Recurrent risk of hospitalization among older people with problematic alcohol use: a multiple failure-time analysis with a discontinuous risk model

Educational attainment and deaths of despair among individuals assessed for substance use severity: Findings from Swedish Addiction Severity Index (ASI) data

Aims: This study examined the association between educational attainment and the risk of deaths of despair among individuals assessed for substance use severity at municipal social services in Sweden. It aimed to determine whether the protective association between education and despair-related mortality risk, commonly observed in broader population studies, also applies to this high-risk, treatment-seeking population. Methods: We linked data from municipal Addiction Severity Index (ASI) assessments to various population registers. The study population included adults aged 25 years or older who were assessed for substance use severity between 1999 and 2019. Fine-Gray competing risk regression models were employed to examine the association between educational attainment and despair-related mortality, both overall and by subtype (alcohol-related, drug use-related, suicide). Results: Tertiary education was unexpectedly associated with increased risks of overall despair-related mortality, alcohol-related and drug use-related mortality, after controlling for demographic characteristics, ASI composite scores and substance use onset age. No significant associations were found between education and suicide. Conclusions: The counterintuitive finding that tertiary education is linked to a greater risk of despair-related mortality among social service users may be attributed to differences between the treatment-seeking population and the general population. Highly educated individuals who seek treatment from municipal social services might have severe substance use and complex psychosocial problems and/or contact social services after exhausting other treatment options. Further research is necessary to understand how educational and socioeconomic factors influence treatment pathways for individuals with severe substance use problems in Sweden and how these different pathways impact health-related outcomes.

Utilisation of alcohol-related treatment after a first alcohol use disorder diagnosis in Hamburg, Germany

BACKGROUND

A variety of treatment options for people with alcohol use disorder (AUD) exist. Surveys estimate that 1 in 10 people with AUD utilise treatment, but real-world treatment pathways remain covert. This data-linkage study seeks to characterise treatment utilisation patterns to identify gaps in treatment access and delivery in Germany.

METHODS

Linking individual-level data from three sources (statutory health insurance, pension funds, outpatient addiction care services) identified seven alcohol-related treatment types delivered in outpatient (brief psychiatric consultation; formal psychotherapy; pharmacotherapy; low-threshold counselling), inpatient (standard, somatic inpatient treatment; intensive inpatient treatment with somatic and psychosocial care), or either of the two settings (long-term rehabilitation treatment) during 2016-2021. For patients with a new AUD diagnosis (ICD-10: F10.1-9), treatment utilisation over 24 months was recorded and patterns were identified using latent class analyses.

RESULTS

Of n = 9,491 patients with a new AUD diagnosis, 30% utilised at least one alcohol-related treatment type. Treatment utilisation was associated with younger age, female sex, unemployment, German nationality, and lower physical comorbidity. Among treatment entrants, nearly half received only brief psychiatric consultation. A similar share of patients utilised standard or intensive inpatient treatment; the latter occasionally followed by rehabilitation treatment. Formal psychotherapy, low-threshold counselling, and pharmacotherapy were rarely utilised and were mostly used in conjunction with other treatments.

CONCLUSIONS

The real-world utilisation of alcohol-related treatments contrasts with existing guidelines, as most patients with diagnosed AUD do not receive adequate care. Structural and social barriers should be minimised to ensure healthcare provision for those affected.

Perceived Risk of Binge Drinking among Older Alcohol Users: Associations with Alcohol Use Frequency, Binge Drinking, Alcohol Use Disorder, and Alcohol Treatment Use

Despite the high prevalence of alcohol use and binge drinking among older adults, little research has been conducted on the association between their alcohol risk perception and alcohol use patterns. Using data on past-year alcohol users aged 50 and older (N = 6693) in the 2022 National Survey on Drug Use and Health, we examined the (1) associations between risk perception of binge alcohol use 1-2 times a week and alcohol use frequency, binge use frequency, and alcohol use disorder (AUD), and (2) the association between alcohol treatment use and risk perception. About 40% of past-year alcohol users perceived great risk of binge alcohol use 1-2 times a week, and 27% of past-year users had binge drinking in the past month. Multivariable analyses showed the negative association between great risk perception and alcohol use frequency (IRR = 0.60, 95%CI = 0.48-0.74 for daily use) and past-month binge alcohol use (IRR = 0.33, 95%CI = 0.19-0.57 for 6-19 days of binge use). The odds of great risk perception were also lower among those with mild AUD. Risk perception was not significantly associated with alcohol treatment. The lower likelihood of risk perception among problematic alcohol users and low treatment use is concerning. Education and interventions to reduce harm from alcohol are needed.

Immigrant background, incarceration history and recidivism among adults assessed for illicit substance use severity: Findings from a Swedish registry study

BACKGROUND

In Sweden, as in other countries, individuals with immigrant backgrounds are disproportionately represented within the incarcerated population. This study examined the association between immigrant background and future incarceration for individuals assessed for illicit substance use severity, while considering their prior incarceration history.

METHODS

Using data from Swedish Addiction Severity Index (ASI) assessments linked to register data from Statistics Sweden, we employed Zero-Inflated Negative Binomial (ZINB) regression models to analyse differences in incarceration histories within five years before and after ASI assessments based on immigrant backgrounds. Additionally, Cox proportional-hazard models were used to assess the likelihood of post-assessment incarceration among these groups.

RESULTS

Immigrant background was positively associated with pre- and post-assessment incarceration. First- and second-generation immigrants from the Global South had longer periods of incarceration in the five years before assessments compared to native Swedes. Post-assessment, first-generation immigrants showed longer periods of incarceration. Survival analyses supported these findings, indicating a higher risk of prolonged post-assessment incarceration among all immigrant groups, particularly first-generation immigrants from the Global South.

CONCLUSION

Among individuals assessed for illicit drug use within Swedish municipalities, those with immigrant backgrounds faced higher incarceration risks, even after controlling for substance use severity and prior incarceration. Tailored interventions and support systems are vital to prevent re-entry into the criminal justice system. Timely actions can break re-offending cycles, redirecting paths away from reoffending and towards legal reintegration, thereby reducing incarceration and recidivism rates.

Addiction severity and re-employment in Sweden among adults with risky alcohol and drug use

BACKGROUND

The Addiction Severity Index (ASI) assesses respondents' biopsychosocial problems in seven addiction-related domains (mental health, family and social relations, employment, alcohol use, drug use, physical health, and legal problems). This study examined the association between the seven ASI composite scores and re-employment in a sample of Swedish adults screened for risky alcohol and drug use who were without employment at assessment.

METHODS

We conducted a retrospective cohort analysis of employment outcomes among 6502 unemployed adults living in Sweden who completed an ASI assessment for risky alcohol and drug use. The study linked ASI scores to annual tax register data. The primary outcome was employment, defined as having earnings above an administrative threshold. We used Cox proportional hazard models to estimate the association between time to re-employment and ASI composite scores, controlling for demographic characteristics, RESULTS: Approximately three in ten individuals in the sample regained employment within five years. ASI composite scores suggested widespread biopsychosocial problems. Re-employment was associated with lower ASI composite scores for mental health (estimate: 0.775, 95 % confidence interval: 0.629-0.956), employment (estimate: 0.669, confidence interval: 0.532-0.841), drug use (estimate: 0.628, confidence interval: 0.428-0.924), and health (estimate: 0.798, confidence interval: 0.699-0.912).

CONCLUSIONS

This study suggests that several ASI domains may provide information on the complex factors (i.e., mental health, health, drug use) associated with long-term unemployment for people with risky substance use.

'Ageing with an alcohol problem is not what I envision': reclaiming agency in shaping personal ageing trajectory and recovery from alcohol problems

BACKGROUND

Eliciting and understanding older persons' descriptions of their resources for healthy ageing and the interaction of these resources with alcohol use and alcohol problems can facilitate health promotion. It can also inform clinicians when identifying areas of recovery capital that present risks and strength for older people seeking alcohol treatment. The objective of this study was to illuminate the experiences and perspectives of older persons on ageing, alcohol use, treatment, and recovery from alcohol problems, as well as their understanding of healthy ageing.

METHODS

Eight men and two women, aged 61 to 73 years, with moderate drinking as a treatment goal and treated at an outpatient alcohol clinic in Sweden, participated in semi-structured audio-recorded virtual interviews. A qualitative content analysis examined the transcribed interviews.

RESULTS

Three themes were identified: "Tipping the balance", "Staying behind a veil" and "Lifting the vail". First, participants understood healthy ageing as a personal and multidimensional process that involved actively expanding, maintaining or adjusting to the resources needed to lead an active and meaningful life while preserving autonomy, dignity and independence for as long as possible. Second, most participants viewed moderate alcohol use as a contributor to healthy ageing. They sought treatment when their drinking became unsustainable and an immediate threat to their healthy ageing resources. Stigma, ambivalence and a lack of treatment options, however, contributed to delayed treatment. Third, the participants responded to treatment approaches that elicited their concern, incorporated their expertise and treatment and life goals, appreciated their autonomy and agency, and considered them partners in goal setting and decision making. Reduced drinking helped participants regain their agency and improved their healthy ageing capital which in turn catalyzed continuing recovery.

CONCLUSIONS

Older persons in non-abstinent recovery perceive healthy ageing and alcohol recovery as personal and interacting multidimensional processes involving their agency to improve biopsychosocial functioning. Treatment approaches that recognize older persons' desire for healthy ageing, incorporate their treatment goals and respect their autonomy are likely to be acceptable and effective.

Pilot randomized controlled trial of a hospital-based substance use treatment and recovery team (START) to improve initiation of medication for alcohol or opioid use disorder and linkage to follow-up care

OBJECTIVES

We conducted a pilot randomized controlled trial (RCT) to explore whether a hospital inpatient addiction consult team (Substance Use Treatment and Recovery Team [START]) based on collaborative care was feasible, acceptable to patients, and whether it could improve uptake of medication in the hospital and linkage to care after discharge, as well as reduce substance use and hospital readmission. The START consisted of an addiction medicine specialist and care manager who implemented a motivational and discharge planning intervention.

METHODS

We randomized inpatients age ≥ 18 with a probable alcohol or opioid use disorder to receive START or usual care. We assessed feasibility and acceptability of START and the RCT, and we conducted an intent-to-treat analysis on data from the electronic medical record and patient interviews at baseline and 1-month postdischarge. The study compared RCT outcomes (medication for alcohol or opioid use disorder, linkage to follow-up care after discharge, substance use, hospital readmission) between arms by fitting logistic and linear regression models.

FINDINGS

Of 38 START patients, 97 % met with the addiction medicine specialist and care manager; 89 % received ≥8 of 10 intervention components. All patients receiving START found it to be somewhat or very acceptable. START patients had higher odds of initiating medication during the inpatient stay (OR 6.26, 95 % CI = 2.38-16.48, p < .001) and being linked to follow-up care (OR 5.76, 95 % CI = 1.86-17.86, p < .01) compared to usual care patients (N = 50). The study found no significant differences between groups in drinking or opioid use; patients in both groups reported using fewer substances at the 1-month follow-up.

CONCLUSIONS

Pilot data suggest START and RCT implementation are feasible and acceptable and that START may facilitate medication initiation and linkage to follow-up for inpatients with an alcohol or opioid use disorder. A larger trial should assess effectiveness, covariates, and moderators of intervention effects.