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Rockwell MS, Funk AJ, Huffstetler AN, Villalobos G, Britz JB, Webel B, Richards A, Epling JW, Sabo RT, Krist AH. Screening for Unhealthy Alcohol Use Among Patients With Multiple Chronic Conditions in Primary Care. AJPM FOCUS 2024; 3:100233. [PMID: 38947491 PMCID: PMC11214170 DOI: 10.1016/j.focus.2024.100233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Introduction Unhealthy alcohol use increases the risk for and exacerbation of chronic health conditions. As such, screening, prevention, and management of unhealthy alcohol use is especially critical to improving health outcomes for patients with multiple chronic health conditions. It is unclear to what extent multiple chronic condition status is a barrier to screening for unhealthy alcohol use in the primary care setting. The authors hypothesized that patients with multiple chronic conditions would be at lower odds of being screened for unhealthy alcohol use than patients without multiple chronic conditions. Methods The authors performed a secondary analysis of electronic health record data for patients from 67 primary care practices in Virginia (2020-2023). Using the Center for Medicare and Medicaid Services' chronic disease framework, they classified patients by multiple chronic condition status: no multiple chronic conditions, physical multiple chronic conditions, mental health multiple chronic conditions, and physical and mental health multiple chronic conditions. They used multiple logistic regressions with an added practice-level random effect to analyze the relationship between multiple chronic condition status and the odds of receiving an alcohol-related assessment, of being screened for unhealthy alcohol use with a U.S. Preventive Services Task Force-recommended instrument, and of screening positive for unhealthy alcohol use within the past 2 years. Results Within a final cohort of n=11,789, a total of 6,796 patients (58%) had multiple chronic conditions (29% physical multiple chronic conditions, 4% mental health multiple chronic conditions, and 25% physical and mental health multiple chronic conditions). In all, 69% of patients were screened for unhealthy alcohol use, whereas 16% were screened with a U.S. Preventive Services Task Force-recommended instrument, and 7% screened positive for unhealthy alcohol use. Patients with physical and mental health multiple chronic conditions had 0.9 times lower odds of receiving any screening for unhealthy alcohol use than those with no multiple chronic conditions (95% CI=0.8, 1.0; p=0.0240), whereas patients with only physical multiple chronic conditions or only mental health multiple chronic conditions had similar odds. There was no difference in the odds of being screened with a U.S. Preventive Services Task Force-recommended instrument on the basis of multiple chronic condition status. Patients with mental health multiple chronic conditions and physical and mental health multiple chronic conditions had 1.8 and 1.5 times greater odds of screening positive for unhealthy alcohol use, respectively (95% CI=1.3, 2.7; p=0.0014 and 95% CI=1.2, 1.8; p=0.0003). Conclusions Although patients with chronic mental health conditions were more likely to screen positive for unhealthy alcohol use than patients without multiple chronic conditions, Virginia primary care patients with physical and mental health multiple chronic conditions were less likely to receive an alcohol-related assessment during the past 2 years. Given the overall modest rate of screening with a U.S. Preventive Services Task Force-recommended instrument, further efforts are needed to create the conditions for high-quality alcohol-related preventive service delivery in primary care, particularly for patients with high complexity and/or mental health conditions.
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Affiliation(s)
- Michelle S. Rockwell
- Department of Family & Community Medicine, Carilion Clinic and Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Adam J. Funk
- Department of Biostatistics, School of Public Health, Virginia Commonwealth University, Richmond, Virginia
| | - Alison N. Huffstetler
- Department of Family Medicine & Population Health, Virginia Commonwealth University, Richmond, Virginia
- INOVA Family Practice Residency, Fairfax, Virginia
- The Robert Graham Center, Washington, District of Columbia
| | - Gabriela Villalobos
- Department of Family Medicine & Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Jacqueline B. Britz
- Department of Family Medicine & Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Benjamin Webel
- Department of Family Medicine & Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Alicia Richards
- Department of Biostatistics, School of Public Health, Virginia Commonwealth University, Richmond, Virginia
| | - John W. Epling
- Department of Family & Community Medicine, Carilion Clinic and Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Roy T. Sabo
- Department of Biostatistics, School of Public Health, Virginia Commonwealth University, Richmond, Virginia
| | - Alex H. Krist
- Department of Family Medicine & Population Health, Virginia Commonwealth University, Richmond, Virginia
- INOVA Family Practice Residency, Fairfax, Virginia
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Kirabira J, Kagoya EK, Mpagi J, Atala CE, Ndamanywa K, Okibure A, Kibuuka R, Katongole F, Wandabwa J. Burden of alcohol and other substance use and correlates among undergraduate students at Busitema University in rural Eastern Uganda after COVID-19 lockdown. Sci Rep 2024; 14:6194. [PMID: 38486017 PMCID: PMC10940298 DOI: 10.1038/s41598-024-56861-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 03/12/2024] [Indexed: 03/18/2024] Open
Abstract
Use of alcohol and other substances remains a major health concern among higher learning institutions. This study aimed at assessing the prevalence of alcohol and other substance use among students at Busitema University in Eastern Uganda. A cross sectional survey was conducted among 658 undergraduate students using a questionnaire consisting of Alcohol, Smoking and Substance Involvement Screening Tool and participant sociodemographic and clinical factors. Logistic regression was used to explore the associations. Two hundred sixty-five (40.3%) students reported ever using alcohol and 158 (24.0%) had used in last 3 months. Seventy-four (11.2%) students reported ever use of other substances including tobacco, cannabis, cocaine, stimulants sedatives and hallucinogens and 36 (5.5%) had used within the recent 3 months. After controlling for potential confounders, recent alcohol use was associated with engaging in romantic relationship (odd ratio (OR) = 1.9, P value (P) = 0.045) while having chronic medical conditions was protective (OR = 0.3, P = 0.031). On the other hand, recent use of other substances was 7 times higher among males (OR = 7.0, P = 0.008) compared to females while fourth year of study was protective (OR = 0.05, P = 0.011). Although alcohol use is a worsening challenge among university students, use of other substances is also highly prevalent after COVID-19 lockdown. There is need for universities to identify students with above factors and design interventions to address them in order to prevent the likely undesirable outcomes of alcohol and substance use.
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Affiliation(s)
- Joseph Kirabira
- Department of Psychiatry, Busitema University, Faculty of Health Sciences, P.O. Box 1460, Mbale, Uganda.
| | - Enid Kawala Kagoya
- Institute of Public Health, Department of Community Health, Busitema University, Faculty of Health Sciences, P.O. Box 1460, Mbale, Uganda
| | - Joseph Mpagi
- Deans Office, Department of Academics, Research and Innovation, Busitema University, Faculty of Health Sciences, P.O. Box 1460, Mbale, Uganda
| | - Christine Etoko Atala
- Department of Anaesthesia, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Kalisiti Ndamanywa
- Directorate of Graduate Studies, Research and Innovations, Busitema University, P.O. Box 1460, Busia, Uganda
| | - Ambrose Okibure
- Institute of Public Health, Department of Community Health, Busitema University, Faculty of Health Sciences, P.O. Box 1460, Mbale, Uganda
| | - Ronald Kibuuka
- Department of Psychiatry, Busitema University, Faculty of Health Sciences, P.O. Box 1460, Mbale, Uganda
| | - Fauz Katongole
- Department of Pathology, Busitema University, Faculty of Health Sciences, P.O. Box 1460, Mbale, Uganda
| | - Julius Wandabwa
- Institute of Public Health, Department of Community Health, Busitema University, Faculty of Health Sciences, P.O. Box 1460, Mbale, Uganda
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Palzes VA, Chi FW, Weisner C, Kline-Simon AH, Satre DD, Sterling S. Risk profiles of adults with heavy alcohol use: Drinking patterns, behavioral and metabolic factors, health problems, and racial and ethnic disparities. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2023; 47:2301-2312. [PMID: 38151789 PMCID: PMC10755251 DOI: 10.1111/acer.15211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/13/2023] [Accepted: 10/13/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Heavy alcohol use is a growing risk factor for chronic disease, yet little is known about its co-occurrence with other risk factors and health problems. This study aimed to identify risk profiles of adults with heavy alcohol use and examined potential disparities by race and ethnicity. METHODS This cross-sectional study included 211,333 adults with heavy alcohol use (in excess of daily or weekly limits recommended by National Institute on Alcohol Abuse and Alcoholism) between June 1, 2013 and December 31, 2014 in Kaiser Permanente Northern California. Latent class analysis was used to examine how heavy drinking patterns clustered with other behavioral and metabolic risk factors and health problems to form risk profiles. Multinomial logistic regression models were fit to examine associations between race, ethnicity, and risk profiles. RESULTS A 5-class model was selected as best fitting the data and representing clinically meaningful risk profiles: (1) "heavy daily drinking and lower health risks" (DAILY, 44.3%); (2) "substance use disorder and mental health disorder" (SUD/MH, 2.3%); (3) "heavy weekly drinking and lower health risks" (WEEKLY, 19.6%); (4) "heavy daily drinking and more health risks" (DAILY-R, 18.5%); (5) "heavy weekly drinking and more health risks" (WEEKLY-R, 15.3%). American Indian or Alaska Native (AIAN) and Black patients had higher odds than White patients of being in the SUD/MH, DAILY-R, and WEEKLY-R profiles than the DAILY profile. AIAN, Black, and Latino/Hispanic patients had higher odds than White patients of being in the SUD/MH, DAILY-R, and WEEKLY-R profiles rather than the WEEKLY profile. CONCLUSIONS AIAN, Black, and Latino/Hispanic patients with self-reported heavy drinking were more likely to be in risk profiles with greater alcohol consumption, more health risks, and higher morbidity. Targeted, culturally appropriate interventions for heavy alcohol use that may address other modifiable risk factors are needed to work towards health equity.
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Affiliation(s)
- Vanessa A. Palzes
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2304
| | - Felicia W. Chi
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2304
| | - Constance Weisner
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2304
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 675 18 Street, San Francisco, CA 94107
| | - Andrea H. Kline-Simon
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2304
| | - Derek D. Satre
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2304
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 675 18 Street, San Francisco, CA 94107
| | - Stacy Sterling
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA, 94612-2304
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 675 18 Street, San Francisco, CA 94107
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine
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4
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Chi FW, Parthasarathy S, Palzes VA, Kline-Simon AH, Weisner CM, Satre DD, Grant RW, Elson J, Ross TB, Awsare S, Lu Y, Metz VE, Sterling SA. Associations between alcohol brief intervention in primary care and drinking and health outcomes in adults with hypertension and type 2 diabetes: a population-based observational study. BMJ Open 2023; 13:e064088. [PMID: 36657762 PMCID: PMC9853251 DOI: 10.1136/bmjopen-2022-064088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 01/04/2023] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES To evaluate associations between alcohol brief intervention (BI) in primary care and 12-month drinking outcomes and 18-month health outcomes among adults with hypertension and type 2 diabetes (T2D). DESIGN A population-based observational study using electronic health records data. SETTING An integrated healthcare system that implemented system-wide alcohol screening, BI and referral to treatment in adult primary care. PARTICIPANTS Adult primary care patients with hypertension (N=72 979) or T2D (N=19 642) who screened positive for unhealthy alcohol use between 2014 and 2017. MAIN OUTCOME MEASURES We examined four drinking outcomes: changes in heavy drinking days/past 3 months, drinking days/week, drinks/drinking day and drinks/week from baseline to 12-month follow-up, based on results of alcohol screens conducted in routine care. Health outcome measures were changes in measured systolic and diastolic blood pressure (BP) and BP reduction ≥3 mm Hg at 18-month follow-up. For patients with T2D, we also examined change in glycohaemoglobin (HbA1c) level and 'controlled HbA1c' (HbA1c<8%) at 18-month follow-up. RESULTS For patients with hypertension, those who received BI had a modest but significant additional -0.06 reduction in drinks/drinking day (95% CI -0.11 to -0.01) and additional -0.30 reduction in drinks/week (95% CI -0.59 to -0.01) at 12 months, compared with those who did not. Patients with hypertension who received BI also had higher odds for having clinically meaningful reduction of diastolic BP at 18 months (OR 1.05, 95% CI 1.00 to 1.09). Among patients with T2D, no significant associations were found between BI and drinking or health outcomes examined. CONCLUSIONS Alcohol BI holds promise for reducing drinking and helping to improve health outcomes among patients with hypertension who screened positive for unhealthy drinking. However, similar associations were not observed among patients with T2D. More research is needed to understand the heterogeneity across diverse subpopulations and to study BI's long-term public health impact.
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Affiliation(s)
- Felicia W Chi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sujaya Parthasarathy
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Andrea H Kline-Simon
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Constance M Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
| | - Richard W Grant
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Joseph Elson
- Permanente Medical Group, San Francisco, California, USA
| | - Thekla B Ross
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | | | - Yun Lu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Verena E Metz
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
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5
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Villanueva-Blasco VJ, J. MM, Villanueva-Silvestre V, Vázquez-Martínez A. Relationship Between Depression and Risky Alcohol Consumption in Women: the Mediating Role of Coping Styles and Age. Int J Ment Health Addict 2022:1-18. [PMID: 36248266 PMCID: PMC9555268 DOI: 10.1007/s11469-022-00931-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
Women are more likely to use alcohol as a coping strategy for psychological distress, with higher rates of comorbidity with depression being found in those with an alcohol use disorder. The objective of this study was to analyze changes in problematic alcohol consumption and depression during the COVID-19 lockdown, and to establish a predictive model based on age. A total of 1889 women aged 18-64 years (M = 36.14) participated. The Patient Health Questionnaire was applied for depression, the Alcohol Use Disorders Identification Test-Short Version for alcohol, and active and avoidant coping were considered. In the period prior to the pandemic, depression and avoidant coping were good predictors of alcohol consumption in women, regardless of age. During lockdown, this predictive capacity was only maintained in women aged 35-64 years. In the mediational models, differences were observed according to age. For women aged 18-34 years, depression was the predictor variable of problematic alcohol consumption, but for women aged 35-64 years it was the avoidant coping style, which is the predominant style in women of this age with clinical depression. The relevance of age in the combined treatments of depression and problematic alcohol consumption is highlighted, and training in active coping strategies is suggested.
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Affiliation(s)
- V. J. Villanueva-Blasco
- Faculty of Health Sciences, Valencian International University, Valencia, Spain
- Research Group On Health and Psycho-Social Adjustment (GI-SAPS), Valencian International University, C/ Pintor Sorolla, 21, 46002 Valencia, Spain
| | - Mateu-Mollá J.
- Faculty of Health Sciences, Valencian International University, Valencia, Spain
- Research Group On Health and Psycho-Social Adjustment (GI-SAPS), Valencian International University, C/ Pintor Sorolla, 21, 46002 Valencia, Spain
| | - V. Villanueva-Silvestre
- Faculty of Health Sciences, Valencian International University, Valencia, Spain
- Research Group On Health and Psycho-Social Adjustment (GI-SAPS), Valencian International University, C/ Pintor Sorolla, 21, 46002 Valencia, Spain
| | - A. Vázquez-Martínez
- Faculty of Health Sciences, Valencian International University, Valencia, Spain
- Research Group On Health and Psycho-Social Adjustment (GI-SAPS), Valencian International University, C/ Pintor Sorolla, 21, 46002 Valencia, Spain
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Angleitner A, Dehn L, Driessen M, Beblo T. Kognitive Beeinträchtigungen alkoholabhängiger Patient_innen im Abstinenzverlauf und die Relevanz depressiver Komorbidität. ZEITSCHRIFT FÜR NEUROPSYCHOLOGIE 2022. [DOI: 10.1024/1016-264x/a000361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
Zusammenfassung: Hintergrund: Mit dieser Studie wird der Frage nachgegangen, inwieweit sich kognitive Beeinträchtigungen alkoholabhängiger Patient_innen in Abhängigkeit von Abstinenz und Depressivität im Behandlungsverlauf verbessern. Methode: Alkoholabhängige Patient_innen mit ( n = 22) und ohne Depression ( n = 58) wurden neuropsychologisch und hinsichtlich der Depressivität zu drei Zeitpunkten untersucht (nach Entzug und 6 Wochen bzw. 6 Monate später). 33 gesunde Kontrollproband_innen wurden zusätzlich zum ersten Zeitpunkt untersucht. Ergebnisse: Alkoholabhängige Patient_innen zeigten verglichen mit gesunden Kontrollpersonen eine verminderte Leistung im schlussfolgernden Denken. Im Behandlungsverlauf zeigte sich eine trendweise günstigere Entwicklung für abstinente verglichen mit rückfälligen Patient_innen und eine größere Depressivität war mit schwächeren Leistungen assoziiert. Diskussion: Alkoholabhängige Patient_innen leiden an kognitiven Defiziten, die sich z. T. im weiteren Behandlungsverlauf zu verbessern scheinen, v. a. bei Abstinenz.
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Affiliation(s)
- Alexander Angleitner
- Universitätsklinik für Psychiatrie und Psychotherapie, Universität Bielefeld, Deutschland
| | - Lorenz Dehn
- Universitätsklinik für Psychiatrie und Psychotherapie, Universität Bielefeld, Deutschland
- Fakultät für Psychologie und Sportwissenschaft, Universität Bielefeld, Deutschland
| | - Martin Driessen
- Universitätsklinik für Psychiatrie und Psychotherapie, Universität Bielefeld, Deutschland
- Fakultät für Psychologie und Sportwissenschaft, Universität Bielefeld, Deutschland
| | - Thomas Beblo
- Universitätsklinik für Psychiatrie und Psychotherapie, Universität Bielefeld, Deutschland
- Fakultät für Psychologie und Sportwissenschaft, Universität Bielefeld, Deutschland
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Figueroa JF, Phelan J, Newton H, Orav EJ, Meara ER. ACO Participation Associated With Decreased Spending For Medicare Beneficiaries With Serious Mental Illness. HEALTH AFFAIRS (PROJECT HOPE) 2022; 41:1182-1190. [PMID: 35914206 DOI: 10.1377/hlthaff.2022.00096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Serious mental illness (SMI) is a major source of suffering among Medicare beneficiaries. To date, limited evidence exists evaluating whether Medicare accountable care organizations (ACOs) are associated with decreased spending among people with SMI. Using national Medicare data from the period 2009-17, we performed difference-in-differences analyses evaluating changes in spending and use associated with enrollment in the Medicare Shared Savings Program (MSSP) among beneficiaries with SMI. After five years, participation in MSSP ACOs was associated with small savings for beneficiaries with SMI (-$233 per person per year) in total health care spending, primarily related to savings from chronic medical conditions (excluding mental health; -$227 per person per year) and not from savings related to mental health services (-$6 per person per year). Savings were driven by reductions in acute and postacute care for medical conditions. Further work is needed to ensure that Medicare ACOs invest in strategies to reduce potentially unnecessary care related to mental health disorders and to improve health outcomes.
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Affiliation(s)
- José F Figueroa
- José F. Figueroa , Harvard University and Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Helen Newton
- Helen Newton, Yale University, New Haven, Connecticut
| | - E John Orav
- E. John Orav, Harvard University and Brigham and Women's Hospital
| | - Ellen R Meara
- Ellen R. Meara, Harvard University; Dartmouth College, Lebanon, New Hampshire; and National Bureau of Economic Research, Cambridge, Massachusetts
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8
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Chi FW, Parthasarathy S, Palzes VA, Kline-Simon AH, Metz VE, Weisner C, Satre DD, Campbell CI, Elson J, Ross TB, Lu Y, Sterling SA. Alcohol brief intervention, specialty treatment and drinking outcomes at 12 months: Results from a systematic alcohol screening and brief intervention initiative in adult primary care. Drug Alcohol Depend 2022; 235:109458. [PMID: 35453082 PMCID: PMC10122418 DOI: 10.1016/j.drugalcdep.2022.109458] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 04/04/2022] [Accepted: 04/07/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Alcohol screening, brief intervention and referral to treatment (SBIRT) in adult primary care is an evidence-based, public health strategy to address unhealthy alcohol use, but evidence of effectiveness of alcohol brief intervention (ABI) in real-world implementation is lacking. METHODS We fit marginal structural models with inverse probability weighting to estimate the causal effects of ABI on 12-month drinking outcomes using longitudinal electronic health records data for 312,056 adults with a positive screening result for unhealthy drinking between 2014 and 2017 in a large healthcare system that implemented systematic primary care-based SBIRT. We examined effects of ABI with and without adjusting for receipt of specialty alcohol use disorder (AUD) treatment, and whether effects varied by patient demographic characteristics and alcohol use patterns. RESULTS Receiving ABI resulted in significantly greater reductions in heavy drinking days (mean difference [95% CI] = -0.26 [-0.45, -0.08]), drinking days per week (-0.04 [-0.07, -0.01]), drinks per drinking day (-0.05 [-0.08, -0.02]) and drinks per week (-0.16 [-0.27, -0.04]). Effects of ABI on 12-month drinking outcomes varied by baseline consumption level, age group and whether patients already had an AUD, with better improvement in those who were drinking at levels exceeding only daily limits, younger, and without an AUD. CONCLUSIONS Systematic ABI in adult primary care has the potential to reduce drinking among people with unhealthy drinking considerably on both an individual and population level. More research is needed to help optimize ABI, in particular tailoring it to diverse sub-populations, and studying its long-term public health impact.
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Affiliation(s)
- Felicia W Chi
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA.
| | - Sujaya Parthasarathy
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Andrea H Kline-Simon
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Verena E Metz
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA; Department of Psychiatry, Weill Institute of Neurosciences, University of California, 401 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Joseph Elson
- The Permanente Medical Group, 1600 Owens Street, San Francisco, CA 94158, USA
| | - Thekla B Ross
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Yun Lu
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612, USA
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9
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Metz VE, Palzes VA, Kline-Simon AH, Chi FW, Campbell CI, Weisner CM, Sterling SA. Substance use disorders among primary care patients screening positive for unhealthy alcohol use. Fam Pract 2022; 39:226-233. [PMID: 34964877 PMCID: PMC8947771 DOI: 10.1093/fampra/cmab171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Despite high prevalence of polysubstance use, recent data on concurrent alcohol use in patients with specific substance use disorders (SUDs) are lacking. OBJECTIVE To examine associations between specific SUDs and alcohol consumption levels. METHODS Using electronic health record data, we conducted a cross-sectional study of 2,720,231 primary care adults screened for alcohol use between 2014 and 2017 at Kaiser Permanente Northern California. Alcohol consumption levels were categorized as no reported use, low-risk use, and unhealthy use (exceeding daily, weekly, or both recommended drinking limits). Using multinomial logistic regression, and adjusting for sociodemographic and health characteristics, we examined the odds of reporting each alcohol consumption level in patients with a prior-year SUD diagnosis (alcohol, cannabis, cocaine, inhalant, opioid, sedative/anxiolytic, stimulant, other drug, nicotine, any SUD except nicotine) compared to those without. RESULTS The sample was 52.9% female, 48.1% White; the mean age was 46 years (SD = 18). Patients with SUDs were less likely to report low-risk alcohol use relative to no use compared with patients without SUDs. Patients with alcohol or nicotine use disorder had higher odds of reporting unhealthy alcohol use relative to no use; however, patients with all other SUDs (except cocaine) had lower odds. Among patients who reported any alcohol use (n = 861,427), patients with SUDs (except opioid) had higher odds of exceeding recommended limits than those without. CONCLUSION The associations of unhealthy alcohol use and SUDs suggest that screening for both alcohol and drug use in primary care presents a crucial opportunity to prevent and treat SUDs early.
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Affiliation(s)
- Verena E Metz
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA
| | - Vanessa A Palzes
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA
| | - Andrea Hessel Kline-Simon
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA
| | - Felicia W Chi
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA
| | - Cynthia I Campbell
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA.,Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, USA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, 100 S. Los Robles Ave, Pasadena, CA 91101, USA
| | - Constance M Weisner
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA.,Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, USA
| | - Stacy A Sterling
- Center for Addiction and Mental Health Research, Division of Research, Kaiser Permanente Northern California, Oakland, CA 94612, USA.,Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, 401 Parnassus Avenue, Box 0984, San Francisco, CA 94143, USA.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, 100 S. Los Robles Ave, Pasadena, CA 91101, USA
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10
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Ferrante G, Rossini PG, Rousset S, Ostacoli L, Piccinelli C, Carletto S, Giordano L. The emotional side of post-traumatic stress reaction during COVID-19 pandemic: an Italian survey. BMC Public Health 2022; 22:333. [PMID: 35172782 PMCID: PMC8851796 DOI: 10.1186/s12889-022-12749-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 02/02/2022] [Indexed: 11/13/2022] Open
Abstract
Background Social restrictions due to COVID-19 might have had a significant impact on mental health. The aim of this study was to assess the prevalence of four emotional domains (nervousness, anger, numbness, physiological arousal) in a sample of citizens during the first pandemic wave in 2020, and their association with sociodemographic characteristics, housing conditions and lifestyle modifications. Methods A cross-sectional study based on a self-administered online questionnaire was set up to investigate emotions. Respondents were recruited through a non-probabilistic snowball sampling approach. The SPAN questionnaire was used to measure emotions in the interviewed population. The association between emotions and independent variables (gender, age, marital status, educational level, working condition, housing condition, COVID-19 positivity, sleep disturbance, increase in alcohol consumption and decrease in physical activity) was assessed through the multivariate Poisson regression. Results A total of 6,675 subjects were included in the analysis. Almost half of respondents (48.9%) experienced nervousness, 41.3% anger, 15.6% numbness and 18.8% physiological arousal. Females were more likely to face nervousness, anger and physiological arousal. For all the outcomes a decreasing trend was observed from younger to older. Singles were more likely to experience numbness compared to married people. Increase in alcohol consumption was associated with nervousness, anger and numbness. Decrease in physical activity was associated with nervousness, anger and physiological arousal. Restless sleep was the variable most associated with all emotional domains. Conclusions The first COVID-19 pandemic wave had a significant emotional impact on this sample, especially among younger people, singles and females. Even without reaching clinical relevance, these emotions could represent a form of psychological distress, which requires the implementation of preventive strategies, in particular regarding lifestyle care. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-022-12749-1.
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Affiliation(s)
- Gianluigi Ferrante
- SSD Epidemiologia Screening, CPO-AOU Città Della Salute E Della Scienza Di Torino, Via Cavour, 31, 10123, Torino, Italy
| | | | - Stefano Rousset
- SSD Epidemiologia Screening, CPO-AOU Città Della Salute E Della Scienza Di Torino, Via Cavour, 31, 10123, Torino, Italy.
| | - Luca Ostacoli
- Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Cristiano Piccinelli
- SSD Epidemiologia Screening, CPO-AOU Città Della Salute E Della Scienza Di Torino, Via Cavour, 31, 10123, Torino, Italy
| | - Sara Carletto
- Department of Neuroscience, University of Torino, Torino, Italy
| | - Livia Giordano
- SSD Epidemiologia Screening, CPO-AOU Città Della Salute E Della Scienza Di Torino, Via Cavour, 31, 10123, Torino, Italy
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11
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Metz VE, Palzes VA, Chi FW, Campbell CI, Sterling SA. Alcohol Use Among Young Adults in Northern California During the COVID-19 Pandemic-An Electronic Health Records-Based Study. Front Psychiatry 2022; 13:883306. [PMID: 35903628 PMCID: PMC9315391 DOI: 10.3389/fpsyt.2022.883306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/21/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Individuals globally were affected by the COVID-19 pandemic in myriad of ways, including social isolation and economic hardship, resulting in negative impacts on mental health and substance use. Young adults have been subjected to extraordinary challenges such as job loss, virtual school, or childcare issues, but have received limited attention from research so far. METHODS Using electronic health record data from a large integrated healthcare system in Northern California, this longitudinal observational study examined changes in the prevalence of unhealthy alcohol use (identified via systematic alcohol screening in adult primary care) from pre- (3/1/2019-12/31/2019) to post-COVID onset (3/1/2020-12/31/2020) among young adults (18-34 years). Among the 663,111 and 627,095 young adults who utilized primary care in the pre- and post-COVID onset periods, 342,889 (51.9%) and 186,711 (29.8%) received alcohol screening, respectively. We fit generalized estimating equation Poisson models to estimate the change in prevalence of unhealthy alcohol use from pre- to post-COVID onset among those who were screened, while using inverse probability weighting to account for potential selection bias of receiving alcohol screening. Heterogeneity in the change of prevalence by patient characteristics was also examined. RESULTS Overall, the unadjusted prevalence of unhealthy alcohol use slightly decreased from 9.2% pre-COVID to 9.0% post-COVID onset. After adjusting for patient covariates, the prevalence of unhealthy alcohol use decreased by about 2% [adjusted prevalence ratio (aPR) = 0.98, 95% CI = 0.96, 1.00]. The prevalence of unhealthy alcohol use increased among women by 8% (aPR = 1.08, 95% CI = 1.06, 1.11), patients 18-20 years by 7% (aPR = 1.07, 95% CI = 1.00, 1.15), and Latino/Hispanic patients by 7% (aPR = 1.07, 95% CI = 1.03, 1.11). While the prevalence of unhealthy alcohol use decreased among men by 12% (aPR = 0.88, 95% CI = 0.86, 0.90), patients 21-34 years by 2% (aPR = 0.98, 95% CI = 0.96, 0.99), White patients by 3% (95% CI = 0.95, 1.00), and patients living in neighborhoods with the lowest deprivation indices by 9% (aPR = 0.91, 95% CI = 0.88, 0.94), their unadjusted prevalence remained higher than their counterparts post-COVID onset. There was no variation in the change of prevalence by comorbid mental health conditions or drug use disorders. CONCLUSIONS While changes in unhealthy alcohol use prevalence among young adults were small, findings raise concerns over increased drinking among women, those younger than the U.S. legal drinking age, and Latino/Hispanic patients.
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Affiliation(s)
- Verena E Metz
- Center for Addiction and Mental Health Research, Kaiser Permanente Division of Research, Oakland, CA, United States
| | - Vanessa A Palzes
- Center for Addiction and Mental Health Research, Kaiser Permanente Division of Research, Oakland, CA, United States
| | - Felicia W Chi
- Center for Addiction and Mental Health Research, Kaiser Permanente Division of Research, Oakland, CA, United States
| | - Cynthia I Campbell
- Center for Addiction and Mental Health Research, Kaiser Permanente Division of Research, Oakland, CA, United States.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
| | - Stacy A Sterling
- Center for Addiction and Mental Health Research, Kaiser Permanente Division of Research, Oakland, CA, United States.,Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, CA, United States.,Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
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12
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Novais F, Ganança L, Barbosa M, Telles-Correia D. Communication skills in psychiatry for undergraduate students: A scoping review. Front Psychiatry 2022; 13:972703. [PMID: 36032255 PMCID: PMC9402997 DOI: 10.3389/fpsyt.2022.972703] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/21/2022] [Indexed: 11/25/2022] Open
Abstract
Communication skills are paramount in all areas of medicine but particularly in psychiatry due to the challenges posed by mental health patients and the essential role of communication from diagnosis to treatment. Despite the prevalence of psychiatric disorders in different medical specialties, particularly in primary care settings, communication skills in psychiatry and their training are not well studied and are often not included in the undergraduate medical curriculum. Our paper explores the relevance of teaching communication competencies in psychiatry for undergraduate medical students. Our work focused on reviewing the methods for teaching communication skills to undergraduate students in Psychiatry. Eleven studies were selected to be included in this review. We found considerable heterogeneity among methods for teaching communication skills but also some common elements such as the use of simulated patients and providing feedback. This review has identified two models: the Calgary-Cambridge interview model and the Kolb cycle-based model. However, most studies still lack a theoretical background model. We believe that the inclusion of communication skills training in medical curricula is fundamental to teaching medical students general communication skills but also specific training on establishing adequate communication with psychiatric patients. However, more research is needed to determine the best method for training but also regarding its translation to patient care and cost-effectiveness.
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Affiliation(s)
- Filipa Novais
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Centro Hospitalar Universitário Lisboa Norte, Santa Maria Hospital, Lisbon, Portugal.,ISAMB - Instituto de Saúde Ambiental - Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Licínia Ganança
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Centro Hospitalar Universitário Lisboa Norte, Santa Maria Hospital, Lisbon, Portugal
| | - Miguel Barbosa
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Faculdade de Psicologia, Universidade de Lisboa, Lisboa, Portugal
| | - Diogo Telles-Correia
- Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,ISAMB - Instituto de Saúde Ambiental - Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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13
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Lu Y, Chi FW, Parthasarathy S, Palzes VA, Kline-Simon AH, Metz VE, Weisner C, Satre DD, Campbell CI, Elson J, Ross TB, Awsare SV, Sterling SA. Patient and provider factors associated with receipt and delivery of brief interventions for unhealthy alcohol use in primary care. Alcohol Clin Exp Res 2021; 45:2179-2189. [PMID: 34486124 DOI: 10.1111/acer.14702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/06/2021] [Accepted: 08/15/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Unhealthy alcohol use is a serious and costly public health problem. Alcohol screening and brief interventions are effective in reducing unhealthy alcohol consumption. However, rates of receipt and delivery of brief interventions vary significantly across healthcare settings, and relatively little is known about the associated patient and provider factors. METHODS This study examines patient and provider factors associated with the receipt of brief interventions for unhealthy alcohol use in an integrated healthcare system, based on documented brief interventions in the electronic health record. Using multilevel logistic regression models, we retrospectively analyzed 287,551 adult primary care patients (and their 2952 providers) who screened positive for unhealthy drinking between 2014 and 2017. RESULTS We found lower odds of receiving a brief intervention among patients exceeding daily or weekly drinking limits (vs. exceeding both limits), females, older age groups, those with higher medical complexity, and those already diagnosed with alcohol use disorders. Patients with other unhealthy lifestyle activities (e.g., smoking, no/insufficient exercise) were more likely to receive a brief intervention. We also found that female providers and those with longer tenure in the health system were more likely to deliver brief interventions. CONCLUSIONS These findings point to characteristics that can be targeted to improve universal receipt of brief intervention.
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Affiliation(s)
- Yun Lu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Felicia W Chi
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sujaya Parthasarathy
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Andrea H Kline-Simon
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Verena E Metz
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Psychiatry and Behavioral Sciences, Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Psychiatry and Behavioral Sciences, Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Psychiatry and Behavioral Sciences, Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, California, USA
| | - Joseph Elson
- The Permanente Medical Group, San Francisco, California, USA
| | - Thekla B Ross
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sameer V Awsare
- The Permanente Medical Group, TPMG Executive Offices, Oakland, California, USA
| | - Stacy A Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.,Department of Psychiatry and Behavioral Sciences, Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, California, USA
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14
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Lopez E, Jeanne G, Lefort LH, Autissier C, Picot MC, Peyrière H, Donnadieu-Rigole H. Characterization of benzodiazepine misuse and comorbidities in patients with alcohol use disorder. Fundam Clin Pharmacol 2021; 35:1133-1140. [PMID: 33797099 DOI: 10.1111/fcp.12678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 03/11/2021] [Accepted: 03/29/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Due to the frequent presence of anxious symptoms and sleep disorders, benzodiazepines (BZD) are often prescribed to patients with alcohol use disorder (AUD). OBJECTIVES To assess BZD misuse and psychiatric comorbidities in patients with AUD. METHODS This prospective, monocentric study included all adult patients with AUD hospitalized in a French addiction unit for alcohol withdrawal from November 2017 to May 2018. RESULTS Among the 153 patients included, 75 (49%) were using BZD at the time of their hospitalization. Duration of alcohol addiction was longer in BZD users: (33 ± 27 years vs. 29 ± 11 years; P = 0.001). BZD misuse was noted in 27 patients consuming benzodiazepines (36% of BZD users and 18% of all included patients), mainly increase in the dose (on average, 3 ± 4 times the prescribed dose). The most frequently misused benzodiazepines were diazepam (43.2%), alprazolam (18.9%), and lormetazepam (13.5%). The frequency of patients with lifetime use of cocaine or heroin was higher among BZD misusers than among non-misusers (84.6% vs. 42.2%; <0.01 and 53.9% vs. 27.1%; P = 0.04). The frequency of patients consuming cocaine in the last month was higher in BZD misusers than in others: 16% versus 6%, P = 0.002. In multivariate analysis, age (OR=1.65 for 5 years, 95% CI = 1.19-2.27; P = 0.023), psychiatric comorbidities (at least one comorbidity: OR=6.03, 95% CI = 1.40-25.83; P = 0.015) and lifetime cocaine consumption (OR=4.37, 95% CI = 1.21-15.86; P = 0.025) were independently associated with BZD misuse. CONCLUSION BZD prescription for long periods might result in tolerance and dose increase. Educational therapy, prescribers' awareness, and development of therapeutic alternatives are essential to limit BZD misuse.
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Affiliation(s)
- Elodie Lopez
- Département d'Addictologie et complications somatiques des addictions, CHU Montpellier, Montpellier, France
| | - Guillaume Jeanne
- Département d'Addictologie et complications somatiques des addictions, CHU Montpellier, Montpellier, France
| | - Laure-Hélène Lefort
- Département d'Addictologie et complications somatiques des addictions, CHU Montpellier, Montpellier, France
| | - Cécile Autissier
- Département de l'Information Médicale, CHU Montpellier, Montpellier, France
| | | | - Hélène Peyrière
- Département de Pharmacologie Médicale et Toxicologie, Centre d'Addictovigilance, CHU Montpellier, Montpellier, France.,INSERM U 1058, Pathogenesis and Control of Chronic Infections (PCCI), Montpellier, France
| | - Hélène Donnadieu-Rigole
- Département d'Addictologie et complications somatiques des addictions, CHU Montpellier, Montpellier, France.,INSERM U 1058, Pathogenesis and Control of Chronic Infections (PCCI), Montpellier, France
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