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1.  Adolescent substance use screening in primary care: validity of computer self-administered vs. clinician-administered screening 
Substance abuse  2015;37(1):197-203.
Computer self-administration may help busy pediatricians’ offices increase adolescent substance use screening rates efficiently and effectively, if proven to yield valid responses. The CRAFFT screening protocol for adolescents has demonstrated validity as an interview, but a computer self-entry approach needs validity testing. The aim of this study was to evaluate the criterion validity and time efficiency of a computerized adolescent substance use screening protocol implemented by self-administration or clinician-administration.
12- to 17-year-old patients coming for routine care at three primary care clinics completed the computerized screen by both self-administration and clinician-administration during their visit. To account for order effects, we randomly assigned participants to self-administer the screen either before or after seeing their clinician. Both were conducted using a tablet computer and included identical items (any past-12-month use of tobacco, alcohol, drugs; past-3-months frequency of each; and six CRAFFT items). The criterion measure for substance use was the Timeline Follow-Back, and for alcohol/drug use disorder, the Adolescent Diagnostic Interview, both conducted by confidential research assistant-interview after the visit. Tobacco dependence risk was assessed with the self-administered Hooked on Nicotine Checklist (HONC). Analyses accounted for the multi-site cluster sampling design.
Among 136 participants, mean age was 15.0±1.5 yrs, 54% were girls, 53% were Black or Hispanic, and 67% had ≥3 prior visits with their clinician. Twenty-seven percent reported any substance use (including tobacco) in the past 12 months, 7% met criteria for an alcohol or cannabis use disorder, and 4% were HONC-positive. Sensitivity/specificity of the screener were high for detecting past-12-month use or disorder and did not differ between computer and clinician. Mean completion time was 49 seconds (95%CI 44-54) for computer and 74 seconds (95%CI 68-87) for clinician (paired comparison p<0.001).
Substance use screening by computer self-entry is a valid and time-efficient alternative to clinician-administered screening.
PMCID: PMC4573375  PMID: 25774878
Adolescents; substance use; primary care; screening; validity (epidemiology); computers; alcohol; tobacco; cannabis; drugs
2.  Validation of Self-Administered Single-Item Screening Questions (SISQs) for Unhealthy Alcohol and Drug Use in Primary Care Patients 
Journal of General Internal Medicine  2015;30(12):1757-1764.
Very brief single-item screening questions (SISQs) for alcohol and other drug use can facilitate screening in health care settings, but are not widely used. Self-administered versions of the SISQs could ease barriers to their implementation.
We sought to validate SISQs for self-administration in primary care patients.
Participants completed SISQs for alcohol and drugs (illicit and prescription misuse) on touchscreen tablet computers. Self-reported reference standard measures of unhealthy use, and more specifically of risky consumption, problem use, and substance use disorders, were then administered by an interviewer, and saliva drug tests were collected.
Adult patients aged 21–65 years were consecutively enrolled from two urban safety-net primary care clinics.
Main Measures
The SISQs were compared against reference standards to determine sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) for alcohol and drug use.
Key Results
Among the 459 participants, 22 % reported unhealthy alcohol use and 25 % reported drug use in the past year. The SISQ-alcohol had sensitivity of 73.3 % (95 % CI 65.3–80.3) and specificity of 84.7 % (95 % CI 80.2–88.5), AUC = 0.79 (95 % CI 0.75–0.83), for detecting unhealthy alcohol use, and sensitivity of 86.7 % (95 % CI 75.4–94.1) and specificity of 74.2 % (95 % CI 69.6–78.4), AUC = 0.80 (95 % CI 0.76–0.85), for alcohol use disorder. The SISQ-drug had sensitivity of 71.3 % (95 % CI 62.4–79.1) and specificity of 94.3 % (95 % CI 91.3–96.6), AUC = 0.83 (95 % CI 0.79–0.87), for detecting unhealthy drug use, and sensitivity of 85.1 (95 % CI 75.0–92.3) and specificity of 88.6 % (95 % CI 85.0–91.6), AUC = 0.87 (95 % CI 0.83–0.91), for drug use disorder.
The self-administered SISQs are a valid approach to detecting unhealthy alcohol and other drug use in primary care patients. Although self-administered SISQs may be less accurate than the previously validated interviewer-administered versions, they are potentially easier to implement and more likely to retain their fidelity in real-world practice settings.
PMCID: PMC4636560  PMID: 25986138
Screening; Substance use; Validation; Alcohol; Illicit drugs
3.  Changes in health outcomes as a function of abstinence and reduction in illicit psychoactive drug use: A prospective study in primary care 
Addiction (Abingdon, England)  2015;110(9):1476-1483.
To test 1) whether abstinence and reduction in illicit psychoactive drug use were associated with changes in health outcomes in primary care patients and 2) whether these associations varied by drug type.
Secondary analysis of data from a randomized controlled trial that tested a brief intervention for drug use in primary care patients (589 enrolled, 574 completed 6-month assessment). Analyses were conducted overall and stratified by the most commonly self-identified main drugs (marijuana, cocaine, and opioids).
Setting and participants
Patients who screened positive for illicit drug use at an urban primary care clinic in Boston, Massachusetts, USA.
Differences in past-month main drug use at baseline and 6-month outcome were categorized as continued or increased use, decreased use without abstinence, and abstinence. Primary outcomes were 6-month changes in drug use consequences (Short Inventory of Problems scores [range 0–45]), depressive symptoms, and health-related quality of life (HRQOL).
Abstinence was associated with a greater decrease in adverse drug use consequences than continued or increased use among the full sample and cocaine and opioids subgroups (adjusted means, full sample: −8.11 vs. −0.05, p<0.001; cocaine: −13.33 vs. +1.09, p<0.001, opioids; −16.84 vs. −2.10, p<0.001). Differences were not significant between those who decreased use compared with those who continued or increased use. There were no significant associations between drug use and depressive symptoms or HRQOL. Neither abstinence nor decreased use was significantly associated with consequences in the marijuana subgroup.
Among primary care patients in the US who use illicit psychoactive drugs, abstinence but not reduction in use without abstinence appears to be associated with decreased adverse drug use consequences.
PMCID: PMC4521992  PMID: 26075702
4.  Are decreases in drug use risk associated with reductions in HIV sex risk behaviors among adults in an urban hospital primary care setting? 
Preventive Medicine Reports  2016;4:410-416.
Drug use is associated with increased sexual risk behaviors. We examined whether decreases in drug use risk are associated with reduction in HIV-related sex risk behaviors among adults. Data was from a cohort of participants (n = 574) identified by drug use screening in a randomized trial of brief intervention for drug use in an urban primary care setting. Inverse probability of treatment weighted (IPTW) logistic regression models were used to examine the relationship between decreases in drug use risk and sex-related HIV risk behavior reduction from study entry to six months. Weights were derived from propensity score modeling of decreases in drug use risk as a function of potential confounders. Thirty seven percent of the study participants (213/574) reported a decrease in drug use risk, and 7% (33/505) reported decreased sex-related HIV risk behavior at the six-month follow-up point. We did not detect a difference in reduction of risky sexual behaviors for those who decreased drug use risk (unadjusted: OR 1.32, 95% CI 0.65–2.70; adjusted OR [AOR] 1.12, 95% CI 0.54–2.36). Adults who screened positive for high drug use risk had greater odds of reducing sex risk behavior in unadjusted analyses OR 3.71, 95% CI 1.81–7.60; but the results were not significant after adjusting for confounding AOR 2.50, 95% CI 0.85–7.30). In this primary care population, reductions in HIV sex risk behaviors have complex etiologies and reductions in drug use risk do not appear to be an independent predictor of them.
•No detected difference in reduced sex risk behaviors after decreased drug use risk.•Adults with drug dependence had greater odds of reducing sex risk behavior.•Target behavioral interventions on multiple risks beyond reductions in drug use
PMCID: PMC4992042  PMID: 27570734
Sex risk behavior; Unprotected sex; Drug use; HIV/AIDS
5.  A brief patient self-administered substance use screening tool for primary care: two-site validation study of the Substance Use Brief Screen (SUBS) 
The American journal of medicine  2015;128(7):784.e9-784.e19.
Substance use screening is widely encouraged in healthcare settings, but the lack of a screening approach that fits easily into clinical workflows has restricted its broad implementation. The Substance Use Brief Screen (SUBS) was developed as a brief, self-administered instrument to identify unhealthy use of tobacco, alcohol, illicit drugs, and prescription drugs. We evaluated the validity and test-retest reliability of the SUBS in adult primary care patients.
Adults age 18-65 were enrolled from urban safety net primary care clinics to self-administer the SUBS using touch-screen tablet computers for a test-retest reliability study (n=54) and a two-site validation study (n=586). In the test-retest reliability study, the SUBS was administered twice within a 2-week period. In the validation study, the SUBS was compared to reference standard measures, including self-reported measures and saliva drug tests. We measured test-retest reliability and diagnostic accuracy of the SUBS for detection of unhealthy use and substance use disorder for tobacco, alcohol, and drugs (illicit and prescription drug misuse).
Test-retest reliability was good or excellent for each substance class. For detection of unhealthy use, the SUBS had sensitivity and specificity of 97.8% (95% CI 93.7 to 99.5) and 95.7% (95% CI 92.4 to 97.8), respectively, for tobacco; and 85.2% (95% CI 79.3 to 89.9) and 77.0% (95% CI 72.6 to 81.1) for alcohol. For unhealthy use of illicit or prescription drugs, sensitivity was 82.5% (95% CI 75.7 to 88.0) and specificity 91.1% (95% CI 87.9 to 93.6). With respect to identifying a substance use disorder, the SUBS had sensitivity and specificity of 100.0% (95% CI 92.7 to 100.0) and 72.1% (95% CI 67.1 to 76.8) for tobacco; 93.5% (95% CI 85.5 to 97.9) and 64.6% (95% CI 60.2 to 68.7) for alcohol; and 85.7% (95% CI 77.2 to 92.0) and 82.0% (95% CI 78.2 to 85.3) for drugs. Analyses of area under the receiver operating curve (AUC) indicated good discrimination (AUC 0.74-0.97) for all substance classes. Assistance in completing the SUBS was requested by 11% of participants.
The SUBS was feasible for self-administration and generated valid results in a diverse primary care patient population. The 4-item SUBS can be recommended for primary care settings that are seeking to implement substance use screening.
PMCID: PMC4475501  PMID: 25770031
screening; substance use; validation; alcohol; illicit drugs; tobacco
6.  Drinking to toxicity: college students referred for emergency medical evaluation 
In 2009, a university adopted a policy of emergency department transport of students appearing intoxicated on campus. The objective was to describe the change in ED referrals after policy initiation and describe a group of students at risk for acute alcohol-related morbidity.
A retrospective cohort of university students during academic years 2007–2011 (September–June) transported to local ED’s was evaluated. Data were compared 2 years prior to initiation of the policy and 3 years after and included total number of ED transports and blood or breath alcohol level.
971 Students were transported to local ED’s. The mean number of yearly transports 2 years prior to policy initiation was 131 and 3 years after was 236 (56 % increase, p < 0.01). 92 % had a blood or breath alcohol level obtained. The mean alcohol level was 193 mg/dL. Twenty percent of students had alcohol levels greater than 250 mg/dL.
Adoption of a university alcohol policy was followed by a significant increase in ED transports of intoxicated students. College students identified as intoxicated frequently drank to toxicity.
PMCID: PMC4898400  PMID: 27277284
7.  Do Brief Alcohol Motivational Interventions Work Like We Think They Do? 
Questions remain about how brief motivational interventions (BMIs) for unhealthy alcohol use work and addressing these questions may be important for improving their efficacy. Therefore, we assessed the effects of various characteristics of BMIs on drinking outcomes across three randomized controlled trials (RCTs).
Audio recordings of 314 BMIs were coded. We used the global rating scales of the Motivational Interviewing Skills Code (MISC) 2.1: counselor’s acceptance, empathy, and motivational interviewing (MI) spirit, and patient’s self-exploration were rated. MI proficiency was defined as counselor’s rating scale scores ≥5. We also used the structure, confrontation and advice sub-scale scores of the Therapy Process Rating Scale; and the Working Alliance Inventory. We examined these process characteristics in interventions across: one US RCT of middle-aged medical inpatients with unhealthy alcohol use (n=124) and two Swiss RCTs of young men with binge drinking in a non-clinical setting: Swiss-one (n=62) and Swiss-two (n=128). We assessed the associations between these characteristics and drinks/day reported by participants 3–6 months after study entry.
In all 3 RCTs, mean MISC counselor’s rating scales scores were consistent with MI proficiency. In overdispersed Poisson regression models, most BMI characteristics were not significantly associated with drinks/day in follow-up. In the US RCT, confrontation and self-exploration were associated with more drinking. Giving advice was significantly associated with less drinking in the Swiss-one RCT. Contrary to expectations, MI spirit was not consistently associated with drinking across studies.
Across different populations and settings, intervention characteristics viewed as central to efficacious BMIs were neither robust nor consistent predictors of drinking outcome. Although there may be alternative reasons why the level of MI processes were not predictive of outcomes in these studies (limited variability in scores), efforts to understand what makes BMIs efficacious may require attention to factors beyond intervention process characteristics typically examined.
PMCID: PMC4879497  PMID: 24125097
Alcohol; brief motivational intervention; intervention process
8.  The relationship between sexual and physical abuse and substance abuse consequences 
This study examines the relationship between a history of physical and sexual abuse (PhySexAbuse) and drug and alcohol related consequences. We performed a cross-sectional analysis of data from 359 male and 111 female subjects recruited from an inpatient detoxification unit. The Inventory of Drug Use Consequences (InDUC), measured negative life consequences of substance use. Eighty-one percent of women and 69% of men report past PhySexAbuse, starting at a median age of 13 and 11, respectively. In bivariate and multivariable analyses, PhySexAbuse was significantly associated with more substance abuse consequences ( p < 0.001). For men, age ≤ 17 years at first PhySexAbuse was significantly associated with more substance abuse consequences than an older age at first abuse, or no abuse ( p = 0.048). For women, the association of PhySexAbuse with substance use consequences was similar across all ages ( p = 0.59). Future research should develop interventions to lessen the substance abuse consequences of physical and sexual abuse.
PMCID: PMC4861063  PMID: 12039614
Physical abuse; Sexual abuse; Childhood abuse; Substance use consequences; Detoxification
9.  The prescription of addiction medications after implementation of chronic care management for substance dependence in primary care 
People with addictive disorders commonly do not receive efficacious medications. Chronic care management (CCM) is designed to facilitate delivery of effective therapies. Using data from the CCM group in a trial testing its effectiveness for addiction (n=282), we examined factors associated with the prescription of addiction medications. Among participants with alcohol dependence, 17% (95%CI 12.0–22.1%) were prescribed alcohol dependence medications. Among those with drug dependence, 9% (95%CI 5.5–12.6%) were prescribed drug dependence medications. Among those with opioids as a substance of choice, 15% (95%CI 9.3–20.9%) were prescribed opioid agonist therapy. In contrast, psychiatric medications were prescribed to 64% (95%CI 58.2–69.4%). Absence of co-morbid drug dependence was associated with prescription of alcohol dependence medications. Lower alcohol addiction severity and recent opioid use were associated with prescription of drug dependence medications. Better understanding of infrequent prescription of addiction medications, despite a supportive clinical setting, might inform optimal approaches to delivering addiction medications.
PMCID: PMC4382414  PMID: 25524751
chronic care management; substance abuse treatment; medications; naltrexone; acamprosate; buprenorphine
10.  Chronic care management for substance dependence in primary care among patients with co-occurring mental disorders 
Co-occurring substance use and mental disorders are associated with worse outcomes than a single disorder alone. In this exploratory subgroup analysis of a randomized trial, we hypothesized that chronic care management (CCM) for substance dependence would have a beneficial effect among people with substance dependence and major depressive disorder or substance dependence and post-traumatic stress disorder (PTSD).
Participants were adults with alcohol and/or drug dependence. CCM was provided by a nurse care manager, social worker, internist and psychiatrist. Outcomes were clinical (any use of opioids, stimulants or heavy drinking, severity of depressive and anxiety symptoms), and treatment utilization (emergency department use and hospitalization). Longitudinal regression models were used to compare randomized arms within the two subgroups with co-occurring disorders.
Among all participants (n=563), 79% (443/563) met criteria for major depressive disorder and 36% (205/563) for PTSD at baseline. No significant effect of CCM was observed for any outcome within either subgroup including any use of opioids, stimulants or heavy drinking, depressive symptoms, anxiety symptoms, or hospitalizations. Participants with depression receiving CCM had fewer days in the emergency department but was only borderline significant (AOR=0.76, 95%CI=.57–1.02, p=.06).
Among patients with co-occurring substance dependence and mental disorders, chronic care management was not significantly more effective for improving clinical outcomes or treatment utilization than usual care in this study.
PMCID: PMC4282827  PMID: 25219686
11.  The spectrum of unhealthy drug use and quality of care for hypertension and diabetes: a longitudinal cohort study 
BMJ Open  2015;5(12):e008508.
Although it is well known that addiction is associated with adverse medical consequences, the effects of the spectrum of unhealthy drug use (illicit drug or prescription misuse) on chronic conditions such as hypertension and diabetes are understudied. This study evaluated the associations between measures of drug use (ie, frequency, severity and type) and standard quality metrics for inadequate blood pressure (BP) and blood glucose (BG) control.
Longitudinal cohort study.
Adult primary care patients with unhealthy drug use and hypertension or diabetes.
Urban hospital-based primary care practice.
Outcomes were (1) inadequate BP (systolic BP ≥140 or diastolic BP ≥90) and (2) inadequate BG (glycated haemoglobin ≥8%) control (Healthcare Effectiveness Data and Information Set criteria). Drug use was characterised by a primary independent variable, drug use frequency, and two secondary variables, severity of use and drug type. We fit separate regression models for each drug use measure and outcome.
Overall, 40% (65/164) of the sample with hypertension had inadequate BP control and 44% (24/54) of those with diabetes had inadequate BG control. More frequent drug use was not significantly associated with inadequate BP control (adjusted OR (AOR) 0.67; 95% CI 0.31 to 1.46, highest vs lowest tertile; AOR 0.72; 95% CI 0.36 to 1.41, middle vs lowest tertile) or BG control (AOR 0.27; 95% CI 0.07 to 1.10, highest vs lowest tertile; AOR 1.01; 95% CI 0.38 to 2.69, middle vs lowest tertile). Drug use severity was also not associated with BP or BG control. Cocaine use was associated with inadequate BG control compared to marijuana use (AOR 8.82; 95% CI1.86 to 41.90).
Among primary care patients with recent drug use and hypertension or diabetes, drug type was significantly associated with inadequate BG, but not BP control. Frequency and severity of use were not significant predictors of either outcome.
PMCID: PMC4691731  PMID: 26692554
12.  Screening and Brief Intervention for Drug Use in Primary Care 
JAMA  2014;312(5):502-513.
The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy.
To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)—a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)—compared with no brief intervention.
This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of $4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts.
Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by master’s-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources.
Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization.
At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity.
Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention.
TRIAL REGISTRATION Identifier: NCT00876941
PMCID: PMC4667772  PMID: 25096690
13.  Effect of telephone follow-up on retention and balance in an alcohol intervention trial 
Preventive Medicine Reports  2015;2:746-749.
Telephone follow-up is not currently recommended as a strategy to improve retention in randomized trials. The aims of this study were to estimate the effect of telephone follow-up on retention, identify participant characteristics predictive of questionnaire completion during or after telephone follow-up, and estimate the effect of including participants who provided follow-up data during or after telephone follow-up on balance between randomly allocated groups in a trial estimating the effect of electronic alcohol screening and brief intervention on alcohol consumption in hospital outpatients with hazardous or harmful drinking.
Trial participants were followed up 6 months after randomization (June–December 2013) using e-mails containing a hyperlink to a web-based questionnaire when possible and by post otherwise. Telephone follow-up was attempted after two written reminders and participants were invited to complete the questionnaire by telephone when contact was made.
Retention before telephone follow-up was 62.1% (520/837) and 82.8% (693/837) afterward: an increase of 20.7% (173/837). Therefore, 55% (95% CI 49%–60%) of the 317 participants who had not responded after two written reminders responded during or after the follow-up telephone call. Age < 55 years, a higher AUDIT-C score and provision of a mobile/cell phone number were predictive of questionnaire completion during or after telephone follow-up. Balance between randomly allocated groups was present before and after inclusion of participants who completed the questionnaire during or after telephone follow-up.
Telephone follow-up improved retention in this randomized trial without affecting balance between the randomly allocated groups.
•Telephone follow-up was associated with a 20% increase in retention of participants.•Younger age and heavier drinking predicted retention by telephone.•Providing a mobile/cell number also predicted retention by telephone.•Balance between the randomly allocated groups was not affected by telephone follow-up.•Telephone follow-up may improve retention in randomized trials.
PMCID: PMC4721312  PMID: 26844146
Telephone; Lost to follow-up; Randomized controlled trial; Alcohol consumption
14.  Marijuana Use and Achievement of Abstinence from Alcohol and Other Drugs among People with Substance Dependence: A Prospective Cohort Study 
Many with alcohol and other drug dependence have concurrent marijuana use, yet it is not clear how to address it during addiction treatment. This is partially due to the lack of clarity about whether marijuana use impacts one’s ability to achieve abstinence from the target of addiction treatment. We examined the association between marijuana use and abstinence from other substances among individuals with substance dependence.
A secondary analysis of the Addiction Health Evaluation And Disease management study, a randomized trial testing the effectiveness of chronic disease management. Individuals met criteria for drug or alcohol dependence and reported recent drug (i.e. opioid or stimulant) or heavy alcohol use. Recruitment occurred at an inpatient detoxification unit, and all participants were referred to primary medical care. The association between marijuana use and later abstinence from drug and heavy alcohol use was assessed using longitudinal multivariable models.
Of 563 study participants, 98% completed at least one follow-up assessment and 535 (95%) had at least one pair of consecutive assessments and were included. In adjusted analyses, marijuana use was associated with a 27% reduction in the odds of abstinence from drug and heavy alcohol use (adjusted odds ratio 0.73 [95% CI, 0.56–0.97], P=0.03).
Marijuana use among individuals with alcohol or other drug dependence is associated with a lower odds of achieving abstinence from drug and heavy alcohol use. These findings add evidence that suggests concomitant marijuana use among patients with addiction to other drugs merits attention from clinicians.
PMCID: PMC4127123  PMID: 24986785
Marijuana use; Abstinence; Relapse; Substance dependence; Alcohol dependence; Drug dependence
15.  Web-based Screening and Brief Intervention for Student Marijuana Use in a University Health Center: Pilot Study to Examine the Implementation of eCHECKUP TO GO in Different Contexts 
Addictive behaviors  2014;39(9):1346-1352.
This pilot study sought to test the feasibility of procedures to screen students for marijuana use in Student Health Services (SHS) and test the efficacy of a web-based intervention designed to reduce marijuana use and consequences. Students were asked to participate in voluntary screening of health behaviors upon arrival at SHS. One hundred and twenty-three students who used marijuana at least monthly completed assessments and were randomized to one of four intervention conditions in a 2 (Intervention: Marijuana eCHECKUP TO GO vs. Control) × 2 (Site of Intervention: On-site vs. Off-site) between-groups design. Follow-up assessments were conducted online at 3 and 6 months. Latent growth modeling was used to provide effect size estimates for the influence of intervention on outcomes. One thousand and eighty undergraduate students completed screening. The intervention did not influence marijuana use frequency. However, there was evidence of a small overall intervention effect on marijuana-related consequences and a medium effect in stratified analyses in the on-site condition. Analyses of psychological variables showed that the intervention significantly reduced perceived norms regarding peer marijuana use. These findings demonstrate that it is feasible to identify marijuana users in SHS and deliver an automated web-based intervention to these students in different contexts. Effect size estimates suggest that the intervention has some promise as a means of correcting misperceptions of marijuana use norms and reducing marijuana-related consequences. Future work should test the efficacy of this intervention in a full scale randomized controlled trial.
PMCID: PMC4197812  PMID: 24845164
cannabis; computer; prevention; college student; student health
16.  Comparing Alcohol Screening Measures Among HIV Infected and Uninfected Men 
Brief measures of unhealthy alcohol use have not been well-validated among people with HIV. We compared the Alcohol Use Disorders Identification Test (AUDIT) to reference standards for unhealthy alcohol use based on 30 day Timeline Follow Back (TLFB) and Composite International Diagnostic Interview - Substance Abuse Module (CIDI-SAM), among 873 male HIV infected and uninfected patients in the Veterans Aging Cohort Study.
Three reference standards were: 1)Risky drinking - based on TLFB: >14 drinks over 7 consecutive days or >4 drinks on one day; 2)Alcohol dependence - based on a CIDI-SAM diagnosis; and 3)Unhealthy alcohol use - risky drinking or a CIDI-SAM diagnosis of abuse or dependence. Various cutoffs for the AUDIT, AUDIT-C, and heavy episodic drinking were compared to the reference standards.
Mean age of patients was 52 years, 53% (444) were HIV infected, and 53% (444) were African-American. Among HIV infected and uninfected patients, the prevalence of risky drinking (14% vs. 12% respectively), alcohol dependence (8% vs. 7%), and unhealthy alcohol use (22% vs. 20%) was similar. For risky drinking and alcohol dependence, multiple cutoffs of AUDIT, AUDIT-C, and heavy episodic drinking provided good sensitivity (>80%) and specificity (>90%). For unhealthy alcohol use, few cutoffs provided sensitivity >80%; however, many cutoffs provided good specificity. For all three alcohol screening measures, sensitivity improved when heavy episodic drinking was included with the cutoff. Sensitivity of measures for risky drinking and unhealthy alcohol use were lower in HIV infected than in uninfected patients.
For identifying risky drinking, alcohol dependence, and unhealthy alcohol use, AUDIT-C performs as well as AUDIT and similarly in HIV infected and uninfected patients. Cutoffs should be based on the importance of specific operating characteristics for the intended research or clinical use. Incorporating heavy episodic drinking increased sensitivity for detecting alcohol dependence and unhealthy alcohol use.
PMCID: PMC4492202  PMID: 23050632
18.  How Accurate Are Blood (or Breath) Tests for Identifying Self-Reported Heavy Drinking Among People with Alcohol Dependence? 
Managing patients with alcohol dependence includes assessment for heavy drinking, typically by asking patients. Some recommend biomarkers to detect heavy drinking but evidence of accuracy is limited.
Among people with dependence, we assessed the performance of disialo-carbohydrate-deficient transferrin (%dCDT, ≥1.7%), gamma-glutamyltransferase (GGT, ≥66 U/l), either %dCDT or GGT positive, and breath alcohol (> 0) for identifying 3 self-reported heavy drinking levels: any heavy drinking (≥4 drinks/day or >7 drinks/week for women, ≥5 drinks/day or >14 drinks/week for men), recurrent (≥5 drinks/day on ≥5 days) and persistent heavy drinking (≥5 drinks/day on ≥7 consecutive days). Subjects (n = 402) with dependence and current heavy drinking were referred to primary care and assessed 6 months later with biomarkers and validated self-reported calendar method assessment of past 30-day alcohol use.
The self-reported prevalence of any, recurrent and persistent heavy drinking was 54, 34 and 17%. Sensitivity of %dCDT for detecting any, recurrent and persistent self-reported heavy drinking was 41, 53 and 66%. Specificity was 96, 90 and 84%, respectively. %dCDT had higher sensitivity than GGT and breath test for each alcohol use level but was not adequately sensitive to detect heavy drinking (missing 34–59% of the cases). Either %dCDT or GGT positive improved sensitivity but not to satisfactory levels, and specificity decreased. Neither a breath test nor GGT was sufficiently sensitive (both tests missed 70–80% of cases).
Although biomarkers may provide some useful information, their sensitivity is low the incremental value over self-report in clinical settings is questionable.
PMCID: PMC4060735  PMID: 24740846
19.  Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study 
Objective To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics.
Design Case-cohort study.
Setting Veterans Health Administration (VHA), 2004-09.
Participants US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420 386) who received VHA medical services and opioid analgesics.
Main outcome measure Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index.
Results During the study period 27% (n=112 069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose.
Conclusions Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion.
PMCID: PMC4462713  PMID: 26063215
20.  Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study 
The BMJ  2015;350:h2698.
Objective To study the association between benzodiazepine prescribing patterns including dose, type, and dosing schedule and the risk of death from drug overdose among US veterans receiving opioid analgesics.
Design Case-cohort study.
Setting Veterans Health Administration (VHA), 2004-09.
Participants US veterans, primarily male, who received opioid analgesics in 2004-09. All veterans who died from a drug overdose (n=2400) while receiving opioid analgesics and a random sample of veterans (n=420 386) who received VHA medical services and opioid analgesics.
Main outcome measure Death from drug overdose, defined as any intentional, unintentional, or indeterminate death from poisoning caused by any drug, determined by information on cause of death from the National Death Index.
Results During the study period 27% (n=112 069) of veterans who received opioid analgesics also received benzodiazepines. About half of the deaths from drug overdose (n=1185) occurred when veterans were concurrently prescribed benzodiazepines and opioids. Risk of death from drug overdose increased with history of benzodiazepine prescription: adjusted hazard ratios were 2.33 (95% confidence interval 2.05 to 2.64) for former prescriptions versus no prescription and 3.86 (3.49 to 4.26) for current prescriptions versus no prescription. Risk of death from drug overdose increased as daily benzodiazepine dose increased. Compared with clonazepam, temazepam was associated with a decreased risk of death from drug overdose (0.63, 0.48 to 0.82). Benzodiazepine dosing schedule was not associated with risk of death from drug overdose.
Conclusions Among veterans receiving opioid analgesics, receipt of benzodiazepines was associated with an increased risk of death from drug overdose in a dose-response fashion.
PMCID: PMC4462713  PMID: 26063215
21.  Use of a single alcohol screening question to identify other drug use 
Drug and alcohol dependence  2014;139:178-180.
People who consume unhealthy amounts of alcohol are more likely to use illicit drugs. We tested the ability of a screening test for unhealthy alcohol use to simultaneously detect drug use.
Adult English speaking patients (n=286) were enrolled from a primary care waiting room. They were asked the screening question for unhealthy alcohol use “How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men and 4 for women, and a response of one or more is considered positive. A standard diagnostic interview was used to determine current (past year) drug use or a drug use disorder (abuse or dependence). Oral fluid testing was also used to detect recent use of common drugs of abuse.
The single screening question for unhealthy alcohol use was 67.6% sensitive (95% confidence interval [CI], 50.2%- 82.0%) and 64.7% specific (95% CI, 58.4%- 70.6%) for the detection of a drug use disorder. It was similarly insensitive for drug use detected by oral fluid testing and/or self-report.
Although a patient with a drug use disorder has twice the odds of screening positive for unhealthy alcohol use compared to one without a drug use disorder, suggesting patients who screen positive for alcohol should be asked about drug use, a single screening question for unhealthy alcohol use was not sensitive or specific for the detection of other drug use or drug use disorders in a sample of primary care patients.
PMCID: PMC4085274  PMID: 24768061
Screening; alcohol; drug use; primary care
22.  Inflammatory cytokines and mortality in a cohort of HIV-infected adults with alcohol problems 
AIDS (London, England)  2014;28(7):1059-1064.
HIV infection leads to chronic inflammation and alterations in levels of inflammatory cytokines. The association between cytokine levels and mortality in HIV-infection is not fully understood.
We analyzed data from a cohort of HIV-infected adults with alcohol problems who were recruited in 2001-2003, and were prospectively followed until 2010 for mortality using the National Death Index.
The main independent variables were inflammatory biomarkers [IL-6, IL-10, TNF-alpha, C-reactive protein (CRP), Serum Amyloid A, Monocyte Chemotactic Protein-1 and Cystatin-C], measured at baseline in peripheral blood and categorized as high (defined as being in the highest quartile) vs. low. A secondary analysis was conducted using inflammatory burden score, defined as the number of biomarkers in the highest quartile (0,1,2 or ≥3). Cox models were used to assess the association between both biomarker levels and inflammatory burden with mortality adjusting for potential confounders.
Four hundred HIV-infected patients were included (74.8% male, mean age 42 years, 50% HCV-infected). As of 31st December 2009, 85 patients had died. In individual multivariable analyses for each biomarker, high levels of IL-6 and CRP were significantly associated with mortality [HR=2.49 (1.69-5.12), p<0.01] and [HR=1.87 (1.11-3.15), p=0.02], respectively. There was also a significant association between inflammatory burden score and mortality [HR=2.18 (1.29; 3.66) for ≥3 vs. 0, p=0.04]. In the fully adjusted multivariable analysis high levels of IL-6 remained independently associated with mortality [HR=2.57 (1.58-4.82), p<0.01].
High IL-6 levels and inflammatory burden score were associated with mortality in a cohort of HIV-infected adults with alcohol problems.
PMCID: PMC4105144  PMID: 24401638
IL-6; mortality; cytokines; HIV; alcohol
23.  Personalized Feedback as a Universal Prevention Approach for College Drinking: A Randomized Trial of an e-Mail Linked Universal Web-Based Alcohol Intervention 
Alcohol use among first-year university students continues to be a central health concern. Efforts to address drinking in this population have increasingly relied on web-based interventions, which have the capacity to reach large numbers of students through a convenient and highly utilized medium. Despite evidence for the utility of this approach for reducing hazardous drinking, recent studies that have examined the effectiveness of this approach as a universal prevention strategy in campus-wide studies have produced mixed results. We sought to test the effectiveness of a web-based alcohol intervention as a universal prevention strategy for first-year students. An e-mail invitation linked to a brief, web-based survey on health behaviors was sent to all first-year students during the fall semester. Those who completed the baseline assessment were randomized to receive either a feedback-based alcohol intervention (intervention condition) or feedback about other health-related behaviors such as sleep and nutrition (control condition). A second web-based survey was used to collect follow-up drinking data 5 months later. The number of heavy drinking episodes in the previous month and alcohol-related consequences in the previous 3 months served as the primary dependent variables. Negative binomial regression analyses did not indicate a significant effect of the intervention at follow-up on either heavy drinking episodes or alcohol-related consequences. Analyses of additional drinking outcomes among the subsample of students who reported that they did not drink at baseline showed that those who received the alcohol intervention were subsequently less likely to drink alcohol. These results suggest that web-based alcohol interventions may be a potentially useful method of maintaining abstinence among underage, non-drinking students. Overall, however, results indicate that an e-mail-linked, campus-wide, web-intervention approach to address alcohol use among first-year students may have limited effectiveness as an approach to minimize hazardous drinking over the course of the year.
PMCID: PMC4136501  PMID: 24421075
Alcohol; University; Computer; Freshmen; Intervention; Internet; e-Mail
24.  Association of Recent Incarceration with Traumatic Injury, Substance Use Related Health Consequences, and Health Care Utilization 
Journal of addiction medicine  2014;8(1):66-72.
The higher risk of death among recently released inmates relative to the general population may be due to the higher prevalence of substance dependence among inmates or an independent effect of incarceration. We explored the effects of recent incarceration on health outcomes that may be intermediate markers for mortality.
Longitudinal multivariable regression analysis were conducted on interview data (baseline, 3, 6, and 12 month follow-up) from alcohol and/or drug dependent individuals (n=553) participating in a randomized clinical trial to test the effectiveness of chronic disease management for substance dependence in primary care. The main independent variable was recent incarceration (spending ≥1 night in jail or prison in the past 3 months). The three main outcomes of this study were: any traumatic injury; substance use-related health consequences; and health care utilization defined as hospitalization (excluding addiction treatment or detoxification) and/or emergency department visit.
Recent incarceration was not significantly associated with traumatic injury (adjusted odds ratio (AOR=0.98, 95%CI 0.65–1.49) or health care utilization (AOR=0.88, 95%CI: 0.64–1.20). However, recent incarceration was associated with higher odds for substance use-related health consequences (AOR=1.42, 95% CI: 1.02–1.98).
Among people with alcohol and/or drug dependence, recent incarceration was significantly associated with substance use-related health consequences but not injury or health care utilization after adjustment for covariates. These findings suggest that substance use related health consequences may be part of the explanation for the increased risk of death faced by former inmates.
PMCID: PMC3962184  PMID: 24365804
Incarceration; substance dependence; trauma; health care utilization
25.  Does experiencing homelessness affect women’s motivation to change alcohol or drug use?? 
Background and Objectives
Homeless women are at high risk of drug and alcohol dependence and may receive less opportunity for treatment. Our objective was to examine the association between experiencing homelessness and motivation to change drug or alcohol use.
Women (n=154) participants in a study of substance dependence at an urban medical center (69 with some homeless days in the last 90 days; 85 continuously housed at baseline) completed 6 items rating motivation to change alcohol or drug use (i.e., importance, readiness, and confidence) at baseline and in 3, 6, and 12-month follow up interviews. Unadjusted, and longitudinal analyses controlling for covariates (e.g., demographics, insurance status, substance use consequences, mental health status, and participation in treatment), were conducted.
There were no significant differences between women experiencing homeless days versus continuously housed women in the odds of reporting high motivation to change alcohol or drug use, either in unadjusted baseline analyses or longitudinal analyses adjusted for covariates. Covariates that were significantly associated with high importance, readiness or confidence to change behavior were higher life time consequences of substance use, and participation in 12-step programs.
Discussion and Conclusions
The findings suggest that clinicians should not make assumptions that homeless women have low motivation to change their substance use.
Scientific Significance and Future Directions
The same opportunities for addiction treatment should be offered to homeless as to housed women.
PMCID: PMC3857556  PMID: 24313245
Women; Homelessness; Motivation to Change; Alcohol Dependence; Drug Dependence

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