruited from both those who responded at wave 2 and those who did not.
The primary predictor of interest is the strength of the local restaurant smoking regulation in the respondents’ town of residence at the baseline of each transition period.
Main Outcome Measures
(1) Overall progression to established smoking (having smoked ≥100 cigarettes in one’s lifetime), (2) transition from nonsmoking (never having puffed a cigarette) to experimentation, and (3) transition from experimentation to established smoking.
Youths living in towns with a strong restaurant smoking regulation at baseline had significantly lower odds of progressing to established smoking (odds ratio, 0.60; 95% confidence interval, 0.42–0.85) compared with those living in towns with weak regulations. The observed association between strong restaurant smoking regulations and impeded progression to established smoking was entirely due to an effect on the transition from experimentation to established smoking (odds ratio, 0.53; 95% confidence interval, 0.33–0.86).
Local smoke-free restaurant laws may significantly lower youth smoking initiation by impeding the progression from cigarette experimentation to established smoking.
Opioid-dependent patients often have co-occurring chronic illnesses requiring medications that interact with methadone. Methadone maintenance treatment (MMT) is typically provided separately from medical care. Hence, coordination of medical care and substance use treatment is important to preserve patient safety.
To identify potential safety risks among MMT patients engaged in medical care by evaluating the frequency that opioid dependence and MMT documentation are missing in medical records and characterizing potential medication-methadone interactions.
Among patients from a methadone clinic who received primary care from an affiliated, but separate, medical center, we reviewed electronic medical records for documentation of methadone, opioid dependence, and potential drug-methadone interactions. The proportions of medical records without opioid dependence and methadone documentation were estimated and potential medication-methadone interactions were identified.
Among the study subjects ( = 84), opioid dependence documentation was missing from the medical record in 30% (95% CI, 20%–41%) and MMT documentation was missing from either the last primary care note or the last hospital discharge summary in 11% (95% CI, 5%-19%). Sixty-nine percent of the study subjects had at least 1 medication that potentially interacted with methadone; 19% had 3 or more potentially interacting medications.
Among patients receiving MMT and medical care at different sites, documentation of opioid dependence and MMT in the medical record occurs for the majority, but is missing in a substantial number of patients. Most of these patients are prescribed medications that potentially interact with methadone. This study highlights opportunities for improved coordination between medical care and MMT.
methadone; medication interactions; patient safety; care coordination
We studied whether readiness to change predicts alcohol consumption (drinks per day) 3 months later in 267 medical inpatients with unhealthy alcohol use. We used 3 readiness to change measures: a 1 to 10 visual analog scale (VAS) and two factors of the Stages of Change Readiness and Treatment Eagerness Scale: Perception of Problems (PP) and Taking Action (TA). Subjects with the highest level of VAS-measured readiness consumed significantly fewer drinks 3 months later [Incidence rate ratio (IRR) and 95% confidence interval (CI): 0.57 (0.36, 0.91) highest vs. lowest tertile]. Greater PP was associated with more drinking [IRR (95%CI): 1.94 (1.02, 3.68) third vs. lowest quartile]. Greater TA scores were associated with less drinking [IRR (95%CI): 0.42 (0.23, 0.78) highest vs. lowest quartile]. Perception of Problems' association with more drinking may reflect severity rather than an aspect of readiness associated with ability to change; high levels of Taking Action appear to predict less drinking. Although assessing readiness to change may have clinical utility, assessing the patient's planned actions may have more predictive value for future improvement in alcohol consumption.
unhealthy alcohol use; readiness to change; medical inpatients; Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES)
To determine whether adolescents living in parental homes where smoking is banned are more likely to move into smoke-free living quarters when they leave home.
We analyzed data on 693 youths from a four-year, three-wave prospective study of a representative sample of Massachusetts adolescents (aged 12–17). All youths resided in independent living quarters at follow-up. The primary outcome was presence of a smoking ban in the living quarters at follow-up. The primary predictor was presence of a household smoking ban in the parental home, assessed two years prior to the outcome. Generalized linear mixed effects models examined the effect of a parental household smoking ban on the odds of moving into smoke-free living quarters at follow-up overall and stratified by smoking status at follow-up.
Youths leaving home had much higher odds of moving to smoke-free living quarters if their parental household had had a smoking ban (odds ratio [OR] = 12.70, 95% CI, 6.19–26.04). Other independent predictors included moving into a school or college residence (odds ratio [OR] = 3.88, 95% CI 1.87–8.05), and not living with smokers at follow-up (odds ratio [OR] = 3.91, 95% CI 1.93–7.92).
A household smoking ban in the parental home appears to lead youth to prefer smoke-free living quarters once youths leave home.
adolescent health; health policy; smoking; tobacco smoke pollution