Need and non-need factors associated with addiction treatment utilization in a cohort of homeless and housed urban poor

BACKGROUND

Research on addiction treatment utilization in indigent samples mainly has been retrospective, without measures of addictive consequences, social network influences, and motivation. Prospective assessment of factors influencing utilization could inform policy and clinical care.

OBJECTIVE

We sought to identify factors associated with utilization of addiction treatment and mutual help groups among substance-dependent persons with high rates of homelessness.

RESEARCH AND METHODS

This was a prospective cohort of patients detoxified from alcohol or drugs at baseline who were followed for 2 years in a randomized clinical trial of linkage to primary care (n = 274). Outcomes included utilization of Inpatient/Residential, Outpatient, Any Treatment, and Mutual Help Groups. Predictor variables in longitudinal regression analyses came from the literature and clinical experience, organized according to theoretical categories of Need, and non-Need (eg, Predisposing and Enabling).

RESULTS

Many subjects used Inpatient/Residential (72%), Outpatient (62%), Any Treatment (88%) or Mutual Help Groups (93%) at least once. In multivariable analyses, addictive consequences (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.12-1.71), motivation (OR 1.32, 95% CI 1.09-1.60), and female gender (OR 1.80, 95% CI 1.13-2.86) were associated with most treatment types (ORs are for Any Treatment). Homelessness was associated with Residential/Inpatient (for Chronically Homeless vs. Housed, OR 1.75, 95% CI 1.04-2.94). Living with one's children (OR 0.51, 95% CI 0.31-0.84) and substance-abusing social environment (OR 0.65, 95% CI 0.43-0.98) were negatively associated with Any Treatment.

CONCLUSIONS

In this cohort of substance-dependent persons, addictive consequences, social network variables, and motivation were associated with treatment utilization. Non-need factors, including living with one's children and gender, also were significant.

Relationship of depressive symptoms and mental health functioning to repeat detoxification

To better understand residential detoxification use, we assessed the roles of depressive symptoms (DS) and mental health functioning (MHF) on repeat detoxification. A prospective cohort of residential detoxification patients (N=400) without primary medical care was followed over 2 years at 6-month intervals. Subsequent detoxification admissions were examined using a statewide administrative database and DS (Center for Epidemiologic Studies Depression Scale) and MHF (SF-36 mental component summary subscale) measurements at follow-up. Incidence rate ratios of return to detoxification were estimated using multivariable longitudinal Poisson regression. In separate analyses, greater DS and worse MHF predicted higher detoxification use rates. Clinically significant worsening (10 points) of DS and MHF on objective scales predicted a 20% increased rate of detoxification readmission. Male sex, heroin as a problem substance, and race/ethnicity each predicted detoxification use. These data suggest that identifying individuals with DS or worse MHF after detoxification may provide opportunities for clinical intervention to reduce recurrent residential detoxification.

Health utility ratings for a spectrum of alcohol-related health states

BACKGROUND

Preference-based utility ratings for health conditions are important components of cost-utility analyses and population burden of disease estimates. However, utility ratings for alcohol problems have not been determined.

OBJECTIVES

The objectives of this study were to directly measure utility ratings for a spectrum of alcohol-related health states and to compare different methods of utility measurement.

DESIGN, SETTING, AND SUBJECTS

The authors conducted a cross-sectional interview of 200 adults from a clinic and community sample.

METHODS

Subjects completed computerized visual analog scale (VAS), time tradeoff (TTO), and standard gamble (SG) utility measurement exercises for their current health, a blindness scenario, and for 6 alcohol-related health state scenarios presented in random order. The main outcome measures were the utility ratings, scaled from 0 to 1, and anchored by death (0) and perfect health (1).

RESULTS

The 200 subjects were middle-aged (mean, 41 +/- 14 years), 61% women, and racially diverse (48% black, 43% white). Utility ratings decreased as the severity of the alcohol-related health state increased, but differed significantly among the VAS, TTO, and SG methods within each health state. Adjusted mean (95% confidence interval) utility ratings for alcohol dependence (VAS, 0.38 [0.34-0.41]; TTO, 0.54 [0.48-0.60]; SG, 0.68 [0.63-0.73]) and alcohol abuse (VAS, 0.53 [0.49-0.56]; TTO, 0.71 [0.65-77]; SG, 0.76 [0.71-0.81]) were significantly lower than utility ratings for nondrinking, moderate drinking, at-risk drinking, current health, and blindness.

CONCLUSIONS

Utility ratings for alcohol-related health states decrease as the severity of alcohol use increases. The low utility ratings for alcohol abuse and alcohol dependence are similar to those reported for other severe chronic medical conditions.

Homeless chronicity and health-related quality of life trajectories among adults with addictions

BACKGROUND

New federal initiatives target funds toward chronically homeless as distinct from other homeless persons. Few data exist, however, to substantiate the implications of chronic homelessness for major health outcomes.

OBJECTIVES

Using data from a 2-year cohort of addicted persons, we tested whether changes in mental and physical health-related quality of life (HRQOL) differed according to homeless chronicity.

METHODS

Using self-reported homelessness, we classified subjects as chronically homeless (CH; n = 60), transitionally homeless (TRANS; n = 108), or as housed comparison subjects (HSD; n = 106). The Short Form-36 Health Survey, administered at baseline and 2 follow-ups over a period of 2 years, provided a Mental Component Summary (MCS) and a Physical Component Summary (PCS) for HRQOL. Mixed model linear regression was used to test the association between housing status, MCS, and PCS. Additional models assessed whether medical, psychiatric, addiction, and social support measures could account for HRQOL differences.

RESULTS

All subjects had low MCS scores at study entry (mean, 31.2; SD, 12.6). However, there was a significant housing status-by-time interaction (P = 0.01). At final follow-up, CH and TRANS subjects had lower adjusted MCS scores than HSD subjects (33.4, 38.8, and 43.7 for the 3 groups, respectively; all P < or = 0.01). By contrast, housing status and PCS were not significantly associated (P = 0.19). Medical, psychiatric, addiction, and social support variables had significant associations with MCS, and their inclusion in the regression reduced the apparent effect of housing status on MCS.

CONCLUSIONS

Chronic homelessness was associated with especially poor mental but not physical HRQOL over time. These findings reinforce a new typology of homelessness.

Addressing Smoking Cessation in Methadone Programs

Little is known about how well methadone programs address smoking cessation. We describe the frequency of smoking cessation counseling, and factors affecting its provision in methadone programs. We conducted a cross-sectional survey of methadone patients and their counselors. Of 575 patients, 76% were eligible smokers. Although only 48% of patients reported receiving smoking cessation counseling within the previous six months, 97% of counselors reported providing it (p < 0.0001). Time with one counselor was significantly associated with patient report of receiving smoking cessation counseling (OR 1.19 [95% CI 1.04-1.36]). Although addiction counseling is required in methadone programs, nicotine addiction is addressed less than half the time. Methadone programs should prioritize the provision of effective smoking cessation and facilitate continuity of patient-counselor relationships.

Primary medical care and reductions in addiction severity: a prospective cohort study

AIMS

To assess whether receipt of primary medical care can lead to improved outcomes for adults with addictions.

DESIGN

We studied a prospective cohort of adults enrolled in a randomized trial to improve linkage with primary medical care.

METHODS

Subjects at a residential detoxification unit with alcohol, heroin or cocaine as a substance of choice, and no primary medical care were enrolled. Receipt of primary medical care was assessed over 2 years. Outcomes included (1) alcohol severity, (2) drug severity and (3) any substance use.

FINDINGS

For the 391 subjects, receipt of primary care (> or = 2 visits) was associated with a lower odds of drug use or alcohol intoxication (adjusted odds ratio (AOR) 0.45, 95% confidence interval (CI) 0.29-0.69, 2 d.f. chi(2)P = 0.002). For 248 subjects with alcohol as a substance of choice, alcohol severity was lower in those who received primary care [predicted mean Addiction Severity Index (ASI) alcohol scores for those reporting > or = 2, 1 and 0 visits, respectively, 0.30, 0.26 and 0.34, P = 0.04]. For 300 subjects with heroin or cocaine as a substance of choice, drug severity was lower in those who received primary care (predicted mean ASI drug scores for those reporting > or = 2, 1 and 0 visits, respectively, 0.13, 0.15 and 0.16, P = 0.01).

CONCLUSIONS

Receipt of primary medical care is associated with improved addiction severity. These results support efforts to link patients with addictions to primary medical care services.

Suicidal behavior, drug use and depressive symptoms after detoxification: a 2-year prospective study

INTRODUCTION

Individuals with substance-related disorders are at increased risk for suicidal behavior. Identifying those at higher risk for suicide among this population is difficult and informed mainly on the basis of cross-sectional data.

METHODS

We examined factors associated with drug-related suicidal behavior using multivariable regression analyses in a 2-year prospective study of 470 inpatients enrolled from an unlocked, detoxification unit. Suicidal behavior included suicidal ideation (SI) and suicide attempt (SA).

RESULTS

Lifetime prevalence for SI was 28.5%, and for SA, 21.9%. During the 2-year follow-up, 19.9% of the sample endorsed suicidal ideation and 6.9% reported a suicide attempt. Correlates of lifetime suicidal behavior included younger age, female, Hispanic, greater depressive symptoms, past sexual abuse, and problem sedative or alcohol use. Factors associated with suicidal behavior at follow-up included past suicidal behavior, more depressive symptoms, and more frequent benzodiazepine and alcohol use. Cocaine and heroin use did not reach statistical significance.

CONCLUSIONS

Suicidal behavior is common among individuals with substance-related disorders. Differences in "suicide potential" may exist between drug categories with CNS depressants increasing the risk. These findings highlight the importance of addressing the recurrent 'suicide risk' of patients with substance-related disorders and regular monitoring for changes in depressive symptoms and drug use. Based on the prevalence and severity of this problem, the role of universal suicide screening of individuals with substance-related disorders merits greater attention.

Web-based screening and brief intervention for the spectrum of alcohol problems

CONTEXT

Many persons who drink excessively remain unidentified and do not receive interventions. Screening and intervention using the World Wide Web could make such services more accessible and therefore more widely used.

OBJECTIVE

To evaluate the use of a novel alcohol screening and brief intervention Web site.

DESIGN

A Web site was developed, posted, and its use was evaluated. We analyzed a sample of visitors who completed alcohol screening over a 14-month period to describe their alcohol use, and their use of portions of the Web site that provide information and referral resources.

SETTING

The Internet.

PATIENTS OR OTHER PARTICIPANTS

Web site visitors, with a focus on visitors who completed an alcohol-screening questionnaire about their own drinking.

INTERVENTION

Brief intervention via the Web site, consisting mainly of feedback, advice, and a menu of change options and referral information.

MAIN OUTCOME MEASURES

Self-reported drinking amounts and alcohol screening test scores, and utilization of Web site components.

RESULTS

Visitors completed online alcohol screening questionnaires at a rate of 50,711/year of 115,925 visitors/year. In a 14-month period, 39,842 adults completed the questionnaire about their own drinking habits; 66% were men, 90% reported drinking hazardous amounts (per occasion or typical weekly amounts), 88% reported binge (per occasion) drinking, and 55% reported typically exceeding weekly risky drinking limits. Most (65%) had alcohol screening test results (AUDIT > or = 8) consistent with alcohol abuse or dependence; similar proportions of women and men were hazardous drinkers. One-fifth of visitors visited portions of the Web site that provided additional information about alcohol use and referrals. Visitors with possible alcohol abuse or dependence were more likely than those without these disorders to visit a part of the Web site designed for those seeking additional help (33% vs. 8%, P < 0.0001).

CONCLUSIONS

A well-publicized, easily accessible, research-based screening and intervention Web site can attract many users, most of whom are drinking excessively, and many of whom avail themselves of referral information after receiving individualized feedback.

Burden of medical illness in drug- and alcohol-dependent persons without primary care

Little is known about the frequency, severity, and risk factors for disease in drug- and alcohol-dependent persons without primary medical care. Our aims are to assess the burden of medical illness, identify patient and substance dependence characteristics associated with worse physical health, and compare measures of illness burden in this population. This was accomplished through a cross-sectional study among alcohol-, heroin- or cocaine-dependent persons without primary medical care who were admitted to an urban inpatient detoxification unit. The mean age of these patients was 35.7 (SD 7.8) years; 76% were male and 46% were Black. Forty-five percent reported being diagnosed with a chronic illness, and 80% had prior medical hospitalizations. The mean age-adjusted SF-36 Physical Component Summary (PCS) score was lower than the general U.S. population norm (44.1 vs 50.1; p<0.001). In multivariable analysis, female gender (adjusted mean change in PCS score: -3.71 points, p=.002), problem use of hallucinogens (-3.51, p=0.013), heroin (-2.94, p=0.008), other opiates (-3.20, p=.045), living alone (-3.15, p=.023), having medical insurance (-2.26, p=0.014) and older age (-.22 points per year, p=0.001) were associated with worse health. From these data, it seems that alcohol- and drug-dependent persons without primary medical care have a substantial burden of medical illness compared to age- and gender-matched U.S. population controls. While the optimal measure of medical illness burden in this population is unclear, a variety of health measures document this medical illness burden in addicted persons.

Linkage with primary medical care in a prospective cohort of adults with addictions in inpatient detoxification: room for improvement

OBJECTIVE

To identify patient characteristics and health care experiences associated with primary care linkage after alcohol or drug detoxification.

DATA SOURCES/STUDY SETTING

Primary data collected over two years. Subjects were adults without primary medical care, in an urban residential detoxification program.

STUDY DESIGN

A prospective cohort study in the context of a randomized trial of a linkage intervention, and an expansion of Medicaid benefits.

DATA COLLECTION/EXTRACTION METHODS

Data were collected by interview assessment of predisposing, enabling, and illness variables. Linkage was defined as self-report of at least one visit with a primary care clinician during follow-up.

PRINCIPAL FINDINGS

Of 400 subjects, 63 percent linked with primary medical care. In a multivariable model adjusting for randomization assignment, predisposing, enabling, and illness variables, women, those with no recent incarceration, those with support for abstinence by family or friends, and those who had visited a medical clinic or physician recently were significantly more likely to link with primary care. Those with health insurance during follow-up were also more likely to link. Recent mental health or addictions treatment utilization and health status were not associated with linkage.

CONCLUSIONS

A substantial proportion of adults with addictions do not link with primary medical care. These data suggest that efforts could be focused on those least likely to link, that contacts with mental health and addictions treatment providers are underutilized opportunities for these efforts, and that health policy changes such as expanding health insurance benefits may improve entry of substance-dependent patients into primary medical care.

Establishment of a Multidisciplinary Health Evaluation and Linkage to Primary Care (HELP) Clinic in a Detoxification Unit

We evaluated the feasibility of establishing a multidisciplinary Health Evaluation and Linkage to Primary care (HELP) clinic at an urban residential detoxification unit. Patients received a clinical evaluation and facilitated linkage to primary medical care including personalized referral, reminders, and appointment rescheduling. Of 235 adults reporting alcohol, cocaine or heroin as first or second drug of choice and without a primary care physician, 178 (76%) received a full HELP clinic evaluation, 35 (15%) some clinic components, and 7 (3%) only a primary care appointment. Of those with a full evaluation, 28% received pneumococcal vaccination, and most received health behavior counseling. Over the subsequent 2 years, 131 (60%) of the 220 patients whom had any contact with the HELP clinic had at least one primary care visit. A multidisciplinary health clinic to evaluate patients during detoxification is feasible and can link patients with substance dependence to primary medical care.

Alcohol Use Disorders: Screening and Diagnosis

The purpose of this article is to provide an overview of empirically supported, primarily self-report methods of screening and diagnosis related to alcohol use disorders (AUDs). The discussion of screening instruments focuses on the primary care setting, and the diagnosis instruments discussion centers on the alcohol (and other drug) treatment setting. The literature shows that the AUDIT and the CAGE are the most widely validated methods of screening for AUDs in primary care and may be applied readily in that context. Similarly, a number of instruments designed to derive DSM-IV (and ICD-10) AUD diagnoses, as well as constructs related to how AUDs are defined, are available and can meet a variety of clinical needs. Future research priorities include further development of brief methods to identify hazardous drinkers or individuals who have an AUD, as well as refinement of diagnosis instruments to increase their application across treatment settings and subpopulations.

Linking alcohol- and drug-dependent adults to primary medical care: a randomized controlled trial of a multi-disciplinary health intervention in a detoxification unit

AIM

Pragmatic approaches to integration of medical care and substance abuse treatment are desired. We assessed the effectiveness of a novel multi-disciplinary clinic for linking patients in a residential detoxification program to primary medical care.

PARTICIPANTS

We enrolled patients undergoing in-patient detoxification from alcohol, heroin or cocaine who had no primary care physician into a randomized controlled trial. The intervention consisted of a clinical evaluation at the detoxification unit in the health evaluation and linkage to primary care (HELP) clinic by a nurse, social worker and physician and facilitated referral to an off-site primary care clinic. The primary outcome of interest was attendance at a primary care appointment within 12 months. Secondary outcomes assessed over 24 months were addiction severity, health-related quality of life, utilization of medical and addiction services and HIV risk behaviors.

FINDINGS

Of the 470 subjects enrolled, 235 were randomized to the HELP clinic intervention. Linkage to primary medical care occurred in 69% of the intervention group compared to 53% in the control group (P = 0.0003). The clinic was similarly effective for subjects with alcohol and illicit drug problems. Randomization to the HELP clinic resulted in no significant differences in secondary outcomes.

CONCLUSIONS

The HELP clinic, a multi-disciplinary clinic located in a detoxification unit, effectively linked alcohol- and drug-dependent individuals to primary medical care. This intervention utilized a 'reachable moment', the period of addiction care, as a window of opportunity for linking substance abusers to medical care.

Slowing the revolving door: stabilization programs reduce homeless persons' substance use after detoxification

This study examined whether homelessness predicted earlier resumption of substance use after detoxification, and sought evidence concerning the impact of post-detoxification stabilization programs among homeless and nonhomeless individuals. Kaplan-Meier plots and proportional hazards models were used to determine the association between homelessness, stabilization program use, and recurrent substance use in a prospective cohort of persons entering inpatient detoxification (n=470). Among 254 persons available at 6 months, 76% reported recurrent substance use. Homeless persons not using stabilization programs experienced the highest hazard of return to substance use after detoxification, Hazard Ratio (HR) 1.26, 95% CI (0.88, 1.80). Homeless persons using these programs had the lowest rate of return to substance use: HR 0.61, 95% CI (0.40, 0.94). A similar impact of stabilization programs was not seen among nonhomeless subjects. Post-detoxification stabilization programs were associated with improved outcomes for homeless addicted persons. This treatment modality may slow the "revolving door" phenomenon of relapse after detoxification among homeless persons.

Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The screening and intervention in primary care (SIP) study

BACKGROUND

Screening and intervention for alcohol problems can reduce drinking and its consequences but are often not implemented.

OBJECTIVE

To test whether providing physicians with patients' alcohol screening results and simple individualized recommendations would affect the likelihood of a physician's having a discussion with patients about alcohol during a primary care visit and would affect subsequent alcohol use.

DESIGN

Cluster randomized, controlled trial.

SETTING

Urban academic primary care practice.

PARTICIPANTS

41 faculty and resident primary care physicians and 312 patients with hazardous drinking.

INTERVENTIONS

Providing physicians with alcohol screening results (CAGE questionnaire responses, alcohol consumption, and readiness to change) and recommendations for their patients at a visit.

MEASUREMENTS

Patient self-report of discussions about alcohol use immediately after the physician visit and alcohol use 6 months later.

RESULTS

Of 312 patients, 240 visited faculty physicians, 301 (97%) completed the outcome assessment after the office visit, and 236 (76%) were followed for 6 months. Faculty physicians in the intervention group tended to be more likely than faculty physicians in the control group to give patients advice about drinking (adjusted proportion, 64% [95% CI, 47% to 79%] vs. 42% [CI, 33% to 53%]) and to discuss problems associated with alcohol use (74% [CI, 59% to 85%] vs. 51% [CI, 39% to 62%]). Resident physicians' advice and discussions did not differ between groups. Six months later, patients who saw resident physicians in the intervention group had fewer drinks per drinking day (adjusted mean number of drinks, 3.8 [CI, 1.9 to 5.7] versus 11.6 [CI, 5.4 to 17.7]).

CONCLUSIONS

Although effects seem to differ by physician level of training, prompting physicians with alcohol screening results and recommendations for action can modestly increase discussions about alcohol use and advice to patients and may decrease alcohol consumption.

Education of preventive medicine residents: alcohol, tobacco, and other drug abuse

BACKGROUND

Generalist physicians' addiction training is inadequate, but general preventive medicine residency (PMR) programs have not been studied. We determined PMR programs' alcohol, tobacco, and other drug abuse (ATOD) training from 1995 to 2000 and identified barriers to this education.

METHODS

Interviewer-administered telephone survey of program directors (PDs) of accredited PMR programs in the United States.

RESULTS

We interviewed all 41 PMR PDs. While 78% of PMR PDs reported interest in increasing ATOD education, for 68% it was not a high educational priority. Tobacco ranked in the top third of preventive medicine topics by 58%, while alcohol and other drugs ranked in the bottom third by 48% and 52%, respectively. Twenty-two percent of programs required a clinical ATOD rotation, most commonly smoking-cessation clinics. Only 29% of PMR PDs felt that residents were well prepared in clinical aspects of ATOD, while 60% felt that residents were prepared in ATOD research and public health issues. The most commonly reported barriers to ATOD training were lack of resident interest and defined competencies (64% each); limited faculty time (59%); limited teaching time (54%); lack of available teaching materials (53%); and lack of faculty expertise (51%).

CONCLUSIONS

While the majority of PMR PDs recognize the importance of incorporating teaching about addictions into training, much of the ATOD education in PMRs focuses on tobacco alone. Setting educational standards, defining competencies, investing in faculty development, and creating ATOD curricular modules are important next steps toward preparing preventive medicine physicians to effectively reduce the public health toll of addictions.

Professional satisfaction experienced when caring for substance-abusing patients: faculty and resident physician perspectives

This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients' family history. Physicians were less likely (P <.05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction. Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician satisfaction may improve care for patients with addictions.

The relationship between sexual and physical abuse and substance abuse consequences

This study examines the relationship between a history of physical and sexual abuse (PhySexAbuse) and drug and alcohol related consequences. We performed a cross-sectional analysis of data from 359 male and 111 female subjects recruited from an inpatient detoxification unit. The Inventory of Drug Use Consequences (InDUC), measured negative life consequences of substance use. Eighty-one percent of women and 69% of men report past PhySexAbuse, starting at a median age of 13 and 11, respectively. In bivariate and multivariable analyses, PhySexAbuse was significantly associated with more substance abuse consequences (p < 0.001). For men, age < or =17 years at first PhySexAbuse was significantly associated with more substance abuse consequences than an older age at first abuse, or no abuse (p = 0.048). For women, the association of PhySexAbuse with substance use consequences was similar across all ages (p = 0.59). Future research should develop interventions to lessen the substance abuse consequences of physical and sexual abuse.

Injury among detoxification patients: alcohol users' greater risk

BACKGROUND

Little information exists about serious injury in alcohol or drug abusers who seek detoxification. This study examined injury prevalence, and the impact of alcohol use on injury, among alcohol- and drug-dependent persons.

METHOD

We enrolled patients at a detoxification unit into a prospective cohort study and performed follow-up interviews to determine the prevalence of injury. Baseline and follow-up (6, 12, 18, and 24 month) data were examined separately by using multivariate logistic regression to determine factors associated with self-reported episodes of serious injury. The main independent variable was self-reported first and second substances of choice at admission: alcohol only, drug only, or both.

RESULTS

Overall, 24% of the 470 subjects reported at least one instance of serious injury over the 6-month period before detoxification. Similarly, approximately 20% of subjects had serious injury during each 6-month follow-up period. Injury in the past 6 months was highest among the 63% of subjects who reported alcohol as a drug of choice (28-29% vs. 16% for drug only), even after we controlled for potential confounders. Analysis of 2-year follow-up data revealed a similar association, after we controlled for baseline injury and alcohol consumption.

CONCLUSIONS

Injury is a serious problem for a substantial proportion of patients who undergo detoxification, particularly those with alcohol dependence. This marked risk for serious injury persisted for 24 months after detoxification. Patients at detoxification, particularly those with alcohol problems, represent a high-risk population for injury that may benefit from interventions to reduce these preventable complications.