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Biondi BE, Freibott CE, Cheng DM, Blokhina E, Lioznov D, Rateau L, Patts GJ, Bendiks S, Gnatienko N, Tindle HA, Freiberg MS, Krupitsky E, Samet JH, Stein MD. Healthcare Utilization Among Persons with HIV and Unhealthy Alcohol Use in St. Petersburg, Russia. AIDS Behav 2024; 28:19-25. [PMID: 37682403 PMCID: PMC10961700 DOI: 10.1007/s10461-023-04161-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/09/2023]
Abstract
Few studies have examined the association between healthcare utilization and heavy alcohol use in Russia among persons with HIV (PWH), a group with high healthcare needs. This study analyzed the association between unhealthy alcohol use (defined as AUDIT score ≥ 8) and healthcare utilization among PWH with heavy alcohol use and daily smoking in St. Petersburg, Russia. This secondary analysis used data from a randomized controlled trial addressing alcohol use. The primary outcome was seeing an infectionist for HIV care in the past year. Outcomes were measured at baseline, 6 months, and 12 months. We assessed the association between unhealthy alcohol use and healthcare utilization outcomes with a repeated measures logistic regression model, controlling for relevant covariates. Nearly all (96.0%) participants had unhealthy alcohol use at baseline, and 90.0% had seen an infectionist for HIV care in the past year. In adjusted analyses, unhealthy alcohol use was associated with a 36% decrease in seeing an infectionist for HIV care (aOR = 0.64, 95% CI 0.43-0.95). Participants reported low levels of emergency department visits and hospitalizations. Understanding how to engage this population in alcohol use disorder treatment and HIV care is an important next step for improving health outcomes for this population.
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Affiliation(s)
- Breanne E Biondi
- Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Talbot Building, Boston, MA, 02118, USA.
| | - Christina E Freibott
- Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Talbot Building, Boston, MA, 02118, USA
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Elena Blokhina
- First Pavlov State Medical, University of St. Petersburg, St. Petersburg, Russian Federation
| | - Dmitry Lioznov
- First Pavlov State Medical, University of St. Petersburg, St. Petersburg, Russian Federation
| | - Lindsey Rateau
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Gregory J Patts
- Biostatistics and Epidemiology Data Analytics Center (BEDAC), Boston University School of Public Health, Boston, MA, USA
| | - Sally Bendiks
- Department of Medicine, Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Natalia Gnatienko
- Department of Medicine, Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Hilary A Tindle
- Division of Internal Medicine & Public Health and Vanderbilt Ingram Cancer Center (VICC), Vanderbilt Center for Tobacco, Addiction and Lifestyle (VITAL), Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S Freiberg
- Cardiovascular Division, Vanderbilt Center for Clinical Cardiovascular Trials Evaluation (V-C3REATE), Vanderbilt University Medical Center, Nashville, TN, USA
| | - Evgeny Krupitsky
- First Pavlov State Medical, University of St. Petersburg, St. Petersburg, Russian Federation
- Department of Addictions, V.M. Bekhterev National Medical Research Center for Psychiatry and Neurology, St. Petersburg, Russian Federation
| | - Jeffrey H Samet
- Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Michael D Stein
- Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Talbot Building, Boston, MA, 02118, USA
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Nieto SJ, Enders CK, Witkiewitz K, O'Malley SS, Ray LA. Combination treatment with varenicline and naltrexone reduces World Health Organization risk drinking levels. Alcohol Clin Exp Res 2022; 46:2258-2266. [PMID: 36515648 DOI: 10.1111/acer.14953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 08/10/2022] [Accepted: 09/23/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND The U.S. Food and Drug Administration identifies abstinence and the absence of heavy drinking days as outcomes for pharmacotherapy trials for alcohol use disorder (AUD). However, many individuals with AUD struggle to achieve these outcomes, which may discourage them from seeking treatment. World Health Organization (WHO) risk drinking levels have garnered attention in the alcohol field as potential non-abstinent outcomes for AUD medication trials. Further, testing combination pharmacotherapy for AUD represents an important direction in the field, particularly using medications such as naltrexone and varenicline, which are approved for treating AUD and smoking, respectively. The objective of the current study was to test the utility of the WHO risk drinking levels as a drinking outcome in a randomized clinical trial of combined varenicline and naltrexone for smoking cessation and drinking reduction. These analyses provide additional tests of the efficacy of this combination treatment. METHODS The current study is a secondary analysis of a phase 2, randomized, double-blind clinical trial, wherein participants (N = 165) who were daily smokers and heavy drinkers were randomly assigned to receive either 2 mg/day of varenicline plus 50 mg/day of naltrexone or 2 mg/day of varenicline plus placebo for 12 weeks. Medication effects on 1- and 2-level reductions in WHO risk drinking levels were assessed at 4, 8, and 12 weeks into the active medication period. RESULTS In logistic growth curve models individuals receiving the combined treatment had greater reductions in WHO risk drinking levels than individuals taking varenicline alone when assessed at 4 weeks into the active medication period. Among individuals who were WHO high and very high risk drinkers at baseline, the largest effect sizes favoring combination treatment were at Week 4 for the WHO 2-level reduction outcome (Cohen's h = 0.202) and Week 12 for the WHO 1-level reduction outcome (Cohen's h = 0.244), although these effects did not reach statistical significance. CONCLUSIONS These findings provide evidence that combined varenicline plus naltrexone treatment is effective at reducing WHO risk drinking levels, particularly among individuals who smoke cigarettes daily and drink heavily. These results add to a growing body of literature validating reductions in WHO risk drinking levels as outcomes of alcohol medication trials.
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Affiliation(s)
- Steven J Nieto
- Department of Psychology, University of California at Los Angeles, Los Angeles, California, USA
| | - Craig K Enders
- Department of Psychology, University of California at Los Angeles, Los Angeles, California, USA
| | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Lara A Ray
- Department of Psychology, University of California at Los Angeles, Los Angeles, California, USA.,Department of Psychiatry and Biobehavioral Sciences, University of California at Los Angeles, Los Angeles, California, USA
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3
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Hagman BT, Falk D, Litten R, Koob GF. Defining Recovery From Alcohol Use Disorder: Development of an NIAAA Research Definition. Am J Psychiatry 2022; 179:807-813. [PMID: 35410494 DOI: 10.1176/appi.ajp.21090963] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The objective of this article is to provide an operational definition of recovery from alcohol use disorder (AUD) to facilitate the consistency of research on recovery and stimulate further research. The construct of recovery has been difficult to operationalize in the alcohol treatment and recovery literature. Several formal definitions of recovery have been developed but have limitations because 1) they require abstinence from both alcohol and substance use, 2) they do not include the DSM-5 diagnostic criteria for AUD as part of the recovery process (i.e., no focus on remission from AUD), 3) they do not link remission and cessation from heavy drinking to improvements in biopsychosocial functioning and quality-of-life constructs, and 4) they do not distinguish between alcohol and other drug use. The authors present a newly developed National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition of recovery from DSM-5 AUD based on qualitative feedback from key recovery stakeholders (e.g., researchers, clinicians, and recovery specialists). The definition views recovery as both a process of behavioral change and an outcome and incorporates two key components of recovery, namely, remission from DSM-5 AUD and cessation from heavy drinking, a nonabstinent recovery outcome. The NIAAA definition of recovery also emphasizes the importance of biopsychosocial functioning and quality of life in enhancing recovery outcomes. This new NIAAA definition of recovery is an operational definition that can be used by diverse stakeholders to increase consistency in recovery measurement, stimulate research to better understand recovery, and facilitate the process of recovery.
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Affiliation(s)
- Brett T Hagman
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md
| | - Daniel Falk
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md
| | - Raye Litten
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md
| | - George F Koob
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md
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4
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Aldridge AP, Zarkin GA, Dowd WN, Witkiewitz K, Hasin DS, O'Malley SS, Isenberg K, Anton RF. The Relationship Between Reductions in WHO Risk Drinking Levels During Treatment and Subsequent Healthcare Costs for the ACTIVE Workgroup. J Addict Med 2022; 16:425-432. [PMID: 34864785 PMCID: PMC9163210 DOI: 10.1097/adm.0000000000000925] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Abstinence has historically been considered the target outcome for alcohol use disorder (AUD) treatment, yet recent work has found drinking reductions after AUD treatment, as measured by World Health Organization (WHO) risk drinking levels, are associated with meaningful improvements in functioning, physical health, and quality of life. OBJECTIVES This study extends previous analyses of AUD treatment outcomes by estimating the association between changes in WHO risk drinking levels (very high, high, medium, and low, based on average daily alcohol consumption) and healthcare costs. METHODS Secondary data analysis of the COMBINE study, a multisite randomized clinical trial of acamprosate, naltrexone and behavioral interventions for AUD. Generalized gamma regression models were used to estimate relationships between WHOrisk drinking level reductions over the course of treatment and healthcare costs in the year after treatment (N = 964) and up to 3 years following treatment (N = 651). RESULTS SustainedWHOrisk drinking reductions of 2 or more levels throughout treatment were associated with 52.0% lower healthcare costs ( P < 0.001) in the year following treatment, and 44.0% lower costs ( P < 0.0025) over 3 years. A reduction of exactly 1 level was associated with 34.8% lower costs over 3 years, which was not significant ( P = 0.05). Cost reductions were driven by lower inpatient behavioral health and emergency department utilization. CONCLUSIONS Reduction in WHO risk drinking levels of at least 2 levels was associated with lower healthcare costs over 1 and 3 years. Our results add to literature showing drinking reductions are associated with improvement in health.
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Affiliation(s)
- Arnie P Aldridge
- From the Behavioral Health Research Division, RTI International, NC (APA, GAZ, WND), Department of Psychology, University of NewMexico, 2650 Yale SE MSC11-6280, Albuquerque, NM (KW), Department of Epidemiology, Columbia University, New York, NY (DSH), Department of Medicine, Yale University, Connecticut Mental Health Center, New Haven, CT (SSO), Anthem Inc., Indianapolis, IN (KI), Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC (RFA)
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5
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Hietanen S, Herajärvi J, Lahtinen S, Käkelä R, Ala-Kokko T, Liisanantti J. Utilization of health care resources, long-term survival and causes of death after intensive care unit admission in relation to high-risk alcohol consumption. JOURNAL OF SUBSTANCE USE 2020. [DOI: 10.1080/14659891.2020.1838636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Siiri Hietanen
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Johanna Herajärvi
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Sanna Lahtinen
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Riikka Käkelä
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Tero Ala-Kokko
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
| | - Janne Liisanantti
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
- Oulu University Medical Research Center, Research Group of Surgery, Anesthesiology and Intensive Care, University of Oulu, Oulu, Finland
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6
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Liver transplantation in patients with alcohol-related liver disease: current status and future directions. Lancet Gastroenterol Hepatol 2020; 5:507-514. [DOI: 10.1016/s2468-1253(19)30451-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/15/2019] [Accepted: 12/19/2019] [Indexed: 12/19/2022]
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7
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Roos CR, Nich C, Mun CJ, Mendonca J, Babuscio TA, Witkiewitz K, Carroll KM, Kiluk BD. Patterns of Cocaine Use During Treatment: Associations With Baseline Characteristics and Follow-Up Functioning. J Stud Alcohol Drugs 2020. [PMID: 31495380 DOI: 10.15288/jsad.2019.80.431] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Abstinence outcomes are typically prioritized in the treatment of cocaine use disorder while ignoring patterns of low-frequency cocaine use. This study examined patterns of cocaine use frequency during treatment and evaluated how these patterns related to baseline characteristics and functioning outcomes 6 and 12 months after treatment. METHOD We used a pooled dataset (N = 720) from seven randomized clinical trials for cocaine use disorder. The Addiction Severity Index (ASI) was used to assess functioning. Repeated-measures latent class analysis was used to derive patterns of cocaine use. RESULTS Three patterns were identified: abstinence (10.6%), low-frequency use (approximately 1 day/week; 66.3%), and persistent frequent use (approximately 4 days/week; 23.1%). The low-frequency group was associated with male gender, younger age, and a criminal justice referral. The abstinent group had the highest alcohol problem severity score at baseline. At Month 6, the low-frequency group reported lower problem severity than the persistent frequent use group across multiple ASI areas, including the cocaine use as well as psychological, family, employment, and legal domains. At Month 12, the low-frequency group did not differ from the abstinent group in problem severity on any ASI domain and, relative to the persistent frequent use group, had lower cocaine use and employment problem severity. CONCLUSIONS These findings highlight the importance of adopting a harm reduction approach and recognizing the potential clinical benefits associated with nonabstinent outcomes.
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Affiliation(s)
- Corey R Roos
- Yale University School of Medicine, New Haven, Connecticut
| | - Charla Nich
- Yale University School of Medicine, New Haven, Connecticut
| | - Chung Jung Mun
- John Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | | | - Brian D Kiluk
- Yale University School of Medicine, New Haven, Connecticut
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8
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Barbosa C, Dowd WN, Aldridge AP, Timko C, Zarkin GA. Estimating Long-Term Drinking Patterns for People with Lifetime Alcohol Use Disorder. Med Decis Making 2019; 39:765-780. [PMID: 31580211 DOI: 10.1177/0272989x19873627] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background. There is a lack of data on alcohol consumption over time. This study characterizes the long-term drinking patterns of people with lifetime alcohol use disorders who have engaged in treatment or informal care. Methods. We developed multinomial logit models using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to estimate short-term transition probabilities (TPs) among the 4 World Health Organization drinking risk levels (low, medium, high, and very high risk) and abstinence by age, sex, and race/ethnicity. We applied an optimization algorithm to convert 3-year TPs from NESARC to 1-year TPs, then used simulated annealing to calibrate TPs to a propensity-scored matched set of participants derived from a separate 16-year study of alcohol consumption. We validated the resulting long-term TPs using NESARC-III, a cross-sectional study conducted on a different cohort. Results. Across 24 demographic groups, the 1-year probability of remaining in the same state averaged 0.93, 0.81, 0.49, 0.51, and 0.63 for abstinent, low, medium, high, and very high-risk states, respectively. After calibration to the 16-year study data (N = 420), resulting TPs produced state distributions that hit the calibration target. We find that the abstinent or low-risk states are very stable, and the annual probability of leaving the very high-risk state increases by about 20 percentage points beyond 8 years. Limitations. TPs for some demographic groups had small cell sizes. The data used to calibrate long-term TPs are based on a geographically narrow study. Conclusions. This study is the first to characterize long-term drinking patterns by combining short-term representative data with long-term data on drinking behaviors. Current research is using these patterns to estimate the long-term cost effectiveness of alcohol treatment.
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Affiliation(s)
- Carolina Barbosa
- Behavioral Health Research Division, RTI International, Chicago, IL, USA
| | - William N Dowd
- Behavioral Health Research Division, RTI International, Chicago, IL, USA
| | - Arnie P Aldridge
- Behavioral Health Research Division, RTI International, Chicago, IL, USA
| | - Christine Timko
- Health Services Research & Development Center for Innovation to Implementation, Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Gary A Zarkin
- Behavioral Health Research Division, RTI International, Chicago, IL, USA
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9
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Roos CR, Nich C, Mun CJ, Mendonca J, Babuscio TA, Witkiewitz K, Carroll KM, Kiluk BD. Patterns of Cocaine Use During Treatment: Associations With Baseline Characteristics and Follow-Up Functioning. J Stud Alcohol Drugs 2019; 80:431-440. [PMID: 31495380 PMCID: PMC6739643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/06/2019] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE Abstinence outcomes are typically prioritized in the treatment of cocaine use disorder while ignoring patterns of low-frequency cocaine use. This study examined patterns of cocaine use frequency during treatment and evaluated how these patterns related to baseline characteristics and functioning outcomes 6 and 12 months after treatment. METHOD We used a pooled dataset (N = 720) from seven randomized clinical trials for cocaine use disorder. The Addiction Severity Index (ASI) was used to assess functioning. Repeated-measures latent class analysis was used to derive patterns of cocaine use. RESULTS Three patterns were identified: abstinence (10.6%), low-frequency use (approximately 1 day/week; 66.3%), and persistent frequent use (approximately 4 days/week; 23.1%). The low-frequency group was associated with male gender, younger age, and a criminal justice referral. The abstinent group had the highest alcohol problem severity score at baseline. At Month 6, the low-frequency group reported lower problem severity than the persistent frequent use group across multiple ASI areas, including the cocaine use as well as psychological, family, employment, and legal domains. At Month 12, the low-frequency group did not differ from the abstinent group in problem severity on any ASI domain and, relative to the persistent frequent use group, had lower cocaine use and employment problem severity. CONCLUSIONS These findings highlight the importance of adopting a harm reduction approach and recognizing the potential clinical benefits associated with nonabstinent outcomes.
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Affiliation(s)
- Corey R. Roos
- Yale University School of Medicine, New Haven, Connecticut
| | - Charla Nich
- Yale University School of Medicine, New Haven, Connecticut
| | - Chung Jung Mun
- John Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | | | - Brian D. Kiluk
- Yale University School of Medicine, New Haven, Connecticut
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10
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Falk DE, O’Malley SS, Witkiewitz K, Anton RF, Litten RZ, Slater M, Kranzler HR, Mann KF, Hasin DS, Johnson B, Meulien D, Ryan M, Fertig J. Evaluation of Drinking Risk Levels as Outcomes in Alcohol Pharmacotherapy Trials: A Secondary Analysis of 3 Randomized Clinical Trials. JAMA Psychiatry 2019; 76:374-381. [PMID: 30865232 PMCID: PMC6450273 DOI: 10.1001/jamapsychiatry.2018.3079] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE The US Food and Drug Administration recognizes total abstinence and no heavy drinking days as outcomes for pivotal pharmacotherapy trials for alcohol use disorder (AUD). Many patients have difficulty achieving these outcomes, which can discourage seeking treatment and has slowed the development of medications that affect alcohol use. OBJECTIVE To compare 2 drinking-reduction outcomes with total abstinence and no heavy drinking outcomes. DESIGN, SETTING, AND PARTICIPANTS Data were obtained from 3 multisite, randomized, placebo-controlled clinical trials of medications for treating alcohol dependence (naltrexone, varenicline, and topiramate) in adults with DSM-IV-categorized alcohol dependence. MAIN OUTCOMES AND MEASURES Within each trial, the percentage of participants in active and placebo conditions who met responder definitions of abstinence, no heavy drinking days, a WHO 1-level reduction, and a WHO 2-level reduction was computed by month with corresponding effect sizes (Cohen h). RESULTS Across the 3 trials (N = 1169; mean [SD] age, 45 [10] years; 824 [70.5%] men), the percentage of participants classified as responders during the last 4 weeks of treatment was lowest for abstinence (naltrexone, 34.7% [100 of 288]; varenicline, 7.3% [7 of 96]; topiramate, 11.7% [21 of 179]) followed by no heavy drinking days (naltrexone, 51.0% [147 of 288]; varenicline, 24.0% [23 of 96]; topiramate, 20.7% [37 of 179]), WHO 2-level reduction (naltrexone, 75.0% [216 of 288]; varenicline, 55.2% [53 of 96]; topiramate, 44.7% [80 of 179]), and WHO 1-level reduction (naltrexone, 83.3% [240 of 288]; varenicline, 69.8 [67 of 96]; topiramate, 54.7% [98 of 179]) outcomes. Standardized treatment effects observed for the WHO 2-level reduction outcomes (naltrexone, Cohen h = 0.214 [95% CI, 0.053 -0.375]; varenicline, 0.273 [95% CI, -0.006 to 0.553]; topiramate, 0.230 [95% CI, 0.024-0.435]) and WHO 1-level reduction (naltrexone, Cohen h = 0.116 [95% CI, -0.046 to 0.277]; varenicline, 0.338 [95% CI, 0.058-0.617]; topiramate, 0.014 [95% CI, -0.192 to 0.219]) were comparable with those obtained using abstinence (naltrexone, Cohen h = 0.142 [95% CI, -0.020 to 0.303]; varenicline, 0.146 [95% CI, -0.133 to 0.426]; topiramate, 0.369 [95% CI, 0.163-0.574]) and no heavy drinking days (naltrexone, Cohen h = 0.140 [95% CI, -0.021 to 0.302]; varenicline, 0.232 [95% CI, -0.048 to 0.511]; topiramate, 0.207 [95% CI, 0.002-0.413]). CONCLUSIONS AND RELEVANCE WHO drinking risk level reductions appear to be worthwhile indicators of treatment outcome in AUD pharmacotherapy trials. These outcomes may align with drinking reduction goals of many patients and capture clinically meaningful improvements experienced by more patients than either abstinence or no heavy drinking days. TRIAL REGISTRATION ClinicalTrials.gov identifiers: NCT00006206; NCT01146613; NCT00210925.
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Affiliation(s)
- Daniel E. Falk
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
| | | | | | - Raymond F. Anton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston
| | - Raye Z. Litten
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
| | | | | | - Karl F. Mann
- Department of Addictive Behaviour and Addiction Medicine, Central Institute of Mental Health, Mannheim, Germany
| | - Deborah S. Hasin
- Department of Psychiatry, Mailman School of Public Health, Columbia University, New York, New York,Department of Epidemiology, Columbia University, New York, New York
| | - Bankole Johnson
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore
| | | | - Megan Ryan
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
| | - Joanne Fertig
- National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, Maryland
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11
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Falk DE, Ryan ML, Fertig JB, Devine EG, Cruz R, Brown ES, Burns H, Salloum IM, Newport DJ, Mendelson J, Galloway G, Kampman K, Brooks C, Green AI, Brunette MF, Rosenthal RN, Dunn KE, Strain EC, Ray L, Shoptaw S, Ait-Daoud Tiouririne N, Gunderson EW, Ransom J, Scott C, Leggio L, Caras S, Mason BJ, Litten RZ. Gabapentin Enacarbil Extended-Release for Alcohol Use Disorder: A Randomized, Double-Blind, Placebo-Controlled, Multisite Trial Assessing Efficacy and Safety. Alcohol Clin Exp Res 2018; 43:158-169. [PMID: 30403402 DOI: 10.1111/acer.13917] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/27/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Several single-site alcohol treatment clinical trials have demonstrated efficacy for immediate-release (IR) gabapentin in reducing drinking outcomes among individuals with alcohol dependence. The purpose of this study was to conduct a large, multisite clinical trial of gabapentin enacarbil extended-release (GE-XR) (HORIZANT® ), a gabapentin prodrug formulation, to determine its safety and efficacy in treating alcohol use disorder (AUD). METHODS Men and women (n = 346) who met DSM-5 criteria for at least moderate AUD were recruited across 10 U.S. clinical sites. Participants received double-blind GE-XR (600 mg twice a day) or placebo and a computerized behavioral intervention (Take Control) for 6 months. Efficacy analyses were prespecified for the last 4 weeks of the treatment period. RESULTS The GE-XR and placebo groups did not differ significantly on the primary outcome measure, percentage of subjects with no heavy drinking days (28.3 vs. 21.5, respectively, p = 0.157). Similarly, no clinical benefit was found for other drinking measures (percent subjects abstinent, percent days abstinent, percent heavy drinking days, drinks per week, drinks per drinking day), alcohol craving, alcohol-related consequences, sleep problems, smoking, and depression/anxiety symptoms. Common side-effects were fatigue, dizziness, and somnolence. A population pharmacokinetics analysis revealed that patients had lower gabapentin exposure levels compared with those in other studies using a similar dose but for other indications. CONCLUSIONS Overall, GE-XR at 600 mg twice a day did not reduce alcohol consumption or craving in individuals with AUD. It is possible that, unlike the IR formulation of gabapentin, which showed efficacy in smaller Phase 2 trials at a higher dose, GE-XR is not effective in treating AUD, at least not at doses approved by the U.S. Food and Drug Administration for treating other medical conditions.
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Affiliation(s)
- Daniel E Falk
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - Megan L Ryan
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - Joanne B Fertig
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
| | - Eric G Devine
- Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts
| | - Ricardo Cruz
- Section of General Internal Medicine, Department of Medicine, School of Medicine and Boston Medical Center, Section of General Internal Medicine, Boston University, Boston, Massachusetts
| | - E Sherwood Brown
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Heather Burns
- Department of Psychiatry, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ihsan M Salloum
- Division of Alcohol and Substance Abuse, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - D Jeffrey Newport
- Division of Alcohol and Substance Abuse, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | | | | | - Kyle Kampman
- Department of Psychiatry, Perelman School of Medicine, Center for Studies of Addiction, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Catherine Brooks
- Department of Psychiatry, Perelman School of Medicine, Center for Studies of Addiction, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alan I Green
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Mary F Brunette
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Richard N Rosenthal
- Division of Addiction Psychiatry, Stony Brook University, Stony Brook, New York.,Mount Sinai St. Luke's Hospital, New York, New York
| | - Kelly E Dunn
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric C Strain
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lara Ray
- Department of Psychology and Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, California
| | - Steven Shoptaw
- Department of Family Medicine and of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | | | - Erik W Gunderson
- Department of Psychiatry and Neurobehavioral Sciences and Department of Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Janet Ransom
- Fast Track Drugs and Biologics, North Potomac, Maryland
| | - Charles Scott
- Fast Track Drugs and Biologics, North Potomac, Maryland
| | - Lorenzo Leggio
- Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, National Institute on Alcohol Abuse and Alcoholism and National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | | | - Barbara J Mason
- Department of Neuroscience, The Scripps Research Institute, La Jolla, California
| | - Raye Z Litten
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, Maryland
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12
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Witkiewitz K, Kranzler HR, Hallgren KA, O'Malley SS, Falk DE, Litten RZ, Hasin DS, Mann KF, Anton RF. Drinking Risk Level Reductions Associated with Improvements in Physical Health and Quality of Life Among Individuals with Alcohol Use Disorder. Alcohol Clin Exp Res 2018; 42:2453-2465. [PMID: 30395350 PMCID: PMC6286196 DOI: 10.1111/acer.13897] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 09/24/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Abstinence and no heavy drinking days are currently the only Food and Drug Administration-approved end points in clinical trials for alcohol use disorder (AUD). Many individuals who fail to meet these criteria may substantially reduce their drinking during treatment, and most individuals with AUD prefer drinking reduction goals. One- and two-level reductions in World Health Organization (WHO) drinking risk levels have been proposed as alternative end points that reflect reduced drinking and are associated with reductions in drinking consequences, improvements in mental health, and reduced risk of developing alcohol dependence. The current study examined the association between WHO drinking risk level reductions and improvements in physical health and quality of life in a sample of individuals with alcohol dependence. METHODS Secondary data analysis of individuals with alcohol dependence (n = 1,142) enrolled in the longitudinal, prospective COMBINE study, a multi site randomized placebo-controlled clinical trial, examining the association between reductions in WHO drinking risk levels and change in blood pressure, liver enzyme levels, and self-reported quality of life following treatment for alcohol dependence. RESULTS One- and two-level reductions in WHO drinking risk level during treatment were associated with significant reductions in systolic blood pressure (p < 0.001), improvements in liver enzyme levels (all p < 0.01), and significantly better quality of life (p < 0.001). CONCLUSIONS One- and two-level reductions in WHO drinking risk levels predicted significant improvements in markers of physical health and quality of life, suggesting that the WHO drinking risk level reduction could be a meaningful surrogate marker of improvements in how a person "feels and functions" following treatment for alcohol dependence. The WHO drinking risk levels could be useful in medical practice for identifying drinking reduction targets that correspond with clinically significant improvements in health and quality of life.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology , University of New Mexico, Albuquerque, New Mexico
| | - Henry R Kranzler
- Department of Psychiatry , University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kevin A Hallgren
- Department of Psychiatry and Behavioral Sciences , University of Washington, Seattle, Washington
| | | | - Daniel E Falk
- National Institute on Alcohol Abuse and Alcoholism , Bethesda, Maryland
| | - Raye Z Litten
- National Institute on Alcohol Abuse and Alcoholism , Bethesda, Maryland
| | - Deborah S Hasin
- Department of Epidemiology , Columbia University, New York, New York
| | - Karl F Mann
- Medical Faculty Mannheim , Central Institute of Mental Health, Heidelberg University, Mannheim, Germany
| | - Raymond F Anton
- Department of Psychiatry and Behavioral Sciences , Medical University of South Carolina, Charleston, South Carolina
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13
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Ray LA, Bujarski S, Roche DJO, Magill M. Overcoming the "Valley of Death" in Medications Development for Alcohol Use Disorder. Alcohol Clin Exp Res 2018; 42:1612-1622. [PMID: 29969156 PMCID: PMC6146966 DOI: 10.1111/acer.13829] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/27/2018] [Indexed: 12/29/2022]
Abstract
As the development of novel pharmacotherapies for alcohol use disorder (AUD) has been slow, the discovery and testing of more efficacious pharmacotherapies for AUD represent a high priority research area. In fact, the transition from preclinical to clinical testing of novel compounds has been termed the "valley of death" in medications development. One key obstacle consists of the lack of an articulated set of goals for each stage of medications development. Specifically, the knowledge outputs required to make the transition from safety testing, to early efficacy detection, to confirming clinical efficacy remain unclear, and this is despite a great deal of interest and substantial financial investment in developing novel therapeutics for AUD. This qualitative critical review seeks to draw parallels and lessons from the well-established stage model for behavioral therapies research with alcohol and other substance use disorders and to apply these insights into AUD pharmacotherapy development. We argue that human laboratory models and/or pilot randomized controlled trials should serve as intermediaries in the transition from preclinical studies to large, and costly, randomized controlled efficacy trials. The relative strengths and weaknesses of pilot clinical trials versus human laboratory studies for bridging the "valley of death" are discussed and explored via a Monte Carlo data simulation study. Multiple permutations of suitable research designs informed by the behavioral therapies development model are discussed with the overall goal of promoting consilience and maximizing efficiency across all phases of clinical testing of novel AUD pharmacotherapies.
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Affiliation(s)
- Lara A. Ray
- Department of Psychology, University of California, Los
Angeles, Los Angeles, CA, USA
| | - Spencer Bujarski
- Department of Psychology, University of California, Los
Angeles, Los Angeles, CA, USA
| | | | - Molly Magill
- Center for Alcohol and Addiction Studies, Brown University,
Providence, RI, USA
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14
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Pan CH, Li MS, Yang TW, Huang MC, Su SS, Hung YN, Chen CC, Kuo CJ. Identification and medical utilization of incident cases of alcohol dependence: A population-based case-control study. Drug Alcohol Depend 2018; 188:216-223. [PMID: 29778776 DOI: 10.1016/j.drugalcdep.2018.03.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 03/24/2018] [Accepted: 03/27/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Patients with alcohol dependence (AD) often seek help from medical professionals due to alcohol-related diseases, but the overall distribution of medical specialties identifying new AD cases is unclear. We investigated how such cases were identified and how medical resources were utilized before the identification of AD in a nationwide cohort. METHODS We enrolled a population-based cohort (N = 1,000,000) using the National Health Insurance Research Database of Taiwan; 8181 cases with incident AD were retrieved between January 1, 2000, and December 31, 2010. For this nested case-control study, four controls were matched for age and sex with each case based on risk-set sampling. We measured various dimensions of medical utilization before AD was diagnosed, including department visited, physical comorbidity, and medication used. Conditional logistic regression was used for estimating the variables associated with AD. RESULTS Patients living in less urbanized areas who were unemployed were more likely to develop AD. The highest proportions (34.2%) of AD cases were identified in the internal medicine department, followed by the emergency (22.3%) and psychiatry (18.7%) departments. AD patients had a higher risk of comorbid chronic hepatic disease (adjusted RR = 2.72, p < 0.001) before identification of AD than controls. AD patients also had greater numbers of hospital admissions than controls, including non-psychiatric and psychiatric hospitalizations. Outpatient visit numbers were similar for AD patients and controls. CONCLUSIONS The findings indicate that clinicians providing care in diverse medical settings should be prepared to screen for unhealthy alcohol use and to mitigate its detrimental effects.
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Affiliation(s)
- Chun-Hung Pan
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; Department of Psychology, National Chengchi University, Taipei, Taiwan
| | - Min-Shan Li
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan
| | - Tien-Wey Yang
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ming-Chyi Huang
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Sheng-Shiang Su
- Department of Computerized Center, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yen-Ni Hung
- School of Gerontology Health Management and Master Program in Long-Term Care, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Chiao-Chicy Chen
- Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan; Department of Psychiatry, Mackay Memorial Hospital, Taipei, Taiwan; Department of Psychiatry, Mackay Medical College, Taipei, Taiwan
| | - Chian-Jue Kuo
- Taipei City Psychiatric Center, Taipei City Hospital, Taipei, Taiwan; Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan.
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15
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Kiluk BD, Frankforter TL, Cusumano M, Nich C, Carroll KM. Change in DSM-5 Alcohol Use Disorder Criteria Count and Severity Level as a Treatment Outcome Indicator: Results from a Randomized Trial. Alcohol Clin Exp Res 2018; 42:10.1111/acer.13807. [PMID: 29870051 PMCID: PMC6281805 DOI: 10.1111/acer.13807] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 05/30/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Most clinical trials evaluating treatments for alcohol use target individuals meeting diagnostic criteria for alcohol use disorder (AUD), but few address change in diagnostic status following treatment or as a potential outcome indicator. This study evaluated whether DSM-5 AUD total criteria count or severity category was sensitive to change over time and treatment effects. METHODS Data were drawn from a randomized clinical trial that evaluated the efficacy of computer-based cognitive behavioral therapy program (CBT4CBT) for AUD. Sixty-eight individuals were randomized to 1 of the 3 weekly outpatient treatments for an 8-week period: (i) treatment as usual (TAU), (ii) TAU+CBT4CBT, and (iii) CBT4CBT+brief monitoring. Structured clinical interviews were used to determine current (past 30 days) AUD diagnosis at baseline, end-of-treatment, and 6 months following end-of-treatment. Change in the total number of DSM criteria endorsed, as well as severity categories (mild, moderate, severe), was evaluated across time and by treatment condition. RESULTS Generalized Poisson's linear mixed models revealed a significant reduction in the number of DSM criteria from baseline to treatment end point [time effect χ2 (1) = 35.54, p < 0.01], but no significant interactions between time and treatment condition. Fewer total criteria endorsed, as well as achieving at least a 2-level reduction in AUD severity category at end-of-treatment, were associated with better outcomes during follow-up. Chi-square results indicated a greater proportion of individuals assigned to TAU+CBT4CBT had at least a 2-level reduction in severity category compared to TAU, at trend-level significance [χ2 (2, 54) = 5.13, p = 0.07], consistent with primary alcohol use outcomes in the main trial. CONCLUSIONS This is the first study to demonstrate change in DSM-5 AUD total criteria count, as well as severity category, in a randomized clinical trial. These findings offer support for their use as a potential clinically meaningful outcome indicator.
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Affiliation(s)
- Brian D Kiluk
- Yale University School of Medicine, New Haven, Connecticut
| | | | | | - Charla Nich
- Yale University School of Medicine, New Haven, Connecticut
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16
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Riihimäki K, Heiska-Johansson A, Ketola E. Case-mix tool, costs and effectiveness in improving primary care mental health and substance abuse services. Nord J Psychiatry 2018; 72:109-111. [PMID: 29081248 DOI: 10.1080/08039488.2017.1395475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Despite its importance in improving care and developing services, high-quality data evaluating cost-effectiveness and services in different case-mix populations is scarce in primary care. AIMS The objective was to investigate the service use of those mental health and substance abuse patients, who use lots of services. METHODS Primary health care diagnosis-related groups (pDRG) is a tool to evaluate service provider system and improve efficiency, productivity and quality. We viewed all pDRG results available from the year 2015 concerning municipal mental health and substance abuse services. RESULTS In primary care mental health and substance abuse services, the most common ICD-10-codes were depression and substance abuse. One-fifth of patients produced 57% of costs. Their medium of appointments was 16 per year versus 6 per year of all patients. Only 54% of their diagnoses were recorded in the electronic health records versus 75% of all patients. They made 5.7 different pDRG episodes, including 1.8 episodes of depression, per patient. The average episode cost for this patient group was 301€. CONCLUSIONS pDRG makes health care production transparent also in mental health and substance abuse services. It is easy to identify patients, who use a lot of services and thus induce the majority of costs, and focus on their needs in managing and developing services.
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Affiliation(s)
- Kirsi Riihimäki
- a Mental Health and Substance Abuse Services, Social and Health Care , City of Järvenpää , Järvenpää , Finland
| | - Ainomaija Heiska-Johansson
- a Mental Health and Substance Abuse Services, Social and Health Care , City of Järvenpää , Järvenpää , Finland
| | - Eeva Ketola
- b Social and Health Care , City of Järvenpää , Järvenpää , Finland
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17
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Aldridge AP, Zarkin GA, Dowd WN, Bray JW. The Relationship Between End-of-Treatment Alcohol Use and Subsequent Healthcare Costs: Do Heavy Drinking Days Predict Higher Healthcare Costs? Alcohol Clin Exp Res 2017; 40:1122-8. [PMID: 27110675 DOI: 10.1111/acer.13054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 02/23/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND A challenge for evaluating alcohol treatment efficacy is determining what constitutes a "good" outcome or meaningful improvement. Abstinence at the end of treatment is an unambiguously good outcome; however, a focus on abstinence ignores the potential benefits of patients reducing their drinking to less problematic levels. Patients may be drinking at low-risk levels at the end of treatment but may be high-functioning and impose few social costs. In this study, we estimate the relationship between drinking at the end of COMBINE treatment and subsequent healthcare costs with an emphasis on heavy and nonheavy drinking levels. METHODS Indicators of heavy drinking days (HDDs; 5+ drinks for men, 4+ for women) and nonheavy drinking days (non-HDDs) during the last 30 days of COMBINE treatment were constructed for 748 patients enrolled in the COMBINE Economic Study. Generalized linear models were used to model total costs following COMBINE treatment as a function of drinking indicators. Different model specifications analyzed alternative counts of HDDs (e.g., 1 HDD and 2 to 30 HDDs), and groups having Both non-HDDs and HDDs. RESULTS Patients with HDDs had 66.4% (p < 0.01) higher healthcare costs than those who were abstinent. Having more than 2 HDDs was associated with the highest costs (75.9%, p < 0.01). Patients with non-HDDs had costs that were not significantly different than abstainers, even if they also had HDDs. However, those with HDDs only had costs 91.7% higher than abstainers (p < 0.01). CONCLUSIONS Having HDDs at the end of treatment is associated with higher costs. Patients who had Only HDDs at the end of treatment had worse subsequent outcomes than those who had Both non-HDDs and HDDs. These findings offer new context for evaluating treatment outcomes and provide new information on the association of drinking with consequences.
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Affiliation(s)
- Arnie P Aldridge
- Behavioral Health Economics Program , RTI International, Research Triangle Park, North Carolina
| | - Gary A Zarkin
- Behavioral Health Economics Program , RTI International, Research Triangle Park, North Carolina
| | - William N Dowd
- Behavioral Health Economics Program , RTI International, Research Triangle Park, North Carolina
| | - Jeremy W Bray
- Bryan School of Business and Economics , University of North Carolina, Greensboro, North Carolina
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18
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Bardazzi G, Zanna I, Ceroti M, Bendinelli B, Iozzi A, Caini S, Nesi G, Saieva C. A 5-Year Follow-Up of a Cohort of Italian Alcoholics: Hospital Admissions and Overall Survival. Alcohol Clin Exp Res 2017; 41:1309-1318. [PMID: 28425123 DOI: 10.1111/acer.13404] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 04/11/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Alcohol use disorders (AUDs), including alcohol dependence and alcohol abuse defined according to specific DSM-IV and ICD-10 criteria, can be potentially lethal, because they are associated with several medical and psychiatric conditions. This study aimed to describe the causes of hospitalization of a large cohort of subjects with alcohol dependence (alcoholics) enrolled in Florence (Italy) over a 5-year follow-up period and to evaluate the effect of hospitalization on overall survival. METHODS One thousand one hundred and thirty alcoholics, newly diagnosed from 1997 to 2001, were linked to the Regional Mortality Registry for update of vital status as of December 31, 2006, and to the Hospital Discharge electronic archives of the Regional Health System of Tuscany to verify hospital admissions (HAs) during the 5-year postcohort enrollment follow-up. Kaplan-Meier survival and Cox regression analyses were performed to evaluate any association of HA with overall survival. RESULTS A total of 3,916 new hospitalizations occurred during the 5-year follow-up. Most alcoholics (70.6%) reported at least 1 new hospitalization, with a first hospitalization rate of 61.7 per 100 person-years in the first year of follow-up. The mean number of hospitalizations per admitted subject was 4.87 (SD 7.4), and mean length of hospital stay was 8.5 days (SD 11.3). The main causes of hospitalization were mental disorders and diseases of the digestive system, as well as accidents or violence. Among those alcoholics alive after 1 year of follow-up, a significantly increased risk of dying in the following years could be predicted by early hospitalization in the 12 months preceding (hazard ratio [HR] 1.73; 95% confidence interval [CI] 1.15 to 2.60) or following (HR 3.59; 95% CI 2.31 to 5.61) enrollment in the cohort. CONCLUSIONS Our results confirm the association of AUDs with several serious medical conditions. This fact may be responsible for a high impact on health resource utilization and high social costs. Early hospitalization significantly predicts vital status at 5 years.
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Affiliation(s)
- Gabriele Bardazzi
- Local Health Unit (ASL10), Alcohol Day Service UFM C, Florence, Italy
| | - Ines Zanna
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Cancer Research and Prevention Institute (ISPO), Florence, Italy
| | - Marco Ceroti
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Cancer Research and Prevention Institute (ISPO), Florence, Italy
| | - Benedetta Bendinelli
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Cancer Research and Prevention Institute (ISPO), Florence, Italy
| | - Adriana Iozzi
- Local Health Unit (ASL10), Drug Addiction Unit UFM C, Florence, Italy
| | - Saverio Caini
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Cancer Research and Prevention Institute (ISPO), Florence, Italy
| | - Gabriella Nesi
- Department of Surgery and Translational Medicine, University of Florence, Florence, Italy
| | - Calogero Saieva
- Cancer Risk Factors and Lifestyle Epidemiology Unit, Cancer Research and Prevention Institute (ISPO), Florence, Italy
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19
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Kline-Simon AH, Litten RZ, Weisner CM, Falk DE. Posttreatment Low-Risk Drinking as a Predictor of Future Drinking and Problem Outcomes Among Individuals with Alcohol Use Disorders: A 9-Year Follow-Up. Alcohol Clin Exp Res 2017; 41:653-658. [PMID: 28072453 PMCID: PMC5567827 DOI: 10.1111/acer.13334] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Accepted: 01/06/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treatment for alcohol use disorders (AUDs) has traditionally been abstinence oriented, but new research and regulatory guidelines suggest that low-risk drinking may also be an acceptable treatment outcome. However, little is known about long-term outcomes for patients who become low-risk drinkers posttreatment. This study explores a posttreatment low-risk drinking outcome as a predictor of future drinking and psychosocial outcomes over 9 years. METHODS Study participants were adults with AUDs at treatment entry who received follow-up interviews 6 months posttreatment intake (N = 1,061) in 2 large randomized studies conducted at Kaiser Permanente Northern California, a large private, nonprofit, integrated health system. Six-month drinking status was defined as abstinent, low-risk (nonabstinent, no 5+ drinking days), or heavy drinking (1 or more days of 5+ drinks). Using logistic regression models, we explored the relationship between past 30-day drinking status at 6 months and odds of being abstinent or a low-risk drinker (compared to heavy drinking), and positive Addiction Severity Index psychosocial outcomes over 9 years (9-year follow-up rate of 73%). RESULTS Abstainers and low-risk drinkers at 6 months had higher odds of recent abstinence/low-risk drinking over 9 years than heavy drinkers; abstainers had better drinking outcomes than low-risk drinkers. Additionally, among those with interview data, 95% of abstainers and 94% of low-risk drinkers at 6 months were abstinent/low-risk drinkers at 9 years; surprisingly, 89% of heavy drinkers at 6 months were also abstinent/low-risk drinkers although still significantly fewer than the other groups. Abstainers and low-risk drinkers at 6 months had better psychiatric outcomes, and abstainers had better family/social outcomes than heavy drinkers; medical outcomes did not differ. Low-risk drinkers and abstainers showed no reliable differences across psychosocial measures. CONCLUSIONS The findings suggest that a low-risk drinking outcome may be reasonable over the long-term for some alcohol-dependent individuals receiving addiction treatment.
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Affiliation(s)
- Andrea H. Kline-Simon
- Division of Research, Kaiser Permanente Northern California,
Oakland, California, 94612-2304
| | - Raye Z. Litten
- National Institute on Alcohol Abuse and Alcoholism (NIAAA),
Bethesda, MD 20892-9304
| | - Constance M. Weisner
- Division of Research, Kaiser Permanente Northern California,
Oakland, California, 94612-2304
- Department of Psychiatry, University of California, San Francisco,
401 Parnassus Avenue, San Francisco, CA, 94143-0984
| | - Daniel E. Falk
- National Institute on Alcohol Abuse and Alcoholism (NIAAA),
Bethesda, MD 20892-9304
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20
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Kline-Simon AH, Chi FW, Mertens JR, Weisner C. Trajectories of remission and mortality over 13 years after intake to substance use treatment. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017. [PMID: 28635344 DOI: 10.1080/00952990.2016.1271883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Andrea H Kline-Simon
- a Division of Research , Kaiser Permanente Northern California , Oakland , CA , USA
| | - Felicia W Chi
- a Division of Research , Kaiser Permanente Northern California , Oakland , CA , USA
| | - Jennifer R Mertens
- b Aurora Public Schools Division of Accountability and Research , Aurora , CO , USA
| | - Constance Weisner
- a Division of Research , Kaiser Permanente Northern California , Oakland , CA , USA.,c Department of Psychiatry , University of California , San Francisco , CA , USA
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21
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Witkiewitz K, Hallgren KA, Kranzler HR, Mann KF, Hasin DS, Falk DE, Litten RZ, O'Malley SS, Anton RF. Clinical Validation of Reduced Alcohol Consumption After Treatment for Alcohol Dependence Using the World Health Organization Risk Drinking Levels. Alcohol Clin Exp Res 2016; 41:179-186. [PMID: 28019652 PMCID: PMC5205540 DOI: 10.1111/acer.13272] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 10/12/2016] [Indexed: 11/30/2022]
Abstract
Background Alcohol use disorder (AUD) is a highly prevalent public health problem associated with considerable individual and societal costs. Abstinence from alcohol is the most widely accepted target of treatment for AUD, but it severely limits treatment options and could deter individuals who prefer to reduce their drinking from seeking treatment. Clinical validation of reduced alcohol consumption as the primary outcome of alcohol clinical trials is critical for expanding treatment options. One potentially useful measure of alcohol treatment outcome is a reduction in the World Health Organization (WHO, International Guide for Monitoring Alcohol Consumption and Related Harm. Geneva, Switzerland, 2000) risk levels of alcohol use (very high risk, high risk, moderate risk, and low risk). For example, a 2‐shift reduction in WHO risk levels (e.g., high risk to low risk) has been used by the European Medicines Agency (2010, Guideline on the Development of Medicinal Products for the Treatment of Alcohol Dependence. UK) to evaluate nalmefene as a treatment for alcohol dependence (AD; Mann et al. 2013, Biol Psychiatry 73, 706–13). Methods The current study was a secondary data analysis of the COMBINE study (n = 1,383; Anton et al., 2006) to examine the association between reductions in WHO risk levels and reductions in alcohol‐related consequences and mental health symptoms during and following treatment in patients with AD. Results Any reduction in WHO risk drinking level during treatment was associated with significantly fewer alcohol‐related consequences and improved mental health at the end of treatment and for up to 1 year posttreatment. A greater reduction in WHO risk drinking level predicted a greater reduction in consequences and greater improvements in mental health. Conclusions Changes in WHO risk levels appear to be a valid end point for alcohol clinical trials. Based on the current findings, reductions in WHO risk drinking levels during treatment reflect meaningful reductions in alcohol‐related consequences and improved functioning.
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Affiliation(s)
- Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico
| | - Kevin A Hallgren
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington
| | - Henry R Kranzler
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Karl F Mann
- Department of Addictive Behaviour and Addiction Medicine, Central Institute of Mental Health, Mannheim, Germany
| | - Deborah S Hasin
- Department of Psychiatry, Mailman School of Public Health, Department of Epidemiology, Columbia University, New York City, New York
| | - Daniel E Falk
- National Institute on Alcohol Abuse and Alcoholism, National Insitutes of Health, Rockville, Maryland
| | - Raye Z Litten
- National Institute on Alcohol Abuse and Alcoholism, National Insitutes of Health, Rockville, Maryland
| | - Stephanie S O'Malley
- Department of Psychiatry, Substance Abuse Treatment Unit, Yale University, New Haven, Connecticut
| | - Raymond F Anton
- Medical University of South Carolina, Charleston, South Carolina
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22
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Measures of outcome for stimulant trials: ACTTION recommendations and research agenda. Drug Alcohol Depend 2016; 158:1-7. [PMID: 26652899 PMCID: PMC4698050 DOI: 10.1016/j.drugalcdep.2015.11.004] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Revised: 11/06/2015] [Accepted: 11/07/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND The development and approval of an efficacious pharmacotherapy for stimulant use disorders has been limited by the lack of a meaningful indicator of treatment success, other than sustained abstinence. METHODS In March, 2015, a meeting sponsored by Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) was convened to discuss the current state of the evidence regarding meaningful outcome measures in clinical trials for stimulant use disorders. Attendees included members of academia, funding and regulatory agencies, pharmaceutical companies, and healthcare organizations. The goal was to establish a research agenda for the development of a meaningful outcome measure that may be used as an endpoint in clinical trials for stimulant use disorders. RESULTS AND CONCLUSIONS Based on guidelines for the selection of clinical trial endpoints, the lessons learned from prior addiction clinical trials, and the process that led to identification of a meaningful indicator of treatment success for alcohol use disorders, several recommendations for future research were generated. These include a focus on the validation of patient reported outcome measures of functioning, the exploration of patterns of stimulant abstinence that may be associated with physical and/or psychosocial benefits, the role of urine testing for validating self-reported measures of stimulant abstinence, and the operational definitions for reduction-based measures in terms of frequency rather than quantity of stimulant use. These recommendations may be useful for secondary analyses of clinical trial data, and in the design of future clinical trials that may help establish a meaningful indicator of treatment success.
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Constant A, Le Gruyer A, Le Lan C, Riou F, Moirand R. Postdetoxification Factors Predicting Alcohol-Related Emergency Room Visits 12 to 24 Months After Discharge: Results from a Prospective Study of Patients with Alcohol Dependence. Alcohol Clin Exp Res 2015; 39:1236-42. [PMID: 26033309 DOI: 10.1111/acer.12753] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 04/14/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Relapse is common in patients with alcohol dependence, even after detoxification. The aims of this prospective study were to investigate changes affecting patients during the first 6 months after discharge from hospitalization for detoxification and to determine the influence of these changes on the likelihood of alcohol-related emergency room (ER) visits in the following 18-month period. METHODS The study included 88 patients hospitalized for participation in a detoxification program in the addiction department of a university hospital in Rennes, France. Alcohol consumption, psychiatric symptoms, and life events were investigated by addiction specialists during hospitalization and 6 months afterward. For each patient, the number of alcohol-related ER visits in the last 6 months was prospectively recorded at the hospital 12, 18, and 24 months after hospitalization. The rate ratios of ER visits as a function of sociodemographic variables and changes observed 6 months after discharge were estimated using Poisson regression with autoregressive errors. RESULTS Nearly half of the patients (47.7%) had ER visits in the 12- to 24-month period following discharge. The likelihood of ER visits was higher for patients living with friends/parents and for those with aggravated psychiatric symptoms, negative changes in their family life, and who had a medical follow-up in the 6 months after discharge. In contrast, the likelihood of ER visits was lower for patients living with children and those with improved psychiatric morbidity. Alcohol consumption and psychiatric symptoms at baseline had no significant effect. CONCLUSIONS Monitoring changes in psychiatric symptoms and family life early after a detoxification program may help identify patients who are vulnerable to relapse in the subsequent 18-month period. Systematic screening for these changes as early as possible, in combination with appropriate treatment and the establishment of a social support system, could be fundamental in avoiding further relapses and ER visits.
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Affiliation(s)
| | - Antonia Le Gruyer
- CHU de Rennes, Unité d'Addictologie, Rennes, France.,Faculté de Médecine, Univ Rennes 1, Rennes, France
| | | | - Francoise Riou
- Faculté de Médecine, Univ Rennes 1, Rennes, France.,Department of Public Health, Rennes University Hospital, Rennes, France
| | - Romain Moirand
- CHU de Rennes, Unité d'Addictologie, Rennes, France.,Faculté de Médecine, Univ Rennes 1, Rennes, France.,INSERM UMR 991, Rennes, France
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