Predictors of treatment initiation for alcohol use disorders in primary care

Disparities in Treatment for Alcohol Use Disorder Among All of Us Participants

OBJECTIVE

The authors examined racial/ethnic and socioeconomic disparities in receiving treatment for alcohol use disorder (AUD).

METHODS

A retrospective cohort study was conducted that included adults (≥18 years) with AUD from the All of Us Controlled Tier database v7. Outcomes were lifetime receipt of FDA-approved medications (disulfiram, acamprosate, and naltrexone), psychotherapy (individual, family, and group-based session), and combination treatment (medication and psychotherapy). The study examined treatment receipt by race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other), insurance (private, Medicare, Medicare and Medicaid, Medicaid, Veteran Affairs [VA], none), income (<$10K, $10-<$50K, $50-$100K, >$100K), and area deprivation index (ADI) quintiles. Multivariable logistic and multinomial logistic regressions were used to assess the association between patient characteristics and treatment receipt.

RESULTS

The cohort consisted of 18,692 patients (mean age=57.1 years; 60.7% were male; 47.1% were non-Hispanic White). Almost 70% received no treatment, 11.4% received medication, 24.0% received psychotherapy, and 4.9% received combination treatment. In adjusted analysis, non-Hispanic Black (aOR=0.78, 95% CI=0.69-0.89) and Hispanic (aOR=0.75, 95% CI=0.64-0.88) individuals were less likely to receive medication than non-Hispanic White counterparts. There was no association between race/ethnicity and receipt of psychotherapy or combination treatment. Compared with private insurance, dual eligibility was associated with less use of medication, Medicare and Medicaid with less use of medication and combination treatment, and VA and no insurance with more use of psychotherapy and combination treatment. Higher income and lower ADI were positively associated with all treatment types.

CONCLUSIONS

There are disparities in AUD treatment by race/ethnicity, socioeconomic status, and insurance. Systematic approaches are required to improve equitable access to effective treatment.

Factors Related to Receipt of Help for Alcohol Use: Extending the Focus of Treatment to the Continuum of Unhealthy Alcohol Use

Background

Unhealthy alcohol use is one of the leading preventable causes of mortality in the U.S. Despite evidence of the growing burden of alcohol-associated mortality and disease, treatment is severely underutilized. Prior literature has often focused on assessing treatment among patients with severe alcohol use.

Objectives

Assess factors associated with uptake of treatment for alcohol use among a broad population of those regularly exceeding U.S. guidelines for alcohol use.

Design

Cross-sectional study.

Methods

Using data from the National Epidemiologic Survey on Alcohol and Related Conditions - Wave III (NESARC-III) collected April 2012 to June 2013, weighted descriptive statistics were used to describe the U.S. population who self-reported regularly exceeding U.S. guidelines for moderate alcohol use at least monthly. Weighted multivariable regression was used to assess the association of individual-level factors with receipt of help for unhealthy alcohol use.

Results

In weighted analyses of 6467 NESARC-III participants, 17% of the U.S. population reported regular engagement in unhealthy alcohol use (76% use exceeding guidelines, 14% binge drinking, 11% heavy drinking) and were predominantly male (62%), below age 65 (93%), non-Hispanic White (65%), and had lower levels of education and income. Half (53%) met criteria for alcohol use disorder. Only 5% reported receipt of help for their alcohol use. Compared to non-Hispanic White individuals, non-Hispanic Asian/Native Hawaiian or Other Pacific Islander (odds ratio [OR] 0.40, 95% confidence interval [CI] 0.18-0.90) and non-Hispanic Black (OR 0.68, 95% CI 0.48-0.96) individuals were less likely to receive help for alcohol use. Factors associated with greater receipt of help included being older, educational attainment, Medicaid insurance, concomitant drug use, liver disease, acute healthcare utilization, and greater alcohol-related problems.

Conclusion

Identification of the factors associated with receipt of alcohol-related treatment, including race and ethnicity, age, education, insurance, and drug use can inform interventions to increase treatment receipt.

Design of CLARO+ (Collaboration Leading to Addiction Treatment and Recovery from Other Stresses, Plus): A randomized trial of collaborative care to decrease overdose and suicide risk among patients with co-occurring disorders

BACKGROUND

The United States is mired in two intertwined epidemics of death from suicide and overdose. Opioid use disorder (OUD) and mental illness contribute to both, and individuals with co-occurring disorders (CODs) are a complex population at high risk. Although universal prevention makes sense from a public health perspective, medical and behavioral health providers often lack the time to proactively address these issues with all patients. In this study, we build upon a parent study called Collaboration Leading to Addiction Treatment and Recovery from Other Stresses (CLARO), a model of collaborative care in which care coordinators deliver preventative measures to high-risk patients and coordinate care with the patients' care team, with the goal of increasing MOUD retention and decreasing risk of suicide and overdose.

METHODS

CLARO+ adds intervention components on overdose prevention, recognition, and response training; lethal means safety counseling; and an effort to mail compassionate messages called Caring Contacts. Both CLARO and CLARO+ have been implemented at 17 clinics in New Mexico and California, and this study seeks to determine the difference in effectiveness between the two versions of the intervention. This paper describes the design protocol for CLARO+.

CONCLUSION

CLARO+ is an innovative approach that aims to supplement existing collaborative care with additional suicide and overdose prevention strategies.

CLINICALTRIALS

gov: NCT04559893.

Integration of pharmacotherapy for alcohol use disorder treatment in primary care settings: A scoping review

BACKGROUND

Alcohol use disorder (AUD) represents the most prevalent addiction in the United States. Integration of AUD treatment in primary care settings would expand care access. The objective of this scoping review is to examine models of AUD treatment in primary care that include pharmacotherapy (acamprosate, disulfiram, naltrexone).

METHODS

The team undertook a search across MEDLINE, PsycINFO, CINAHL, the Cochrane Central Register of Controlled Trials, and Web of Science on May 21, 2021. Eligibility criteria included: patient population ≥ 18 years old, primary care-based setting, US-based study, presence of an intervention to promote AUD treatment, and prescription of FDA-approved AUD pharmacotherapy. Study design was limited to controlled trials and observational studies. We assessed study bias using a modified Oxford Centre for Evidence-based Medicine Rating Framework quality rating scheme.

RESULTS

The qualitative synthesis included forty-seven papers, representing 25 primary studies. Primary study sample sizes ranged from 24 to 830,825 participants and many (44 %) were randomized controlled trials. Most studies (80 %) included a nonpharmacologic intervention for AUD: 56 % with brief intervention, 40 % with motivational interviewing, and 12 % with motivational enhancement therapy. A plurality of studies (48 %) included mixed pharmacologic interventions, with administration of any combination of naltrexone, acamprosate, and/or disulfiram. Of the 47 total studies included, 68 % assessed care initiation and engagement. Fewer studies (15 %) explored practices surrounding screening for or diagnosing AUD. Outcome measures included receipt of pharmacotherapy and alcohol consumption, which about half of studies included (53 % and 51 %, respectively). Many of these outcomes showed significant findings in favor of integrated care models for AUD.

CONCLUSIONS

The integration of AUD pharmacotherapy in primary care settings may be associated with improved process and outcome measures of care. Future research should seek to understand the varied experiences across care integration models.

Alcohol-related consequences and the intention to seek care in treatment naïve women and men with severe alcohol use disorder

INTRODUCTION

Research on treatment utilization for alcohol use disorder (AUD) is based primarily on clinical samples and community samples of low AUD severity that may not need formal care. Using a community sample of adults with untreated but severe AUD symptoms, we tested the hypothesis that alcohol-related consequences, but not alcohol consumption levels, are associated with the intention to seek AUD treatment, examined associations of specific types of alcohol-related consequences with intention, and explored sex differences in these associations.

METHODS

The sample was recruited using social media ads for a randomized controlled trial to test a brief intervention to promote AUD treatment seeking. This report is based on analysis of baseline data collected prior to treatment intervention. Multiple linear regressions examined associations of measures of alcohol consumption, alcohol-related consequences broadly, and specific alcohol-related consequences with the intention to seek treatment. Moderating effects of sex on associations were explored.

RESULTS

Subjects (n = 349) averaged 41 years of age, 48% were female, 6% were Latinx, 80% were white, 15% were Black, and 92% met criteria for severe AUD. Alcohol consumption measures were not associated with intention to seek treatment whereas interpersonal- and intrapersonal- consequences were associated with intention. Sex served as a moderator, with intrapersonal consequences (e.g., sad mood) showing a stronger association with intention in women and social responsibility consequences (particularly financial) associated with intention in men.

CONCLUSION

Select alcohol-related consequences may be keys to understanding increased intention to seek AUD treatment including intrapersonal consequences in women and financial consequences in men.

Associations of housing stress with later substance use outcomes: A systematic review

A synthesis of existing evidence regarding the association of housing stress with later substance use outcomes can help support and inform housing interventions as a potential strategy to address problematic substance use. We conducted a comprehensive search of PubMed, Web of Science, PsycInfo, CINAHL, Social Work Abstracts, and Sociological Abstracts and systematically screened for articles examining housing stress and later substance use outcomes among U.S. adults. Across 38 relevant articles published from 1991 to 2020, results demonstrated an association of homelessness with an increased likelihood of substance use, substance use disorders (SUD), and overdose death. Results regarding the association of homelessness with receipt and completion of SUD treatment were mixed, and one study indicated no association of homelessness with motivation to change substance use behaviors. Several studies did not find an association of unstable housing with substance use or receipt of SUD treatment, while others found an association of unstable housing with intensified SUD symptoms and a decreased likelihood of completing SUD treatment. Overall, while there is evidence of an association of homelessness with later substance use, SUD, and overdose death, results for other forms of housing stress and some substance use outcomes are less consistent. There are several methodological considerations specific to selected measures of housing stress and substance use, study populations, and analytic approaches that have implications for results and directions for future research. Despite these considerations, results collectively suggest that innovative interventions to address housing stress, namely homelessness, may help mitigate some substance use outcomes.

Understanding low treatment seeking rates for alcohol use disorder: A narrative review of the literature and opportunities for improvement

Despite a well-documented global burden of disease attributable to alcohol use disorder (AUD), treatment seeking rates remain low. In this qualitative literature review, we address treatment seeking for AUD from a host of perspectives and summarize the literature on key factors. First, we summarize the rates of alcohol treatment seeking across various epidemiological surveys, spanning decades. Second, we discuss the definition of treatment seeking and 'what' is typically considered formal treatment. Third, we consider timing and discuss 'when' individuals are most likely to seek treatment. Fourth, we review the literature on 'who' is most likely to seek treatment, including demographic and clinical correlates. Fifth, we address the critical question of 'why' so few people receive clinical services for AUD, relative to the number of individuals affected by the disorder, and review barriers to treatment seeking at the treatment- and person-levels of analysis. Finally, we identify opportunities to improve treatment seeking rates by focusing on tangible points of intervention. Specifically, we recommend a host of adaptations to models of care including efforts to make treatment more appealing across stages of AUD severity, accept a range of health-enhancing drinking goals as opposed to an abstinence-only model, educate providers and consumers about evidence-based behavioral and pharmacological treatments, and incentivize the delivery of evidence-based services.

Characterizing the Variation of Alcohol Cessation Pharmacotherapy in Primary Care

BACKGROUND

Alcohol use disorder (AUD) imposes a high mortality and economic burden. Effective treatment is available, though underutilized.

OBJECTIVE

Describe trends in AUD pharmacotherapy, variation in prescribing, and associated patient factors.

DESIGN

Retrospective cohort using electronic health records from 2010 to 2019.

PARTICIPANTS

Primary care patients from 39 clinics in Ohio and Florida with diagnostic codes for alcohol dependence or abuse plus social history indicating alcohol use. PCPs in family or internal medicine with at least 20 AUD patients.

MAIN MEASURES

Pharmacotherapy for AUD (naltrexone, acamprosate, and disulfiram), abstinence from alcohol, patient demographics, and comorbidities. Generalized linear mixed models were used to identify patient factors associated with prescriptions and the association of pharmacotherapy with abstinence.

KEY RESULTS

We identified 13,250 patients; average age was 54 years, 66.9% were male, 75.0% were White, and median household income was $51,776 per year. Over 10 years, the prescription rate rose from 4.4 to 5.6%. Patients who were Black (aOR 0.74; 95% CI 0.58, 0.94) and insured by Medicare versus commercial insurance (aOR 0.61; 95% CI 0.48, 0.78) were less likely to be treated. Higher median household income ($10,000 increment, aOR 1.06; 95% CI 1.03, 1.10) and Medicaid versus commercial insurance (aOR 1.52; 95% CI 1.24, 1.87) were associated with treatment. Receiving pharmacotherapy was associated with subsequent documented abstinence from alcohol (aOR 1.60; 95% CI 1.33, 1.92). We identified 236 PCPs. The average prescription rate was 3.6% (range 0 to 24%). The top decile prescribed to 14.6% of their patients. The bottom 4 deciles had no prescriptions. Family physicians had higher rates of pharmacotherapy than internists (OR 1.50; 95% CI 1.21, 1.85).

CONCLUSIONS

Medications for AUD are infrequently prescribed, but there is considerable variation among PCPs. Increasing the use of pharmacotherapy by non-prescribers may increase abstinence from alcohol.

Predictors of Opioid and Alcohol Pharmacotherapy Initiation at Hospital Discharge Among Patients Seen by an Inpatient Addiction Consult Service

BACKGROUND

Medications for opioid use disorder (MOUD) and alcohol use disorder (MAUD) are effective and under-prescribed. Hospital-based addiction consult services can engage out-of-treatment adults in addictions care. Understanding which patients are most likely to initiate MOUD and MAUD can inform interventions and deepen understanding of hospitals' role in addressing substance use disorders (SUD).

OBJECTIVE

Determine patient- and consult-service level characteristics associated with MOUD/MAUD initiation during hospitalization.

METHODS

We analyzed data from a study of the Improving Addiction Care Team (IMPACT), an interprofessional hospital-based addiction consult service at an academic medical center. Researchers collected patient surveys and clinical data from September 2015 to May 2018. We used logistic regression to identify characteristics associated with medication initiation among participants with OUD, AUD, or both. Candidate variables included patient demographics, social determinants, and treatment-related factors.

RESULTS

Three hundred thirty-nine participants had moderate to severe OUD, AUD, or both and were not engaged in MOUD/MAUD care at admission. Past methadone maintenance treatment (aOR 2.07, 95%CI (1.17, 3.66)), homelessness (aOR 2.63, 95%CI (1.52, 4.53)), and partner substance use (aOR 2.05, 95%CI (1.12, 3.76) were associated with MOUD/MAUD initiation. Concurrent methamphetamine use disorder (aOR 0.32, 95%CI (0.18, 0.56)) was negatively associated with MOUD/MAUD initiation.

CONCLUSIONS

The association of MOUD/MAUD initiation with homelessness and partner substance use suggests that hospitalization may be an opportunity to reach highly-vulnerable people, further underscoring the need to provide hospital-based addictions care as a health-system strategy. Methamphetamine's negative association with MOUD/MAUD warrants further study.

Improving Medication Access within Integrated Treatment for Individuals with Co-Occurring Disorders in Substance Use Treatment Agencies

BACKGROUND

The best approach to provide comprehensive care for individuals with co-occurring disorders (CODs) related to substance use and mental health is to address both disorders through an integrated treatment approach. However, only 25% of behavioral health agencies offer integrated care and less than 7% of individuals who need integrated treatment receive it. A project used a cluster-randomized waitlist control group design to evaluate the effectiveness of Network for the Improvement of Addiction Treatment (NIATx) implementation strategies to improve access to addiction and psychotropic medications.

METHODS

This study represents a secondary analysis of data from the NIATx project. Forty-nine agencies were randomized to Cohort1 (active implementation group, receiving the NIATx strategy [n=25]) or Cohort2 (waitlist control group [n=24]). Data were collected at three time points (Baseline, Year1 and Year2). A two-level (patient within agency) multinomial logistic regression model investigated the effects of implementation strategy condition on one of four medication outcomes: both medication types, only psychotropic medication, only addiction medication, or neither medication type. A per-protocol analysis included time, NIATx fidelity, and agency focus as predictors.

RESULTS

The intent-to-treat analysis found a statistically significant change in access to addiction versus neither medication, but Cohort1 compared to Cohort2 at Year1 showed no differences. Changes were associated with the experimental intervention and occurred in the transition from Year 1 to Year 2, where greater increases were seen for agencies in Cohort2 versus Cohort1. The per-protocol analysis showed increased access to both medications and addiction medications from pre- to post-intervention for agencies in both cohorts; however, differences in change between high- and low-implementation agencies were not significant.

CONCLUSIONS

Access to integrated services for people with CODs is a long-standing problem. NIATx implementation strategies had limited effectiveness in improving medication access for individuals with CODs. Implementation strategy adherence is associated with increased medication access.

Endogenous Opiates and Behavior: 2018

This paper is the forty-first consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2018 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (2), the roles of these opioid peptides and receptors in pain and analgesia in animals (3) and humans (4), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (5), opioid peptide and receptor involvement in tolerance and dependence (6), stress and social status (7), learning and memory (8), eating and drinking (9), drug abuse and alcohol (10), sexual activity and hormones, pregnancy, development and endocrinology (11), mental illness and mood (12), seizures and neurologic disorders (13), electrical-related activity and neurophysiology (14), general activity and locomotion (15), gastrointestinal, renal and hepatic functions (16), cardiovascular responses (17), respiration and thermoregulation (18), and immunological responses (19).

Perception of treatment need among adults with substance use disorders: Longitudinal data from a representative sample of adults in the United States

BACKGROUND

Most individuals with substance use disorders (SUDs) do not seek treatment. Lack of perceived treatment need (PTN) is one contributing factor, but little is known about PTN over time. We estimated whether PTN changed over three years among those with SUDs in the United States and identified select variables, including sociodemographics and symptom burden, that predict malleability vs. stability of PTN.

METHODS

Data were from Waves 1 (collected 2001-2002) and 2 (collected 2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC); 1695 adults who met DSM criteria for alcohol or non-alcohol SUD at Wave 1 and maintained ≥1 diagnostic symptom at Wave 2 were included.

RESULTS

Most individuals with SUDs (77.2%) did not perceive a need for treatment at Wave 1 baseline. Only about 1 in 8 individuals not perceiving a need for treatment in Wave 1 came to perceive a need in Wave 2 (adjusted odds ratio = 0.18, 99% confidence interval = 0.11-0.29). In contrast, about half the individuals who perceived a need for treatment in Wave 1 no longer did so in Wave 2, despite maintaining ≥1 SUD symptom. Married respondents, and respondents with more SUD symptoms, were more likely to transition from low- to high-PTN status three years later. Respondents with incomes >$35,000 were less likely to transition to high-PTN status three years later.

CONCLUSIONS

PTN was more likely to decline than increase over time. Low PTN appears to be stable among adults with SUDs in the United States, presenting a potentially enduring barrier to treatment-seeking.