The role of continuing care in 9-year cost trajectories of patients with intakes into an outpatient alcohol and drug treatment program

Costs, benefits, and net benefit of 13 inpatient substance use treatments for 14,947 women and men

In an attempt to replicate earlier findings that substance use disorder treatment (SUDTx) has monetary outcomes (benefits) for taxpayers that exceed treatment costs several times over for the average participant, costs of SUDTx were contrasted to observed costs of healthcare, criminal justice services, and economic assistance, plus potential increases in earned income, for 14,947 substance-using individuals treated at 13 intensive inpatient programs varying in gender sensitivity. Those who received higher levels of gender-sensitive treatment were expected to better offset treatment costs through greater reductions in subsequent service costs and economic assistance, and greater increases in earned income. Compared to the 24 months preceding treatment, archival data from state databases showed that use of health and criminal justice services, and receipt of economic assistance, actually increased during the 24 months following treatment, and that earned income decreased, resulting in unexpectedly negative net benefits, i.e., a net loss, from a taxpayer perspective. More gender-sensitive treatment was less costly per participant, however, making the net loss less for persons receiving more gender-sensitive treatment. Alternative explanations for these findings are explored, including utilization of archival records of service use rather than the more bias-sensitive self-reports of service use that others have examined previously. The importance of evaluating nonmonetary, as well as monetary, outcomes of substance use disorder (SUD) treatment is noted as well.

Patterns of Health Care Use 5 Years After an Intervention Linking Patients in Addiction Treatment With a Primary Care Practitioner

Importance

Substance use disorders are associated with high rates of emergency department (ED) use and challenges engaging with primary care services.

Objective

To examine 5-year health care engagement and utilization outcomes for participants in the LINKAGE trial, given previously reported associations of LINKAGE with improved care engagement in the short term.

Design, Setting, and Participants

In this post hoc analysis of a nonrandomized controlled trial, participants were assigned to the LINKAGE or usual care (UC) groups using a nonrandomized 3-month alternating off and on strategy over 30 months. Baseline through 5-year follow-up data were collected from April 2011 to October 2018. The trial was conducted at an urban outpatient addiction treatment clinic within a large health system among patients newly enrolled in addiction treatment. Data analysis was conducted from April 2021 to February 2022.

Intervention

The LINKAGE intervention included 6 group-based sessions emphasizing patient agency, skill, and motivation in navigating health care services as well as a facilitated telephone or email connection with a primary care practitioner. The UC group received medical education.

Main Outcomes and Measures

Substance use problem discussions with primary care practitioners (by patient self-report at 1-, 2-, and 5-year follow-up interview) and annual use of the electronic patient portal, primary care, and ED based on electronic health records.

Results

A total of 503 participants, with a mean (SD) age of 42 (12) years, 346 (69%) male participants and 37 (7%) African American, 34 (7%) Asian, and 101 (20%) Hispanic participants, were assigned to LINKAGE (252 participants) or UC (251 participants). Compared with UC participants, LINKAGE participants were significantly more likely to discuss substance use problems with a primary care practitioner at 1-year follow-up (risk ratio [RR], 1.30; 95% CI, 1.03-1.65; P = .03) and use the electronic patient portal at 1- and 2-year follow-up (eg, messaging clinicians at 2 years: RR, 1.24; 95% CI, 1.04-1.47; P = .02). The LINKAGE group had small, statistically significant 5-year annual increases in primary care use (RR, 1.03; 95% CI, 1.003-1.07; P = .03) and significant annual decreases in substance-related ED use (RR, 0.79; 95% CI, 0.64-0.97; P = .03), relative to UC. The LINKAGE group did not significantly differ from the UC group on other types of ED utilization.

Conclusions and Relevance

In this study, a patient activation intervention embedded in outpatient addiction treatment was associated with sustained improvements in health care engagement beyond previously reported 6-month outcomes and with long-term improvements in health care use patterns.

Trial Registration

ClinicalTrials.gov Identifier: NCT01621711.

Multimorbidity classes indicate differential patterns of health care engagement among people who inject drugs

BACKGROUND

Aging people who inject drugs (PWID) have complex health needs. Health care management could be complicated by persistent substance use, multiple health challenges, and inconsistent access to care. However, we know little about the relationship between chronic multimorbidity and health care engagement in this population. The purpose of this study is to characterize patterns and correlates of chronic disease multimorbidity among PWID.

METHODS

We conducted a latent class analysis (LCA) using data from the AIDS Linked to the IntraVenous Experience (ALIVE) Study, a community-based observational cohort, to determine classes of multimorbid chronic diseases. We then conducted regressions to determine factors associated with class membership and the impact of each multimorbid class on health events and utilization.

RESULTS

Of 1387 individuals included, the majority were male (67%) and Black (81%), with a mean age of 53 years. We identified four classes of multimorbidity: Low Multimorbidity (54%), and Low Multimorbidity Including Psychiatric Comorbidity (26%), Multimorbidity (12%), and Multimorbidity Including Psychiatric Comorbidity (7%). Female sex, baseline age, and receipt of disability were factors significantly associated with membership in all three classes compared to the Low Multimorbidity class. Additionally, PWID in these three classes were significantly more likely to utilize emergency room and outpatient health care. Membership in both classes with psychiatric comorbidity was associated with significantly higher adjusted odds of receiving medication for opioid use disorder.

DISCUSSION

Holistic health care systems can best address the needs of aging PWID with integrated care that provides harm reduction, substance use and mental health treatment together, and wrap around services.

Predictors of early and sustained cessation of heavy drinking over 5 years among adult primary care patients

AIMS

To identify factors asociated with early and sustained cessation of heavy drinking.

DESIGN

Retrospective cohort study over 5 years.

SETTING

Kaiser Permanente Northern California, United States.

PARTICIPANTS

Adults reporting heavy drinking during primary care-based alcohol screening between 1 June 2013 and 31 May 2014. The sample (n = 85 434) was 40.7% female and 33.8% non-white; mean age was 50.3 years (standard deviation = 18.1).

MEASUREMENTS

Following US guidelines, early and sustained cessation of heavy drinking was defined as reporting lower-risk drinking or abstinence at 1 year and to 5 years after achieving early cessation, respectively. Associations between patient characteristics and service use and cessation outcomes were examined using logistic regression with inverse probability weights addressing attrition.

FINDINGS

Nearly two-thirds of participants achieved early cessation of heavy drinking. Women [odds ratio (OR) = 1.39, 95% confidence interval (CI) = 1.35, 1.44], middle-age (35-64 years: ORs = 1.16-1.19), non-white race/ethnicity (ORs = 1.03-1.57), medical conditions (OR = 1.05, 95% CI = 1.04, 1.06), psychiatric (OR = 1.10, 95% CI = 1.06, 1.15) and drug use disorders (OR = 1.35, 95% CI = 1.17, 1.56) and addiction treatment (OR = 1.19, 95% CI = 1.09, 1.30) were associated with higher odds of early cessation, while older age (≥ 65 years: OR = 0.91, 95% CI = 0.86, 0.96), smoking (OR = 0.81, 95% CI = 0.77, 0.84), higher index drinking levels (exceeding both daily and weekly limits: OR = 0.30, 95% CI = 0.29, 0.32) and psychiatric treatment (OR = 0.91, 95% CI = 0.84, 0.99) were associated with lower odds. Among those who achieved early cessation (n = 19 200), 60.0% sustained cessation. Associations between patient factors and sustained cessation paralleled those observed in analyses of early cessation. Additionally, routine primary care (OR = 1.57, 95% CI = 1.44, 1.71) and addiction treatment post-1 year (OR = 1.41, 95% CI = 1.19, 1.66) were associated with higher odds of sustained cessation. Lower-risk drinking versus abstinence at 1 year was associated with lower odds of sustained cessation (OR = 0.62, 95% CI = 0.57, 0.66).

CONCLUSIONS

Nearly two-thirds of a large, diverse sample of patients who reported heavy drinking in a Californian health-care system achieved early and sustained cessation of heavy drinking. Vulnerable subgroups (i.e. non-white patients and those with psychiatric disorders), patients who received routine primary care and those who received addiction treatment were more likely to sustain cessation of heavy drinking than other participants.

Comparing narrative-informed occupational therapy in adult outpatient mental health to treatment as usual: A quasi-experimental feasibility study with preliminary treatment outcomes

This paper describes implementation of a narrative-informed occupation-based service in an outpatient community mental health setting that addressed several gaps, including 1) the need for outcome data on occupational therapy in this setting; 2) an ongoing mental health provider shortage; and 3) a need for innovative approaches to supporting mental health. We found a significant improvement from baseline to post-intervention in occupational participation, and dose of occupational therapy was significantly related to improvements in the areas of roles, habits, values, long-term goals, social environment, and readiness for change. This study suggests future, larger effectiveness studies of narrative-informed occupation-based interventions delivered by occupational therapists in outpatient community mental health are warranted.

Cost trajectories as a measure of functional resilience after hospitalization in older adults

BACKGROUND

Administrative data sets lack functional measures.

AIM

We examined whether trajectories of cost can be used as a marker of functional recovery after hospitalization.

METHODS

Secondary analysis of the National Health and Aging Trends Study merged with Centers for Medicare and Medicaid Services data. Community-dwelling participants with a first hospitalization occurring after any annual survey were included (N = 937). Monthly total cost trajectories were constructed for the 3 months before and 3 months following hospitalization. Growth mixture models identified groups of patients with similar trajectories. The association of cost classes with five functional outcomes was examined using multivariate models, controlling for pre-hospitalization function and lead time.

RESULTS

Four cost trajectory classes describing common recovery patterns were identified-persistently high, persistently moderate, low-spike-recover, and low variable. Cost class membership was significantly associated with change in Activities of Daily Living (ADL), instrumental ADL, Short Physical Performance Battery, and grip strength (p < 0.005), but not gait speed (p = 0.08). The proportion of patients who maintained or improved SPPB score was 46.8% in the persistently high, 49.2% in the persistently moderate, 52.7% in the low-spike-recover, and 57.2% in the low-variable groups. In models adjusted for known predictors of functional outcome, the magnitude and direction of association was maintained but significance was lost, indicating that cost trajectories' mirror is mediated by predictors of recovery not available in administrative data.

CONCLUSION

Cost trajectories and total costs are associated with functional recovery following hospitalization in older adults. Cost may be useful as a measure of recovery in administrative data.

Association of behavioral health factors and social determinants of health with high and persistently high healthcare costs

A high proportion of U.S. health care costs are attributable to a relatively small proportion of patients. Understanding behavioral and social factors that predict initial and persistent high costs for these "high utilizers" is critical for health policy-makers. This prospective observational study was conducted at Kaiser Permanente Northern California (KPNC), an integrated healthcare delivery system with 4.1 million members. A stratified random sample of high-cost vs. non-high-cost adult KPNC members matched by age, gender, race/ethnicity, type of health insurance, and medical severity (N = 378) was interviewed between 3/14/2013 and 3/20/2014. Data on health care costs and clinical diagnoses between 1/1/2008 and 12/31/2012 were derived from the electronic health record (EHR). Social-economic status, depression symptoms, adverse childhood experiences (ACEs), interpersonal violence, financial stressors, neighborhood environment, transportation access, and patient activation and engagement were obtained through telephone interviews. Initial and subsequent high-cost status were defined as being classified in top 20% cost levels over 1/1/2009-12/31/2011 and 1/1/2012-12/31/2012, respectively. Psychiatric diagnosis (OR 2.55, 95% CI 1.52-4.29, p < 0.001), financial stressors (OR 1.97, 95% CI 1.19-3.26, p = 0.009), and ACEs (OR 1.10, 95% CI 1.00-1.20, p = 0.051) predicted initial high-cost status. ACEs alone predicted persistent high-cost status in the subsequent year (OR 1.12, 95% CI 1.00-1.25, p = 0.050). Non-medical factors such as psychiatric problems, financial stressors and adverse childhood experiences contribute significantly to the likelihood of high medical utilization and cost. Efforts to predict and reduce high utilization must include measuring and potentially addressing these factors.

Alcohol, marijuana, and opioid use disorders: 5-Year patterns and characteristics of emergency department encounters

BACKGROUND

Changes in substance use patterns stemming from opioid misuse, ongoing drinking problems, and marijuana legalization may result in new populations of patients with substance use disorders (SUDs) using emergency department (ED) resources. This study examined ED admission trends in a large sample of patients with alcohol, marijuana, and opioid use disorders in an integrated health system.

METHODS

In a retrospective design, electronic health record (EHR) data identified patients with ≥1 of 3 common SUDs in 2010 (n = 17,574; alcohol, marijuana, or opioid use disorder) and patients without SUD (n = 17,574). Logistic regressions determined odds of ED use between patients with SUD versus controls (2010-2014); mixed-effect models examined 5-year differences in utilization; moderator models identified subsamples for which patients with SUD may have a greater impact on ED resources.

RESULTS

Odds of ED use were higher at each time point (2010-2014) for patients with alcohol (odds ratio [OR] range: 5.31-2.13, Ps < .001), marijuana (OR range: 5.45-1.97, Ps < .001), and opioid (OR range: 7.63-4.19, Ps < .001) use disorders compared with controls; odds decreased over time (Ps < .001). Patients with opioid use disorder were at risk of high ED utilization; patients were 7.63 times more likely to have an ED visit in 2010 compared with controls and remained 5.00 (average) times more likely to use ED services. ED use increased at greater rates for patients with alcohol and opioid use disorders with medical comorbidities relative to controls (Ps < .045).

CONCLUSIONS

ED use is frequent in patients with SUDs who have access to private insurance coverage and integrated medical services. ED settings provide important opportunities in health systems to identify patients with SUDs, particularly patients with opioid use disorder, to initiate treatment and facilitate ongoing care, which may be effective for reducing excess medical emergencies and ED encounters.

The role of marijuana use disorder in predicting emergency department and inpatient encounters: A retrospective cohort study

BACKGROUND

Marijuana use disorder (MUD) is the most common illegal drug use disorder and its prevalence is increasing. It is associated with psychiatric and medical problems, but little is known about its impact on emergency department (ED) and inpatient utilization rates.

DESIGN

In a retrospective cohort design, we used electronic health record (EHR) data to identify patients with MUD (n=2752) and demographically matched patients without MUD (n=2752) in 2010. Logistic regressions determined risk of ED and inpatient visits each year from 2010 to 2014 for MUD patients versus controls; mixed-effect growth models examined differences in utilization rates over 5-years. Patient characteristics predicting increased risk of utilization were examined among the MUD sample only.

KEY RESULTS

Rates of ED (OR=0.87, p<0.001) and inpatient (OR=0.76, p<0.001) services use significantly declined over 5 years for all patients. Patients with MUD exhibited a significantly greater decline in ED (OR=0.81, p<0.001) and inpatient (OR=0.64, p<0.001) use relative to controls. However, MUD patients had significantly greater risk of having ED and inpatient visits at each time point (p's<0.001). MUD patients with co-occurring other substance use, medical, and/or psychiatric disorders had a greater risk of having ED or inpatient encounters over 5 years (p's<0.001).

CONCLUSIONS

MUD patients remain at high risk for ED and inpatient visits despite decreasing utilization rates over 5 years. Addressing MUD patients' comorbid conditions in outpatient settings may help reduce inappropriate service use.

Trajectories of remission and mortality over 13 years after intake to substance use treatment

BACKGROUND

Little is known about the relationships between long-term patterns of substance use and mortality risk among substance use disorder (SUD) patients.

OBJECTIVE

To determine distinct patterns of remission and relapse of SUD over time and examine their relationship with mortality.

METHODS

The study site was Kaiser Permanente of Northern California. Data for 997 adults who entered substance use treatment between 1994 and 1996 and 4,241 non-SUD patients with similar demographic distributions (35% women in both groups) were analyzed. Latent class growth analysis identified distinct remission trajectory groups over 13 years among SUD patients, and survival analyses were conducted to examine the risk of death between remission trajectory groups, and SUD and non-SUD patients within each remission trajectory group.

RESULTS

Three distinct remission trajectory groups were identified among SUD patients: 1) early relapse-low remission probabilities; 2) declining remission-decreasing remission probabilities; and 3) stable remission-stable remission probabilities across all time points. Among the SUD patients, the early relapse group had a higher risk of death than those stably remitted; stable and declining remission groups did not differ. Comparisons within each remission trajectory group showed that SUD patients in the early relapse and stable remission groups had higher risks of death compared with non-SUD patients; there were no differences within the declining group.

CONCLUSIONS

SUD patients in the stable remission group had lower survival rates compared with non-SUD patients. These findings underline the importance of continuously addressing healthcare needs of individuals with SUD, even in the presence of long-term remission.

Examination of the Effects of an Intervention Aiming to Link Patients Receiving Addiction Treatment With Health Care: The LINKAGE Clinical Trial

IMPORTANCE

Research has shown that higher activation and engagement with health care is associated with better self-management. To our knowledge, the linkage intervention (LINKAGE) is the first to engage patients receiving addiction treatment with health care using the electronic health record and a patient activation approach.

OBJECTIVE

To examine the effects of an intervention aiming to link patients receiving addiction treatment with health care.

DESIGN, SETTING, AND PARTICIPANTS

A nonrandomized clinical trial evaluating the LINKAGE intervention vs usual care by applying an alternating 3-month off-and-on design over 30 months. Participants were recruited from an outpatient addiction treatment clinic in a large health system between April 7, 2011, and October 2, 2013.

INTERVENTIONS

Six group-based, manual-guided sessions on patient engagement in health care and the use of health information technology resources in the electronic health record, as well as facilitated communication with physicians, vs usual care.

MAIN OUTCOMES AND MEASURES

Primary outcomes, measured at 6 months after enrollment, were patient activation (by interview using the Patient Activation Measure), patient engagement in health care (by interview and electronic health record), and alcohol, drug, and depression outcomes (by interview using the Addiction Severity Index for alcohol and drug outcomes and Patient Health Questionnaire (PHQ) for depression).

RESULTS

A total of 503 patients were recruited and assigned to the LINKAGE (n = 252) or usual care (n = 251) conditions, with no differences in baseline characteristics between conditions. The mean (SD) age of the patients was 42.5 (11.8) years, 31.0% (n = 156) were female, and 455 (90.5%) completed the 6-month interview. Compared with usual care participants, LINKAGE participants showed an increase in the mean number of log-in days (incidence rate ratio, 1.53; 95% CI, 1.19-1.97; P = .001). Similar results were found across types of patient portal use (communicating by email, viewing laboratory test results and information, and obtaining medical advice). LINKAGE participants were more likely to talk with their physicians about addiction problems (odds ratio, 2.30; 95% CI, 1.52-3.49; P < .001). Although 6-month abstinence rates were high for both conditions (≥70.0% for both) and depression symptoms improved (the proportion with scores ≥15 on the 9-item PHQ dropped from 15.1% [38 of 252] to 8.0% [18 of 225] among LINKAGE participants), there were no differences between conditions. Those who received all intervention components had significantly better alcohol and other drug outcomes than those who received fewer intervention components.

CONCLUSIONS AND RELEVANCE

Findings support the feasibility and effectiveness of the LINKAGE intervention in helping patients receiving addiction treatment engage in health care and increase communication with their physicians. The intervention did not affect short-term abstinence or depression outcomes. Understanding if the LINKAGE intervention helps prevent relapse and manage long-term recovery will be important.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01621711.

Does age at first treatment episode make a difference in outcomes over 11 years?

This study examines the associations between age at first substance use treatment entry and trajectory of outcomes over 11 years. We found significant differences in individual and treatment characteristics between adult intakes first treated during young adulthood (25 years or younger) and those first treated at an older age. Compared to their first treated older age counterparts matched on demographics and dependence type, those who entered first treatment during young adulthood had on average an earlier onset for substance use but a shorter duration between first substance use and first treatment entry; they also had worse alcohol and other drug outcomes 11 years post treatment entry. While subsequent substance use treatment and 12-step meeting attendance are important for both age groups in maintaining positive outcomes, relationships varied by age group. Findings underline the importance of different continuing care management strategies for those entering first treatment at different developmental stages.

Explaining long-term outcomes among drug dependent mothers treated in women-only versus mixed-gender programs

Specialized substance abuse treatment for parenting women is thought to improve outcomes, but long-term impacts and how they occur are poorly understood. Utilizing a sample of 789 California mothers followed for 10 years after admission to women-only (WO) or mixed-gender (MG) drug treatment, we examine the relationship between WO treatment and outcomes and whether it is mediated by post-treatment exposures to criminal justice and health services systems. At follow-up, 48% of mothers had a successful outcome (i.e., no use of illicit drugs, not involved with the criminal justice system, alive). Controlling for patient characteristics, WO (vs. MG) treatment increased the odds of successful outcome by 44%. In the structural equation model WO treatment was associated with fewer post-treatment arrests, which was associated with better outcomes. Women-only substance abuse treatment has long-term benefits for drug-dependent mothers, a relationship that may be partially explained by post-treatment exposure to the criminal justice system. Findings underscore additional leverage points for relapse prevention and recovery-supportive efforts for drug-dependent mothers.

Integrating substance abuse care with community diabetes care: implications for research and clinical practice

Cigarette smoking and alcohol use are prevalent among individuals with diabetes in the US, but little is known about screening and treatment for substance use disorders in the diabetic population. This commentary discusses the scope and clinical implications of the public health problem of coexisting substance use and diabetes, including suggestions for future research. Diabetes is the seventh leading cause of death in the US, and is associated with many severe health complications like cardiovascular disease, stroke, kidney damage, and limb amputations. There are an estimated 24 million adults in the US with type 2 diabetes. Approximately 20% of adults aged 18 years or older with diabetes report current cigarette smoking. The prevalence of current alcohol use in the diabetic population is estimated to be around 50%-60% in epidemiological surveys and treatment-seeking populations. Cigarette smoking is associated with an increased risk of type 2 diabetes in a dose-dependent manner and is an independent modifiable risk factor for development of type 2 diabetes. Diabetic patients with an alcohol or other drug use disorder show a higher rate of adverse health outcomes. For example, these patients experience more frequent and severe health complications as well as an increased risk of hospitalization, and require longer hospital stays. They are also less likely to seek routine care for diabetes or adhere to diabetes treatment than those without an alcohol or other drug use disorder. The Affordable Care Act of 2010 and the Mental Health Parity Act and Addiction Equity Act of 2008 provide opportunities for facilitating integration of preventive services and evidence-based treatments for substance use disorders with diabetes care in community-based medical settings. These laws also offer emerging areas for research.

Ten-year stability of remission in private alcohol and drug outpatient treatment: non-problem users versus abstainers

BACKGROUND

This study examined stability of remission in patients who were abstainers and non-problem users at 1-year after entering private, outpatient alcohol and drug treatment. We examined: (a) How does risk of relapse change over time? (b) What was the risk of relapse for non-problem users versus abstainers? (c) What individual, treatment, and extra-treatment characteristics predicted time to relapse, and did these differ by non-problem use versus abstinence?

METHODS

The sample consisted of 684 adults in remission (i.e., abstainers or non-problem users) 1 year following treatment intake. Participants were interviewed at intake, and 1, 5, 7, 9, and 11 years after intake. We used discrete-time survival analysis to examine when relapse is most likely to occur and predictors of relapse.

RESULTS

Relapse was most likely at 5-year, and least likely at 11-year follow-up. Non-problem users had twice the odds of relapse compared to abstainers. Younger individuals and those with fewer 12-step meetings and shorter index treatment had higher odds of relapse than others. We found no significant interactions between non-problem use and the other covariates suggesting that significant predictors of outcome did not differ for non-problem users.

CONCLUSIONS

Non-problem use is not an optimal 1-year outcome for those in an abstinence-oriented, heterogeneous substance use treatment program. Future research should examine whether these results are found in harm reduction treatment and self-help models, or in those with less severe problems. Results suggest treatment retention and 12-step participation are prognostic markers of long-term positive outcomes for those achieving remission at 1 year.