1
|
Bischof G, Bischof A, Rumpf HJ. Anonyme Alkoholiker wirksamer als Psychotherapie? SUCHTTHERAPIE 2021. [DOI: 10.1055/a-1404-4936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungEine 2020 veröffentlichte, aktualisierte Cochrane-Analyse zu Anonymen
Alkoholikern und 12-Schritte Programmen zur Behandlung alkoholbezogener
Störungen schreibt diesen Interventionsformen eine bessere Evidenz
gegenüber etablierten psychotherapeutischen Verfahren zu. Der
Beitrag stellt zentrale Befunde des Reviews vor und
überprüft deren interne und externe Validität. Diese
sind eingeschränkt durch die verwendeten Definitionen der
Outcomeparameter, der Interventions- und Kontrollbedingungen, die
Selektivität der berichteten Ergebnisse und die
eingeschränkte Generalisierbarkeit der Stichproben.
Collapse
Affiliation(s)
- Gallus Bischof
- Klinik für Psychiatrie und Psychotherapie, Universität
zu Lübeck
| | - Anja Bischof
- Klinik für Psychiatrie und Psychotherapie, Universität
zu Lübeck
| | | |
Collapse
|
2
|
Kelly JF, Abry A, Ferri M, Humphreys K. Alcoholics Anonymous and 12-Step Facilitation Treatments for Alcohol Use Disorder: A Distillation of a 2020 Cochrane Review for Clinicians and Policy Makers. Alcohol Alcohol 2020; 55:641-651. [PMID: 32628263 PMCID: PMC8060988 DOI: 10.1093/alcalc/agaa050] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2020] [Indexed: 01/12/2023] Open
Abstract
AIMS A recently completed Cochrane review assessed the effectiveness and cost-benefits of Alcoholics Anonymous (AA) and clinically delivered 12-Step Facilitation (TSF) interventions for alcohol use disorder (AUD). This paper summarizes key findings and discusses implications for practice and policy. METHODS Cochrane review methods were followed. Searches were conducted across all major databases (e.g. Cochrane Drugs and Alcohol Group Specialized Register, PubMed, Embase, PsycINFO and ClinicalTrials.gov) from inception to 2 August 2019 and included non-English language studies. Randomized controlled trials (RCTs) and quasi-experiments that compared AA/TSF with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants or no treatment, were included. Healthcare cost offset studies were also included. Studies were categorized by design (RCT/quasi-experimental; nonrandomized; economic), degree of manualization (all interventions manualized versus some/none) and comparison intervention type (i.e. whether AA/TSF was compared to an intervention with a different theoretical orientation or an AA/TSF intervention that varied in style or intensity). Random-effects meta-analyses were used to pool effects where possible using standard mean differences (SMD) for continuous outcomes (e.g. percent days abstinent (PDA)) and the relative risk ratios (RRs) for dichotomous. RESULTS A total of 27 studies (21 RCTs/quasi-experiments, 5 nonrandomized and 1 purely economic study) containing 10,565 participants were included. AA/TSF interventions performed at least as well as established active comparison treatments (e.g. CBT) on all outcomes except for abstinence where it often outperformed other treatments. AA/TSF also demonstrated higher health care cost savings than other AUD treatments. CONCLUSIONS AA/TSF interventions produce similar benefits to other treatments on all drinking-related outcomes except for continuous abstinence and remission, where AA/TSF is superior. AA/TSF also reduces healthcare costs. Clinically implementing one of these proven manualized AA/TSF interventions is likely to enhance outcomes for individuals with AUD while producing health economic benefits.
Collapse
Affiliation(s)
- John F Kelly
- Recovery Research Institute, Center for Addiction Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Alexandra Abry
- Recovery Research Institute, Center for Addiction Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Marica Ferri
- Best Practices, Knowledge Exchange and Economic Issues, European Monitoring Centre for Drugs and Drug Addiction, Lisbon, Portugal
| | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, Stanford University Stanford School of Medicine, Stanford, CA, USA
| |
Collapse
|
3
|
Murphy SM, Jeng PJ, Poole SA, Jalali A, Vocci FJ, Gordon MS, Woody GE, Polsky D. Health and economic outcomes of treatment with extended-release naltrexone among pre-release prisoners with opioid use disorder (HOPPER): protocol for an evaluation of two randomized effectiveness trials. Addict Sci Clin Pract 2020; 15:15. [PMID: 32321570 PMCID: PMC7178627 DOI: 10.1186/s13722-020-00188-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 04/08/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Persons with an opioid use disorder (OUD) who were incarcerated face many challenges to remaining abstinent; concomitantly, opioid-overdose is the leading cause of death among this population, with the initial weeks following release proving especially fatal. Extended-release naltrexone (XR-NTX) is the most widely-accepted, evidence-based OUD pharmacotherapy in criminal justice settings, and ensures approximately 30 days of protection from opioid overdose. The high cost of XR-NTX serves as a barrier to uptake by many prison/jail systems; however, the cost of the medication should not be viewed in isolation. Prison/jail healthcare budgets are ultimately determined by policymakers, and the benefits/cost-offsets associated with effective OUD treatment will directly and indirectly affect their overall budgets, and society as a whole. METHODS This protocol describes a study funded by the National Institute of Drug Abuse (NIDA) to: evaluate changes in healthcare utilization, health-related quality-of-life, and other resources associated with different strategies of XR-NTX delivery to persons with OUD being released from incarceration; and estimate the relative "value" of each strategy. Data from two ongoing, publicly-funded, randomized-controlled trials will be used to evaluate these questions. In Study A, (XR-NTX Before vs. After Reentry), participants are randomized to receive their first XR-NTX dose before release, or at a nearby program post-release. In Study B, (enhanced XR-NTX vs. XR-NTX), both arms receive XR-NTX prior to release; the enhanced arm receives mobile medical (place of residence) XR-NTX treatment post-release, and the XR-NTX arm receives referral to a community treatment program post-release. The economic data collection instruments required to evaluate outcomes of interest were incorporated into both studies from baseline. Moreover, because the same instruments are being used in both trials on comparable populations, we have the opportunity to not only assess differences in outcomes between study arms within each trial, but also to merge the data sets and test for differences across trials. DISCUSSION Initiating XR-NTX for OUD prior to release from incarceration may improve patient health and well-being, while also producing downstream cost-offsets. This study offers the unique opportunity to assess the effectiveness and cost-effectiveness of multiple strategies, according to different stakeholder perspectives.
Collapse
Affiliation(s)
- Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61st Street, Suite 301, New York, NY, 10065, USA.
| | - Philip J Jeng
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61st Street, Suite 301, New York, NY, 10065, USA
| | - Sabrina A Poole
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ali Jalali
- Department of Population Health Sciences, Weill Cornell Medical College, 425 East 61st Street, Suite 301, New York, NY, 10065, USA
| | | | | | - George E Woody
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Polsky
- Department of Health Policy and Management, Bloomberg School of Public Health, Carey Business School, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
4
|
Abstract
BACKGROUND Alcohol use disorder (AUD) confers a prodigious burden of disease, disability, premature mortality, and high economic costs from lost productivity, accidents, violence, incarceration, and increased healthcare utilization. For over 80 years, Alcoholics Anonymous (AA) has been a widespread AUD recovery organization, with millions of members and treatment free at the point of access, but it is only recently that rigorous research on its effectiveness has been conducted. OBJECTIVES To evaluate whether peer-led AA and professionally-delivered treatments that facilitate AA involvement (Twelve-Step Facilitation (TSF) interventions) achieve important outcomes, specifically: abstinence, reduced drinking intensity, reduced alcohol-related consequences, alcohol addiction severity, and healthcare cost offsets. SEARCH METHODS We searched the Cochrane Drugs and Alcohol Group Specialized Register, Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, CINAHL and PsycINFO from inception to 2 August 2019. We searched for ongoing and unpublished studies via ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) on 15 November 2018. All searches included non-English language literature. We handsearched references of topic-related systematic reviews and bibliographies of included studies. SELECTION CRITERIA We included randomized controlled trials (RCTs), quasi-RCTs and non-randomized studies that compared AA or TSF (AA/TSF) with other interventions, such as motivational enhancement therapy (MET) or cognitive behavioral therapy (CBT), TSF treatment variants, or no treatment. We also included healthcare cost offset studies. Participants were non-coerced adults with AUD. DATA COLLECTION AND ANALYSIS We categorized studies by: study design (RCT/quasi-RCT; non-randomized; economic); degree of standardized manualization (all interventions manualized versus some/none); and comparison intervention type (i.e. whether AA/TSF was compared to an intervention with a different theoretical orientation or an AA/TSF intervention that varied in style or intensity). For analyses, we followed Cochrane methodology calculating the standard mean difference (SMD) for continuous variables (e.g. percent days abstinent (PDA)) or the relative risk (risk ratios (RRs)) for dichotomous variables. We conducted random-effects meta-analyses to pool effects wherever possible. MAIN RESULTS We included 27 studies containing 10,565 participants (21 RCTs/quasi-RCTs, 5 non-randomized, and 1 purely economic study). The average age of participants within studies ranged from 34.2 to 51.0 years. AA/TSF was compared with psychological clinical interventions, such as MET and CBT, and other 12-step program variants. We rated selection bias as being at high risk in 11 of the 27 included studies, unclear in three, and as low risk in 13. We rated risk of attrition bias as high risk in nine studies, unclear in 14, and low in four, due to moderate (> 20%) attrition rates in the study overall (8 studies), or in study treatment group (1 study). Risk of bias due to inadequate researcher blinding was high in one study, unclear in 22, and low in four. Risks of bias arising from the remaining domains were predominantly low or unclear. AA/TSF (manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi-randomized evidence) RCTs comparing manualized AA/TSF to other clinical interventions (e.g. CBT), showed AA/TSF improves rates of continuous abstinence at 12 months (risk ratio (RR) 1.21, 95% confidence interval (CI) 1.03 to 1.42; 2 studies, 1936 participants; high-certainty evidence). This effect remained consistent at both 24 and 36 months. For percentage days abstinent (PDA), AA/TSF appears to perform as well as other clinical interventions at 12 months (mean difference (MD) 3.03, 95% CI -4.36 to 10.43; 4 studies, 1999 participants; very low-certainty evidence), and better at 24 months (MD 12.91, 95% CI 7.55 to 18.29; 2 studies, 302 participants; low-certainty evidence) and 36 months (MD 6.64, 95% CI 1.54 to 11.75; 1 study, 806 participants; low-certainty evidence). For longest period of abstinence (LPA), AA/TSF may perform as well as comparison interventions at six months (MD 0.60, 95% CI -0.30 to 1.50; 2 studies, 136 participants; low-certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at 12 months, as measured by drinks per drinking day (DDD) (MD -0.17, 95% CI -1.11 to 0.77; 1 study, 1516 participants; moderate-certainty evidence) and percentage days heavy drinking (PDHD) (MD -5.51, 95% CI -14.15 to 3.13; 1 study, 91 participants; low-certainty evidence). For alcohol-related consequences, AA/TSF probably performs as well as other clinical interventions at 12 months (MD -2.88, 95% CI -6.81 to 1.04; 3 studies, 1762 participants; moderate-certainty evidence). For alcohol addiction severity, one study found evidence of a difference in favor of AA/TSF at 12 months (P < 0.05; low-certainty evidence). AA/TSF (non-manualized) compared to treatments with a different theoretical orientation (e.g. CBT) (randomized/quasi-randomized evidence) For the proportion of participants completely abstinent, non-manualized AA/TSF may perform as well as other clinical interventions at three to nine months follow-up (RR 1.71, 95% CI 0.70 to 4.18; 1 study, 93 participants; low-certainty evidence). Non-manualized AA/TSF may also perform slightly better than other clinical interventions for PDA (MD 3.00, 95% CI 0.31 to 5.69; 1 study, 93 participants; low-certainty evidence). For drinking intensity, AA/TSF may perform as well as other clinical interventions at nine months, as measured by DDD (MD -1.76, 95% CI -2.23 to -1.29; 1 study, 93 participants; very low-certainty evidence) and PDHD (MD 2.09, 95% CI -1.24 to 5.42; 1 study, 286 participants; low-certainty evidence). None of the RCTs comparing non-manualized AA/TSF to other clinical interventions assessed LPA, alcohol-related consequences, or alcohol addiction severity. Cost-effectiveness studies In three studies, AA/TSF had higher healthcare cost savings than outpatient treatment, CBT, and no AA/TSF treatment. The fourth study found that total medical care costs decreased for participants attending CBT, MET, and AA/TSF treatment, but that among participants with worse prognostic characteristics AA/TSF had higher potential cost savings than MET (moderate-certainty evidence). AUTHORS' CONCLUSIONS There is high quality evidence that manualized AA/TSF interventions are more effective than other established treatments, such as CBT, for increasing abstinence. Non-manualized AA/TSF may perform as well as these other established treatments. AA/TSF interventions, both manualized and non-manualized, may be at least as effective as other treatments for other alcohol-related outcomes. AA/TSF probably produces substantial healthcare cost savings among people with alcohol use disorder.
Collapse
Affiliation(s)
- John F Kelly
- Massachusetts General Hospital and Harvard Medical School, Recovery Research Institute, Center for Addiction Medicine, 151 Merrimac Street, 6th Floor, Boston, Massachusetts, USA, 02114
| | - Keith Humphreys
- Stanford University Stanford School of Medicine, Veterans Affairs and Stanford University Medical Centers, 401 North Quarry Road, Stanford, CA, USA
| | - Marica Ferri
- European Monitoring Centre for Drugs and Drug Addiction, Best practices, knowledge exchange and economic issues, Cais do Sodre' 1249-289 Lisbon, Lisbon, Portugal
| |
Collapse
|
5
|
Ling W, Nadipelli VR, Ronquest NA, Albright VA, Aldridge AP, Learned SM, Mehra V, Heidbreder C. Remission from chronic opioid use—Studying environmental and socio-economic factors on recovery (RECOVER): Study design and participant characteristics. Contemp Clin Trials 2019; 76:93-103. [DOI: 10.1016/j.cct.2018.11.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/20/2018] [Accepted: 11/30/2018] [Indexed: 11/15/2022]
|
6
|
Rehm J, Barbosa C. The cost-effectiveness of therapies to treat alcohol use disorders. Expert Rev Pharmacoecon Outcomes Res 2017; 18:43-49. [DOI: 10.1080/14737167.2018.1392241] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- J. Rehm
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Canada
- Addiction Policy, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Institute of Medical Science, University of Toronto, Faculty of Medicine, Toronto, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - C. Barbosa
- Behavioral Health and Criminal Justice Division, RTI International, Chicago, IL, USA
| |
Collapse
|
7
|
Hagedorn HJ, Noorbaloochi S, Bangerter A, Stitzer ML, Kivlahan D. Health care cost trajectories in the year prior to and following intake into Veterans Health Administration outpatient substance use disorders treatment. J Subst Abuse Treat 2017; 79:46-52. [DOI: 10.1016/j.jsat.2017.05.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/18/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
|
8
|
Jun M, Tracy EM, Min MO. Formal and Informal Concrete Support and Discharge Disposition among Women in Substance Abuse Treatment in the U.S. CHONGSIN POGON KWA SAHOE SAOP 2017; 45:144-169. [PMID: 29151801 PMCID: PMC5687517 DOI: 10.24301/mhsw.2017.03.45.1.144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The purpose of this study is to examine the relative contribution and the relationships between formal (treatment related members) • informal (family members) concrete support and discharge disposition. A total of 172 women interviewed upon intake in one of 3 counties funded substance abuse treatment programs in Cleveland, Ohio. Hierarchical logistic regression was performed to assess the impact of formal concrete support and informal concrete support on the likelihood of a discharge disposition of completed treatment. Formal concrete support showed a statistically significant contribution to discharge disposition, while informal concrete support did not. Findings of this study highlight the importance of formal concrete support. Future research should continue to expand our knowledge of how support from formal treatment services interacts with support from informal (family) networks.
Collapse
Affiliation(s)
- MinKyoung Jun
- Research Fellow, Gyeonggido Family and Women's Research Institute, Republic of Korea
| | - Elizabeth M Tracy
- Grace Longwell Coyle Professor, Case Western Reserve University, USA
| | - Meeyoung O Min
- Research Associate Professor, Case Western Reserve University, USA
| |
Collapse
|
9
|
|
10
|
Allen JL, Mowbray O. Sexual orientation, treatment utilization, and barriers for alcohol related problems: Findings from a nationally representative sample. Drug Alcohol Depend 2016; 161:323-30. [PMID: 26936411 DOI: 10.1016/j.drugalcdep.2016.02.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/02/2016] [Accepted: 02/12/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Gay, lesbian, and bisexual (GLB) individuals appear to have an increased likelihood of alcohol use disorders and treatment utilization for alcohol related problems compared to heterosexual individuals. Despite this increase, treatment utilization rates among GLB individuals remain low. In an effort to address this, our paper examined whether or not GLB individuals encounter unique barriers when pursuing treatment for alcohol related problems. METHODS Using data from the National Epidemiologic Survey on Alcohol Related Conditions (NESARC), we examined service sector specific factors, some of which included (a) utilization rates, (b) self-reported treatment barriers, and (c) whether or not there were emergent differences among GLB individuals, after controlling for socio-demographic and clinical characteristics. RESULTS Findings indicated that GLB individuals reported higher severity rates for alcohol use disorders when compared to heterosexual individuals, and were significantly more likely to utilize treatment services for alcohol related problems, however, not across all treatment sectors. While similar patterns were observed when examining barriers to treatment, bisexual individuals reported significantly more barriers than heterosexual and gay/lesbian individuals. CONCLUSION These findings underscored the importance of identifying and developing interventions that addresses treatment barriers associated with alcohol use service utilization among GLB populations, and creating improved outreach and education programs to better address stigmas associated with substance use and sexuality.
Collapse
Affiliation(s)
- Junior Lloyd Allen
- School of Social Work, University of Georgia, 279 Williams Street, Athens, GA 30605, United States.
| | - Orion Mowbray
- School of Social Work, University of Georgia, 279 Williams Street, Athens, GA 30605, United States.
| |
Collapse
|
11
|
Leggio L, Zywiak WH, Fricchione SR, Edwards SM, de la Monte SM, Swift RM, Kenna GA. Intravenous ghrelin administration increases alcohol craving in alcohol-dependent heavy drinkers: a preliminary investigation. Biol Psychiatry 2014; 76:734-41. [PMID: 24775991 PMCID: PMC4176606 DOI: 10.1016/j.biopsych.2014.03.019] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 03/14/2014] [Accepted: 03/14/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND There is a need to identify novel pharmacologic targets to treat alcoholism. Animal and human studies suggest a role for ghrelin in the neurobiology of alcohol dependence and craving. Here, we were the first to test the hypothesis that intravenous administration of exogenous ghrelin acutely increases alcohol craving. METHODS This was a double-blind, placebo-controlled human laboratory proof-of-concept study. Nontreatment-seeking, alcohol-dependent, heavy-drinking individuals were randomized to receive intravenous ghrelin 1 mcg/kg, 3 mcg/kg or 0 mcg/kg (placebo), followed by a cue-reactivity procedure, during which participants were exposed to neutral (juice) and alcohol cues. The primary outcome variable was the increase in alcohol craving (also called urge) for alcohol, assessed by the Alcohol Visual Analogue Scale. RESULTS Out of 103 screenings, 45 individuals received the study drug. Repeated measures of analysis of covariance revealed a group effect across ghrelin doses in increasing alcohol craving (p < .05). A dose-specific examination revealed a significant effect of ghrelin 3 mcg/kg versus placebo in increasing alcohol craving (p < .05) with a large effect size (d = .94). By contrast, no significant ghrelin effect was found in increasing either urge to drink juice or food craving (p = ns). No significant differences in side effects were found (p = ns). CONCLUSIONS Intravenous administration of exogenous ghrelin increased alcohol craving in alcohol-dependent heavy-drinking individuals. Although the small sample requires confirmatory studies, these findings provide preliminary evidence that ghrelin may play a role in the neurobiology of alcohol craving, thus demonstrating a novel pharmacologic target for treatment.
Collapse
Affiliation(s)
- Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, Laboratory of Clinical and Translational Studies, National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland; Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland; Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence.
| | - William H. Zywiak
- Decision Sciences Institute, P.I.R.E., Pawtucket, RI,Center for Alcohol and Addiction Studies, Department of Psychiatry and Human Behavior, Brown University, Providence, RI
| | - Samuel R. Fricchione
- Center for Alcohol and Addiction Studies, Department of Behavioral and Social Sciences, Brown University, Providence, RI
| | - Steven M. Edwards
- Department of Psychology, University of Nebraska-Lincoln, Lincoln, NE
| | - Suzanne M. de la Monte
- Departments of Pathology, Neurology, and Neurosurgery, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI
| | - Robert M. Swift
- Center for Alcohol and Addiction Studies, Department of Psychiatry and Human Behavior, Brown University, Providence, RI,Veterans Affairs Medical Center, Providence, RI
| | - George A. Kenna
- Center for Alcohol and Addiction Studies, Department of Psychiatry and Human Behavior, Brown University, Providence, RI
| |
Collapse
|
12
|
Cheatle MD, Barker C. Improving opioid prescription practices and reducing patient risk in the primary care setting. J Pain Res 2014; 7:301-11. [PMID: 24966692 PMCID: PMC4062552 DOI: 10.2147/jpr.s37306] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Chronic pain is complex, and the patient suffering from chronic pain frequently experiences concomitant medical and psychiatric disorders, including mood and anxiety disorders, and in some cases substance use disorders. Ideally these patients would be referred to an interdisciplinary pain program staffed by pain medicine, behavioral health, and addiction specialists. In practice, the majority of patients with chronic pain are managed in the primary care setting. The primary care clinician typically has limited time, training, or access to resources to effectively and efficiently evaluate, treat, and monitor these patients, particularly when there is the added potential liability of prescribing opioids. This paper reviews the role of opioids in managing chronic noncancer pain, including efficacy and risk for misuse, abuse, and addiction, and discusses several models employing novel technologies and health delivery systems for risk assessment, intervention, and monitoring of patients receiving opioids in a primary care setting.
Collapse
Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Cody Barker
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
13
|
Miller WR, Rollnick S. The effectiveness and ineffectiveness of complex behavioral interventions: Impact of treatment fidelity. Contemp Clin Trials 2014; 37:234-41. [DOI: 10.1016/j.cct.2014.01.005] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Revised: 01/13/2014] [Accepted: 01/18/2014] [Indexed: 12/26/2022]
|
14
|
Cheatle M, Comer D, Wunsch M, Skoufalos A, Reddy Y. Treating pain in addicted patients: recommendations from an expert panel. Popul Health Manag 2013; 17:79-89. [PMID: 24138341 DOI: 10.1089/pop.2013.0041] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Clinicians may face pragmatic, ethical, and legal issues when treating addicted patients. Equal pressures exist for clinicians to always address the health care needs of these patients in addition to their addiction. Although controversial, mainly because of the lack of evidence regarding their long-term efficacy, the use of opioids for the treatment of chronic pain management is widespread. Their use for pain management in the addicted population can present even more challenges, especially when evaluating the likelihood of drug-seeking behavior. As the misuse and abuse of opioids continues to burgeon, clinicians must be particularly vigilant when prescribing chronic opioid therapy. The purpose of this article is to summarize recommendations from a recent meeting of experts convened to recommend how primary care physicians should approach treatment of chronic pain for addicted patients when an addiction specialist is not available for a referral. As there is a significant gap in guidelines and recommendations in this specific area of care, this article serves to create a foundation for expanding chronic pain guidelines in the area of treating the addicted population. This summary is designed to be a practical how-to guide for primary care physicians, discussing risk assessment, patient stratification, and recommended therapeutic approaches.
Collapse
Affiliation(s)
- Martin Cheatle
- 1 University of Pennsylvania Center for Studies of Addiction , Philadelphia, PA
| | | | | | | | | |
Collapse
|
15
|
Serdarevic M, Lemke S. Motivational interviewing with the older adult. INTERNATIONAL JOURNAL OF MENTAL HEALTH PROMOTION 2013. [DOI: 10.1080/14623730.2013.862362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
16
|
Manning V, Gomez B, Koh PK, Ng A, Guo S, Kandasami G, Wong KE. Treatment outcome and its predictors among Asian problem drinkers. Drug Alcohol Rev 2012; 32:178-86. [PMID: 23043535 DOI: 10.1111/j.1465-3362.2012.00518.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Accepted: 08/31/2012] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIMS Evidence of treatment effectiveness for alcohol use disorders (AUD) have emerged predominantly from Western studies, using highly controlled trials that may not reflect real-world settings. This paper examines treatment outcome and its predictors among Asian problem drinkers participating in a treatment outcome monitoring program at an addiction treatment centre in Singapore. DESIGN AND METHODS Data were collected at intake and 3, 6 and 12 months, although the focus of this paper is on reliable change at 3 months among the 70% who were followed up. Five hundred and forty-one AUD-diagnosed outpatients presenting for treatment, over a 2-year period, were assessed on drinking behaviours and administered the Addiction Severity Index-Lite, Personal Wellbeing Index (PWI) and Treatment Perceptions Questionnaire. RESULTS At 3 months, drinking days, alcohol units and alcohol use severity had more than halved and 69% were either abstinent or had reliably reduced their drinking days. Baseline drinking days and treatment satisfaction predicted 3-month drinking frequency but not severity. Positive alcohol outcomes observed at 3 months were sustained among those followed up until 12 months. Mean PWI score improved significantly and fell within the 'normal' range. Treatment satisfaction also emerged as the only significant predictor of reliable positive change in both drinking days and PWI score. DISCUSSION AND CONCLUSIONS Significant reductions in drinking frequency and severity are possible for Asian problem drinkers after 12 weeks of outpatient treatment. The identified predictors suggest that more frequent drinkers and patients with past/current psychiatric comorbidities may require a more intensive treatment approach to optimise treatment outcomes.
Collapse
Affiliation(s)
- Victoria Manning
- National Addictions Management Service, Institute of Mental Health, Singapore.
| | | | | | | | | | | | | |
Collapse
|
17
|
Cheatle MD, Klocek JW, McLellan AT. Managing pain in high-risk patients within a patient-centered medical home. Transl Behav Med 2012; 2:47-56. [PMID: 24073097 PMCID: PMC3717821 DOI: 10.1007/s13142-012-0113-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Chronic pain remains a major healthcare problem despite noteworthy advancements in diagnostics, pharmacotherapy, and invasive and non-invasive interventions. The prevalence of chronic pain in the United States is staggering and continues to grow, and the personal and societal costs are not inconsequential. The etiology of pain is complex, and individuals suffering from chronic pain tend to have significant medical and psychiatric comorbidities such as depression, anxiety, and in some cases, substance use disorders. There is great concern regarding the burgeoning rate of prescription opioid misuse/abuse both for non-medical use and in pain patients receiving chronic opioid therapy. While there is ongoing debate about the "true" incidence of opioid abuse in the pain population, clearly, patients afflicted with both pain and substance use disorder are particularity challenging. The majority of patients with chronic pain including those with co-occurring substance use disorders are managed in the primary care setting. Primary care practitioners have scant time, resources and training to effectively assess, treat and monitor these complicated cases. A number of evidence- and expert consensus-based treatment guidelines on opioid therapy and risk mitigation have been developed but they have been underutilized in both specialty and primary care clinics. This article will discuss the utilization of new technologies and delivery systems for risk stratification, intervention and monitoring of patients with pain receiving opioid.
Collapse
Affiliation(s)
- Martin D Cheatle
- Center for Studies of Addiction, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, 4th floor, Philadelphia, PA 19104 USA ; Behavioral Medicine Center, The Reading Hospital and Medical Center, West Reading, PA USA
| | | | | |
Collapse
|
18
|
Smedslund G, Berg RC, Hammerstrøm KT, Steiro A, Leiknes KA, Dahl HM, Karlsen K. Motivational interviewing for substance abuse. Cochrane Database Syst Rev 2011; 2011:CD008063. [PMID: 21563163 PMCID: PMC8939890 DOI: 10.1002/14651858.cd008063.pub2] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There are 76.3 million people with alcohol use disorders worldwide and 15.3 million with drug use disorders. Motivational interviewing (MI) is a client-centred, semi-directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The intervention is used widely, and therefore it is important to find out whether it helps, harms or is ineffective. OBJECTIVES To assess the effectiveness of motivational interviewing for substance abuse on drug use, retention in treatment, readiness to change, and number of repeat convictions. SEARCH STRATEGY We searched 18 electronic databases, 5 web sites, 4 mailing lists, and reference lists from included studies and reviews. Search dates were November 30, 2010 for Cochrane Library, Medline, Embase and PsychINFO. SELECTION CRITERIA Randomized controlled trials with persons dependent or abusing substance. Interventions were MI or motivational enhancement therapy. The outcomes were extent of substance abuse, retention in treatment, motivation for change, repeat conviction. DATA COLLECTION AND ANALYSIS Three authors independently assessed studies for inclusion, and two authors extracted data. Results were categorized into (1) MI versus no-treatment control, (2) MI versus treatment as usual, (3) MI versus assessment and feedback, and (4) MI versus other active treatment. Within each category, we computed meta-analyses separately for post-intervention, short, medium and long follow-ups. MAIN RESULTS We included 59 studies with a total of 13,342 participants. Compared to no treatment control MI showed a significant effect on substance use which was strongest at post-intervention SMD 0.79, (95% CI 0.48 to 1.09) and weaker at short SMD 0.17 (95% CI 0.09 to 0.26], and medium follow-up SMD 0.15 (95% CI 0.04 to 0.25]). For long follow-up, the effect was not significant SMD 0.06 (95% CI-0.16 to 0.28). There were no significant differences between MI and treatment as usual for either follow-up post-intervention, short and medium follow up. MI did better than assessment and feedback for medium follow-up SMD 0.38 (95% CI 0.10 to 0.66). For short follow-up, there was no significant effect . For other active intervention there were no significant effects for either follow-up.There was not enough data to conclude about effects of MI on the secondary outcomes. AUTHORS' CONCLUSIONS MI can reduce the extent of substance abuse compared to no intervention. The evidence is mostly of low quality, so further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Collapse
Affiliation(s)
- Geir Smedslund
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Rigmor C Berg
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Karianne T Hammerstrøm
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Asbjørn Steiro
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Kari A Leiknes
- Norwegian Knowledge Centre for the Health ServicesPostboks 7004St. Olavs plassOsloN‐0130Norway
| | - Helene M Dahl
- Institute of Clinical MedicineDepartment of Clinical PsychiatryUniversity of Tromsø, Asgard,TromsøNorway9291
| | - Kjetil Karlsen
- Institute of Clinical MedicineDepartment of Clinical PsychiatryUniversity of Tromsø, Asgard,TromsøNorway9291
| | | |
Collapse
|
19
|
Fishman PA, Bonomi AE, Anderson ML, Reid RJ, Rivara FP. Changes in health care costs over time following the cessation of intimate partner violence. J Gen Intern Med 2010; 25:920-5. [PMID: 20414736 PMCID: PMC2917667 DOI: 10.1007/s11606-010-1359-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2009] [Revised: 01/19/2010] [Accepted: 03/18/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Research has documented greater health care costs attributable to intimate partner violence (IPV) among women during and after exposure. However, no studies have determined whether health care costs for abused women return to baseline levels at some point after their abuse ceases. OBJECTIVE We examine whether health care costs among women exposed to IPV converge with those of non-abused women during a 10-year period following the end of exposure. DESIGN Retrospective cohort analysis. SETTING Group Health Cooperative, a large integrated health care system in the Pacific Northwest. PARTICIPANTS Random sample of English-speaking women aged 18-64 enrolled within Group Health and who participated in a telephone survey between June 2003 and August 2005. MEASUREMENTS Total health care costs over an 11-year period from January 1, 1992 to December 31, 2002 were compiled using automated health plan data and comparisons made among women exposed to IPV since age 18 and those who never experienced IPV. IPV included physical, sexual, or psychological violence involving an intimate partner, and was assessed using five questions from the Behavioral Risk Factor Surveillance System. RESULTS Relative to women with no IPV history, total health care costs were significantly higher during IPV exposure, costs that were sustained for 3 years following the end of exposure. By the 4th year following the end of exposure to IPV, health care costs among IPV-exposed women were similar to non-abused women, and this pattern held for the remainder of the 10-year study period. CONCLUSIONS Policy makers should consider the ongoing needs of victims following abuse exposure. Interventions to reduce the prevalence of IPV or to mitigate the impact of IPV have the potential to reduce the rate of growth of health care costs.
Collapse
Affiliation(s)
- Paul A Fishman
- Group Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA 98101, USA.
| | | | | | | | | |
Collapse
|
20
|
The effect of alcohol treatment on social costs of alcohol dependence: results from the COMBINE study. Med Care 2010; 48:396-401. [PMID: 20393362 DOI: 10.1097/mlr.0b013e3181d68859] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The COMBINE (combined pharmacotherapies and behavioral intervention) clinical trial recently evaluated the efficacy of pharmacotherapies, behavioral therapies, and their combinations for the treatment of alcohol dependence. Previously, the cost and cost-effectiveness of COMBINE have been studied. Policy makers, patients, and nonalcohol-dependent individuals may be concerned not only with alcohol treatment costs but also with the effect of alcohol interventions on broader social costs and outcomes. OBJECTIVES To estimate the sum of treatment costs plus the costs of health care utilization, arrests, and motor vehicle accidents for the 9 treatments in COMBINE 3 years postrandomization. RESEARCH DESIGN A cost study based on a randomized controlled clinical trial. SUBJECTS : The study involved 786 participants 3 years postrandomization. RESULTS Multivariate results show no significant differences in mean costs between any of the treatment arms as compared with medical management (MM) + placebo for the 3-year postrandomization sample. The median costs of MM + acamprosate, MM + naltrexone, MM + acamprosate + naltrexone, and MM + acamprosate + combined behavioral intervention were significantly lower than the median cost for MM + placebo. CONCLUSIONS The results show that social cost savings are generated relative to MM + placebo by 3 years postrandomization, and the magnitude of these cost savings is greater than the costs of the COMBINE treatment received 3 years prior. Our study suggests that several alcohol treatments may indeed lead to reduced median social costs associated with health care, arrests, and motor vehicle accidents.
Collapse
|
21
|
Evaluation of the Washington State Screening, Brief Intervention, and Referral to Treatment Project. Med Care 2010; 48:18-24. [DOI: 10.1097/mlr.0b013e3181bd498f] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
22
|
Bager P, Vilstrup H. Post-discharge Brief Intervention Increases the Frequency of Alcohol Abstinence—A Randomized Trial. J Addict Nurs 2010. [DOI: 10.3109/10884601003628104] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
23
|
Abstract
The widely disseminated clinical method of motivational interviewing (MI) arose through a convergence of science and practice. Beyond a large base of clinical trials, advances have been made toward "looking under the hood" of MI to understand the underlying mechanisms by which it affects behavior change. Such specification of outcome-relevant aspects of practice is vital to theory development and can inform both treatment delivery and clinical training. An emergent theory of MI is proposed that emphasizes two specific active components: a relational component focused on empathy and the interpersonal spirit of MI, and a technical component involving the differential evocation and reinforcement of client change talk. A resulting causal chain model links therapist training, therapist and client responses during treatment sessions, and posttreatment outcomes.
Collapse
Affiliation(s)
- William R Miller
- Center on Alcoholism, Substance Abuse, and Addictions, MSC11 6280, University of New Mexico, Albuquerque, NM 87131-0001, USA.
| | | |
Collapse
|
24
|
Miller WR, Manuel JK. How large must a treatment effect be before it matters to practitioners? An estimation method and demonstration. Drug Alcohol Rev 2008; 27:524-8. [PMID: 18608445 DOI: 10.1080/09595230801956165] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION AND AIMS Treatment research is sometimes criticised as lacking in clinical relevance, and one potential source of this friction is a disconnection between statistical significance and what clinicians regard to be a meaningful difference in outcomes. This report demonstrates a novel methodology for estimating what substance abuse practitioners regard to be clinically important differences. DESIGN AND METHODS To illustrate the estimation method, we surveyed 50 substance abuse treatment providers participating in the National Institute on Drug Abuse (NIDA) Clinical Trials Network. Practitioners identified thresholds for clinically meaningful differences on nine common outcome variables, indicated the size of effect that would justify their learning a new treatment method and estimated current outcomes from their services. RESULTS Clinicians judged a difference between two treatments to be meaningful if outcomes were improved by about 10 - 12 points on the percentage of patients totally abstaining, arrested for driving while intoxicated, employed or having abnormal liver enzymes. A 5 percentage-point reduction in patient mortality was regarded as clinically significant. On continuous outcome measures (such as percentage of days abstinent or drinks per drinking day), practitioners judged an outcome to be significant when it doubled or halved the base rate. When a new treatment meets such criteria, practitioners were interested in learning it. DISCUSSION AND CONCLUSIONS Effects that are statistically significant in clinical trials may be unimpressive to practitioners. Clinicians' judgements of meaningful differences can inform the powering of clinical trials.
Collapse
Affiliation(s)
- William R Miller
- Center on Alcoholism, Substance Abuse and Addictions (CASAA), The University of New Mexico, Albuquerque, New Mexico, USA.
| | | |
Collapse
|
25
|
Soyka M, Kranzler HR, Berglund M, Gorelick D, Hesselbrock V, Johnson BA, Möller HJ, Soyka M, Kranzler HR, Berglund M, Gorelick D, Hesselbrock V, Johnson BA, Möller HJ, THE WFSBP TASK FORCE ON TREATMENT G. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Substance Use and Related Disorders, Part 1: Alcoholism. World J Biol Psychiatry 2008; 9:6-23. [PMID: 18273737 DOI: 10.1080/15622970801896390] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
These practice guidelines for the biological treatment of substance use disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of substance use disorders, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by physicians evaluating and treating people with substance use disorders and are primarily concerned with the biological treatment of adults suffering from substance use disorders. The data used to develop these guidelines were extracted primarily from various national treatment guidelines for substance use disorders, as well as from meta-analyses, reviews and randomized clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorized into four levels of evidence (A-D). This first part of the guidelines covers the treatment of alcohol dependence; Part 2 will be devoted to the treatment of drug dependence.
Collapse
Affiliation(s)
- Michael Soyka
- Psychiatric Hospital Meiringen, Meiringen, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
26
|
The cost-effectiveness and cost-benefit of screening and brief intervention for unhealthy alcohol use in medical settings. Subst Abus 2008; 28:67-77. [PMID: 18077304 DOI: 10.1300/j465v28n03_07] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Economic evaluation can be a valuable tool for assessing the efficiency and value of health care programs. To examine the literature on the economic evaluation of alcohol screening and brief intervention in medical settings, relevant studies were identified in the MEDLINE database (1966 through November 2006) and by hand-searching the references of identified articles and relevant journals. The 15 identified studies used a range of economic evaluation methods, including cost analysis, cost-benefit, cost-effectiveness, and cost-utility. Nearly all of the studies supported the use of alcohol screening and brief intervention. The studies that prospectively collected cost and effect data and/or conformed closely to methodological guidelines demonstrated a strong economic benefit of alcohol screening and brief intervention when compared to usual care. Overall, the reviewed studies support alcohol SBI in medical settings as a wise use of health care resources and illustrate the usefulness of economic evaluation for assessing alcohol prevention and treatment programs.
Collapse
|
27
|
Bjerre B, Kostela J, Selén J. Positive health-care effects of an alcohol ignition interlock programme among driving while impaired (DWI) offenders. Addiction 2007; 102:1771-81. [PMID: 17935585 DOI: 10.1111/j.1360-0443.2007.02006.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To compare the costs of hospital care and sick leave/disability pensions between two groups of driving while impaired (DWI) offenders: participants in an alcohol ignition interlock programme (AIIP) and controls with revoked licences, but with no comparable opportunity to participate in an AIIP. SETTING As an alternative to licence revocation DWI offenders can participate in a voluntary 2-year AIIP permitting the offender to drive under strict regulations entailing regular medical check-ups. The participants are forced to alter their alcohol habits and those who cannot demonstrate sobriety are dismissed from the programme. Participants are liable for all costs themselves. DESIGN Quasi-experimental, with a non-equivalent control group used for comparison; intent-to-treat design. Based on the number of occasions/days in hospital and on sick leave/disability pension, the health-care costs for public insurance have been calculated. FINDING Average total health-care costs were 25% lower among AIIP participants (1156 individuals) than among controls (815 individuals) during the 2-year treatment period. This corresponds to over 1000 euros (SEK9610) less annual costs per average participant. For those who complete the 2-year programme the cost reduction was more pronounced; 37% during the treatment and 20% during the post-treatment period. CONCLUSIONS The positive health-care effects were due apparently to reduced alcohol consumption. The social benefit of being allowed to drive while in the AIIP may also have contributed. The reduction in health-care costs was significant only during the 2-year treatment period, but among those who completed the entire AIIP sustained effects were also observed in the post-treatment period. The effects were comparable to those of regular alcoholism treatment programmes.
Collapse
Affiliation(s)
- Bo Bjerre
- Traffic Medicine, Swedish Road Administration, Borlänge, Sweden.
| | | | | |
Collapse
|
28
|
Del Boca FK, Darkes J. Enhancing the validity and utility of randomized clinical trials in addictions treatment research: I. Treatment implementation and research design. Addiction 2007; 102:1047-56. [PMID: 17567393 DOI: 10.1111/j.1360-0443.2007.01862.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE This paper is the first in a series that examines methods for improving the validity and utility of randomized clinical trials (RCTs) in addictions treatment research. The specific foci of this article are treatment implementation and research design. SCOPE We begin by considering the conditions under which the RCT provides an appropriate design choice. Sections that follow discuss methodological issues with respect to RCT structure and collaborative arrangements; treatment specification, delivery and cost; experimental design; and randomization/blinding procedures. We emphasize the importance of advance planning; treatment integrity and discriminability; treatment standardization; staff training and supervision; client compliance; maintenance of between-group equivalence across study conditions; and inclusion of appropriate comparison groups in study designs. CONCLUSIONS Investigators are encouraged to maximize the internal validity of RCTs, but also to consider methods for enhancing external validity. The utility of addictions RCTs for advancing theory and improving clinical practice can be enhanced by investigating underlying mechanisms of action.
Collapse
Affiliation(s)
- Frances K Del Boca
- Department of Psychology, University of South Florida, Tampa, FL 33620-8200, USA.
| | | |
Collapse
|
29
|
Cartwright WS. Economic costs of drug abuse: financial, cost of illness, and services. J Subst Abuse Treat 2007; 34:224-33. [PMID: 17596904 DOI: 10.1016/j.jsat.2007.04.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Revised: 03/19/2007] [Accepted: 04/05/2007] [Indexed: 10/23/2022]
Abstract
This article examines costs as they relate to the financial costs of providing drug abuse treatment in private and public health plans, costs to society relating to drug abuse, and many smaller costing studies of various stakeholders in the health care system. A bibliography is developed from searches across PubMed, Web of Science, and other bibliographic sources. The review indicates that a wide collection of cost findings is available to policy makers. For example, the financial aspects of health plans have been dominated by considerations of actuarial costs of parity for drug abuse treatment. Cost-of-illness methods have been developed and extended to drug abuse costing to measure the national level of burden and are important to the economic evaluation of interventions at the program level. Costing is done in many small and focused studies, reflecting the interests of different stakeholders in the health care system. For costs in programs and health plans, as well as cost offsets of the impact of substance abuse treatment on medical expenditures, findings are surprisingly important to policy makers. Maintaining ongoing research that is highly policy relevant from the point of view of health services, more is needed on costing concepts and measurement applications.
Collapse
|
30
|
Jacobson JO, Robinson PL, Bluthenthal RN. Racial disparities in completion rates from publicly funded alcohol treatment: economic resources explain more than demographics and addiction severity. Health Serv Res 2007; 42:773-94. [PMID: 17362217 PMCID: PMC1955365 DOI: 10.1111/j.1475-6773.2006.00612.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To assess racial and ethnic differences in rates of completion from publicly funded alcohol treatment programs, and to estimate the extent to which any identified racial differences in completion rates are related to differences in patient characteristics. DATA SOURCES Administrative intake and discharge records from all publicly funded outpatient and residential alcohol treatment recovery programs in Los Angeles County (LAC) during 1998-2000. Study participants (N=10,591) are African American, Hispanic, and white patients discharged from these programs, ages 18 or older, who reported alcohol as their primary substance abuse problem. STUDY DESIGN Bivariate tests identified racial and ethnic differences in rates of treatment completion and patient characteristics. Logistic regression models assessed the contribution of differences in patient characteristics to differences in completion. PRINCIPAL FINDINGS Significantly lower completion rates by African Americans (17.5 percent) relative to whites (26.7 percent) (odds ratio [OR]=0.58, 95 percent confidence interval [CI]: 0.50-0.68) are partially explained (40 percent) by differences in patient characteristics in outpatient care (adjusted OR=0.75, 95 percent CI: 0.63-0.90), mostly by indicators of economic resources (i.e., employment, homelessness, and Medi-Cal beneficiary). In residential care, only 7 percent of differences in completion (30.7 versus 46.1 percent) could be explained by the patient-level measures available (OR=0.52, 95 percent CI: 0.45-0.59; AOR=0.55, 95 percent CI: 0.47-0.65). Differences in completion rates between Hispanic and white patients were not detected. CONCLUSIONS Large differences in rates of outpatient and residential alcohol treatment completion between African American and white patients at publicly funded programs in LAC, the nation's second largest, publicly funded alcohol and drug treatment system, are partially because of economic differences among patients, but remain largely unexplained. These racial disparities merit additional investigation and the attention of health professionals.
Collapse
Affiliation(s)
- Jerry O Jacobson
- Strategic Information Unit, Global AIDS Program, Central America and Panama, Centers for Disease Control and Prevention, Universidad del Valle, 18 Av. 11-37, VH III, Edificio GAP, Zona 15, CP 01015, Ciudad de Guatemala, Guatemala
| | | | | |
Collapse
|
31
|
Feeney GFX, Connor JP, McD Young R, Tucker J, McPherson A. Is acamprosate use in alcohol dependence treatment reflected in improved subjective health status outcomes beyond cognitive behavioural therapy alone? J Addict Dis 2007; 25:49-58. [PMID: 17088225 DOI: 10.1300/j069v25n04_05] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To examine whether the addition of acamprosate to Cognitive Behavioural Therapy (CBT) outpatient alcohol dependence treatment impacted on subjective health status. METHOD Among 268 patients consecutively treated for alcohol dependence, 149 chose CBT alone. A matched design was used. From a possible pool of 119 Acamprosate + CBT and 149 CBT-only patients, 86 Acamprosate + CBT subjects were individually matched with 86 CBT-only patients on parameters of gender, age, prior detoxification and alcohol dependence severity. Health Status (SF-36) and Psychological Well-Being (GHQ-28) was assessed pre- and post-treatment. RESULTS Pre-treatment, both self-reported health status and psychological well-being was markedly below normative (community) ranges. Program completers significantly improved across both measures over 12 weeks of treatment and some health domains approximated community levels. No treatment group differences were observed. CONCLUSIONS Participants who completed the CBT-based treatment showed significant improvement in self-reported health status. The use of acamprosate did not register additional improvement on either SF-36 or GHQ-28, beyond CBT alone.
Collapse
Affiliation(s)
- Gerald F X Feeney
- Department of Psychiatry, The University of Queensland, Brisbane, Australia.
| | | | | | | | | |
Collapse
|
32
|
Rivara FP, Anderson ML, Fishman P, Bonomi AE, Reid RJ, Carrell D, Thompson RS. Healthcare utilization and costs for women with a history of intimate partner violence. Am J Prev Med 2007; 32:89-96. [PMID: 17234483 DOI: 10.1016/j.amepre.2006.10.001] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2006] [Revised: 09/07/2006] [Accepted: 10/02/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine the healthcare utilization and medical care costs of women with a history of intimate partner violence (IPV) compared to women without a history of IPV. DESIGN Longitudinal cohort study. SETTING Mixed-model health maintenance organization. PARTICIPANTS Over 3000 (3333) women aged 18 to 64 years with > or = 3 year's cumulative enrollment prior to the survey, at least 1 year of which was after the 18th birthday. MAIN EXPOSURE IPV since age 18 as determined from responses to telephone interview using questions from the Behavioral Risk Factor Surveillance System and also the Women's Experience with Battering Scale. OUTCOME MEASURES Healthcare utilization and costs (from automated data) during the time that IPV occurred and following its cessation, compared to healthcare utilization for women who did not report IPV since age 18. RESULTS A total of 1546 women reported IPV in their lifetime; at the time of interview, IPV had ceased in 87% of women, on average 16.0 years prior to interview. Healthcare utilization was higher for all categories of service during IPV compared to women without IPV, and decreased over time after cessation of IPV. However, healthcare utilization was still 20% higher 5 years after women's abuse ceased compared to women without IPV. Adjusted annual total healthcare costs were 19% higher in women with a history of IPV (amounting to $439 annually) compared to women without IPV. Based on prevalence for IPV of 44%, the excess costs due to IPV are approximately $19.3 million per year for every 100,000 women enrollees aged 18-64. CONCLUSIONS Women with a history of IPV had significantly higher healthcare utilization and costs, continuing long after IPV ended. Given its high prevalence, IPV has a major impact on medical care resource utilization and efforts to prevent its occurrence and consequences are clearly indicated.
Collapse
Affiliation(s)
- Frederick P Rivara
- Harborview Injury Prevention and Research Center and the Department of Pediatrics, University of Washington, Seattle, Washington 98104, USA.
| | | | | | | | | | | | | |
Collapse
|
33
|
Jacobson JO, Robinson P, Bluthenthal RN. A multilevel decomposition approach to estimate the role of program location and neighborhood disadvantage in racial disparities in alcohol treatment completion. Soc Sci Med 2007; 64:462-76. [PMID: 17055634 DOI: 10.1016/j.socscimed.2006.08.032] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2006] [Indexed: 11/17/2022]
Abstract
Large racial disparities in completion rates from substance abuse treatment programs in urban settings remain largely unexplained, although evidence is accumulating that neighborhood conditions may influence individual substance abuse patterns and consequences. Understanding racial disparities in alcohol treatment completion, in particular, is crucial to resolving health disparities because racial/ethnic minorities bear a disproportionate burden of alcohol-related health consequences. Patient records for all non-homeless African American (N=1677), Hispanic (N=1635), and white (N=1216) alcohol outpatients, ages 18 or older, discharged during 1998-2000 from publicly funded treatment programs in Los Angeles County, the second largest system of publicly funded substance abuse treatment in the United States, were combined with census data. We tested the hypothesis that racial differences in treatment completion are related to differences in neighborhood context, particularly neighborhood-level disadvantage. Estimates from multilevel statistical models indicate that treatment neighborhood disadvantage is independently associated with treatment completion after controlling for patient characteristics and facility- and zip code-level random effects. Results of a Oaxaca decomposition of the regression estimates indicate that racial differences in treatment neighborhood disadvantage account for 32.3% of African American-white differences in treatment completion. Hispanic-white differences in completion, and the effect of home neighborhood disadvantage on completion, were non-significant. We conclude that the location of publicly funded alcohol treatment programs is related to racial disparities in treatment completion, but additional research is necessary to understand the mechanism behind this association.
Collapse
Affiliation(s)
- Jerry Owen Jacobson
- Department of Psychiatry, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA.
| | | | | |
Collapse
|
34
|
Morley KC, Teesson M, Reid SC, Sannibale C, Thomson C, Phung N, Weltman M, Bell JR, Richardson K, Haber PS. Naltrexone versus acamprosate in the treatment of alcohol dependence: A multi-centre, randomized, double-blind, placebo-controlled trial. Addiction 2006; 101:1451-62. [PMID: 16968347 DOI: 10.1111/j.1360-0443.2006.01555.x] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To compare the efficacy of acamprosate and naltrexone in the treatment of alcohol dependence. DESIGN A double-blind, placebo-controlled trial. SETTING Three treatment centres in Australia. PARTICIPANTS A total of 169 alcohol dependent subjects were given naltrexone (50 mg/day), acamprosate (1998 mg/day) or placebo for 12 weeks. INTERVENTION All subjects were offered manualized compliance therapy, a brief intervention that targets problems that may affect treatment compliance such as ambivalence and misperceptions about medication. MEASUREMENTS Time to the first drink, time to first relapse, drinks per drinking day and cumulative abstinence. FINDINGS In intention-to-treat analyses, there were no differences between groups on outcome measures of drinking, craving or biochemical markers. Similarly, analyses of the 94 subjects that completed the study in full and demonstrated 80% compliance, revealed no significant treatment effects. Differential treatment effects were identified after stratification according to scores on the Alcohol Dependence Scale (ADS) and Depression Anxiety and Stress Scale (DASS). A significant beneficial treatment effect on time to first relapse was revealed for subjects with 'no depression' allocated to naltrexone (n = 56; P < 0.01). In addition, a significant beneficial treatment effect was revealed in subjects with 'low dependence' allocated to naltrexone (n = 34; P < 0.05). CONCLUSIONS The results of this study support the efficacy of naltrexone in the relapse prevention of alcoholism amongst those with low levels of clinical depression and alcohol dependence severity. No effect of acamprosate was found in our sample.
Collapse
Affiliation(s)
- Kirsten C Morley
- Central Clinical School of Medicine, University of Sydney, NSW, Australia
| | | | | | | | | | | | | | | | | | | |
Collapse
|
35
|
Ettner SL, Huang D, Evans E, Ash DR, Hardy M, Jourabchi M, Hser YI. Benefit-cost in the California treatment outcome project: does substance abuse treatment "pay for itself"? Health Serv Res 2006; 41:192-213. [PMID: 16430607 PMCID: PMC1681530 DOI: 10.1111/j.1475-6773.2005.00466.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To examine costs and monetary benefits associated with substance abuse treatment. DATA SOURCES Primary and administrative data on client outcomes and agency costs from 43 substance abuse treatment providers in 13 counties in California during 2000-2001. STUDY DESIGN Using a social planner perspective, the estimated direct cost of treatment was compared with the associated monetary benefits, including the client's costs of medical care, mental health services, criminal activity, earnings, and (from the government's perspective) transfer program payments. The cost of the client's substance abuse treatment episode was estimated by multiplying the number of days that the client spent in each treatment modality by the estimated average per diem cost of that modality. Monetary benefits associated with treatment were estimated using a pre-posttreatment admission study design, i.e., each client served as his or her own control. DATA COLLECTION Treatment cost data were collected from providers using the Drug Abuse Treatment Cost Analysis Program instrument. For the main sample of 2,567 clients, information on medical hospitalizations, emergency room visits, earnings, and transfer payments was obtained from baseline and 9-month follow-up interviews, and linked to information on inpatient and outpatient mental health services use and criminal activity from administrative databases. Sensitivity analyses examined administrative data outcomes for a larger cohort (N=6,545) and longer time period (1 year). PRINCIPAL FINDINGS On average, substance abuse treatment costs $1,583 and is associated with a monetary benefit to society of $11,487, representing a greater than 7:1 ratio of benefits to costs. These benefits were primarily because of reduced costs of crime and increased employment earnings. CONCLUSIONS Even without considering the direct value to clients of improved health and quality of life, allocating taxpayer dollars to substance abuse treatment may be a wise investment.
Collapse
Affiliation(s)
- Susan L Ettner
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, UCLA, Los Angeles, CA 90095-1736, USA
| | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
OBJECTIVE To compare the cost effectiveness of social behaviour and network therapy, a new treatment for alcohol problems, with that of the proved motivational enhancement therapy. DESIGN Cost effectiveness analysis alongside a pragmatic randomised trial. SETTING Seven treatment sites around Birmingham, Cardiff, and Leeds. PARTICIPANTS 742 clients with alcohol problems; 617 (83.2%) were interviewed at 12 months and full economic data were obtained on 608 (98.5% of 617). Main economic measures Quality adjusted life years (QALYs), costs of trial treatments, and consequences for public sector resources (health care, other alcohol treatment, social services, and criminal justice services). RESULTS Both therapies saved about five times as much in expenditure on health, social, and criminal justice services as they cost. Neither net savings nor cost effectiveness differed significantly between the therapies, despite the average cost of social behaviour and network therapy (221 pounds sterling; 385 dollars; 320 euros) being significantly more than that of motivational enhancement therapy (129 pounds sterling). If a QALY were worth 30,000 pounds sterling, then the motivational therapy would have 58% chance of being more cost effective than the social therapy, and the social therapy would have 42% chance of being more cost effective than the motivational therapy. CONCLUSION Participants reported highly significant reductions in drinking and associated problems and costs. The novel social behaviour and network therapy did not differ significantly in cost effectiveness from the proved motivational enhancement therapy.
Collapse
|
37
|
Anton RF, Moak DH, Latham P, Waid LR, Myrick H, Voronin K, Thevos A, Wang W, Woolson R. Naltrexone combined with either cognitive behavioral or motivational enhancement therapy for alcohol dependence. J Clin Psychopharmacol 2005; 25:349-57. [PMID: 16012278 DOI: 10.1097/01.jcp.0000172071.81258.04] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although naltrexone has been shown to be effective in the treatment of alcohol dependence, less is known about its efficacy when combined with different behavioral therapies. Previous work has suggested that naltrexone works best when combined with weekly cognitive behavioral therapy (CBT). This study examined the efficacy of naltrexone when combined with CBT or a motivational enhancement therapy involving less patient contact. Outpatient alcoholics (N = 160) were randomly assigned to either naltrexone (50 mg/d) or placebo and either CBT (12 sessions) or motivational enhancement therapy (4 sessions), in a 4-cell design, and treated over a 12-week period. Subjects were evaluated periodically for alcohol consumption, craving, and biologic markers of drinking (carbohydrate-deficient transferrin and gamma-glutamyltransferase). There was high retention and adherence to therapy and medication in the trial with no significant difference across the treatment groups. Naltrexone, independent of therapy assignment, increased the time to first relapse. However, the CBT-naltrexone group did better than the other groups on a variety of outcome measures. Fewer CBT-naltrexone-treated subjects relapsed, and those that did had both fewer, and more time between, subsequent relapses. This randomized controlled trial is consistent with previous reports about the utility of combining naltrexone with CBT. Despite being more efficient to administer, the combination of motivational enhancement therapy and naltrexone is less effective than CBT and naltrexone. Because CBT and naltrexone share common mechanisms of action, such as craving reduction and relapse prevention, these therapies are likely to be well suited to use in combination.
Collapse
Affiliation(s)
- Raymond F Anton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, 67 President Street, Charleston, SC 29425, USA.
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Owens L, Gilmore IT, Pirmohamed M. HOW DO NHS GENERAL HOSPITALS IN ENGLAND DEAL WITH PATIENTS WITH ALCOHOL-RELATED PROBLEMS? A QUESTIONNAIRE SURVEY. Alcohol Alcohol 2005; 40:409-12. [PMID: 16009672 DOI: 10.1093/alcalc/agh184] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Alcohol-related disease represents a major burden on hospitals. However, it is unclear whether hospitals have developed the necessary expertise and guidelines to deal with this burden. The aim of this survey was to determine what measures general hospital NHS Trusts in England had in place to deal with alcohol-related problems, including the employment of dedicated alcohol specialist nurses. METHODS Two postal surveys of all NHS general hospital Trusts in England, the first in 2000 (n = 138; 54% response rate) and the second in 2003 after the publication of the Royal College of Physicians (RCP) report on alcohol in secondary care (n = 164; 75% response rate). RESULTS Between the two surveys, there was a significant increase (P = 0.005) in the number of dedicated alcohol nurses employed by general hospital trusts; however, the numbers remain low (n = 21). Additionally, the availability of prescribing guidelines for the management of alcohol withdrawal increased significantly (P = 0.0001). CONCLUSIONS The survey indicates that most general hospitals do not have appropriate services in place to deal with such patients. Although there is a need and willingness to develop alcohol services in general hospitals, which is one of the key recommendations of the RCP report, the lack of funding is going to act as a major barrier.
Collapse
Affiliation(s)
- Lynn Owens
- Department of Pharmacology, The University of Liverpool, Ashton Street, Liverpool L69 3GE, UK
| | | | | |
Collapse
|
39
|
Poldrugo F, Haeger DA, Comte S, Walburg J, Palmer AJ. A critical review of pharmacoeconomic studies of acamprosate. Alcohol Alcohol 2005; 40:422-30. [PMID: 15939706 DOI: 10.1093/alcalc/agh171] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS This review assessed the published data on the cost-effectiveness of acamprosate for the treatment of alcohol dependence. METHODS Four Markov modelling studies have assessed the therapeutic benefit and economic impact of acamprosate on the treatment of alcohol dependence. These have evaluated both short-term and long-term outcomes and have used German, Belgian, and Spanish costings. A fifth prospective cohort study collected real outcomes and data on expenditure during a 1 year study follow-up period. RESULTS All five studies have produced consistent results, showing the use of acamprosate, which enhances abstinence rates, to reduce the total costs of treatment and thus be dominant over other rehabilitation strategies not involving pharmacotherapy. In all of the studies, the principal cost-driver is hospitalization. Although there is a short-term increase in treatment costs associated with drug acquisition, these are recovered from long-term savings attributable to reduced hospitalization and rehabilitation costs.
Collapse
Affiliation(s)
- Flavio Poldrugo
- Office for Research and Innovative Projects on Alcohol, Other Addictions and Mental Health, Department of Psychiatry, University of Trieste, Via De Pastrovich 5/A, 34126 TRIESTE, Italy.
| | | | | | | | | |
Collapse
|
40
|
Machado MP. Substance abuse treatment, what do we know? An economist's perspective. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2005; 6:53-64. [PMID: 15703912 DOI: 10.1007/s10198-004-0253-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
The literature on treating substance abuse has dealt basically with four important questions: (a) Is treatment effective? (b) Are all programs equally effective? (c) Why do programs differ in their effectiveness? (d) Which treatments are more cost-effective? This paper reviews the substance abuse treatment literature around these four questions and discusses methodological issues that hinder the interpretation and generalization of results to date. The answer to the first question is a sounding "yes," treatment is effective but not all programs are equally effective. Researchers have moved beyond the "black box" literature that concentrated on patient and program characteristics as explanations for differences in effectiveness and search for the "active" ingredients of treatment. These include, for example, the treatment philosophy of the program's director and staff attitudes towards patients. Cost-effectiveness studies are less common, and their conclusions are mixed. In general, it is probably safe to say that for the majority of patients, outpatient or shorter programs are more cost-effective.
Collapse
Affiliation(s)
- Matilde P Machado
- Universidad Carlos III de Madrid, Calle Madrid 126, 28903 Getafe, Spain.
| |
Collapse
|
41
|
Scheurich A, Müller MJ, Anghelescu I, Lörch B, Dreher M, Hautzinger M, Szegedi A. Reliability and validity of the form 90 interview. Eur Addict Res 2005; 11:50-6. [PMID: 15608472 DOI: 10.1159/000081417] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Alcohol consumption is a central variable in substance abuse research and treatment. The study reports the psychometric characteristics of the German version of the Form 90 interview for the assessment of recent alcohol consumption. METHOD Reliability was evaluated in a test-retest study (7 days) with 30 consecutively admitted psychiatric inpatients with alcohol dependence. Validity of Form 90 was assessed with a second sample of 60 alcohol-dependent inpatients. RESULTS Form 90 demonstrated good to excellent retest reliability for the central variables of alcohol consumption. Retest reliability Pearson correlation coefficients (r) ranged from 0.76 to 0.99 and Intraclass Correlation Coefficients (ICC) ranged from 0.74 to 0.98. Reliability coefficients proved to be stable throughout the whole assessment window (90 days). Confidence intervals demonstrated sufficient precision of measures of alcohol consumption. Validity was supported by significant correlations of the amount of alcohol consumed with outcome parameters of the Lifetime Drinking History Interview (r=0.47 and 0.58), gamma-glutamyltransferase on admission to detoxification treatment (r=0.37), physical withdrawal symptoms (r=0.56) and the withdrawal symptom index (r=0.48). CONCLUSIONS Form 90 presented evidence of good to excellent psychometric properties, and its applicability to clinical populations of alcohol-dependent patients in German-speaking countries could be confirmed.
Collapse
Affiliation(s)
- A Scheurich
- Department of Psychiatry, University of Mainz, Mainz, Germany.
| | | | | | | | | | | | | |
Collapse
|
42
|
Bouza C, Angeles M, Magro A, Muñoz A, Amate JM. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: a systematic review. Addiction 2004; 99:811-28. [PMID: 15200577 DOI: 10.1111/j.1360-0443.2004.00763.x] [Citation(s) in RCA: 293] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS To ascertain the efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence. METHODS Systematic review of the literature (1990-2002) and meta-analysis of full published randomized and controlled clinical trials assessing acamprosate or naltrexone therapy in alcohol dependence. Estimates of effect were calculated according to the fixed-effects model. MEASUREMENTS Relapse and abstinence rates, cumulative abstinence duration and treatment compliance were considered as primary outcomes. Findings Thirty-three studies met the inclusion criteria. Acamprosate was associated with a significant improvement in abstinence rate [odds ratio (OR): 1.88 (1.57, 2.25), P < 0.001] and days of cumulative abstinence [WMD: 26.55 (17.56, 36.54]. Short-term administration of naltrexone reduced the relapse rate significantly [OR: 0.62 (0.52, 0.75), P < 0.001], but was not associated with a significant modification in the abstinence rate [OR: 1.26 (0.97,1.64), P = 0.08]. There were insufficient data to ascertain naltrexone's efficacy over more prolonged periods. Acamprosate had a good safety pattern and was associated with a significant improvement in treatment compliance [OR: 1.29 (1.13,1.47), P < 0.001]. Naltrexone's side effects were more numerous, yet the drug was nevertheless tolerated acceptably without being associated with a lower adherence to treatment (OR: 0.94 (0.80, 1.1), P = 0.5). However, overall compliance was relatively low with both medications. CONCLUSIONS Both acamprosate and naltrexone are effective as adjuvant therapies for alcohol dependence in adults. Acamprosate appears to be especially useful in a therapeutic approach targeted at achieving abstinence, whereas naltrexone seems more indicated in programmes geared to controlled consumption. Both drugs are safe and acceptably tolerated but issues of compliance need to be addressed adequately to assure their usefulness in clinical practice.
Collapse
Affiliation(s)
- Carmen Bouza
- Agency for Health Technology Assessment, Madrid, Spain.
| | | | | | | | | |
Collapse
|
43
|
Berglund M, Thelander S, Salaspuro M, Franck J, Andréasson S, Ojehagen A. Treatment of alcohol abuse: an evidence-based review. Alcohol Clin Exp Res 2004; 27:1645-56. [PMID: 14574236 DOI: 10.1097/01.alc.0000090144.99832.19] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article represents the proceedings of a symposium at the 2002 annual meeting of the Research Society on Alcoholism in San Francisco, CA, organized and cochaired by Mats Berglund and Sten Thelander. The presentations were (1) Preventive interventions against hazardous consumption of alcohol, by Mikko Salaspuro; (2) Treatment of alcohol withdrawal, by Johan Franck; (3) Psychosocial treatment for alcohol problems, by Sven Andréasson and Agneta Ojehagen; and (4) Pharmacological treatment of alcohol dependence, by Mats Berglund.
Collapse
Affiliation(s)
- Mats Berglund
- Department of Clinical Alcohol Research, Malmö University Hospital, Malmö, Sweden.
| | | | | | | | | | | |
Collapse
|
44
|
Abstract
Motivational Enhancement Therapy (MET) is a brief therapy for treating substance use-related problems that draws upon the stages of the change model of Prochaska et al. (1992) and the clinical techniques of Motivational Interviewing (MI) Miller et al. (1992). Studies have shown that MET is effective in improving motivation for change and decreasing substance use. However, comparison of MET with more intensive treatment is limited and no studies have compared the standard low dose of MET with higher doses of MET. This article makes the case for a higher dose model. The rationale for the more intensive dose draws upon several sources: 1) Descriptive studies documenting that length of treatment is a predictor of outcome, 2) Well-controlled, randomized psychotherapy trials for other disorders, such as depression, that show a dose-response relationship, and 3) Conceptual considerations about the nature and process of psychotherapy.
Collapse
Affiliation(s)
- Douglas L Polcin
- Haight Ashbury Free Clinics Research, Education, and Training, San Francisco, California 94117, USA.
| | | | | | | |
Collapse
|
45
|
Abstract
The nature and extent of treated health problems in patients with problems related to the use of alcohol and drugs (including both licit and illicit drugs) were compared with the morbidity levels of all patients treated for all conditions in Canada. The morbidity experience of all patients with alcohol or drug (A/D) diagnoses treated as inpatients (n = 52,200 cases) in all Ontario hospitals in 1985-1986 (based on Hospital Medical Records Institute [HMRI] data) was compared with that of the total population of all inpatients treated in all Canadian hospitals using age-sex standardized morbidity ratios (SMR) and adjusting for multiple diagnoses. Of A/D cases, 32% were admitted with a primary A/D diagnosis and 68% with a secondary A/D diagnosis; 17% of A/D cases had multiple A/D diagnosis. On average, cases with a primary A/D diagnosis had 29% more diagnoses per case than all cases treated in Ontario. SMRs were highest for cases with diagnoses relating to the use or misuse of licit drugs (SMR = 13.32 and 3.51 for those with primary and secondary drug diagnoses, respectively), intermediate for illicit drug cases (SMR = 8.87 vs. 4.74 for primary and secondary diagnoses, respectively), and lowest for patients with alcohol diagnoses (SMR = 6.68 and 4.12 for primary and secondary diagnoses, respectively). Excess morbidity for alcohol cases affected more diagnostic categories and body systems, being at a higher level than for drug cases. Alcohol or drug cases had particularly high SMRs for mental disorders, infectious and parasitic conditions, and injury and poisoning diagnoses. Alcohol or drug cases had reduced reproductive morbidity: for complications of pregnancy, childbirth, and the puerperium, SMR = 0.04 to 0.24 for cases with primary A/D diagnoses and SMR = 0.12 to 0.89 for those with secondary A/D diagnoses. Cases with drug diagnoses had a considerable reduction in SMR for certain conditions originating in the perinatal period: SMR = 0.0 for cases with primary drug diagnoses and SMR = 0.0 for secondary illicit drug diagnoses cases and SMR = 0.18 for secondary licit drug diagnoses cases.
Collapse
Affiliation(s)
- Manuella Adrian
- Public Health Program, College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA.
| | | |
Collapse
|
46
|
Stout RL, Papandonatos G. Advances in research design and analysis for alcohol treatment. RECENT DEVELOPMENTS IN ALCOHOLISM : AN OFFICIAL PUBLICATION OF THE AMERICAN MEDICAL SOCIETY ON ALCOHOLISM, THE RESEARCH SOCIETY ON ALCOHOLISM, AND THE NATIONAL COUNCIL ON ALCOHOLISM 2003; 16:39-52. [PMID: 12638631 DOI: 10.1007/0-306-47939-7_5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Affiliation(s)
- Robert L Stout
- Decision Sciences Institute, Providence, Rhode Island 02096, USA
| | | |
Collapse
|
47
|
Friedmann PD, Lemon SC, Anderson BJ, Stein MD. Predictors of follow-up health status in the Drug Abuse Treatment Outcome Study (DATOS). Drug Alcohol Depend 2003; 69:243-51. [PMID: 12633910 DOI: 10.1016/s0376-8716(02)00323-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study examined the predictors of self-reported health status at follow-up in the Drug Abuse Treatment Outcomes Study (DATOS), a longitudinal study of drug abuse treatment programs and patients in 1991-1993. Baseline and follow-up interviews of 2966 patients in 75 programs were performed. The follow-up assessment was targeted to occur 12 months after treatment terminated; long-term methadone patients in treatment for the entire 12-month period were interviewed 24 months after intake. A composite measure, developed through principal component analysis, assessed health status. A multivariate hierarchical linear regression model adjusted for identified independent baseline predictors of health status at follow-up. Poor physical health status (including the composite measure, comorbid conditions and pain) and greater severity of psychiatric symptoms at baseline were the strongest predictors of poor health status at follow-up. Other predictors of worse health status included older age, public insurance coverage and unemployment. We conclude that baseline health status and psychiatric symptoms predict the subsequent health status of patients in substance abuse treatment patients as in other clinical populations. Future research should examine whether early identification and treatment of physical and mental health problems among patients in addiction treatment programs might remediate their adverse effects on long-term health status outcomes.
Collapse
Affiliation(s)
- Peter D Friedmann
- Department of Medicine, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903, USA.
| | | | | | | |
Collapse
|
48
|
Carroll KM, Rounsaville BJ. Bridging the gap: a hybrid model to link efficacy and effectiveness research in substance abuse treatment. Psychiatr Serv 2003; 54:333-9. [PMID: 12610240 PMCID: PMC3650626 DOI: 10.1176/appi.ps.54.3.333] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Many behavioral and pharmacologic treatments for which there is strong empirical support are rarely used in clinical practice in the treatment of substance dependence. In an effort to facilitate greater emphasis on issues such as utility, practicality, and cost earlier in the evaluation of promising therapies, the authors propose a hybrid model to link efficacy and effectiveness research. A hybrid model may foster broader use of empirically validated treatments in substance abuse treatment programs and enhance the scientific yield of effectiveness research. The hybrid model retains essential features of efficacy research (randomization, use of control conditions, independent assessment of outcome, and monitoring of treatment delivery) while expanding the research questions to also address issues of importance in effectiveness studies. Such issues include diversity in settings, clinicians, and patients; cost-effectiveness of treatment; training issues; and patient and clinician satisfaction.
Collapse
Affiliation(s)
- Kathleen M Carroll
- Department of Psychiatry at Yale University School of Medicine, West Haven, Connecticut, USA.
| | | |
Collapse
|
49
|
Nalpas B, Combescure C, Pierre B, Ledent T, Gillet C, Playoust D, Danel T, Bozonnat MC, Martin S, Balmes JL, Daures JP. Financial Costs of Alcoholism Treatment Programs: A Longitudinal and Comparative Evaluation Among Four Specialized Centers. Alcohol Clin Exp Res 2003. [DOI: 10.1111/j.1530-0277.2003.tb02720.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
50
|
French MT, Salomé HJ, Carney M. Using the DATCAP and ASI to estimate the costs and benefits of residential addiction treatment in the State of Washington. Soc Sci Med 2002; 55:2267-82. [PMID: 12409139 DOI: 10.1016/s0277-9536(02)00060-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Funding agencies and policy makers often criticize residential addiction treatment because the cost of residential services is typically higher than for outpatient services and it is unclear whether the outcomes are significantly better for most clients. To address these concerns, proponents of residential treatment require economic evidence to justify further investments in this modality over less intensive and less costly options. Recent studies have developed methods and empirical guidelines for using the drug abuse treatment cost analysis program (DATCAP) and the addiction severity index (ASI) in a comprehensive economic evaluation of addiction treatment. The present study applied these methods and guidelines to estimate the economic costs and benefits of residential addiction treatment at five programs in the State of Washington, USA that serve publicly funded clients. Program- and client-specific economic cost estimates were derived using data collected on-site with the DATCAP along with opportunity cost estimates associated with treatment attendance. Economic benefits were calculated from client self-reported information at treatment entry and at 6 months post discharge using the ASI. Outcome categories included inpatient services, employment, medical and psychiatric conditions, and criminal activity. Results indicate that average weekly economic cost of treatment services at the five programs ranged from 463 dollars to 703 dollars. Average (per client) economic cost of treatment was 4912 dollars (composed of 3650 dollars in program cost and 1262 dollars in client cost) for all subjects that completed both a baseline and follow-up questionnaire (N = 222; 82%). Average (per client) total economic benefit was 21,329 dollars, leading to estimates of 16,418 dollars for average net benefit and 4.34 for the benefit-cost ratio. Total and net economic benefits were significantly related to gender, race, religious preference, and baseline ASI composite scores for drug use and legal status. A detailed sensitivity analysis did not alter the qualitative findings. This study provides conclusive evidence that, for this sample of programs in Washington State, the economic benefits of residential addiction treatment significantly exceeded the economic costs. Although the results are not necessarily generalizable to private-paying clients or clients from other States in the US, the methods are based on widely used data collection instruments and well-accepted economic principles. Thus, extensions of this research to other clients, States, and modalities should be feasible and straightforward.
Collapse
Affiliation(s)
- Michael T French
- Department of Epidemiology and Public Health, Health Services Research Center (D93), University of Miami, 1801 NW 9th Avenue, Third Floor, Miami, FL 33136, USA.
| | | | | |
Collapse
|