Medical conditions of adolescents in alcohol and drug treatment: comparison with matched controls

A latent class approach to understanding longitudinal sleep health and the association with alcohol and cannabis use during late adolescence and emerging adulthood

OBJECTIVE

Sleep is a multi-dimensional health behavior associated with elevated risk of substance use. This is the first study to utilize a latent class approach to characterize sleep health across multiple dimensions and across time from late adolescence to emerging adulthood, and to examine associations with alcohol and cannabis use trajectories.

METHODS

The sample included 2995 emerging adults (mean ages = 18 to 24 years across six waves of data collection; 54% female) who provided data on sleep dimensions (quality, duration, and social jetlag) and frequency and consequences of alcohol and cannabis use. Longitudinal latent class analysis (LLCA) models characterized participants according to the three sleep dimensions. Latent growth models examined trajectories of frequency and consequences of alcohol or cannabis use over time among emergent sleep classes, with and without controlling for covariates.

RESULTS

LLCA models identified four sleep classes: good sleepers (n = 451; 15.2%); untroubled poor sleepers (n = 1024; 34.2%); troubled, moderately good sleepers (n = 1056; 35.3%); and suboptimal sleepers (n = 460; 15.4%). Good sleepers reported significantly lower levels of alcohol or cannabis use and consequences, and less of an increase in alcohol consequences as compared to suboptimal sleepers.

CONCLUSIONS

Persistent poor sleep health was associated with higher levels of alcohol and cannabis use and consequences, and greater increases in alcohol-related consequences during the transition from late adolescence to emerging adulthood. Findings have important clinical implications, highlighting that addressing multi-dimensional sleep health may be an important, novel target of intervention to reduce substance use frequency and consequences.

Young Adult Substance Use and Healthcare Use Associated With Screening, Brief Intervention and Referral to Treatment in Pediatric Primary Care

PURPOSE

Screening, brief intervention, and referral to treatment (SBIRT) may impact future comorbidity and healthcare utilization among adolescents screening positive for substance use or mood problems.

METHODS

In a randomized trial sample, we compared an SBIRT group to usual care for substance use, mental health, medical diagnoses, and healthcare utilization over 7 years postscreening.

RESULTS

In logistic regression models adjusting for patient characteristics, the SBIRT group had lower odds of any substance (Odds Ratio[OR] = 0.80, 95% Confidence Interval [CI] = 0.66-.98), alcohol (OR = 0.69, 95% CI = 0.51-0.94), any drug (OR = 0.73, 95% CI = 0.54-0.98), marijuana (OR = 0.70, 95% CI = 0.50-0.98), and tobacco (OR = 0.83, 95% CI = 0.69-1.00) diagnoses, and lower odds of any inpatient hospitalizations (OR = 0.59, 95% CI = 0.41-0.85) compared with usual care. Negative binomial models examining number of visits among adolescents with at least one visit of that type found that those in the SBIRT group had fewer primary care (incidence rate ratio[iRR] = 0.90, p < .05) and psychiatry (iRR = 0.64, p < .01) and more addiction medicine (iRR = 1.52, p < .01) visits over 7 years compared with usual care. In posthoc analyses, we found that among Hispanic patients, those in the SBIRT group had lower odds of any substance, any drug and marijuana use disorder diagnoses compared with usual care, and among Black/African American patients, those in the SBIRT group had lower odds of alcohol use disorder diagnoses compared with usual care.

DISCUSSION

Beneficial effects of adolescent SBIRT on substance use and healthcare utilization may persist into young adulthood.

Mortality among young people seeking residential treatment for problematic drug and alcohol use: A data linkage study

BACKGROUND

Young people with problematic alcohol and other drug (AOD) use are often referred to residential treatment. Subsequent mortality rates among this high-risk group is not known. This study estimates mortality rates and determines causes of death amongst young people referred to residential treatment in Sydney, Australia.

DESIGN

Retrospective data linkage study. Data of young people (13-18 years) referred to a residential treatment service 2001-2015 (n = 3256) linked with Australian death registration data, and followed up to 16 years (2001-2016).

METHODS

Mortality rates (CMRs) and standardised mortality ratios (SMRs, age-, gender-, calendar-year-adjusted) calculated using population mortality rates. Causes of death were analysed using ICD-10 codes for AOD-induced, AOD as contributory and non-AOD related causes.

RESULTS

During follow-up of the cohort (28,838 person-years), 63 people died (71.4 % males; 48 % Indigenous; median age at death = 21.9 years; median follow-up = 5.1years), with 76 % dying before aged 25 years. Overall mortality (SMR = 4.91, 95 % CI: 3.8-6.2; CMR = 2.18/1000 person-years, 95 % CI: 1.7-2.8) was significantly higher than age-gender-matched general population, particularly in females (SMR = 9.55; males: SMR = 4.11; RR: 2.3, 95 % CI: 1.3-4.1). SMRs were not significantly different between treatment groups (SMRs>5.5) and non-attend group (SMR = 3.7) (p = 0.359). Two-thirds of deaths involved AOD, with AOD-induced deaths comprising 42 % and AOD as contributory for 22 % deaths. Overdose, mainly opioids (including opiates), suicide, and transport accidents were major causes of deaths.

CONCLUSION

Very high mortality rates, particularly among females, and the high incidence of overdose and suicide emphasise early screening for those at high-risk, targeted and culturally appropriate interventions, and maximised continuing after-care accessible to young people.

Predicting adolescent alcohol and other drug problems using electronic health records data

IMPORTANCE

Alcohol and other drug (AOD) use problems may cause significant burden on affected adolescents and their families, yet treatment providers often do not identify these problems early enough.

OBJECTIVE

To develop, and internally and externally validate a multivariable prediction model of adolescent AOD problems using child- and maternal-level predictors before age 12, and child-level predictors between ages 12 to 18, as recorded in the electronic health records (EHR).

DESIGN

A retrospective cohort study conducted time-to-event analyses using Cox proportional hazards models.

SETTING AND PARTICIPANTS

41,172 children born between 1997 and 2000 at four health plans (Kaiser Permanente Hawaii, KPHI; Kaiser Permanente Northern California, KPNC; Geisinger Clinic, GC; and Henry Ford Health System, HFHS) who had continuous membership since birth and linkable maternal records in the health plan.

OUTCOMES

AOD use problems between ages 12 to 18, defined as either: 1) having a contact with the AOD treatment program or 2) receiving a non-tobacco AOD diagnosis in an inpatient or outpatient encounter.

EXPOSURES

Candidate predictor variables include demographics, socioeconomic status, and clinical diagnoses of the children and the mothers.

RESULTS

Overall, 1400 (3.4%) adolescents had an AOD disorder between ages 12 to 18; the median follow-up time post-age 12 was 5.3 years. The research team developed two final prediction models: a "baseline" model of 10 child-level and 7 maternal-level predictors before age 12, and a more comprehensive "time-varying" model, which incorporated child risk factors after age 12 as time-varying covariates in addition to the baseline model predictors. Model performance evaluation showed good discrimination performance of the models, with the concordance index improved for the time-varying model, especially for prediction of AOD events in late adolescence.

CONCLUSIONS AND RELEVANCE

This study identified a number of child and maternal characteristics and diagnoses routinely available in EHR data as predictive of risk for developing AOD problems in adolescence. Further, we found that risk of developing problems varies significantly by the timing and persistence of the risk factors. Findings may have potential clinical implications for prevention and identification of adolescent AOD problems, but more research is needed, especially across additional health systems.

The Role of Melanocortin Plasticity in Pain-Related Outcomes After Alcohol Exposure

The global COVID-19 pandemic has shone a light on the rates and dangers of alcohol misuse in adults and adolescents in the US and globally. Alcohol exposure during adolescence causes persistent molecular, cellular, and behavioral changes that increase the risk of alcohol use disorder (AUD) into adulthood. It is established that alcohol abuse in adulthood increases the likelihood of pain hypersensitivity and the genesis of chronic pain, and humans report drinking alcohol to relieve pain symptoms. However, the longitudinal effects of alcohol exposure on pain and the underlying CNS signaling that mediates it are understudied. Specific brain regions mediate pain effects, alcohol effects, and pain-alcohol interactions, and neural signaling in those brain regions is modulated by neuropeptides. The CNS melanocortin system is sensitive to alcohol and modulates pain sensitivity, but this system is understudied in the context of pain-alcohol interactions. In this review, we focus on the role of melanocortin signaling in brain regions sensitive to alcohol and pain, in particular the amygdala. We also discuss interactions of melanocortins with other peptide systems, including the opioid system, as potential mediators of pain-alcohol interactions. Therapeutic strategies that target the melanocortin system may mitigate the negative consequences of alcohol misuse during adolescence and/or adulthood, including effects on pain-related outcomes.

Health Care Use Over 3 Years After Adolescent SBIRT

BACKGROUND

Most studies on adolescent screening, brief intervention, and referral to treatment (SBIRT) have examined substance use outcomes. However, it may also impact service use and comorbidity-an understudied topic. We address this gap by examining effects of SBIRT on health care use and comorbidities.

METHODS

In a randomized trial sample, we assessed 3 SBIRT care modalities: (1) pediatrician-delivered, (2) behavioral clinician-delivered, and (3) usual. Medical comorbidity and health care use were compared between a brief-intervention group with access to SBIRT for behavioral health (combined pediatrician and behavioral clinician arms) and a group without (usual care) over 1 and 3 years.

RESULTS

Among a sample of eligible adolescents (n = 1871), the SBIRT group had fewer psychiatry visits at 1 year (incidence rate ratio [iRR] = 0.76; P = .05) and 3 years (iRR = 0.65; P < .05). Total outpatient visits did not differ in year 1. The SBIRT group was less likely to have mental health diagnoses (odds ratio [OR] = 0.69; 95% confidence interval [CI] = 0.48-1.01) or chronic conditions (OR = 0.66; 95% CI = 0.45-0.98) at 1 year compared with those in usual care. At 3 years, the SBIRT group had fewer total outpatient visits (iRR = 0.85; P < .05) and was less likely to have substance use diagnoses (OR = 0.64; 95% CI = 0.45-0.91) and more likely to have substance use treatment visits (iRR = 2.04; P < .01).

CONCLUSIONS

Providing SBIRT in pediatric primary care may improve health care use and health, mental health, and substance use outcomes. We recommend further exploring the effects of SBIRT on these outcomes.

Specialty addiction and psychiatry treatment initiation and engagement: Results from an SBIRT randomized trial in pediatrics

OBJECTIVE

Many adolescents needing specialty addiction or psychiatry treatment never access care. We examined initiation and engagement with addiction and/or psychiatry treatment among adolescents referred to treatment from a trial comparing two different modalities of delivering Screening, Brief Intervention and Referral to Treatment (SBIRT) to Usual Care in pediatric primary care. We hypothesized that both intervention arms would have higher initiation and engagement rates than usual care.

METHODS

We randomized all pediatricians (n=52) in a pediatric primary care clinic to three arms: 1) pediatrician-only arm, in which pediatricians were trained to deliver SBIRT for substance use and/or mental health problems; 2) embedded-behavioral health clinician (embedded-BHC arm), in which pediatricians referred adolescents who endorsed substance use and/or mental health problems to a BHC; and 3) Usual Care (UC). We used electronic health record (EHR) data to examine specialty addiction and psychiatry treatment initiation and engagement rates after referral.

RESULTS

Among patients who screened positive for substance use and/or mental health problems and were referred to specialty addiction and/or psychiatry (n=333), those in the embedded-BHC arm had almost four times higher odds of initiating treatment than those in the pediatrician-only arm, OR=3.99, 95% CI=[1.99-8.00]. Compared to UC, those in the pediatrician-only arm had lower odds of treatment initiation (OR=0.53, 95% CI=[0.28-0.99]), while patients in the embedded-BHC arm had marginally higher odds (OR=1.83, 95% CI=[0.99-3.38]). Black patients and those with other/unknown race/ethnicity had lower odds of treatment initiation compared with white adolescents; there were no gender or age differences. We found no differences in treatment engagement across the three arms.

CONCLUSIONS

Embedded BHCs can have a significant positive impact on facilitating treatment initiation for pediatric primary care adolescents referred to addiction and/or psychiatry services.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov #NCT02408952.

Interactive Effect of Parent and Adolescent Psychiatric Symptoms on Substance Use among Adolescents in Community Treatment

Both adolescent and parent psychiatric symptoms are well-established risk factors for adolescent substance use (SU), but the ways that these symptoms interact are not well understood. This study examined the interactive effects of parent and adolescent psychiatric symptoms on adolescent frequency of alcohol and marijuana use, over and above the effects of parental SU. Seventy adolescents presenting to a community mental health center (CMHC) participated. Parent and adolescent psychiatric symptoms were measured with the brief symptom inventory (BSI) and child behavior checklist (CBCL), respectively. Hierarchical regressions revealed different patterns for adolescent alcohol and marijuana use. For alcohol, the BSI parent phobic anxiety subscale predicted increased adolescent use while the parent interpersonal sensitivity subscale predicted decreased use: the effects of these parental symptoms were strongest among adolescents with higher levels of externalizing problems on the CBCL. For marijuana, the BSI parent psychoticism subscale predicted increased adolescent use, whereas paranoid ideation predicted decreased use. Results suggest that adolescent SU treatment and assessment should attend to both adolescent and parent psychiatric symptoms.

Intimacy, Substance Use, and Communication Needs During Cancer Therapy: A Report From the "Resilience in Adolescents and Young Adults" Study

PURPOSE

The prevalence of intimacy and substance use among adolescents and young adults during cancer therapy has not been well described.

METHODS

The "Resilience in Adolescents and Young Adults with Cancer" study was a prospective, multicenter, mixed-methods cohort study. English-speaking patients 14-25 years old with newly diagnosed cancer were invited to complete a comprehensive survey at the time of enrollment (T1) and 3-6 months later (T2). Intimate relationships and health behaviors were assessed with questions adapted from the Guidelines for Adolescent Preventative Services assessment. Descriptive statistics characterized the prevalence of sexual and substance-related behaviors at each time point.

RESULTS

Of 42 eligible and enrolled participants, 35 (83%) and 25 (59%) completed T1 and T2 surveys, respectively. Their mean age was 17.6 years (standard deviation 2.3), 57% were male, and the most common diagnoses were sarcoma and acute leukemia. Over a third of participants reported dating at each time point; 26% were sexually active at T1, and 32% at T2. Of those endorsing sexual activity, fewer than half reported consistent birth control or condom use and 4 reported their first sexual intercourse during our observation. In addition, 46% (T1) and 44% (T2) reported alcohol use and 23% (T1) and 26% (T2) reported illicit drug use. Despite these activities, fewer than 10% endorsed a worry or need to discuss these behaviors with oncology providers.

CONCLUSIONS

Intimacy and substance use among adolescents and young adults are common during cancer therapy. Clinical and research implications include the identification of optimal communication and patient-centered supports.

Marijuana use and service utilization among adolescents 7 years post substance use treatment

BACKGROUND

In an environment of increasingly liberal attitudes towards marijuana use and legalization, little is known about long-term trajectories of marijuana use among clinical samples of adolescents, and how these trajectories relate to health services utilization over time.

METHODS

Latent growth curve analysis was used to identify distinct trajectories of marijuana use in a clinical sample of adolescents (N=391) over 7 years post substance use treatment in an integrated health system. We examined psychiatric problems and polysubstance use associated with the identified trajectory groups using general linear models. Nonlinear mixed-effects logistic regressions were used to examine associations between health services use and the trajectory groups.

RESULTS

We identified three marijuana use trajectory groups: (1) Abstinent (n=117); (2) Low/Stable use (n=174); and (3) Increasing use (n=100). Average externalizing and anxiety/depression scores were significantly lower over time for the Abstinent group compared to the Increasing and Low/Stable groups. The Low Stable and the Increasing group had fewer psychiatric visits over time (p<0.05) and the Low/Stable group used more substance use treatment services over time compared with the Abstinent group (p<0.001).

CONCLUSIONS

Treated adolescents showed distinct marijuana use patterns, one of which indicated a group of adolescents at risk of increased use over time. These individuals have greater psychiatric and polysubstance use over time, but may not be accessing needed services.

High-Deductible Health Plans: Implications for Substance Use Treatment

OBJECTIVE

To examine whether high-deductible health plans are related to patient complexity, health services use, and medical care costs among substance use treatment patients.

DATA SOURCE/STUDY SETTING

Electronic health record data from Kaiser Permanente Northern California; 2007-2011.

STUDY DESIGN

Retrospective analysis of electronic health record data of substance use treatment patients (N = 31,001). We examined relationship of patient demographics, health comorbidities, and services use and cost to deductible level: none, low ($1-$999), and high (≥$1,000).

METHODS

Demographic, membership, diagnostic, and utilization data were merged with cost data. Utilization and costs were summarized into 6-month intervals. Generalized estimation methods for repeated measures with logistic, Poisson, and linear regression were used.

PRINCIPAL FINDINGS

Substance use patients with deductible plans were younger and had less comorbidity than those without deductibles. Patients with high deductibles had lower emergency room and hospital use 12- to 6-month pretreatment, but rates became similar to other groups in the 6 months immediately prior to treatment; treatment costs were similar.

CONCLUSION

Immediately prior to entering treatment, substance use patients with and without high deductibles have similar patterns of health services utilization. We discuss implications for health policy and treatment, particularly in an era of health reform.

Point Prevalence of Co-Occurring Behavioral Health Conditions and Associated Chronic Disease Burden Among Adolescents

OBJECTIVE

To examine the point prevalence of behavioral health conditions (BHCs) and co-occurring chronic medical conditions among adolescents in an integrated health system.

METHOD

The sample consisted of adolescents in an integrated health care system diagnosed with at least 1 of the 5 most prevalent BHCs in 2014 (n = 30,643), and patients without a BHC matched on age, sex, and medical home facility (n = 30,643). Electronic health record data was used to identify all adolescents aged 11 to 18 years with at least 1 BHC diagnosis on their diagnosis list, which included current and pre-existing diagnoses from an outpatient (including psychiatry and chemical dependency specialty treatment), inpatient, or emergency department visit at a Kaiser Permanente Northern California (KPNC) facility between January 1, 2014, and December 31, 2014. The odds of having general medical conditions and specific chronic diseases were compared between adolescents with and without BHCs.

RESULTS

Among adolescents with at least 1 BHC in 2014, the 5 most common BHCs were: depressive disorders (42%), anxiety disorders (40%), attention-deficit/hyperactivity disorders (ADHDs; 37%), substance use disorders (SUDs; 10%), and bipolar spectrum disorders (8%). Overall, patients with a BHC did not have higher odds of any medical comorbidity compared with non-BHC patients. However, compared to individuals without BHCs, adolescents with depression (odds ratio [OR] = 1.16, 95% CI = 1.08-1.26), anxiety (OR = 1.30, 95% CI = 1.20-1.41), and substance use (OR = 1.25, 95% CI = 1.05-1.49) disorders had significantly higher odds of any medical comorbidities; individuals with ADHD and bipolar disorder did not differ from patients without BHCs.

CONCLUSION

BHCs were common and were associated with a disproportionately higher burden of chronic medical disease among adolescents in a large, private health care delivery system. As comorbidity can lead to elevated symptom burden, functional impairment, and treatment complexity, the study findings call for implementation of effective collaborative models of care for these patients.

Barriers to Addressing Adolescent Substance Use: Perceptions of New York School-Based Health Center Providers

BACKGROUND

Adolescent substance use is associated with chronic health conditions, accidents, injury, and school-related problems, including dropping out. Schools have the potential to provide students with substance use prevention and intervention services, albeit with confidentiality challenges. School-based health centers (SBHCs) provide confidentiality, positioning them as ideal settings to provide substance use prevention and intervention. This study identified program directors' and clinicians' barriers to addressing adolescent substance use in SBHCs.

METHODS

Between May and June 2013, an electronic survey was distributed to all 162 New York State SBHC program directors and clinicians serving middle and high school students.

RESULTS

The most prevalent perceived barriers to discussing substance use with students were time constraints (43%), the belief that students are not honest about their use (43%), and clinicians' lack of training (28%). Both directors and clinicians identified challenges in getting students to return for additional sessions to address their use, and they also indicated that confidentiality was a treatment referral barrier.

CONCLUSIONS

This study identified timely opportunities that may be leveraged and unique challenges that may be overcome with targeted dissemination, training, and technical assistance efforts to enable directors and clinicians to routinely address substance use in SBHCs.

Implementation of Screening, Brief Intervention, and Referral to Treatment for Adolescents in Pediatric Primary Care: A Cluster Randomized Trial

IMPORTANCE

Early intervention for substance use is critical to improving adolescent outcomes. Studies have found promising results for Screening, Brief Intervention, and Referral to Treatment (SBIRT), but little research has examined implementation.

OBJECTIVE

To compare SBIRT implementation in pediatric primary care among trained pediatricians, pediatricians working in coordination with embedded behavioral health care practitioners (BHCPs), and usual care (UC).

DESIGN, SETTING, AND PARTICIPANTS

The study is a 2-year (November 1, 2011, through October 31, 2013), nonblinded, cluster randomized, hybrid implementation and effectiveness trial examining SBIRT implementation outcomes across 2 modalities of implementation and UC. Fifty-two pediatricians from a large general pediatrics clinic in an integrated health care system were randomized to 1 of 3 SBIRT implementation arms; patients aged 12 to 18 years were eligible.

INTERVENTIONS

Two modes of SBIRT implementation, (1) pediatrician only (pediatricians trained to provide SBIRT) and (2) embedded BHCP (BHCP trained to provide SBIRT), and (3) UC.

MAIN OUTCOMES AND MEASURES

Implementation of SBIRT (primary outcome), which included assessments, brief interventions, and referrals to specialty substance use and mental health treatment.

RESULTS

The final sample included 1871 eligible patients among 47 pediatricians; health care professional characteristics did not differ across study arms. Patients in the pediatrician-only (adjusted odds ratio [AOR], 10.37; 95% CI, 5.45-19.74; P < .001) and the embedded BHCP (AOR, 18.09; 95% CI, 9.69-33.77; P < .001) arms had higher odds of receiving brief interventions compared with patients in the UC arm. Patients in the embedded BHCP arm were more likely to receive brief interventions compared with those in the pediatrician-only arm (AOR, 1.74; 95% CI, 1.31-2.31; P < .001). The embedded BHCP arm had lower odds of receiving a referral compared with the pediatrician-only (AOR, 0.58; 95% CI, 0.43-0.78; P < .001) and UC (AOR, 0.65; 95% CI, 0.48-0.89; P = .006) arms; odds of referrals did not differ between the pediatrician-only and UC arms.

CONCLUSIONS AND RELEVANCE

The intervention arms had better screening, assessment, and brief intervention rates than the UC arm. Patients in the pediatrician-only and UC arms had higher odds of being referred to specialty treatment than those in the embedded BHCP arm, suggesting lingering barriers to having pediatricians fully address substance use in primary care. Findings also highlight age and ethnic groups less likely to receive these important services.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02408952.

Substance Use and Associated Health Conditions throughout the Lifespan

A life stage perspective is necessary for development of age-appropriate strategies to address substance use disorders (SUDs) and related health conditions in order to produce better overall health and well-being. The current review evaluated the literature across three major life stages: adolescence, adulthood, and older adulthood.

FINDINGS

1) Substance use is often initiated in adolescence, but it is during adulthood that prevalence rates for SUDs peak; and while substance involvement is less common among older adults, the risk for health complications associated with use increases. 2) Alcohol, tobacco, marijuana, and, increasingly, prescription medications, are the most commonly misused substances across age groups; however, the use pattern of these and other drugs and the salient impact vary depending on life stage. 3) In terms of health outcomes, all ages are at risk for overdose, accidental injury, and attempted suicide. Adolescents are more likely to be in vehicular accidents while older adults are at greater risk for damaging falls. Adulthood has the highest rates of associated medical conditions (e.g., cancer, sexually transmitted disease, heart disease) and mental health conditions (e.g., bipolar disorder, anxiety disorders, antisocial personality disorder).

CONCLUSION

Prolonged heavy use of drugs and/or alcohol results in an array of serious health conditions. Addressing SUDs from a life stage perspective with assessment and treatment approaches incorporating co-occurring disorders are necessary to successfully impact overall health.

12-step participation and outcomes over 7 years among adolescent substance use patients with and without psychiatric comorbidity

This study examines the associations between 12-step participation and outcomes over 7 years among 419 adolescent substance use patients with and without psychiatric comorbidities. Although level of participation decreased over time for both groups, comorbid adolescents participated in 12-step groups at comparable or higher levels across time points. Results from mixed-effects logistic regression models indicated that for both groups, 12-step participation was associated with both alcohol and drug abstinence at follow-ups, increasing the likelihood of either by at least 3 times. Findings highlight the potential benefits of 12-step participation in maintaining long-term recovery for adolescents with and without psychiatric disorders.

12-Step participation reduces medical use costs among adolescents with a history of alcohol and other drug treatment

BACKGROUND

Adolescents who attend 12-step groups following alcohol and other drug (AOD) treatment are more likely to remain abstinent and to avoid relapse post-treatment. We examined whether 12-step attendance is also associated with a corresponding reduction in health care use and costs.

METHODS

We used difference-in-difference analysis to compare changes in seven-year follow-up health care use and costs by changes in 12-step participation. Four Kaiser Permanente Northern California AOD treatment programs enrolled 403 adolescents, 13-18-years old, into a longitudinal cohort study upon AOD treatment entry. Participants self-reported 12-step meeting attendance at six-month, one-year, three-year, and five-year follow-up. Outcomes included counts of hospital inpatient days, emergency room (ER) visits, primary care visits, psychiatric visits, AOD treatment costs and total medical care costs.

RESULTS

Each additional 12-step meeting attended was associated with an incremental medical cost reduction of 4.7% during seven-year follow-up. The medical cost offset was largely due to reductions in hospital inpatient days, psychiatric visits, and AOD treatment costs. We estimate total medical use cost savings at $145 per year (in 2010 U.S. dollars) per additional 12-step meeting attended.

CONCLUSIONS

The findings suggest that 12-step participation conveys medical cost offsets for youth who undergo AOD treatment. Reduced costs may be related to improved AOD outcomes due to 12-step participation, improved general health due to changes in social network following 12-step participation, or better compliance to both AOD treatment and 12-step meetings.

Integrating substance use treatment into adolescent health care

Substance use (SU) problems are common among adolescents, a serious health risk for them and a major public health problem, but are inadequately addressed in most pediatric health care settings. Primary care offers an excellent context for SU assessment and treatment for adolescents and their families, offering better access and a less stigmatized environment for receiving treatment than specialty programs. This paper examines the literature on the integration of substance use treatment with adolescent health care, focusing on 2 areas: Screening, Brief Intervention, and Referral to Treatment (SBIRT) in Emergency Departments and Primary Care, and School- and College-Based Health Centers.

Screening for adolescent alcohol and drug use in pediatric health-care settings: predictors and implications for practice and policy

OBJECTIVE

This paper used data from a study of pediatric primary care provider (PCP) screening practices to examine barriers to and facilitators of adolescent alcohol and other drug (AOD) screening in pediatric primary care.

METHODS

A web-based survey (N = 437) was used to examine the influence of PCP factors (attitudes and knowledge, training, self-efficacy, comfort with alcohol and drug issues); patient characteristics (age, gender, ethnicity, comorbidities and risk factors); and organizational factors (screening barriers, staffing resources, confidentiality issues) on AOD screening practices. Self-reported and electronic medical record (EMR)-recorded screening rates were also assessed.

RESULTS

More PCPs felt unprepared to diagnose alcohol abuse (42%) and other drug abuse (56%) than depression (29%) (p < 0.001). Overall, PCPs were more likely to screen boys than girls, and male PCPs were even more likely than female PCPs to screen boys (23% versus 6%, p < 0.0001). Having more time and having other staff screen and review results were identified as potential screening facilitators. Self-reported screening rates were significantly higher than actual (EMR-recorded) rates for all substances. Feeling prepared to diagnose AOD problems predicted higher self-reported screening rates (OR = 1.02, p < 0.001), and identifying time constraints as a barrier to screening predicted lower self-reported screening rates (OR = 0.91, p < 0.001). Higher average panel age was a significant predictor of increased EMR-recorded screening rates (OR = 1.11, p < 0.001).

CONCLUSIONS

Organizational factors, lack of training, and discomfort with AOD screening may impact adolescent substance-abuse screening and intervention, but organizational approaches (e.g., EMR tools and workflow) may matter more than PCP or patient factors in determining screening.

Cigarette Smoking and Alcohol Use among Adolescents and Young Adults with Asthma

Asthma is one of the most common, serious chronic diseases in pediatric and young adult populations. Health-risk behaviors, including cigarette smoking and alcohol use, may exacerbate chronic diseases and complicate their management. The aim of this study was to longitudinally analyze rates of cigarette smoking and alcohol use in adolescents and young adults who have asthma and those who do not have asthma. A secondary analysis of data from the National Longitudinal Study of Adolescent Health was undertaken. Individuals with asthma were found to exhibit increasing rates of cigarette smoking and alcohol use as they aged. When an adolescent with a chronic health issue begins health-risk-taking behaviors, behavior change interventions must be planned. Pediatric nurses, practitioners, and clinicians are uniquely positioned to assess for health-risk behaviors in youth with asthma and to intervene with plans of care that are tailored for the needs of this vulnerable population.

Access to treatment for adolescents with substance use and co-occurring disorders: challenges and opportunities

OBJECTIVE

To review the research on economic and systemic barriers faced by adolescents needing treatment for alcohol and drug problems, particularly those with co-occurring conditions.

METHOD

We reviewed the literature on adolescent access to alcohol and drug services, including early intervention, and integrated and specialty mental health treatment for those with co-occurring disorders, examining the role of health care systems, public policy (health reform), treatment financing and reimbursement systems (public and private), implementation of evidence-based practices, confidentiality practices, and treatment costs and cost/benefits.

RESULTS

Barriers to treatment, particularly integrated treatment, are largely rooted in our organizationally fragmented health care system, which encompasses public and private, carved-out and integrated systems, and different funding mechanisms (Medicaid versus block grants versus private insurance that include "high deductible" plans and other cost controls.) In both systems, carved-out programs de-link services from other mental health and general health care. Barriers are also rooted in disciplinary differences and weak clinical linkages between psychiatry, primary care and substance use, and in confidentiality policies that inhibit communication and coordination, while protecting patient privacy.

CONCLUSION

In this era of health care reform, we have the opportunity to increase access for adolescents and develop new models of integrated services for those with co-occurring conditions. We discuss opportunities for improving treatment access and implementation of evidence-based practices, examine implications of health reform and parity legislation for psychiatric and substance use treatment, and comment on key unanswered questions and future research opportunities.

Office of National Drug Control Policy: a scientist in drug policy in Washington, DC

This essay describes how a basic scientist was thrust into the epicenter, the political cauldron of our national drug control policy, and how the experience altered her professional trajectory and perspective.

Availability of HIV-related health services in adolescent substance abuse treatment programs

Given that alcohol and drug abuse heightens the risk of adolescents acquiring HIV, substance abuse treatment programs for youths may represent an important site of HIV prevention. In this research, we explored the adoption of three HIV-related health services: risk assessment during intake, HIV prevention programing, and HIV testing. Data were collection through telephone interviews with 149 managers of adolescent-only substance abuse treatment programs in the USA. About half of these programs had adopted HIV risk assessment and HIV prevention. On-site HIV testing was less widely adopted, with only one in four programs offering this service. At the bivariate level, the availability of on-site primary medical care and the availability of an overnight level of care were positively associated with these three types of services. The association for the measure of an overnight level of care was no longer significant once medical services were controlled. However, in a separate analysis, it was found that programs offering an overnight level of care were much more likely to offer on-site medical care than outpatient-only facilities. There was also evidence that publicly funded treatment programs were more likely to offer HIV prevention and on-site HIV testing, after controlling for other organizational characteristics. Much more research about the adoption of HIV-related services in adolescent substance abuse treatment is needed, particularly to offer greater insight into why certain types of organizations are more likely to adopt these health services.

Child abuse and other traumatic experiences, alcohol use disorders, and health problems in adolescence and young adulthood

OBJECTIVE

We prospectively examined the health effects of child abuse and other traumatic events, with objective health indicators and consideration of alcohol use disorders (AUD).

METHODS

Adolescents (n = 668) were recruited from clinical and community sources. At baseline, we examined child abuse and other traumas, AUD, health-related symptoms, physical findings, and blood assays. Subjects were assigned to Trauma Classes (TC), including witnessing violence, physical abuse, and sexual abuse. Health outcomes were again determined at 1-year and young adult follow-up.

RESULTS

In adolescence, higher TC severity was associated with more health-related symptoms, increased age-adjusted body mass index, and stress-response immune system indices. In adolescence and young adulthood, the relationships between TC and health-related symptoms were mediated by anxiety. AUD was associated with liver injury, and cigarette smoking with heart/lung symptoms.

CONCLUSIONS

Child abuse predicted persistently elevated health-related symptoms primarily attributable to anxiety, and early signs of liver disease were attributable to AUD.

Effects on substance use outcomes in adolescents receiving motivational interviewing for smoking cessation during psychiatric hospitalization

The purpose of this study was to compare substance involvement among psychiatrically hospitalized adolescent smokers who had received motivational interviewing (MI) versus brief advice (BA) for smoking cessation. One hundred and ninety-one (191) adolescent smokers (62.3% female; 15.4 years of age) were randomly assigned to MI (n=116) or BA (n=75). All patients were assessed at baseline, immediately after hospitalization, and at 1-, 3-, 6-, 9-, and 12-month follow-ups. Rates of substance use in the MI condition during follow-up increased from a low of 8.2% (SD=18.5) to a high of 15.4% (SD=30.0) substance use days, whereas in BA, substance use days increased from a low of 8.4% (SD=20.8) to a high of 21.4% (SD=35.2). The results of this study suggest that MI, relative to BA, for smoking cessation was associated with better substance use outcomes during the first 6 months following psychiatric hospitalization among adolescents. This finding is consistent with previous studies that have shown that smoking cessation does not have a detrimental effect on substance abuse treatment outcomes among youth.

Demographic shifts in health conditions of adolescents 10-19 years, Jamaica: Using cross-sectional data for 2002 and 2007

BACKGROUND

It is well established in health literature that most adolescents have good health, but this does not mitigate the reality that there are some who are living with chronic and other health conditions.

AIMS

To examine the demographic shifts in health conditions and the typology of health conditions experienced by this age cohort.

MATERIALS AND METHOD

The current study extracted a sample of 5,229 and 1,394 for adolescents 10-19 years from two surveys collected jointly by the Planning Institute of Jamaica and the Statistical Institute of Jamaica for 2002 and 2007 respectively. The survey was drawn using stratified random sampling. The sample was weighted to reflect the population of the nation. Descriptive statistics and chi-square were used in this study. The level of significance used in this research was 5% (i.e. 95% confidence interval).

RESULTS

In 2002, most of respondents had cold (28.3%) and in 2007, this shifted to unspecified health conditions (35.5%). The number of reported cases of arthritis in adolescents was 0.4%, in 2002, which fell by 100% in 2007 whereas increases were observed for unspecified conditions, 42%; hypertension, 175%; and diabetes mellitus, 700%.

CONCLUSIONS

There is an immediate need for health promotion and education campaigns geared towards the sensitization of adolescents about the rise in chronic illness, its challenges, lifestyle practices and willingness to seek care if particular symptoms are presently affecting them.

Quality of medical care for people with and without comorbid mental illness and substance misuse: systematic review of comparative studies

BACKGROUND

There has been long-standing concern about the quality of medical care offered to people with mental illness.

AIMS

To investigate whether the quality of medical care received by people with mental health conditions, including substance misuse, differs from the care received by people who have no comparable mental disorder.

METHOD

A systematic review of studies that examined the quality of medical care in those with and without mental illness was conducted using robust critical appraisal techniques.

RESULTS

Of 31 valid studies, 27 examined receipt of medical care in those with and without mental illness and 10 examined medical care in those with and without substance use disorder (or dual diagnosis). Nineteen of 27 and 10 of 10, respectively, suggested inferior quality of care in at least one domain. Twelve studies found no appreciable differences in care or failed to detect a difference in at least one key area. Several studies showed an increase in healthcare utilisation but without any increase in quality. Three studies found superior care for individuals with mental illness in specific subdomains. There was inadequate information concerning patient satisfaction and structural differences in healthcare delivery. There was also inadequate separation of delivery of care from uptake in care on which to base causal explanations.

CONCLUSIONS

Despite similar or more frequent medical contacts, there are often disparities in the physical healthcare delivered to those with psychiatric illness although the magnitude of this effect varies considerably.

Chronic illness and multimorbidity among problem drug users: a comparative cross sectional pilot study in primary care

Background

Although multimorbidity has important implications for patient care in general practice, limited research has examined chronic illness and health service utilisation among problem drug users. This study aimed to determine chronic illness prevalence and health service utilisation among problem drug users attending primary care for methadone treatment, to compare these rates with matched 'controls' and to develop and pilot test a valid study instrument.

Methods

A cross-sectional study of patients attending three large urban general practices in Dublin, Ireland for methadone treatment was conducted, and this sample was compared with a control group matched by practice, age, gender and General Medical Services (GMS) status.

Results

Data were collected on 114 patients. Fifty-seven patients were on methadone treatment, of whom 52(91%) had at least one chronic illness (other then substance use) and 39(68%) were prescribed at least one regular medication. Frequent utilisation of primary care services and secondary care services in the previous six months was observed among patients on methadone treatment and controls, although the former had significantly higher chronic illness prevalence and primary care contact rates. The study instrument facilitated data collection that was feasible and with minimal inter-observer variation.

Conclusion

Multimorbidity is common among problem drug users attending general practice for methadone treatment. Primary care may therefore have an important role in primary and secondary prevention of chronic illnesses among this population. This study offers a feasible study instrument for further work on this issue. (238 words)

Morbidity in a population of low-income, female users of MDMA and other drugs

Few previous studies have reported on the overall health of drug-using women. To investigate this, 696 low-income women aged 18-31 were recruited in a cross-sectional study from gynecological care clinics in Texas between 2001 and 2003. Compared to exclusive marijuana users and non-drug users, women who used MDMA and those who used other illicit drugs but not MDMA reported more gynecological conditions, medical conditions, depressive symptoms, and physical somatic complaints. We concluded that young, low-income women who used more than one illicit drug experience significantly more physical and psychological morbidity. Generalization of this study results may be limited to young women with low income but not to other populations.

The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients

INTRODUCTION

Health problems are prevalent in chemical dependency (CD) treatment populations, and often precede reductions in substance use among untreated populations. Few studies have examined whether medical problems predict better long-term outcomes in treated individuals, or how primary care utilization and CD/primary care service integration affects long-term outcomes among those with health problems.

METHOD

In a sample of 598 CD patients in a private health plan, logistic regression models examined whether substance abuse-related medical conditions (SAMCs), integrated medical and CD care, and on-going primary care predicted remission of CD problems at 5 years.

RESULTS

Those with SAMCs were no more likely than others to be remitted at 5 years except among young adults and those with medical, but not psychiatric SAMCs. Higher levels of medical problem severity at intake and receiving integrated CD and primary care in the index treatment episode predicted remission in the full sample and among those with SAMCs. Among those with SAMCs, individuals with ongoing medical care - 2-10 primary care visits - in the 5 years following intake were more likely to be remitted at 5 years than those with fewer visits.

CONCLUSIONS

This study highlights the potentially important role of medical services in the long-term treatment of CD disorders. CD treatment may benefit from a disease management approach similar to that recommended for other chronic medical problems: specialty care when the condition is severe followed by services in primary care when the condition is stabilized.

Psychiatric considerations in pulmonary disease

Lung disease is a prominent cause of morbidity and mortality worldwide. When a patient has a common lung disease, such as asthma, or a less prevalent one, such as idiopathic pulmonary fibrosis, psychiatric issues should be considered as an integral part of the care plan for each patient. There have been many studies of psychologic factors and psychiatric syndromes in various lung diseases and their treatment. In this article, the authors focus on an evidence-based approach to reviewing this clinical literature.