Comparison of Timeline Follow-Back and Averaging Methods for Quantifying Alcohol Consumption in Treatment Research

What affects timely linkage to HIV Care for Young Men of Color who have sex with Men? Young Men's Experiences Accessing HIV Care after Seroconverting

The HIV care continuum provides intervention points that should be addressed to optimally identify, engage, and retain populations in HIV care. This study addressed the lack of research into barriers and facilitators of linkage to care for HIV-positive young men who have sex with men (YMSM) of color. Data were collected using a qualitative timeline follow-back interview approach with YMSM who had seroconverted in the last 6 months. Interviews were conducted with 15 YMSM from April 2017 to April 2018. This study provides important information about what can delay linkage to care for YMSM of color. These delays include fractured referrals to care providers via mobile HIV testing vans, adapting to an HIV diagnosis and integrating it into their lives, and finding caring and competent providers that offer wraparound services, specifically mental health services, as soon as possible after an HIV diagnosis. Addressing these issues is imperative to optimize YMSM's engagement in the HIV care continuum and work toward ending the epidemic.

Factors for Maintaining Abstinence at 2 and 6 Months After Alcohol Withdrawal

OBJECTIVES

Relapse rates in subjects with an alcohol use disorder who have undergone alcohol detoxification are high, and risk factors vary according to the studied population and the context in which withdrawal occurred. Subjects being treated in psychiatric settings require increased monitoring at the moment of detoxification and during follow-up. It is thus important to identify specific risk factors for relapse in such patients. The objective of this study was to determine factors associated with maintenance of abstinence 2 months after alcohol withdrawal (M2) and to characterize factors associated with later relapses 6 months after withdrawal (M6) among those who were abstainers at M2.

METHODS

We conducted an ancillary study of a specific psychiatric cohort of subjects with an alcohol use disorder who were followed after withdrawal, by analyzing clinical and biological data collected at M2 and M6.

RESULTS

The specific factors predictive of future relapse were age, intensity of craving, number of standard glasses consumed, psychiatric comorbidity (depression), and employment and family/marital status. Substance use (other than the use of tobacco) decreased the likelihood of abstinence at M2, whereas a depressive state at the time of alcohol withdrawal increased the likelihood of abstinence at M2. Consumption of other substances and a greater intensity of craving at the time of alcohol withdrawal decreased the likelihood of abstinence at M6.

CONCLUSIONS

The results of this study highlight the importance of identifying craving, multiple substance use, and psychiatric comorbidities (depression) during comprehensive interviews in follow-up after alcohol withdrawal. In caring for patients after alcohol detoxification, priority should be given to factors that have been shown to enhance the beneficial effects of abstinence, such as mood enhancement.

Liver elastometry and alcohol withdrawal: Median-term follow-up in a psychiatric unit

The measurement of liver stiffness (LS) shows promise as a follow-up tool after alcohol withdrawal, but it has mainly been studied in the early phase or in patients with severe liver disease. A 6-month ancillary study of a specific psychiatric cohort of alcoholic patients without known liver disease followed after withdrawal was conducted (Clinical Trial NCT01491347). Clinical and biological data and LS values were collected every 2 months. A total of 129 patients were included in the study; 93 had an LS assessment within the first 7 days, and 37 had all four LS measurements. Only seven (7.5%) patients had an initial LS > 12.1 kPa, the threshold used to define severe fibrosis. Abstinence was not associated with changes in LS at the various median-term follow-up periods. However, LS of abstinent subjects decreased significantly relative to that of non-abstinent subjects between M0 and M2. CAP™ values were not associated with abstinence. The systematic median-term follow-up of withdrawn patients does not appear to be contributory. However, LS could help to detect relapse in the first 2 months after withdrawal for subjects treated in a psychiatric hospital for dependence. It thus could serve as a motivation tool. Prospective studies with various and higher baseline LS values are warranted for simultaneous longitudinal assessment, including for very short- and long-term LS after withdrawal.

Evolution of BDNF serum levels during the first six months after alcohol withdrawal

OBJECTIVES

Brain-Derived Neurotrophic Factor (BDNF) has been associated with alcohol dependence and appear to vary after withdrawal, although the link with the withdrawal outcome on the long term is unknown. We aimed to assess the evolution of BDNF levels during the six months following withdrawal and determine the association with the status of alcohol consumption.

METHODS

Serum BDNF levels of alcohol-dependent patients (n = 248) and biological and clinical parameters were determined at the time of alcohol cessation (D0), 14 days (D14), 28 days (D28), and 2, 4, and 6 months after (M2, M4, M6).

RESULTS

Abstinence decreased during follow-up and was 31.9% after six months. BDNF levels increased by 14 days after withdrawal and remained elevated throughout the six-month period, independently of alcohol consumption. Serum BDNF levels evolved over time (p < 0.0001), with a correlation between BDNF and GGT levels. The prescription of baclofen at the time of withdrawal was associated with higher serum BDNF levels throughout the follow-up and that of anti-inflammatory drugs with lower BDNF levels.

CONCLUSIONS

A link between BDNF levels, liver function, and the inflammatory state in the context of alcohol abuse and not only with alcohol dependence itself is proposed.

BDNF levels and liver stiffness in subjects with alcohol use disorder: Evaluation after alcohol withdrawal

Background: Brain-derived neurotrophic factor (BDNF) plays a key role in the processes of withdrawal and addiction in alcohol use disorder (AUD), and is also involved in liver homeostasis. The role of BDNF in liver damage and its link with liver stiffness are not known. We hypothesize that serum BDNF levels are linked to changes in hepatic elasticity, both of which depend on variations in alcohol consumption.Objectives: We aimed to study the evolution of BDNF levels and changes in the liver stiffness (LS) of AUD subjects, within two months following withdrawal.Methods: We measured LS by FibroScan® (as an indicator of the degree of liver fibrosis), gamma glutamyl transferase (GGT) levels (as a nonspecific but sensitive marker of liver status) and serum BDNF levels of 62 alcohol-dependent subjects without previously identified liver complications. Measures were obtained at the time of withdrawal (M0) and two months later (M2). Results: BDNF levels increased after alcohol withdrawal and small variations of LS were observed. BDNF values increased significantly according to fibrosis stages measured by LS (p = .028 at M0), and were predicted by GGT levels in a regression model (p = .007 at M0 and p = .003 at M2).Conclusion: In AUD, BDNF levels were associated with measured LS when divided into fibrosis risk categories. Changes in LS and BDNF levels after alcohol withdrawal may be related to changes in homeostatic mechanisms, in addition to those of liver status.

Computational Markers of Risky Decision-making for Identification of Temporal Windows of Vulnerability to Opioid Use in a Real-world Clinical Setting

IMPORTANCE

Opioid addiction is a major public health problem. Despite availability of evidence-based treatments, relapse and dropout are common outcomes. Efforts aimed at identifying reuse risk and gaining more precise understanding of the mechanisms conferring reuse vulnerability are needed.

OBJECTIVE

To use tools from computational psychiatry and decision neuroscience to identify changes in decision-making processes preceding opioid reuse.

DESIGN, SETTING, AND PARTICIPANTS

A cohort of individuals with opioid use disorder were studied longitudinally at a community-based treatment setting for up to 7 months (1-15 sessions per person). At each session, patients completed a risky decision-making task amenable to computational modeling and standard clinical assessments. Time-lagged mixed-effects logistic regression analyses were used to assess the likelihood of opioid use between sessions (t to t + 1; within the subsequent 1-4 weeks) from data acquired at the current session (t). A cohort of control participants completed similar procedures (1-5 sessions per person), serving both as a baseline comparison group and an independent sample in which to assess measurement test-retest reliability. Data were analyzed between January 1, 2018, and September 5, 2019.

MAIN OUTCOMES AND MEASURES

Two individual model-based behavioral markers were derived from the task completed at each session, capturing a participant's current tolerance of known risks and ambiguity (partially unknown risks). Current anxiety, craving, withdrawal, and nonadherence were assessed via interview and clinic records. Opioid use was ascertained from random urine toxicology tests and self-reports.

RESULTS

Seventy patients (mean [SE] age, 44.7 [1.3] years; 12 women and 58 men [82.9% male]) and 55 control participants (mean [SE] age, 42.4 [1.5] years; 13 women and 42 men [76.4% male]) were included. Of the 552 sessions completed with patients (mean [SE], 7.89 [0.59] sessions per person), 252 (45.7%) directly preceded opioid use events (mean [SE], 3.60 [0.44] sessions per person). From the task parameters, only ambiguity tolerance was significantly associated with increased odds of prospective opioid use (adjusted odds ratio, 1.37 [95% CI, 1.07-1.76]), indicating patients were more tolerant specifically of ambiguous risks prior to these use events. The association of ambiguity tolerance with prospective use was independent of established clinical factors (adjusted odds ratio, 1.29 [95% CI, 1.01-1.65]; P = .04), such that a model combining these factors explained more variance in reuse risk. No significant differences in ambiguity tolerance were observed between patients and control participants, who completed 197 sessions (mean [SE], 3.58 [0.21] sessions per person); however, patients were more tolerant of known risks (B = 0.56 [95% CI, 0.05-1.07]).

CONCLUSIONS AND RELEVANCE

Computational approaches can provide mechanistic insights about the cognitive factors underlying opioid reuse vulnerability and may hold promise for clinical use.

The Association between Distress Tolerance and Alcohol Related Problems: The Pathway of Drinking to Cope

Binge drinking (BD) and alcohol related problems (ARP) are highly prevalent among college students. However, current models examining ARP suggest drinking quantity only accounts for a portion of the variance, suggesting other variables contribute to ARP. Distress tolerance (DT), or the ability to withstand negative affect, is associated with alcohol misuse and may be an important mechanism related to ARP. However, studies have reported inconsistent findings on this association, which may be due to the use of only global scores to measure DT rather than specific DT components. Furthermore, the mechanisms underlying this association remain unknown. Drinking to cope with negative affect has been associated with both DT and ARP, suggesting it may be a mechanism explaining the relationship between DT and ARP. The current study examined the association between specific proposed DT components (i.e., tolerance, absorption, appraisal, and regulation) and drinking to cope and ARP in 147 college students who BD. A hierarchical linear regression was performed in order to examine which DT component best predicted ARP. Four follow-up mediation models were then tested to examine whether drinking to cope mediated the relationship between each DT component and ARP. Appraisal of DT was the only DT component that significantly predicted ARP, in the model controlling for drinking quantity and sex differences. Drinking to cope mediated the relationship between ARP and tolerance, absorption, and regulation, but not appraisal of DT. Implications for furthering our understanding of DT and treatment of BD as it relates to DT are explored.

Physical activity as treatment for alcohol use disorders (FitForChange): study protocol for a randomized controlled trial

BACKGROUND

Help-seeking for alcohol use disorders (AUDs) is low and traditional treatments are often perceived as stigmatizing. Physical activity has positive effects on mental and physical health which could benefit this population. We propose to compare the effects of aerobic training, yoga, and usual care for AUDs in physically inactive Swedish adults.

METHODS

This is a three-group, parallel, single-blind, randomized controlled trial (RCT). In total, 210 adults (aged 18-75 years) diagnosed with an AUD will be invited to participate in a 12-week intervention. The primary study outcome is alcohol consumption measure by the Timeline Follow-back method and the Alcohol Use Disorders Identification Test (AUDIT). Secondary outcomes include: depression, anxiety, perceived stress, sleep quality, physical activity levels, fitness, self-efficacy, health-related quality of life, and cognition. Blood samples will be taken to objectively assess heavy drinking, and saliva to measure cortisol. Acute effects of exercise on the urge to drink alcohol, mood, and anxiety will also be assessed.

DISCUSSION

The treatment potential for exercise in AUDs is substantial as many individuals with the disorder are physically inactive and have comorbid health problems. The study is the first to assess the effects of physical activity as a stand-alone treatment for AUDs. Considerable attention will be given to optimizing exercise adherence. Both the feasibility and treatment effects of exercise interventions in AUDs will be discussed. The Ethical Review Board (EPN) at Karolinska Institutet has approved the study (DNR: 2017/1380-3).

TRIAL REGISTRATION

German Clinical Trials Register, ID: DRKS00012311. Registered on 26 September 2017.

Determinants of Blood Brain-Derived Neurotrophic Factor Blood Levels in Patients with Alcohol Use Disorder

BACKGROUND

Blood brain-derived neurotrophic factor (BDNF) levels are influenced by both addiction and mood disorders, as well as somatic conditions, gender, and genetic polymorphisms, leading to widely varying results. Depressive symptoms and episodes are frequently observed in patients with alcohol use disorder, and vary widely over time, making it a challenge to determine which aspects are specifically involved in variations of serum BDNF levels in this population.

METHODS

We assessed 227 patients with alcohol dependence involved in a detoxification program, at baseline and after a follow-up of 6 months, for the Alcohol Use Disorders Identification Test score, the length of alcohol dependence, and the number of past detoxification programs. The Beck Depression Inventory and information on current tobacco and alcohol use, suicidal ideation, body mass index, age, gender, and psychotropic treatments were also collected. Serum BDNF (ELISA) and 2 genetic polymorphisms of the BDNF gene (Val33Met and rs962369) were analyzed.

RESULTS

The presence of the Met allele, 2 markers of the history of alcohol dependence (gamma glutamyl transferase and the number of past treatments in detoxification programs), and the presence of a depressive episode (but not depressive score) were significantly associated with the 2 blood levels of BDNF at baseline and after 6 months. After controlling for baseline BDNF levels, the presence of the Met allele and an ongoing depressive episode were the only variables associated with changes in BNDF levels after 6 months.

CONCLUSIONS

Low serum BDNF levels are associated with characteristics related to alcohol consumption and mood disorders, and variants of the BDNF gene in alcohol use disorder patients. The factors that most strongly influenced changes in serum BDNF levels following treatment in an alcohol detoxification program were variants of the BDNF gene and ongoing depression.

Postdetoxification Factors Predicting Alcohol-Related Emergency Room Visits 12 to 24 Months After Discharge: Results from a Prospective Study of Patients with Alcohol Dependence

BACKGROUND

Relapse is common in patients with alcohol dependence, even after detoxification. The aims of this prospective study were to investigate changes affecting patients during the first 6 months after discharge from hospitalization for detoxification and to determine the influence of these changes on the likelihood of alcohol-related emergency room (ER) visits in the following 18-month period.

METHODS

The study included 88 patients hospitalized for participation in a detoxification program in the addiction department of a university hospital in Rennes, France. Alcohol consumption, psychiatric symptoms, and life events were investigated by addiction specialists during hospitalization and 6 months afterward. For each patient, the number of alcohol-related ER visits in the last 6 months was prospectively recorded at the hospital 12, 18, and 24 months after hospitalization. The rate ratios of ER visits as a function of sociodemographic variables and changes observed 6 months after discharge were estimated using Poisson regression with autoregressive errors.

RESULTS

Nearly half of the patients (47.7%) had ER visits in the 12- to 24-month period following discharge. The likelihood of ER visits was higher for patients living with friends/parents and for those with aggravated psychiatric symptoms, negative changes in their family life, and who had a medical follow-up in the 6 months after discharge. In contrast, the likelihood of ER visits was lower for patients living with children and those with improved psychiatric morbidity. Alcohol consumption and psychiatric symptoms at baseline had no significant effect.

CONCLUSIONS

Monitoring changes in psychiatric symptoms and family life early after a detoxification program may help identify patients who are vulnerable to relapse in the subsequent 18-month period. Systematic screening for these changes as early as possible, in combination with appropriate treatment and the establishment of a social support system, could be fundamental in avoiding further relapses and ER visits.

Inequitable access to substance abuse treatment services in Cape Town, South Africa

BACKGROUND

Despite high levels of substance use disorders in Cape Town, substance abuse treatment utilization is low among people from disadvantaged communities in Cape Town, South Africa. To improve substance abuse treatment utilization, it is important to identify any potential barriers to treatment initiation so that interventions to reduce these barriers can be implemented. To date, substance abuse research has not examined the factors associated with substance abuse treatment utilization within developing countries. Using the Behavioural Model of Health Services Utilization as an analytic framework, this study aimed to redress this gap by examining whether access to substance abuse treatment is equitable and the profile of variables associated with treatment utilization for people from poor communities in Cape Town, South Africa.

METHODS

This study used a case-control design to compare 434 individuals with substance use disorders from disadvantaged communities who had accessed treatment with 555 controls who had not accessed treatment on a range of predisposing, treatment need and enabling/restricting variables thought to be associated with treatment utilization. A hierarchical logistic regression was conducted to assess the unique contribution that the need for treatment, predisposing and enabling/restricting variable blocks made on substance abuse treatment utilization.

RESULTS

Findings revealed that non-need enabling/restricting variables accounted for almost equal proportions of the variance in service utilization as the need for treatment variables. These enabling/restricting variables also attenuated the influence of the treatment need and predisposing variables domains on chances of treatment utilization. Several enabling/restricting variables emerged as powerful partial predictors of utilization including competing financial priorities, geographic access barriers and awareness of treatment services. Perceived severity of drug use, a need for treatment variable) was also a partial predictor of utilization.

CONCLUSIONS

Findings point to inequitable access to substance abuse treatment services among people from poor South African communities, with non-need factors being significant determinants of treatment utilization. In these communities, treatment utilization can be enhanced by (i) expanding the existing repertoire of services to include low threshold services that target individuals with less severe problems; (ii) providing food and transport vouchers as part of contingency management efforts, thereby reducing some of the financial and geographic access barriers; (iii) introducing community-based mobile outpatient treatment services that are geographically accessible; and (iv) employing community-based outreach workers that focus on improving awareness of where, when and how to access existing treatment services.

Comparison of noninvasive markers of fibrosis in patients with nonalcoholic fatty liver disease

BACKGROUND & AIMS

There is a need for a reliable and inexpensive noninvasive marker of hepatic fibrosis in patients with nonalcoholic fatty liver disease (NAFLD). We compared the performance of the FIB4 index (based on age, aspartate aminotransferase [AST] and alanine aminotransferase [ALT] levels, and platelet counts) with 6 other non-invasive markers of fibrosis in patients with NAFLD.

METHODS

Using a nation-wide database of 541 adults with NAFLD, jackknife-validated areas under receiver operating characteristic curves (AUROC) of FIB4 and 7 other markers were compared. The sensitivity at 90% specificity, 80% positive predictive value, and 90% negative predictive values were determined along with cutoffs for advanced fibrosis.

RESULTS

The median FIB4 score was 1.11 (interquartile range = 0.74-1.67). The jackknife-validated AUROC for FIB4 was 0.802 (95% confidence interval [CI], 0.758-0.847), which was higher than that of the NAFLD fibrosis score (0.768; 95% CI, 0.720-0.816; P = .09), Goteburg University Cirrhosis Index (0.743; 95% CI, 0.695-0.791; P < .01), AST:ALT ratio (0.742; 95% CI, 0.690-0.794; P < .015), AST:platelet ratio index (0.730; 95% CI, 0.681-0.779; P < .001), AST:platelet ratio (0.720; 95% CI, 0.669-0.770; P < .001), body mass index, AST:ALT, diabetes (BARD) score (0.70; P < .001), or cirrhosis discriminant score (0.666; 95% CI, 0.614-0.718; P < .001). For a fixed specificity of 90% (FIB4 = 1.93), the sensitivity in identifying advanced fibrosis was only 50% (95% CI, 46-55). A FIB4 > or = 2.67 had an 80% positive predictive value and a FIB4 index < or = 1.30 had a 90% negative predictive value.

CONCLUSIONS

The FIB4 index is superior to 7 other noninvasive markers of fibrosis in patients with NAFLD; however its performance characteristics highlight the need for even better noninvasive markers.

Brain activation elicited by affectively positive stimuli is associated with a lower risk of relapse in detoxified alcoholic subjects

BACKGROUND

Stimuli that are regularly associated with alcohol intake (AI) may acquire incentive salience, while other reinforcers can be devalued. We assessed whether brain activation elicited by (1) alcohol associated, (2) affectively positive, and (3) negative versus neutral stimuli is associated with the subsequent risk of relapse.

METHODS

Twelve detoxified alcoholic subjects (6 women and 6 men) and 12 age-matched and gender-matched healthy control subjects were assessed with functional magnetic resonance imaging (fMRI) and a fast single-event paradigm using standardized affective and alcohol-associated pictures. Patients were followed for 6 months and AI was recorded.

RESULTS

In alcoholic subjects, compared with healthy control subjects, (1) alcohol-related versus neutral visual stimuli elicited increased activation in the prefrontal (PFC; BA 6 and 10) and cingulate cortex (BA 23 and 24), precuneus and adjacent parietal cortex; (2) positive versus neutral stimuli elicited increased activation in the anterior cingulate cortex (ACC; BA 24), PFC (BA 10), ventral striatum and thalamus; and (3) negative versus neutral stimuli elicited increased activation in the PFC (BA 10). Seven alcoholic subjects relapsed. Within the follow-up period of 6 months, the number of subsequent drinking days (DD) and the amount of AI were inversely correlated with brain activation elicited by positive versus neutral stimuli in the thalamus (DD: r=-0.63, p=0.03; AI: r=-0.63, p=0.03) and in the ventral striatum (DD: r=-0.60, p=0.04; AI: r=-0.48, p=0.11).

CONCLUSIONS

In this study, brain activation elicited by briefly presented alcohol-associated stimuli was not associated with the prospective risk of relapse. Unexpectedly, alcoholic subjects displayed increased limbic brain activation during the presentation of affectively positive but not negative stimuli, which may reflect a protective factor in detoxified alcoholic subjects.

Validation of the timeline follow-back in the assessment of adolescent smoking

The timeline follow-back instrument (TLFB) is a valid and reliable method of quantifying alcohol use patterns. The use of this instrument has been expanded to assess other behaviors, such as drug use, sexual behavior, binge eating, and panic attacks. Some evidence for the validity and reliability of this assessment instrument has emerged in the area of adult smoking. However, to date, there is no published evidence of its reliability and validity in the assessment of adolescent smoking. The purpose of this study is to present early evidence of the utility of the TLFB to collect information on adolescent smoking behavior. Through secondary data analysis of four studies on adolescent smokers, we examined the associations between the TLFB and measures of dependence, smoking history, respiratory symptoms, and saliva cotinine. Moreover, we examined the stability of the TLFB data across two 15-day time periods. Results provide preliminary evidence of the validity and reliability of the TLFB in the assessment of adolescent smoking. In particular, the TLFB instrument offered important data on the heterogeneity of adolescent smoking patterns beyond a global measure of cigarettes per day, and the reduction of digit bias. Implications of these findings for the assessment of adolescent smoking are discussed.

Assessing sexual risk behaviour with the Timeline Followback (TLFB) approach: continued development and psychometric evaluation with psychiatric outpatients

This paper describes a series of 4 studies, designed to provide evidence of the feasibility, reliability, and validity of the Timeline Followback (TLFB) method when used to assess sexual risk behaviour with psychiatric outpatients. This population was selected because patients often have difficulty completing assessments of sexual risk behaviours due to deficits in attention, memory, and communication skills. All 4 studies demonstrated the feasibility of the HIV-risk TLFB. Study 1 also demonstrated that it can be completed in 20 min, and scored in less than 10 min. Qualitative data revealed that both patients and assessors found the features of the TLFB helpful. Study 2 provided evidence that the HIV-risk TLFB can be reliably scored by interviewers whereas Study 3 demonstrated that this measure can be completed reliably by patients and that TLFB of sexual behaviour were consistent over time. Study 4 provided initial evidence for the validity of the HIV-risk TLFB but also suggested that the TLFB may yield frequency estimates that are slightly less than those obtained with single-item measures. We conclude that the TLFB is feasible, reliable, and valid, even in a population known to have difficulty with self-report measures.