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Saitz R, Cheng DM, Winter M, Kim TW, Meli SM, Allensworth-Davies D, Lloyd-Travaglini CA, Samet JH. Chronic care management for dependence on alcohol and other drugs: the AHEAD randomized trial. JAMA 2013; 310:1156-67. [PMID: 24045740 PMCID: PMC3902022 DOI: 10.1001/jama.2013.277609] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
IMPORTANCE People with substance dependence have health consequences, high health care utilization, and frequent comorbidity but often receive poor-quality care. Chronic care management (CCM) has been proposed as an approach to improve care and outcomes. OBJECTIVE To determine whether CCM for alcohol and other drug dependence improves substance use outcomes compared with usual primary care. DESIGN, SETTING, AND PARTICIPANTS The AHEAD study, a randomized trial conducted among 563 people with alcohol and other drug dependence at a Boston, Massachusetts, hospital-based primary care practice. Participants were recruited from September 2006 to September 2008 from a freestanding residential detoxification unit and referrals from an urban teaching hospital and advertisements; 95% completed 12-month follow-up. INTERVENTIONS Participants were randomized to receive CCM (n=282) or no CCM (n=281). Chronic care management included longitudinal care coordinated with a primary care clinician; motivational enhancement therapy; relapse prevention counseling; and on-site medical, addiction, and psychiatric treatment, social work assistance, and referrals (including mutual help). The no CCM (control) group received a primary care appointment and a list of treatment resources including a telephone number to arrange counseling. MAIN OUTCOMES AND MEASURES The primary outcome was self-reported abstinence from opioids, stimulants, or heavy drinking. Biomarkers were secondary outcomes. RESULTS There was no significant difference in abstinence from opioids, stimulants, or heavy drinking between the CCM (44%) and control (42%) groups (adjusted odds ratio, 0.84; 95% CI, 0.65-1.10; P=.21). No significant differences were found for secondary outcomes of addiction severity, health-related quality of life, or drug problems. No subgroup effects were found except among those with alcohol dependence, in whom CCM was associated with fewer alcohol problems (mean score, 10 vs 13; incidence rate ratio, 0.85; 95% CI, 0.72-1.00; P=.048). CONCLUSIONS AND RELEVANCE Among persons with alcohol and other drug dependence, CCM compared with a primary care appointment but no CCM did not increase self-reported abstinence over 12 months. Whether more intensive or longer-duration CCM is effective requires further investigation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00278447.
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Beck CA, Southern DA, Saitz R, Knudtson ML, Ghali WA. Alcohol and drug use disorders among patients with myocardial infarction: associations with disparities in care and mortality. PLoS One 2013; 8:e66551. [PMID: 24039695 PMCID: PMC3770618 DOI: 10.1371/journal.pone.0066551] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 05/10/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Because alcohol and drug use disorders (SUDs) can influence quality of care, we compared patients with and without SUDs on frequency of catheterization, revascularization, and in-hospital mortality after acute myocardial infarction (AMI). METHODS This study employed hospital discharge data identifying all adult AMI admissions (ICD-9-CM code 410) between April 1996 and December 2001. Patients were classified as having an SUD if they had alcohol and/or drug (not nicotine) abuse or dependence using a validated ICD-9-CM coding definition. Catheterization and revascularization data were obtained by linkage with a clinically-detailed cardiac registry. Analyses (controlling for comorbidities and disease severity) compared patients with and without SUDs for post-MI catheterization, revascularization, and in-hospital mortality. RESULTS Of 7,876 AMI unique patient admissions, 2.6% had an SUD. In adjusted analyses mortality was significantly higher among those with an SUD (odds ratio (OR) 2.02; 95%CI: 1.10-3.69), while there was a trend toward lower catheterization rates among those with an SUD (OR 0.75; 95%CI: 0.55-1.01). Among the subset of AMI admissions who underwent catheterization, the adjusted hazard ratio for one-year revascularization was 0.85 (95%CI: 0.65-1.11) with an SUD compared to without. CONCLUSIONS Alcohol and drug use disorders are associated with significantly higher in-hospital mortality following AMI in adults of all ages, and may also be associated with decreased access to catheterization and revascularization. This higher mortality in the face of poorer access to procedures suggests that these individuals may be under-treated following AMI. Targeted efforts are required to explore the interplay of patient and provider factors that underlie this finding.
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Johnson NA, Kypri K, Saunders JB, Saitz R, Attia J, Dunlop A, Doran C, McElduff P, Wolfenden L, McCambridge J. The hospital outpatient alcohol project (HOAP): protocol for an individually randomized, parallel-group superiority trial of electronic alcohol screening and brief intervention versus screening alone for unhealthy alcohol use. Addict Sci Clin Pract 2013; 8:14. [PMID: 24004498 PMCID: PMC3766680 DOI: 10.1186/1940-0640-8-14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2013] [Accepted: 08/29/2013] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND Electronic screening and brief intervention (e-SBI) is a promising alternative to screening and brief intervention by health-care providers, but its efficacy in the hospital outpatient setting, which serves a large proportion of the population, has not been established. The aim of this study is to estimate the effect of e-SBI in hospital outpatients with hazardous or harmful drinking. METHODS/DESIGN This randomized controlled trial will be conducted in the outpatient department of a large tertiary referral hospital in Newcastle (population 540,000), Australia. Some 772 adults with appointments at a broad range of medical and surgical outpatient clinics who score 5-9 inclusive on the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) subscale will be randomly assigned in a 1:1 ratio to electronic alcohol screening alone (control) or to e-SBI. As randomization will be effected by computer, researchers and participants (who will be invited to participate in a study of alcohol use over time) will be blinded to group assignment. The primary analysis will be based on the intention-to-treat principle and compare weekly volume (grams of alcohol) and the full AUDIT score with a six-month reference period between the groups six months post randomization. Secondary outcomes, assessed six and 12 months after randomization, will include drinking frequency, typical occasion quantity, proportion who report binge drinking, proportion who report heavy drinking, and health-care utilization. DISCUSSION If e-SBI is efficacious in outpatient settings, it offers the prospect of systematically and sustainably reaching a large number of hazardous and harmful drinkers, many of whom do not otherwise seek or receive help. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12612000905864.
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Naimi T, Xuan Z, Saitz R. Immoderately confounding: the effects of low-dose alcohol. Addiction 2013; 108:1552-3. [PMID: 23947730 DOI: 10.1111/add.12297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Naimi TS, Xuan Z, Brown DW, Saitz R. Confounding and studies of 'moderate' alcohol consumption: the case of drinking frequency and implications for low-risk drinking guidelines. Addiction 2013; 108:1534-43. [PMID: 23075385 DOI: 10.1111/j.1360-0443.2012.04074.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 07/13/2012] [Accepted: 08/28/2012] [Indexed: 12/13/2022]
Abstract
AIMS Many observational studies suggest that increased drinking frequency is associated with reduced mortality among those with low-dose alcohol consumption. The purpose of this paper was to examine whether frequent drinkers consume lower-risk amounts during drinking days or have favorable risk factor profiles compared with those who drink less frequently, and discuss implications for the larger debate about the limitations of non-randomized studies about 'moderate' drinking and the development of low-risk drinking guidelines. METHODS Data from the 2008 Behavioral Risk Factor Surveillance System survey were used to characterize alcohol consumption characteristics and their relationship with risk factors among adult drinking men who consumed an average of fewer than two drinks per day and adult drinking adult women who consumed an average of less than one drink per day. RESULTS Those who drank relatively infrequently (14 or fewer days per month) consumed more during drinking days, were more likely to exceed the US Dietary Guidelines drinking limits (41.0% versus 9.7%) and had a larger proportion of drinking days that included binge drinking (13.4% versus 4.3%). Infrequent drinkers also had a higher prevalence of 13 of 15 risk factors assessed. Findings from analyses of those aged ≥40 years were similar. CONCLUSIONS Among those with low average alcohol consumption, infrequent drinkers drink more during drinking days and have unfavorable risk factors profiles compared with more frequent drinkers, suggesting that confounding may contribute to favorable associations with 'moderate' average alcohol consumption and increased drinking frequency observed in non-randomized studies.
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Zarkin G, Bray J, Hinde J, Saitz R. Implementation costs of screening and brief intervention for illicit drug use. Addict Sci Clin Pract 2013. [PMCID: PMC3766121 DOI: 10.1186/1940-0640-8-s1-a88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Tsui JI, Cheng DM, Libman H, Bridden C, Saitz R, Samet JH. Risky alcohol use and serum aminotransferase levels in HIV-infected adults with and without hepatitis C. J Stud Alcohol Drugs 2013; 74:266-70. [PMID: 23384374 DOI: 10.15288/jsad.2013.74.266] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The purpose of this study was to examine the association between risky drinking amounts and serum aminotransferase levels in HIV-infected adults with and without hepatitis C virus (HCV) infection. METHOD In a prospective cohort of HIV-infected adults with current or past alcohol problems, we assessed whether drinking risky amounts (as defined by the National Institute on Alcohol Abuse and Alcoholism) was associated with higher levels of serum aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) over time, stratifying analyses by HCV status. Generalized linear mixed effects regression models were used to examine the association between risky drinking and natural log-transformed AST and ALT over time. RESULTS Among HIV/HCV-coinfected persons (n = 200), risky drinking was associated with a higher adjusted mean AST (62.2 vs. 51.4 U/L; adjusted ratio of means 1.2, 95% CI [1.07, 1.37], p = .003) and ALT (51.3 vs. 41.6 U/L; adjusted ratio of means 1.2, 95% CI [1.07, 1.42], p = .004) compared with non-risky drinking. In contrast, among HIV-infected adults without HCV infection (n = 197), there were no significant differences between those who did and did not drink risky amounts in AST (34.7 vs. 33.3 U/L; adjusted ratio of means = 1.0, 95% CI [0.95, 1.14], p = .36) or ALT (29.1 vs. 28.7 U/L; adjusted ratio of means = 1.0, 95% CI [0.91, 1.13], p = .78). CONCLUSIONS Among HIV-infected adults with HCV, those who drink risky amounts have higher serum aminotransferase levels than those who do not drink risky amounts. These results suggest that drinking risky amounts may be particularly harmful in HIV/HCV-coinfected adults and supports recommendations that providers pay special attention to drinking in this population.
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Upshur CC, Weinreb L, Cheng DM, Kim TW, Samet JH, Saitz R. Does experiencing homelessness affect women's motivation to change alcohol or drug use? Am J Addict 2013; 23:76-83. [PMID: 24313245 DOI: 10.1111/j.1521-0391.2013.12066.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 02/17/2013] [Accepted: 02/19/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Homeless women are at high risk of drug and alcohol dependence and may receive less opportunity for treatment. Our objective was to examine the association between experiencing homelessness and motivation to change drug or alcohol use. METHODS Women (n = 154) participants in a study of substance dependence at an urban medical center (69 with some homeless days in the last 90 days; 85 continuously housed at baseline) completed six items rating motivation to change alcohol or drug use (ie, importance, readiness, and confidence) at baseline and in 3-, 6-, and 12-month follow-up interviews. Unadjusted and longitudinal analyses controlling for covariates (eg, demographics, insurance status, substance use consequences, mental health status, and participation in treatment) were conducted. RESULTS There were no significant differences between women experiencing homeless days versus continuously housed women in the odds of reporting high motivation to change alcohol or drug use, either in unadjusted baseline analyses or longitudinal analyses adjusted for covariates. Covariates that were significantly associated with high importance, readiness or confidence to change behavior were higher life time consequences of substance use, and participation in 12-step programs. DISCUSSION AND CONCLUSIONS The findings suggest that clinicians should not make assumptions that homeless women have low motivation to change their substance use. SCIENTIFIC SIGNIFICANCE AND FUTURE DIRECTIONS The same opportunities for addiction treatment should be offered to homeless as to housed women.
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Elwy AR, Horton NJ, Saitz R. Physicians' attitudes toward unhealthy alcohol use and self-efficacy for screening and counseling as predictors of their counseling and primary care patients' drinking outcomes. Subst Abuse Treat Prev Policy 2013; 8:17. [PMID: 23718191 PMCID: PMC3680085 DOI: 10.1186/1747-597x-8-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 05/18/2013] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Patients' unhealthy alcohol use is often undetected in primary care. Our objective was to examine whether physicians' attitudes and their perceived self-efficacy for screening and counseling patients is associated with physicians' counseling of patients with unhealthy alcohol use, and patients' subsequent drinking. METHODS This study is a prospective cohort study (nested within a randomized trial) involving 41 primary care physicians and 301 of their patients, all of whom had unhealthy alcohol use. Independent variables were physicians' attitudes toward unhealthy substance use and self-efficacy for screening and counseling. Outcomes were patients' reports of physicians' counseling about unhealthy alcohol use immediately after a physician visit, and patients' drinking six months later. RESULTS Neither physicians' attitudes nor self-efficacy had any impact on physicians' counseling, but greater perceived self-efficacy in screening, assessing and intervening with patients was associated with more drinking by patients six months later. CONCLUSIONS Future research needs to further explore the relationship between physicians' attitudes towards unhealthy alcohol use, their self-efficacy for screening and counseling and patients' drinking outcomes, given our unexpected findings.
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Fuster D, Tsui JI, Cheng DM, Quinn EK, Bridden C, Nunes D, Libman H, Saitz R, Samet JH. Impact of lifetime alcohol use on liver fibrosis in a population of HIV-infected patients with and without hepatitis C coinfection. Alcohol Clin Exp Res 2013; 37:1527-35. [PMID: 23647488 DOI: 10.1111/acer.12129] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Accepted: 01/23/2013] [Indexed: 01/14/2023]
Abstract
BACKGROUND The effect of alcohol on liver disease in HIV infection has not been well characterized. METHODS We performed a cross-sectional multivariable analysis of the association between lifetime alcohol use and liver fibrosis in a longitudinal cohort of HIV-infected patients with alcohol problems. Liver fibrosis was estimated with 2 noninvasive indices, "FIB-4," which includes platelets, liver enzymes, and age; and aspartate aminotransferase/platelet ratio index ("APRI"), which includes platelets and liver enzymes. FIB-4 <1.45 and APRI <0.5 defined the absence of liver fibrosis. FIB-4 >3.25 and APRI >1.5 defined advanced liver fibrosis. The main independent variable was lifetime alcohol consumption (<150 kg, 150 to 600 kg, >600 kg). RESULTS Subjects (n = 308) were 73% men, mean age 43 years, 49% with hepatitis C virus (HCV) infection, 60% on antiretroviral therapy, 49% with an HIV RNA load <1,000 copies/ml, and 18.7% with a CD4 count <200 cells/mm(3) . Forty-five percent had lifetime alcohol consumption >600 kg, 32.7% 150 to 600 kg, and 22.3% <150 kg; 33% had current heavy alcohol use, and 69% had >9 years of heavy episodic drinking. Sixty-one percent had absence of liver fibrosis and 10% had advanced liver fibrosis based on FIB-4. In logistic regression analyses, controlling for age, gender, HCV infection, and CD4 count, no association was detected between lifetime alcohol consumption and the absence of liver fibrosis (FIB-4 <1.45) (adjusted odds ratio [AOR] = 1.12 [95% CI: 0.25 to 2.52] for 150 to 600 kg vs. <150 kg; AOR = 1.11 [95% CI: 0.52 to 2.36] for >600 kg vs. <150 kg; global p = 0.95). Additionally, no association was detected between lifetime alcohol use and advanced liver fibrosis (FIB-4 >3.25). Results were similar using APRI, and among those with and without HCV infection. CONCLUSIONS In this cohort of HIV-infected patients with alcohol problems, we found no significant association between lifetime alcohol consumption and the absence of liver fibrosis or the presence of advanced liver fibrosis, suggesting that alcohol may be less important than other known factors that promote liver fibrosis in this population.
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Kim TW, Saitz R, Kretsch N, Cruz A, Winter MR, Shanahan CW, Alford DP. Screening for unhealthy alcohol and other drug use by health educators: do primary care clinicians document screening results? J Addict Med 2013; 7:204-9. [PMID: 23609212 PMCID: PMC11034862 DOI: 10.1097/adm.0b013e31828da017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Health educators are increasingly being used to deliver preventive care including screening and brief intervention (SBI) for unhealthy substance use (SU) (alcohol or drug). There are few data, however, about the "handoff" of information from health educator to primary care clinician (PCC). Among patients identified with unhealthy SU and counseled by health educators, the objective of this study was to examine (1) the proportion of PCC notes with documentation of SBI and (2) the spectrum of SU not documented by PCCs. METHODS Before the PCC-patient encounter, health educators screened for SU, assessed severity (Alcohol, Smoking, and Substance Involvement Screening Test), and counseled patients. They also conveyed this information to the PCC before the PCC-patient encounter. Researchers reviewed the electronic medical record for PCC documentation of SBI performed by the health educator and/or the PCC. RESULTS Among patients with the health educator-identified SU, only 69% (342/495) of PCC notes contained documentation of screening by the health educator and/or the PCC. Documentation was found in all encounters with patients with likely dependent SU, but only 62% and 59% of encounters with patients with risky alcohol and drug use, respectively. Documentation of cocaine or heroin use was higher than that of alcohol or marijuana use but still not universal. Although all SU-identified patients had received a brief intervention (from a health educator and possibly a PCC), only 25% of PCC notes contained documentation of a brief intervention. CONCLUSIONS Among patients screened and counseled by health educators for unhealthy SU, SBI was often not documented by PCCs. These results suggest that strategies are needed to integrate SBI by primary care team members to advance the quality of care for patients with unhealthy SU.
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Saitz R. 'We do not see the lens through which we look': screening mammography evidence and non-financial conflicts of interest. ACTA ACUST UNITED AC 2013; 18:81-2. [PMID: 23611981 DOI: 10.1136/eb-2013-101344] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Saitz R. Accentuating the positive. EVIDENCE-BASED MEDICINE 2013; 18:43. [PMID: 23513210 DOI: 10.1136/eb-2013-101221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Saitz R. Evidence-based design: part of evidence-based medicine? EVIDENCE-BASED MEDICINE 2013; 18:1. [PMID: 22864369 DOI: 10.1136/eb-2012-100934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
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Saitz R, Palfai TP, Cheng DM, Alford DP, Bernstein JA, Lloyd-Travaglini CA, Meli SM, Chaisson CE, Samet JH. Screening and brief intervention for drug use in primary care: the Assessing Screening Plus brief Intervention’s Resulting Efficacy to stop drug use (ASPIRE) randomized trial. Addict Sci Clin Pract 2013. [PMCID: PMC3766125 DOI: 10.1186/1940-0640-8-s1-a61] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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D'Amore MM, Cheng DM, Allensworth-Davies D, Samet JH, Saitz R. Disparities in safe sex counseling & behavior among individuals with substance dependence: a cross-sectional study. Reprod Health 2012; 9:35. [PMID: 23276300 PMCID: PMC3565911 DOI: 10.1186/1742-4755-9-35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 12/21/2012] [Indexed: 05/16/2023] Open
Abstract
Background Despite the vast literature examining disparities in medical care, little is known about racial/ethnic and mental health disparities in sexual health care. The objective of this study was to assess disparities in safe sex counseling and resultant behavior among a patient population at risk of negative sexual health outcomes. Methods We conducted a cross-sectional analysis among a sample of substance dependent men and women in a metropolitan area in the United States. Multiple logistic regression models were used to explore the relationship between race/ethnicity (non-Hispanic black; Hispanic; non-Hispanic white) and three indicators of mental illness (moderately severe to severe depression; any manic episodes; ≥3 psychotic symptoms) with two self-reported outcomes: receipt of safe sex counseling from a primary care physician and having practiced safer sex because of counseling. Results Among 275 substance-dependent adults, approximately 71% (195/275) reported ever being counseled by their regular doctor about safe sex. Among these 195 subjects, 76% (149/195) reported practicing safer sex because of this advice. Blacks (adjusted odds ratio (AOR): 2.71; 95% confidence interval (CI): 1.36,5.42) and those reporting manic episodes (AOR: 2.41; 95% CI: 1.26,4.60) had higher odds of safe sex counseling. Neither race/ethnicity nor any indicator of mental illness was significantly associated with practicing safer sex because of counseling. Conclusions Those with past manic episodes reported more safe sex counseling, which is appropriate given that hypersexuality is a known symptom of mania. Black patients reported more safe sex counseling than white patients, despite controlling for sexual risk. One potential explanation is that counseling was conducted based on assumptions about sexual risk behaviors and patient race. There were no significant disparities in self-reported safer sex practices because of counseling, suggesting that increased counseling did not differentially affect safe sex behavior for black patients and those with manic episodes. Exploring the basis of how patient characteristics can influence counseling and resultant behavior merits further exploration to help reduce disparities in safe sex counseling and outcomes. Trial registration NCT00278447
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Kim TW, Saitz R, Cheng DM, Winter MR, Witas J, Samet JH. Effect of quality chronic disease management for alcohol and drug dependence on addiction outcomes. J Subst Abuse Treat 2012; 43:389-96. [PMID: 22840687 PMCID: PMC3507538 DOI: 10.1016/j.jsat.2012.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2012] [Revised: 06/07/2012] [Accepted: 06/12/2012] [Indexed: 11/22/2022]
Abstract
We examined the effect of the quality of primary care-based chronic disease management (CDM) for alcohol and/or other drug (AOD) dependence on addiction outcomes. We assessed quality using (1) a visit frequency based measure and (2) a self-reported assessment measuring alignment with the chronic care model. The visit frequency based measure had no significant association with addiction outcomes. The self-reported measure of care-when care was at a CDM clinic-was associated with lower drug addiction severity. The self-reported assessment of care from any healthcare source (CDM clinic or elsewhere) was associated with lower alcohol addiction severity and abstinence. These findings suggest that high quality CDM for AOD dependence may improve addiction outcomes. Quality measures based upon alignment with the chronic care model may better capture features of effective CDM care than a visit frequency measure.
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Meltzer EC, Rybin D, Meshesha LZ, Saitz R, Samet JH, Rubens SL, Liebschutz JM. Aberrant drug-related behaviors: unsystematic documentation does not identify prescription drug use disorder. PAIN MEDICINE 2012; 13:1436-43. [PMID: 23057631 DOI: 10.1111/j.1526-4637.2012.01497.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD. DESIGN A cross-sectional study of PC patients at an urban, academic medical center. SUBJECTS Two hundred sixty-four English-speaking patients (ages 18-60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits. OUTCOME MEASURES Composite International Diagnostic Interview defined Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of past year PDUD and no disorder. EMRs were reviewed for 15 prespecified ADRBs (e.g., early refill, stolen medications) in the year before and after study entry. Fisher's exact test compared frequencies of each ADRB between participants with and without PDUD. RESULTS Sixty-one participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only "appearing intoxicated or high" documented more frequently among participants with PDUD (N = 10, 16%) vs no disorder (N = 8, 4%), P = 0.002. The only common ADRB, "emergency visit for pain," did not discriminate between those with and without the disorder (82% PDUD vs 78% no disorder, P = 0.6). CONCLUSIONS EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.
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McGinnis KA, Justice AC, Kraemer KL, Saitz R, Bryant KJ, Fiellin DA. Comparing alcohol screening measures among HIV-infected and -uninfected men. Alcohol Clin Exp Res 2012; 37:435-42. [PMID: 23050632 DOI: 10.1111/j.1530-0277.2012.01937.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Accepted: 07/11/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Brief measures of unhealthy alcohol use have not been well validated among people with HIV. We compared the Alcohol Use Disorders Identification Test (AUDIT) to reference standards for unhealthy alcohol use based on 30-day Timeline Follow Back (TLFB) and Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM), among 837 male HIV-infected and -uninfected patients in the Veterans Aging Cohort Study. METHODS Three reference standards were (i) Risky drinking-based on TLFB >14 drinks over 7 consecutive days or >4 drinks on 1 day; (ii) Alcohol dependence-based on a CIDI-SAM diagnosis; and (iii) Unhealthy alcohol use-risky drinking or a CIDI-SAM diagnosis of abuse or dependence. Various cutoffs for the AUDIT, AUDIT-C, and heavy episodic drinking were compared with the reference standards. RESULTS Mean age of patients was 52 years, 53% (444) were HIV-infected, and 53% (444) were African American. Among HIV-infected and -uninfected patients, the prevalence of risky drinking (14 vs. 12%, respectively), alcohol dependence (8 vs. 7%), and unhealthy alcohol use (22 vs. 20%) was similar. For risky drinking and alcohol dependence, multiple cutoffs of AUDIT, AUDIT-C, and heavy episodic drinking provided good sensitivity (≥80%) and specificity (≥90%). For unhealthy alcohol use, few cutoffs provided sensitivity ≥80%; however, many cutoffs provided good specificity. For all 3 alcohol screening measures, sensitivity improved when heavy episodic drinking was included with the cutoff. Sensitivity of measures for risky drinking and unhealthy alcohol use was lower in HIV-infected than in uninfected patients. CONCLUSIONS For identifying risky drinking, alcohol dependence, and unhealthy alcohol use, AUDIT-C performs as well as AUDIT and similarly in HIV-infected and -uninfected patients. Cutoffs should be based on the importance of specific operating characteristics for the intended research or clinical use. Incorporating heavy episodic drinking increased sensitivity for detecting alcohol dependence and unhealthy alcohol use.
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170
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Yi PH, Kim JS, Hussein KI, Saitz R. Behavior, Knowledge, and Attitudes Towards Khat Among Yemeni Medical Students and Effects of a Seminar. Subst Abus 2012; 33:373-7. [DOI: 10.1080/08897077.2012.662421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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171
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Saitz R, Alford D, Witas J, Allensworth-Davies D, Palfai T, Cheng D, Bernstein J, Samet J. Universal screening for drug use in urban primary care. Addict Sci Clin Pract 2012. [PMCID: PMC3480049 DOI: 10.1186/1940-0640-7-s1-a14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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172
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Saitz R, Samet J. Science to improve care for people affected by unhealthy alcohol and other drug use. Addict Sci Clin Pract 2012; 7:1. [PMID: 22966407 PMCID: PMC3414818 DOI: 10.1186/1940-0640-7-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2012] [Accepted: 03/15/2012] [Indexed: 11/10/2022] Open
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173
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174
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Vargas de Barros V, Martins LF, Saitz R, Bastos RR, Ronzani TM. Mental health conditions, individual and job characteristics and sleep disturbances among firefighters. J Health Psychol 2012; 18:350-8. [PMID: 22517948 DOI: 10.1177/1359105312443402] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study aimed to assess the associations between mental health conditions, individual and job characteristics and sleep disturbances among firefighters. Of 303 participants, 51.2% reported sleep disturbances. Psychological distress and psychosomatic disturbances were significantly associated with sleep disturbances. Suicidal ideation, unhealthy alcohol use and time as a firefighter were also associated with sleep disturbances but at a borderline level of significance (0.05 < p < .085). These findings may be related to the psychological and physical hazards of firefighting and indicate the importance of research on associated professions.
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175
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Meltzer EC, Averbuch T, Samet JH, Saitz R, Jabbar K, Lloyd-Travaglini C, Liebschutz JM. Discrepancy in diagnosis and treatment of post-traumatic stress disorder (PTSD): treatment for the wrong reason. J Behav Health Serv Res 2012; 39:190-201. [PMID: 22076315 PMCID: PMC3310322 DOI: 10.1007/s11414-011-9263-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In primary care (PC), patients with post-traumatic stress disorder (PTSD) are often undiagnosed. To determine variables associated with treatment, this cross-sectional study assessed 592 adult patients for PTSD. Electronic medical record (EMR) review of the prior 12 months assessed mental health (MH) diagnoses and MH treatments [selective serotonin reuptake inhibitor (SSRI) and/or ≥1 visit with MH professional]. Of 133 adults with PTSD, half (49%; 66/133) received an SSRI (18%), a visit with MH professional (14%), or both (17%). Of those treated, 88% (58/66) had an EMR MH diagnosis, the majority (71%; 47/66) depression and (18%; 12/66) PTSD. The odds of receiving MH treatment were increased 8.2 times (95% CI 3.1-21.5) for patients with an EMR MH diagnosis. Nearly 50% of patients with PTSD received MH treatment, yet few had this diagnosis documented. Treatment was likely due to overlap in the management of PTSD and other mental illnesses.
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