Early Treatment for Women with Alcohol Addiction (EWA) reduces mortality: a randomized controlled trial with long-term register follow-up

A scoping review of health inequities in alcohol use disorder

Background: Alcohol Use Disorder (AUD) poses a significant health burden on individuals. The burden occurs more frequently in the medically underserved, as well as racial and sexual minority populations. Ameliorating health inequities is vital to improving patient-centered care.Objectives: The objective of this scoping review is to chart the existing evidence on health inequities related to AUD and identify existing knowledge gaps to guide future equity-centered research.Methods: We performed a literature search using the Ovid (Embase) and MEDLINE (PubMed) databases for articles on AUD that were published in the 5-year period spanning from 2017 to 2021 and written in English. The frequencies of each health inequity examined were analyzed, and findings from each included study were summarized.Results: Our sample consisted of 55 studies for analysis. The most common inequity examined was by race/ethnicity followed by sex or gender. The least reported inequities examined were rural under-resourced areas and occupational status. Our findings indicate that significant research gaps exist in education, rural under-resourced populations, and LGBTQ+ communities with AUD.Conclusions: This scoping review highlights the gaps in research on inequities in AUD. To bridge the current gaps, we recommend research on the following: 1) triage screening tools and the use of telemedicine for rural, under-resourced populations; 2) interventions to increase treatment engagement and retention for women; and 3) community-based participatory methodologies for the LGBTQ+ communities.

Gender specific early treatment for women with alcohol addiction (EWA): Impact on work related outcomes. A 25-year registry follow-up of a randomized controlled trial (RCT)

BACKGROUND

Alcohol contributes to substantial economic burden, at both individual and community levels. We investigated the effect of the Early treatment for Women with Alcohol Addiction (EWA) treatment program on sickness leave, income, unemployment and early retirement pension up to 25 years following intake to treatment.

METHODS

The EWA RCT included 200 women with alcohol use disorder from 1983 to 1984 at the Karolinska University Hospital, Sweden. Participants were randomized to the EWA program, a two-year specialized woman only treatment including psychiatric, interpersonal and family concerns, or treatment as usual (TAU) in a mixed gender setting. We followed the participants in the RCT from 1985 to 2009 through linkage with a national labor market registry and applied latent growth curve modeling to estimate level and change in sickness leave, income, unemployment and early retirement pension.

FINDINGS

Relative to TAU, the EWA group had less increase in sickness leave up to 21 years after treatment. Overall, we found no differences in income between treatment groups, yet, a two-year interval analysis showed greater rise in income up to 8 years after treatment for the EWA group. Level and change in unemployment and early retirement pension did not differ between treatment groups.

CONCLUSIONS

Gender specific treatment emphasizing psychiatric, interpersonal and family issues for women with alcohol addiction had long-term positive effects on sickness leave and income. These findings complement positive clinical outcomes of the EWA treatment program on drinking patterns, mental health and mortality.

Treatment Interventions for Women With Alcohol Use Disorder

Women with alcohol use disorder (AUD) experience more barriers to AUD treatment and are less likely to access treatment than men with AUD. A literature review identified several barriers to women seeking help: low perception of a need for treatment; guilt and shame; co-occurring disorders; employment, economic, and health insurance disparities; childcare responsibilities; and fear of child protective services. Women entering treatment present with more severe AUD and more complex psychological, social, and service needs than men. Treatment program elements that may reduce barriers to AUD treatment include provision of childcare, prenatal care, treatment for co-occurring psychological problems, and supplemental social services. Research has suggested that outcomes for women are best when treatment is provided in women-only programs that include female-specific content. To date, research on treatments tailored to the individual needs of women is limited, but research on mechanisms of change has suggested the importance of targeting anxiety and depression, affiliative statements in treatment, abstinence self-efficacy, coping skills, autonomy, and social support for abstinence. Future research should focus on early interventions, linkages between primary care or mental health clinics and AUD treatment settings, and integrated treatments for co-occurring AUD and other disorders. Further research should also explore novel treatment delivery approaches such as digital platforms and peer support groups.

Elevated maternal and child mortality among women with multiple DUI convictions compared with socio-demographically matched controls

AIMS

To assess whether having multiple convictions for driving while under the influence of alcohol (MDUI) in women is a risk factor for maternal, infant and child mortality.

DESIGN

Retrospective cohort design using record linkage, comparing women with MDUI convictions with propensity-matched women without alcohol-related driving offences ascertained through state records, on rates of maternal, infant and child mortality.

SETTING

Missouri, United States.

PARTICIPANTS

MDUI women (n = 1658) and women with no alcohol-related driving convictions (control, n = 184 252) who gave birth from 2000 to 2004.

MEASUREMENTS

Data were obtained from state administrative records and US Census data. The outcomes were maternal, infant and child mortality. The input variable was presence or absence of MDUI convictions. Propensity-matching variables were maternal (smoking during pregnancy, delayed prenatal care, previous child deaths, age at birth, mother Missouri-born, education, pre-pregnancy obesity, marital status), reproductive partner (un-named partner, race/ethnicity, education, DUI status) and census tract (socio-economic advantage, urbanicity) characteristics.

FINDINGS

Women with MDUI convictions had higher odds of maternal, infant and child mortality than propensity-matched controls [odds ratio (OR) = 2.65, 95% confidence interval (CI) = 2.07-3.40 and OR = 1.75, 95% CI = 1.17-2.61, respectively].

CONCLUSIONS

Having multiple convictions for driving under the influence of alcohol in women appears to be a risk factor for increased maternal, infant and child mortality.

Assessment of Long-term Follow-up of Randomized Trial Participants by Linkage to Routinely Collected Data: A Scoping Review and Analysis

Importance

Follow-up of participants in randomized trials may be limited by logistic and financial factors. Some important randomized trials have been extended well beyond their original follow-up period by linkage of individual participant information to routinely collected data held in administrative records and registries.

Objective

To perform a scoping review of randomized clinical trials extended by record linkage to characterize this literature and explore any additional insights into treatment effectiveness provided by long-term follow-up using record linkage.

Data Sources

A literature search in Embase, CINAHL, MEDLINE, and the Cochrane Register of Controlled Trials was performed for the period January 1, 1945, through November 25, 2016.

Study Selection

Various combinations of search terms were used, as there is no accepted terminology. Determination of study eligibility and extraction of information about trial characteristics and outcomes, for both original and extended trial reports, were performed in duplicate.

Data Extraction and Synthesis

Assessment of study eligibility and data extraction were performed independently by 2 reviewers. All analyses were descriptive.

Main Outcomes and Measures

Outcomes in the pairs of original and extended trials were categorized according to whether any benefits or harms from interventions were sustained, were lost, or emerged during long-term follow-up.

Results

A total of 113 extended trials were included in the study. Linkage to administrative and registry data extended follow-up by between 1 and 55 years. The most common interventions were pharmaceuticals (47 [41.6%]), surgery (19 [16.8%]), and disease screening (19 [16.8%]). End points most frequently studied through record linkage included mortality (88 [77.9%]), cancer (41 [36.3%]), and cardiovascular events (37 [32.7%]). One hundred four trial extensions (92.0%) were analyzed according to the original trial randomization. The reports provided details of 155 analyses of study outcomes. Seventy-four analyses (47.7%) identified statistically significant benefits in the trial extension phase. In 21 of these (28.4%), benefits were significant only in this period. Null results in both the original and extended trials were seen in 34 of the analyses (21.9%). Loss of significant benefits of an intervention were seen in 12 analyses (7.7%). Statistically significant harms were seen in 16 trial extension analyses (10.3%), and in 14 of these (87.5%), the harms were significant only in the trial extension phase.

Conclusions and Relevance

Trial extension by linkage to routinely collected data is a versatile underused approach that may add critical insights beyond those of the original trial. Some beneficial and harmful outcomes of interventions are captured only in the extension phase of randomized trials.

A randomized trial of female-specific cognitive behavior therapy for alcohol dependent women

This study compared Female-Specific Cognitive Behavioral Therapy (FS-CBT) to evidence-based, gender-neutral CBT (GN-CBT; Epstein & McCrady, 2009) for women with alcohol use disorder (AUD). Women (N = 99) with AUD, mean age 48, were randomly assigned to 12 outpatient manual-guided sessions of FS-CBT (n = 44) or GN-CBT (n = 55). Women were assessed at baseline and 3, 9 and 15 months after baseline for drinking and for specific issues common among women with AUD. A FS-CBT protocol was developed that was discriminable on treatment integrity ratings from GN-CBT. No treatment condition differences were found in treatment engagement, changes in drinking, alcohol-related coping, abstinence self-efficacy, motivation to change, or constructs directly targeted in FS-CBT (sociotropy, autonomy, depression, anxiety). Women in both conditions were highly engaged and satisfied with treatment, and reported significant reductions in drinking and changes in desired directions for all other variables except social support for abstinence. In the year following treatment, women in the FS-CBT but not in the CBT condition reported an increase in percentage of abstainers in their social networks (0.69% per month, SE = 0.21, p = .002). The value and appeal of female-specific programming in AUD treatment has been established in the wider literature (Epstein & Menges, 2013), and the current study provides support for the use of the Female-Specific Cognitive Behavioral Therapy (FS-CBT) manual as an option that may yield outcomes similar to standard gender-neutral CBT for women with AUD. Future research should examine whether FS-CBT enhances treatment utilization for women. (PsycINFO Database Record

Register data in the evaluation and program planning of addiction treatment programs: using Sweden as an example

Data from large-scale registers is often underutilized when evaluating addiction treatment programs. Since many programs collect register data regarding clients and interventions, there is a potential to make greater use of such records for program evaluation. The purpose of this article is to discuss the value of using large-scale registers in the evaluation and program planning of addiction treatment systems and programs. Sweden is used as an example of a country where register data is both available and is starting to be used in national evaluation and program planning efforts. The article focuses on possibilities, limitations and practicalities when using large-scale register data to conduct evaluations and program planning of addiction treatment programs. Main conclusions are that using register data for evaluation provides large amounts of data at low cost, limitations associated to the use of register data may be handled statistically, register data can answer important questions in planning of addiction treatment programs, and more accurate measures are needed to account for the diversity of client populations.

Substance use and hepatitis C: an ecological momentary assessment study

OBJECTIVE

The objective of this study was to assess craving and mood related to opioid and cocaine use among asymptomatic hepatitis C virus (HCV)+ and HCV- methadone patients who have not started antiviral treatment.

METHODS

In this 28-week prospective ecological momentary assessment (EMA) study, 114 methadone-maintained, heroin- and cocaine-abusing individuals reported from the field in real time on their mood, craving, exposure to drug-use triggers, and drug use via handheld computers.

RESULTS

Sixty-one percent were HCV+; none were overtly symptomatic or receiving HCV treatment. HCV status was not associated with age, sex, race, or past-30-day or lifetime heroin or cocaine use. In event-contingent EMA entries, HCV+ individuals more often attributed use to having been bored, worried, or sad; feeling uncomfortable; or others being critical of them compared with HCV- participants. In randomly prompted EMA entries, HCV+ participants reported significantly more exposure to drug-use triggers, including handling ≥$10, seeing cocaine or heroin, seeing someone being offered/use cocaine or heroin, being tempted to use cocaine, and wanting to see what would happen if they used just a little cocaine or heroin.

CONCLUSIONS

HCV+ individuals experienced more negative moods and more often cited these negative moods as causes for drug use. HCV+ individuals reported greater exposure to environmental drug-use triggers, but they did not more frequently cite these as causes for drug use. The EMA data reported here suggest that HCV+ intravenous drug users may experience more labile mood and more reactivity to mood than HCV- intravenous drug users. The reason for the difference is not clear, but HCV status may be relevant to tailoring of treatment.