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1.  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
2.  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
3.  No Detectable Association Between Frequency of Marijuana Use and Health or Healthcare Utilization Among Primary Care Patients Who Screen Positive for Drug Use 
Marijuana is the most commonly used illicit drug, yet its impact on health and healthcare utilization has not been studied extensively.
To assess the cross-sectional association between frequency of marijuana use and healthcare utilization (emergency department and hospitalization) and health (comorbidity, health status), we studied patients in an urban primary care clinic who reported any recent (past 3-month) drug use (marijuana, opioids, cocaine, others) on screening. Frequency of marijuana use in the past 3 months was the main independent variable [daily/ almost daily, less than daily and no use (reference group)]. Outcomes assessed were past 3-month emergency department or hospital utilization, the presence of medical comorbidity (Charlson index ≥ 1), and health status with the EuroQol. We used separate multivariable regression models adjusting for age, sex, tobacco and other substance use.
All 589 participants reported recent drug use: marijuana 84 % (29 % daily, 55 % less than daily), cocaine 25 %, opioid 23 %, other drugs 8 %; 58 % reported exclusive marijuana use. Frequency of marijuana use was not significantly associated with emergency department use {adjusted odds ratio [AOR] 0.67, [95 % confidence interval (CI) 0.36, 1.24] for daily; AOR 0.69 [95 % CI 0.40,1.18] for less than daily versus no use}, hospitalization [AOR 0.79 (95 % CI 0.35, 1.81) for daily; AOR 1.23 (95 % CI 0.63, 2.40) for less than daily versus no use], any comorbidity [AOR 0.62, (95 % CI 0.33, 1.18) for daily; AOR 0.67 (95 % CI 0.38, 1.17) for less than daily versus no use] or health status (adjusted mean EuroQol 69.1, 67.8 and 68.0 for daily, less than daily and none, respectively, global p = 0.78).
Among adults in primary care who screen positive for any recent illicit or non-medical prescription drug use, we were unable to detect an association between frequency of marijuana use and health, emergency department use, or hospital utilization.
PMCID: PMC3889953  PMID: 24048656
marijuana; primary care; health status; health service utilization
4.  Chronic Hepatitis C Virus Infection is Associated with All-Cause and Liver-Related Mortality in a Cohort of HIV-Infected Patients with Alcohol Problems 
Addiction (Abingdon, England)  2013;109(1):62-70.
To assess the association between hepatitis C virus (HCV) infection and overall and liver-related death in human immunodeficiency virus (HIV)-infected patients with alcohol problems.
We analyzed data from a cohort of HIV-infected adults with current or past alcohol problems enrolled between 2001 and 2003, searching for causes of death until 2010 using the National Death Index.
Setting and participants
Participants were HIV-infected adults with current or past alcohol problems, recruited in Boston, MA from HIV clinics at two hospitals, homeless shelters, drug treatment programs, subject referrals, flyers, and another cohort study with comparable recruitment sites.
The primary and secondary outcomes were all-cause and liver-related mortality, respectively. The main independent variable was HCV RNA status (positive vs. negative). Mortality rates and Kaplan-Meier survival curves were calculated by HCV status for both overall and liver-related mortality. Cox proportional hazards models were used to assess the association between HCV infection and overall and liver-related death, adjusting for alcohol and drug use over time.
397 adults (50% HCV-infected) were included. As of December 31, 2009, 83 cohort participants had died (60 HCV-infected, 23 HCV-uninfected; log rank test p<0.001), and 26 of those deaths were liver-related (21 HCV-infected, 5 HCV-uninfected; log rank test p<0.001). All-cause and liver-related mortality rates were 4.68 and 1.64 deaths per 100 person-years for HCV-infected patients and 1.65 and 0.36 per 100 person-years for those without HCV, respectively. In the fully adjusted Cox model, HCV infection was associated with both overall [HR 2.55 (95%CI:1.50–4.33), p<0.01], and liver-related mortality [HR 3.24 (95%CI:1.18–8.94), p=0.02].
Hepatitis C virus infection is independently associated with all-cause and liver-related mortality in human immunodeficiency virus-infected patients with alcohol problems, even when accounting for alcohol and other drug use.
PMCID: PMC3947001  PMID: 24112091
5.  Drinking Patterns of Older Adults with Chronic Medical Conditions 
Journal of General Internal Medicine  2013;28(10):1326-1332.
Understanding alcohol consumption patterns of older adults with chronic illness is important given the aging baby boomer generation, the increase in prevalence of chronic conditions and associated medication use, and the potential consequences of excessive drinking in this population.
To estimate the prevalence of alcohol consumption patterns, including at-risk drinking, in older adults with at least one of seven common chronic conditions.
This descriptive study used the nationally representative 2005 Medicare Current Beneficiary Survey linked with Medicare claims. The sample included community-dwelling, fee-for-service beneficiaries 65 years and older with one or more of seven chronic conditions (Alzheimer’s disease and other senile dementia, chronic obstructive pulmonary disease, depression, diabetes, heart failure, hypertension, and stroke; n = 7,422). Based on self-reported alcohol consumption, individuals were categorized as nondrinkers, within-guidelines drinkers, or at-risk drinkers (exceeds guidelines).
Overall, 30.9 % (CI 28.0–34.1 %) of older adults with at least one of seven chronic conditions reported alcohol consumption in a typical month in the past year, and 6.9 % (CI 6.0–7.8 %) reported at-risk drinking. Older adults with higher chronic disease burdens were less likely to report alcohol consumption and at-risk drinking.
Nearly one-third of older adults with selected chronic illnesses report drinking alcohol and almost 7 % drink in excess of National Institute on Alcohol Abuse and Alcoholism (NIAAA) guidelines. It is important for physicians and patients to discuss alcohol consumption as a component of chronic illness management. In cases of at-risk drinking, providers have an opportunity to provide brief intervention or to offer referrals if needed.
PMCID: PMC3785666  PMID: 23609178
at-risk drinking; alcohol consumption; Medicare beneficiaries; chronic conditions; older adults
6.  Screening and Brief Intervention for Unhealthy Drug Use: Little or No Efficacy 
Unhealthy drug use ranges from use that risks health harms through severe drug use disorders. This narrative review addresses whether screening and brief intervention (SBI), efficacious for risky alcohol use, has efficacy for reducing other drug use and consequences. Brief intervention among those seeking help shows some promise. Screening tools have been validated though most are neither brief nor simple enough for use in general health settings. Several randomized trials have tested the efficacy of brief intervention for unhealthy drug use identified by screening in general health settings (i.e., in people not seeking help for their drug use). Substantial evidence now suggests that efficacy is limited or non-existent. Reasons likely include a range of actual and perceived severity (or lack of severity), concomitant unhealthy alcohol use and comorbid mental health conditions, and the wide range of types of unhealthy drug use (e.g., from marijuana, to prescription drugs, to heroin). Although brief intervention may have some efficacy for unhealthy drug users seeking help, the model of SBI that has effects in primary care settings on risky alcohol use may not be efficacious for other drug use.
PMCID: PMC4151000  PMID: 25228887
screening and brief intervention; unhealthy drug use; illicit drug; efficacy; randomized trials; counseling; identification; primary care
7.  Impact of lifetime alcohol use on liver fibrosis in a population of HIV-infected patients with and without hepatitis C coinfection 
The effect of alcohol on liver disease in HIV infection has not been well characterized.
We performed a cross-sectional multivariable analysis of the association between lifetime alcohol use and liver fibrosis in a longitudinal cohort of HIV-infected patients with alcohol problems. Liver fibrosis was estimated with two non-invasive indices, “FIB-4”, which includes platelets, liver enzymes, and age; and “APRI”, which includes platelets and liver enzymes. FIB-4<1.45 and APRI<0.5 defined absence of liver fibrosis. FIB-4>3.25 and APRI>1.5 defined advanced liver fibrosis. The main independent variable was lifetime alcohol consumption (<150 kg, 150–600kg, >600 kg).
Subjects (n=308) were 73% male, mean age 43 years, 49% with hepatitis C virus (HCV) infection, 60% on antiretroviral therapy, 49% with an HIV RNA load<1000 copies/mL, and 18.7% with a CD4 count<200 cells/mm3. Forty-five percent had lifetime alcohol consumption >600 kg, 32.7% 150–600 kg, and 22.3% <150 kg; 33% had current heavy alcohol use, and 69% had >9 years of heavy episodic drinking. Sixty-one percent had absence of liver fibrosis and 10% had advanced liver fibrosis based on FIB-4. In logistic regression analyses controlling for age, gender, HCV infection, and CD4 count, no association was detected between lifetime alcohol consumption and absence of liver fibrosis (FIB-4<1.45) [adjusted odds ratio (AOR)=1.12 (95%CI:0.25–2.52) for 150–600 kg versus <150 kg; AOR=1.11 (95%CI:0.52–2.36) for >600 kg vs. <150 kg; global p=0.95]. Additionally, no association was detected between lifetime alcohol use and advanced liver fibrosis (FIB-4>3.25). Results were similar using APRI, and among those with and without HCV infection.
In this cohort of HIV-infected patients with alcohol problems, we found no significant association between lifetime alcohol consumption and absence of liver fibrosis or the presence of advanced liver fibrosis, suggesting that alcohol may be less important than other known factors that promote liver fibrosis in this population.
PMCID: PMC3758457  PMID: 23647488
alcohol; HIV; Hepatitis C virus; liver fibrosis
8.  When Quality Indicators Undermine Quality: Bias in a Quality Indicator of Follow-up for Alcohol Misuse 
Valid quality indicators are needed to monitor and incentivize identification and management of mental health and substance use conditions (“behavioral conditions”). Because behavioral conditions are frequently under-identified, quality indicators often evaluate the proportion of patients who screen positive for a condition who have appropriate follow-up care documented. However, these “positive-screen-based” quality indicators of follow-up for behavioral conditions could be biased by differences in the denominator due to differential screening quality (“denominator bias”) and could reward identification of fewer patients with the behavioral condition(s) of interest.
To evaluate denominator bias in the performance of Veterans Health Administration (VA) networks on a quality indicator of follow-up for alcohol misuse that used patients with positive alcohol screens as the denominator.
The performance of 21 VA networks on a positive-screen-based quality indicator of follow-up for alcohol misuse was compared to the networks' performance on a population-based quality indicator (proportion of eligible patients who had alcohol misuse identified and follow-up documented) using medical record reviews (n=219,119).
Results of the two quality indicators were inconsistent. For example, two networks performed similarly on the quality indicators (64.7%, 65.4%) even though one identified and documented follow-up for almost twice as many patients (5,411 and 2,899 per 100,000 eligible, respectively). Networks that performed better on the positive-screen-based quality indicator identified fewer patients with alcohol misuse than networks that performed better on the population-based quality indicator (mean 4.1% vs 7.4% respectively).
A positive-screen-based quality indicator of follow-up for alcohol misuse preferentially rewarded networks that identified fewer patients with alcohol misuse.
PMCID: PMC3959120  PMID: 23852137
quality improvement; alcohol counseling; alcohol screening
9.  Chronic Care Management for Dependence on Alcohol and Other Drugs: The AHEAD Randomized Trial 
People with substance dependence have health consequences, high healthcare utilization and frequent comorbidity but often receive poor quality care overall and for dependence. Chronic care management has been proposed as an approach to improve care and outcomes.
To determine whether chronic care management (CCM) for alcohol and other drug (AOD) dependence improves substance use outcomes compared to usual primary care.
Design, Setting, and Participants
The AHEAD study was a randomized trial in people with AOD dependence, not necessarily seeking treatment, at a Boston hospital-based primary care practice. Of the 655 eligible participants, 563 (86%) were randomized. Study participants were recruited from September 2006 to September 2008 from a free-standing residential detoxification unit (74%) and referrals from an urban teaching hospital and advertisements (26%). Participants were randomized to CCM (n=282) or no CCM (n=281).
CCM included longitudinal care coordinated with a primary care clinician, motivational enhancement therapy, relapse prevention counseling, and on-site medical, addiction and psychiatric treatment, social work assistance and referrals (including mutual help). The no CCM group received a primary care appointment, and a list of treatment resources including a phone number to arrange counseling.
Main Outcome and Measure
The primary outcome was self-reported abstinence from opioids, stimulants or heavy drinking. Biomarkers were secondary outcomes. We employed longitudinal analyses for data from 3, 6 and 12 months (last interview January 21, 2010).
Of 563 participants, 95% completed 12-month follow-up. Baseline characteristics of the study participants were similar across randomization groups, but differed significantly for race and depressive symptoms. There was no significant difference in abstinence from opioids, stimulants or heavy drinking between the CCM (44%) and control (42%) groups (adjusted odds ratio 0.84; 95% confidence interval (CI) 0.65–1.10; p=0.21). No significant differences were found for secondary outcomes: addiction severity, health-related quality of life or drug problems. No subgroup effects were found except among those with alcohol dependence in whom CCM was associated with fewer alcohol problems (mean 10 vs. 13, incidence rate ratio 0.85, 95% CI 0.72–1.00, p=0.048).
Conclusions and Relevance
Among persons with AOD dependence, CCM compared with a primary care appointment but no CCM did not increase self-reported abstinence over 12 months. Whether more intensive or longer duration CCM is effective would require further investigation.
PMCID: PMC3902022  PMID: 24045740
10.  The Short Inventory of Problems—Modified for Drug Use (SIP-DU): Validity in a Primary Care Sample 
Primary care physicians can help drug-dependent patients mitigate adverse drug use consequences; instruments validated in primary care to measure these consequences would aid in this effort. This study evaluated the validity of the Short Inventory of Problems—Alcohol and Drugs modified for Drug Use (SIP-DU) among subjects recruited from a primary care clinic (n = 106). SIP-DU internal consistency was evaluated using Cronbach’s alphas, convergent validity by correlating the total SIP-DU score with the DAST-10, and construct validity by analyzing the factor structure. The SIP-DU demonstrated high internal consistency (Cronbach’s alpha for overall scale .95, subscales .72–.90) comparable with other SIP versions and correlated well with the DAST-10 (r = .70). Confirmatory factor analysis suggested an unacceptable fit of previously proposed factors; exploratory factor analyses suggested a single factor of drug use consequences. The SIP-DU offers primary care clinicians a valid and practical assessment tool for drug use consequences.
PMCID: PMC3889861  PMID: 22494228
11.  The best evidence for alcohol screening and brief intervention in primary care supports efficacy, at best, not effectiveness: You say tomāto, I say tomăto? That’s not all it’s about 
The review related to this manuscript is available at
PMCID: PMC4146443  PMID: 25168288
We examinedthe effect ofthe quality of primary care-basedchronic disease management (CDM)for alcohol and/or other drug (AOD) dependenceonaddiction outcomes.We assessed qualityusing 1)avisit frequencybased measure and 2) a self-reported assessment measuring alignment with the chronic care model. The visit frequency based measure had no significant association with addiction outcomes. Theself-reported measure of care - when care was at a CDM clinic - was associated with lower drug addiction severity.The self-reported assessment of care from any healthcare source (CDM clinic or elsewhere)was associated with lower alcoholaddiction severity and abstinence.These findings suggest that high quality CDM for AOD dependence may improve addiction outcomes.Quality measuresbased upon alignment with the chronic care model may better capture features of effective CDM care than a visitfrequency measure.
PMCID: PMC3507538  PMID: 22840687
13.  Aberrant drug-related behaviors: Unsystematic documentation does not identify prescription drug use disorder 
Pain medicine (Malden, Mass.)  2012;13(11):1436-1443.
No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD.
A cross-sectional study of PC patients at an urban, academic medical center.
264 English-speaking patients (ages 18–60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits.
Outcome Measures
Composite International Diagnostic Interview defined DSM-IV diagnoses of past-year PDUD and no disorder. EMRs were reviewed for 15 pre-specified ADRBs (e.g. early refill, stolen medications) in the year before and after study entry. Fisher’s exact test compared frequencies of each ADRB between participants with and without PDUD.
61 participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only “appearing intoxicated or high” documented more frequently among participants with PDUD (n=10, 16%) vs. no disorder (n=8, 4%), p=0.002. The only common ADRB, “emergency visit for pain,” did not discriminate between those with and without the disorder (82% PDUD vs. 78% no disorder, p=0.6).
EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.
PMCID: PMC3501607  PMID: 23057631
Prescription drug use disorder; diagnosis; aberrant drug-related behaviors; primary care; chronic pain
14.  Alcohol and Drug Use Disorders among Patients with Myocardial Infarction: Associations with Disparities in Care and Mortality 
PLoS ONE  2013;8(9):e66551.
Because alcohol and drug use disorders (SUDs) can influence quality of care, we compared patients with and without SUDs on frequency of catheterization, revascularization, and in-hospital mortality after acute myocardial infarction (AMI).
This study employed hospital discharge data identifying all adult AMI admissions (ICD-9-CM code 410) between April 1996 and December 2001. Patients were classified as having an SUD if they had alcohol and/or drug (not nicotine) abuse or dependence using a validated ICD-9-CM coding definition. Catheterization and revascularization data were obtained by linkage with a clinically-detailed cardiac registry. Analyses (controlling for comorbidities and disease severity) compared patients with and without SUDs for post-MI catheterization, revascularization, and in-hospital mortality.
Of 7,876 AMI unique patient admissions, 2.6% had an SUD. In adjusted analyses mortality was significantly higher among those with an SUD (odds ratio (OR) 2.02; 95%CI: 1.10–3.69), while there was a trend toward lower catheterization rates among those with an SUD (OR 0.75; 95%CI: 0.55–1.01). Among the subset of AMI admissions who underwent catheterization, the adjusted hazard ratio for one-year revascularization was 0.85 (95%CI: 0.65–1.11) with an SUD compared to without.
Alcohol and drug use disorders are associated with significantly higher in-hospital mortality following AMI in adults of all ages, and may also be associated with decreased access to catheterization and revascularization. This higher mortality in the face of poorer access to procedures suggests that these individuals may be under-treated following AMI. Targeted efforts are required to explore the interplay of patient and provider factors that underlie this finding.
PMCID: PMC3770618  PMID: 24039695
16.  Physicians’ attitudes toward unhealthy alcohol use and self-efficacy for screening and counseling as predictors of their counseling and primary care patients’ drinking outcomes 
Patients’ unhealthy alcohol use is often undetected in primary care. Our objective was to examine whether physicians’ attitudes and their perceived self-efficacy for screening and counseling patients is associated with physicians’ counseling of patients with unhealthy alcohol use, and patients’ subsequent drinking.
This study is a prospective cohort study (nested within a randomized trial) involving 41 primary care physicians and 301 of their patients, all of whom had unhealthy alcohol use. Independent variables were physicians’ attitudes toward unhealthy substance use and self-efficacy for screening and counseling. Outcomes were patients’ reports of physicians’ counseling about unhealthy alcohol use immediately after a physician visit, and patients’ drinking six months later.
Neither physicians’ attitudes nor self-efficacy had any impact on physicians’ counseling, but greater perceived self-efficacy in screening, assessing and intervening with patients was associated with more drinking by patients six months later.
Future research needs to further explore the relationship between physicians’ attitudes towards unhealthy alcohol use, their self-efficacy for screening and counseling and patients’ drinking outcomes, given our unexpected findings.
PMCID: PMC3680085  PMID: 23718191
Self-efficacy; Attitudes; Screening; Counseling; Physicians; Unhealthy alcohol use
17.  Substance abuse treatment utilization among adults living with HIV/AIDS and alcohol or drug problems 
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.
PMCID: PMC3634563  PMID: 21700412
Substance abuse; treatment; addiction; HIV/AIDS; alcohol
18.  Discrepancy in diagnosis and treatment of post-traumatic stress disorder (PTSD): Treatment for the wrong reason 
In primary care (PC), patients with post-traumatic stress disorder (PTSD) are often undiagnosed. To determine variables associated with treatment, this cross-sectional study assessed 592 adult patients for PTSD. Electronic medical record (EMR) review of the prior 12 months assessed mental health (MH) diagnoses and MH treatments (selective serotonin reuptake inhibitor (SSRI) and/or ≥1 visit with a MH professional). Of 133 adults with PTSD, half (49%; 66/133) received an SSRI (18%), a visit with a MH professional (14%), or both (17%). Of those treated, 88% (58/66) had an EMR MH diagnosis, the majority (71%; 47/66) depression and (18%; 12/66) PTSD. The odds of receiving MH treatment were increased 8.2 times (95% CI 3.1 – 21.5) for patients with an EMR MH diagnosis. Nearly 50% of patients with PTSD received MH treatment, yet few had this diagnosis documented. Treatment was likely due to overlap in the management of PTSD and other mental illnesses.
PMCID: PMC3310322  PMID: 22076315
Post-traumatic Stress Disorder; Primary Care; Mental Health Diagnosis; Mental Health Treatment
19.  Factors associated with attendance in 12-step groups (Alcoholics Anonymous/Narcotics Anonymous) among adults with alcohol problems living with HIV/AIDS 
Drug and alcohol dependence  2010;113(2-3):165-171.
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.
PMCID: PMC3603575  PMID: 20832197
HIV-infection; alcohol addiction disorder; substance-related disorders; 12 step groups; HIV/AIDS
20.  Young Adults at Risk for Excess Alcohol Consumption Are Often Not Asked or Counseled About Drinking Alcohol 
Excessive alcohol consumption is most widespread among young adults. Practice guidelines recommend screening and physician advice, which could help address this common cause of injury and premature death.
To assess the proportion of persons ages 18–39 who, in the past year, saw a physician and were asked about their drinking and advised what drinking levels pose health risk, and whether this differed by age or whether respondents exceeded low-risk drinking guidelines [daily (>4 drinks for men/>3 for women) or weekly (>14 for men/>7 for women)].
Survey of young adults selected from a national internet panel established using random digit dial telephone techniques.
Adults age 18–39 who ever drank alcohol, n = 3,409 from the internet panel and n = 612 non-panel telephone respondents.
Main Measures
Respondents were asked whether they saw a doctor in the past year; those who did see a doctor were asked whether a doctor asked about their drinking, advised about safe drinking levels, or counseled to reduce drinking.
Key Results
Of respondents, 67% saw a physician in the past year, but only 14% of those exceeding guidelines were asked and advised about risky drinking patterns. Persons 18–25 were the most likely to exceed guidelines (68% vs. 56%, p < 0.001) but were least often asked about drinking (34% vs. 54%, p < 0.001).
Despite practice guidelines, few young adults are asked and advised by physicians about excessive alcohol consumption. Physicians should routinely ask all adults about their drinking and offer advice about levels that pose health risk, particularly to young adults.
PMCID: PMC3270224  PMID: 21935753
alcoholism and addictive behavior; communication; patient education; prevention
21.  The hospital outpatient alcohol project (HOAP): protocol for an individually randomized, parallel-group superiority trial of electronic alcohol screening and brief intervention versus screening alone for unhealthy alcohol use 
Electronic screening and brief intervention (e-SBI) is a promising alternative to screening and brief intervention by health-care providers, but its efficacy in the hospital outpatient setting, which serves a large proportion of the population, has not been established. The aim of this study is to estimate the effect of e-SBI in hospital outpatients with hazardous or harmful drinking.
This randomized controlled trial will be conducted in the outpatient department of a large tertiary referral hospital in Newcastle (population 540,000), Australia. Some 772 adults with appointments at a broad range of medical and surgical outpatient clinics who score 5–9 inclusive on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) subscale will be randomly assigned in a 1:1 ratio to electronic alcohol screening alone (control) or to e-SBI. As randomization will be effected by computer, researchers and participants (who will be invited to participate in a study of alcohol use over time) will be blinded to group assignment. The primary analysis will be based on the intention-to-treat principle and compare weekly volume (grams of alcohol) and the full AUDIT score with a six-month reference period between the groups six months post randomization. Secondary outcomes, assessed six and 12 months after randomization, will include drinking frequency, typical occasion quantity, proportion who report binge drinking, proportion who report heavy drinking, and health-care utilization.
If e-SBI is efficacious in outpatient settings, it offers the prospect of systematically and sustainably reaching a large number of hazardous and harmful drinkers, many of whom do not otherwise seek or receive help.
Trial registration
Australian New Zealand Clinical Trials Registry ACTRN12612000905864.
PMCID: PMC3766680  PMID: 24004498
Alcohol; Screening; Brief intervention; Internet; Intervention; Clinical trials; Hospital outpatients
24.  Disparities in safe sex counseling & behavior among individuals with substance dependence: a cross-sectional study 
Reproductive Health  2012;9:35.
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.
Trial registration
PMCID: PMC3565911  PMID: 23276300
Counseling; Disparities; Sexual behavior; Stereotyping
25.  Operating characteristics of carbohydrate–deficient transferrin (CDT) for identifying unhealthy alcohol use in adults with HIV infection 
AIDS care  2011;23(11):1483-1491.
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.
PMCID: PMC3193857  PMID: 21732900
carbohydrate-deficient transferrin; CDT; alcohol; HIV

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