Influence of comorbid drug use disorder on receipt of evidence-based treatment for alcohol use disorder among VA patients with alcohol use disorder and Hepatitis C and/or HIV

Treatment for alcohol use disorder among persons with and without HIV in a clinical care setting in the United States

BACKGROUND

Alcohol use disorders (AUD) can lead to poor health outcomes. Little is known about AUD treatment among persons with HIV (PWH). In an integrated health system in Northern California, 2014-2017, we compared AUD treatment rates between PWH with AUD and persons without HIV (PWoH) with AUD.

METHODS

Using Poisson regression with GEE, we estimated prevalence ratios (PRs) comparing the annual probability of receiving AUD treatment (behavioral intervention or dispensed medication), adjusted for sociodemographics, psychiatric comorbidities, insurance type, and calendar year. Among PWH, we examined independent AUD treatment predictors using PRs adjusted for calendar year only.

RESULTS

PWH with AUD (N = 633; 93% men, median age 49) were likelier than PWoH with AUD (N = 7006; 95% men, median age 52) to have depression (38% vs. 21%) and a non-alcohol substance use disorder (SUD, 48% vs. 25%) (both P < 0.01). Annual probabilities of receiving AUD treatment were 45.4% for PWH and 34.4% for PWoH. After adjusting, there was no difference by HIV status (PR 1.02 [95% CI 0.94-1.11]; P = 0.61). Of treated PWH, 59% received only a behavioral intervention, 5% only a medication, and 36% both, vs. 67%, 4%, 30% for treated PWoH, respectively. Irrespective of HIV status, the most common medication was gabapentin. Among PWH, receiving AUD treatment was associated with having depression (PR 1.78 [1.51-2.10]; P < 0.01) and another SUD (PR 2.68 [2.20-3.27]; P < 0.01).

CONCLUSIONS

PWH with AUD had higher AUD treatment rates than PWoH with AUD in unadjusted but not adjusted analyses, which may be explained by higher psychiatric comorbidity burden among PWH.

Time trends in hospitalizations with anxiolytic, sedative, or hypnotic drug use disorder: a 17-year U.S. national study

BACKGROUND

Limited epidemiological national data are available for anxiolytic, sedative, or hypnotic drug (ASH) use disorder hospitalizations.

OBJECTIVE

To examine the time-trends in and outcomes of ASH use disorder hospitalizations.

METHODS

Rates of ASH use disorder hospitalizations and associated healthcare utilization and mortality were examined using the U.S. National Inpatient Sample data (NIS) from 1998 to 2014. Multivariable-adjusted logistic regression assessed the association of demographic, medical comorbidity (using validated composite score of 17 conditions, the Deyo-Charlson index), and hospital characteristics with healthcare utilization (total hospital charges, length of hospital stay [LOS], and discharge to a non-home setting) and inpatient mortality for hospitalizations with ASH use disorder.

RESULTS

There were an estimated 1,171,673 weighted ASH use disorder hospitalizations. The ASH use disorder hospitalization rates increased 3.12-fold from 96 to 299 per 100,000 NIS hospitalizations from 1998-2000 to 2013-2014. In the same period, associated non-home discharge rate increased 3.33-fold from 12.9 to 43 and in-hospital mortality rate increased 3.17-fold from 0.46 to 1.46 per 100,000 (all p values ≤ .002). In the multivariable-adjusted analyses, older age, black race/ethnicity, Deyo-Charlson index score of 2 or higher, non-private insurance payer, higher income, hospital region, urban setting hospital and a larger hospital bed size, were significantly associated with higher healthcare utilization outcomes and/or mortality. Female sex was associated with higher healthcare utilization outcomes, but lower in-hospital mortality.

CONCLUSIONS

This study confirmed the rising ASH use disorder hospitalization burden in the United States. An increasing inpatient mortality and non-home discharge rate for hospitalizations with ASH use disorder are concerning. The identification of modifiable and non-modifiable risk factors associated with outcomes should allow prognostication and designing of interventions to improve outcomes.

Association of Mental Health Treatment With Outcomes for US Veterans Diagnosed With Non-Small Cell Lung Cancer

Importance

Preexisting mental health disorders (MHDs) are associated with increased mortality in people diagnosed with cancer, yet few data exist on the efficacy of interventions to mitigate this disparity.

Objective

To evaluate the association of participation in mental health treatment programs (MHTPs), housing support programs, or employment support programs with stage at cancer diagnosis, receipt of stage-appropriate treatment, and mortality among patients with a preexisting MHD.

Design, Setting, and Participants

This retrospective, population-based cohort study included 55 315 veterans in the Veterans Affairs Central Cancer Registry (VACCR) who had newly diagnosed non-small cell lung cancer (NSCLC) from September 30, 2000, to December 31, 2011. Data were analyzed from January 15, 2017, to March 17, 2020.

Exposures

Mental health disorders, including schizophrenia, bipolar disorder, depressive disorder, posttraumatic stress disorder, and substance use disorder.

Main Outcomes and Measures

Stage at cancer diagnosis, receipt of stage-appropriate cancer treatment, all-cause mortality, and lung cancer-specific mortality.

Results

Of 55 315 veterans with a new diagnosis of NSCLC included in the analysis (98.1% men; mean [SD] age, 68.1 [9.8] years), 18 229 had a preexisting MHD, among whom participation in MHTPs was associated with a lower likelihood of being diagnosed in a late stage (odds ratio [OR], 0.62; 95% CI, 0.58-0.66; P < .001), a higher likelihood of receiving stage-appropriate treatment (OR, 1.55; 95% CI, 1.26-1.89; P < .001), lower all-cause mortality (adjusted hazard ratio [AHR], 0.74; 95% CI, 0.72-0.77; P < .001), and lower lung cancer-specific mortality (AHR, 0.77; 95% CI, 0.74-0.80; P < .001). Likewise, participation in housing and employment support programs was associated with similar improvements in all outcomes described above.

Conclusions and Relevance

In veterans with preexisting MHDs diagnosed with NSCLC, participation in MHTPs and housing and employment support programs was associated with improved lung cancer-related outcomes. This study might be the first to demonstrate significant improvement in cancer mortality for patients with MHDs who participate in MHTPs, housing support programs, or employment support programs. This work supports substantial literature that investment in mental health and social needs can improve health outcomes and highlights the importance of further research to identify, evaluate, and implement interventions to improve outcomes for patients with MHDs who are diagnosed with cancer.

Use of Medications for the Treatment of Alcohol Dependence: A Retrospective Study Conducted in 2011-2012

BACKGROUND

Pharmacotherapy for Alcohol Dependence (AD) is underutilized. Barriers preventing the use of AD medications include high prices, lack of access to prescribing physicians, and a limited number of available medications.

OBJECTIVE

The study evaluated the use of AD medications in a sample of Italian outpatients who received these medications free of charge, had access to physicians during office hours, and for whom substitution therapy [gamma-hydroxybutyrate (GHB)] was available. We also evaluated the rate of patients who received a combination of non-pharmacological and pharmacological treatments among participants who were still drinking.

METHODS

SCID for AD and questionnaire were filled by to AD outpatients during a face-to-face interview.

RESULTS & DISCUSSION

345 AD outpatients were interviewed: 58.8% were currently receiving at least one AD medication (GHB: 34.3%, disulfiram: 29.6%, acamprosate: 5.9%; naltrexone: 2.5%; more than one medication: 16.7%). Less than 30% of participants who were still drinking, received a combination of non-pharmacological and pharmacological treatments. Nonetheless, we found higher use of AD medications compared to previous studies conducted in other countries. This higher use of AD medications may be due to access to free medications, prescribing physicians' style, and a larger number of available medications.

CONCLUSION

Our results confirm the underutilization of AD medications, as less than 60% of AD outpatients received medications, and less than 30% of those who were still drinking, received a combination of non-pharmacological and pharmacological treatments. These findings may be useful in improving our knowledge of the barriers that prevent the use of AD medications in clinical practice.

Correlates of alcohol use disorder pharmacotherapy receipt in medically insured patients

BACKGROUND

Alcohol use disorder is a highly prevalent disease with multiple medications available for treatment. The overall prevalence of patients receiving pharmacotherapy is believed to be low and the characteristics and comorbidities that affect receipt are not well-established.

METHODS

We created a dataset from Truven Health Analytics MarketScan Commercial Claims and Encounters Database of patients with an outpatient encounter for alcohol abuse or dependence in 2014. We subsequently identified patient characteristics, comorbid medical, psychiatric, or substance use disorders, as well as encounter provider specialties and, using multivariable logistic regression, assessed which variables correlated with increased or decreased receipt of pharmacotherapy for alcohol use disorder for this population.

RESULTS

In our dataset of 123,355 patients, patient receipt of pharmacotherapy for alcohol use disorder was 3.3 %, and 9.3 % when restricted to the former diagnosis of alcohol dependence only. Male sex, younger age, alcohol-related liver disease, and cannabis use disorders correlated with decreased receipt whereas comorbid major depressive disorders and anxiety disorders correlated with increased receipt. Compared to patients seen by psychiatrists, those seen by primary medical doctors had a lower odds of receiving pharmacotherapy.

CONCLUSIONS

Pharmacotherapy for alcohol use disorder is an underutilized treatment modality with a low prevalence of prescription in insured individuals. Patients with specific characteristics and comorbidities are less likely to receive this treatment and greater focus on these patients and in the primary care setting can allow for increased prescribing of these medications.

Motivation to Quit Drinking in Individuals Coinfected with HIV and Hepatitis C

Alcohol consumption is common among individuals coinfected with HIV and hepatitis C (HCV) despite the uniquely harmful effects in this population. Limited research has examined factors that could influence drinking reduction or cessation among HIV/HCV coinfected persons; this study investigates motivation to quit. Participants were 110 alcohol-consuming HIV/HCV coinfected patients recruited from medical clinics. Participants self-reported 90-day drinking frequency and intensity; alcohol-related problems; reasons to quit drinking; reasons to drink; and motivation to quit drinking. Participants consumed alcohol on 54.1 (± 26.9) of the past 90 days. In a multivariate model that controlled for demographic variables, motivation to quit drinking was directly associated with alcohol-related problems (β_y·x = 0.35, p = .007) and reasons to quit drinking (β_y·x = 0.23, p = .021), and inversely associated with drinking for enhancement (β_y·x = - 0.36, p = .004). This study identified several factors associated with motivation to quit drinking in a sample of alcohol-consuming HIV/HCV patients.

Documented brief intervention associated with reduced linkage to specialty addictions treatment in a national sample of VA patients with unhealthy alcohol use with and without alcohol use disorders

BACKGROUND AND AIMS

Alcohol screening, brief intervention (BI) and referral to treatment is often considered stepped care, such that BI with referral links patients to treatment. A meta-analysis of randomized trials found no evidence that BI increases treatment for alcohol use disorder (AUD). This study aimed to determine whether BI is associated with receipt of treatment for AUD among patients receiving BI as part of routine care.

DESIGN

Regression analysis.

SETTING

US Veterans Health Administration (VA), in which BI is supported by performance measurement and electronic clinical reminders.

PARTICIPANTS

VA outpatients with positive Alcohol Use Disorders Identification Test Consumption screens (≥ 5) (n = 830,825) documented nationally from 1 October 2009 to 30 May 2013.

MEASUREMENTS

Regression models estimated the prevalence of receiving VA specialty addictions treatment within 0-365 days for patients with documented BI (advice to reduce/abstain within 0-14 days) compared to those without. Models clustered on patient and adjusted for demographics and mental health and substance use conditions were fit among all patients and stratified across documented past-year AUD diagnosis. Multiple secondary analyses assessed robustness of findings, including assessing repeated BI as a predictor.

FINDINGS

Among 830,825 VA outpatients with unhealthy alcohol use (1,172,606 positive screens), documented BI was associated with lower likelihood of receiving VA specialty addictions treatment [adjusted incidence rate ratio (aIRR) = 0.84, 95% confidence interval (CI) = 0.83-0.84]. Associations were similar for those with and without AUD (aIRR = 0.83, 95% CI = 0.82-0.84 and aIRR = 0.86, 95% CI = 0.83-0.88, respectively) and in most secondary analyses. However, among patients without AUD, documentation of more than one BI was associated with greater likelihood of treatment relative to no BI (aIRR = 1.75, 95% CI = 1.68-1.83).

CONCLUSIONS

In a national sample of US Veterans Health Administration patients with unhealthy alcohol use, documented brief intervention for alcohol use was associated with lower likelihood of receiving specialty addictions treatment regardless of alcohol use disorder diagnosis.