Substance abuse treatment entry, retention, and outcome in women: a review of the literature

This paper reviews the literature examining characteristics associated with treatment outcome in women with substance use disorders. A search of the English language literature from 1975 to 2005 using Medline and PsycInfo databases found 280 relevant articles. Ninety percent of the studies investigating gender differences in substance abuse treatment outcomes were published since 1990, and of those, over 40% were published since the year 2000. Only 11.8% of these studies were randomized clinical trials. A convergence of evidence suggests that women with substance use disorders are less likely, over the lifetime, to enter treatment compared to their male counterparts. Once in treatment, however, gender is not a significant predictor of treatment retention, completion, or outcome. Gender-specific predictors of outcome do exist, however, and individual characteristics and treatment approaches can differentially affect outcomes by gender. While women-only treatment is not necessarily more effective than mixed-gender treatment, some greater effectiveness has been demonstrated by treatments that address problems more common to substance-abusing women or that are designed for specific subgroups of this population. There is a need to develop and test effective treatments for specific subgroups such as older women with substance use disorders, as well as those with co-occurring substance use and psychiatric disorders such as eating disorders. Future research on effectiveness and cost-effectiveness of gender-specific versus standard treatments, as well as identification of the characteristics of women and men who can benefit from mixed-gender versus single-gender treatments, would advance the field.

Sex and gender differences in substance use disorders

The gender gap in substance use disorders (SUDs), characterized by greater prevalence in men, is narrowing, highlighting the importance of understanding sex and gender differences in SUD etiology and maintenance. In this critical review, we provide an overview of sex/gender differences in the biology, epidemiology and treatment of SUDs. Biological sex differences are evident across an array of systems, including brain structure and function, endocrine function, and metabolic function. Gender (i.e., environmentally and socioculturally defined roles for men and women) also contributes to the initiation and course of substance use and SUDs. Adverse medical, psychiatric, and functional consequences associated with SUDs are often more severe in women. However, men and women do not substantively differ with respect to SUD treatment outcomes. Although several trends are beginning to emerge in the literature, findings on sex and gender differences in SUDs are complicated by the interacting contributions of biological and environmental factors. Future research is needed to further elucidate sex and gender differences, especially focusing on hormonal factors in SUD course and treatment outcomes; research translating findings between animal and human models; and gender differences in understudied populations, such as those with co-occurring psychiatric disorders and gender-specific populations, such as pregnant women.

Substance abuse in women

Gender differences in substance use disorders (SUDs) and treatment outcomes for women with SUDs have been a focus of research in the last 15 years. This article reviews gender differences in the epidemiology of SUDs, highlighting the convergence of male/female prevalence ratios of SUDs in the last 20 years. The telescoping course of SUDs, recent research on the role of neuroactive gonadal steroid hormones in craving and relapse, and sex differences in stress reactivity and relapse to substance abuse are described. The role of co-occurring mood and anxiety, eating, and posttraumatic stress disorders is considered in the epidemiology, natural history, and treatment of women with SUDs. Women's use of alcohol, stimulants, opioids, cannabis, and nicotine are examined in terms of recent epidemiology, biologic and psychosocial effects, and treatment. Although women may be less likely to enter substance abuse treatment than men over the course of the lifetime, once they enter treatment, gender itself is not a predictor of treatment retention, completion, or outcome. Research on gender-specific treatments for women with SUDs and behavioral couples treatment has yielded promising results for substance abuse treatment outcomes in women.

The effect of depression on return to drinking: a prospective study

BACKGROUND

The effect of depression on return to drinking among individuals with alcohol dependence is controversial. From February 1, 1993, to April 15, 1996, we consecutively recruited 40 women and 61 men hospitalized for alcohol dependence and followed them up monthly for 1 year to assess the effect of depression on drinking outcomes.

METHODS

We conducted structured interviews during hospitalization and monthly following discharge for 1 year to determine whether depression at treatment entry affected the likelihood of return to drinking and whether this effect differed between sexes. Using survival analysis, we examined the effect of depressive symptoms and a diagnosis of current major depression at treatment entry on times to first drink and relapse during follow-up.

RESULTS

A diagnosis of current major depression at the time of hospitalization was associated with shorter times to first drink (hazard ratio, 2.03; 95% confidence interval [CI], 1.28-3.21; P=.003) and relapse (hazard ratio, 2.12; 95% CI, 1.32-3.39; P=.002). There was no significant difference between women and men in this effect. Depressive symptoms as measured by the Beck Depression Inventory did not predict time to first drink or relapse in women or men.

CONCLUSIONS

A diagnosis of current major depression at entry into inpatient treatment for alcohol dependence predicted shorter times to first drink and relapse in women and men. Our results differ from earlier reports that men and women differ in the effect of depression on return to drinking.

Gender differences in a clinical trial for prescription opioid dependence

Although gender differences in substance use disorders have been identified, few studies have examined gender differences in prescription drug dependence. The aim of this study was to examine gender differences in clinical characteristics and treatment outcomes in a large clinical trial for prescription opioid dependence. Despite no pre-treatment differences in opioid dependence severity, women reported significantly greater functional impairment, greater psychiatric severity, and higher likelihood of using opioids to cope with negative affect and pain than men. Women were also more likely than men to have first obtained opioids via a legitimate prescription and to use opioids via the intended route of administration. Men reported significantly more alcohol problems than women. There were no significant gender differences in medication dose, treatment retention, or opioid outcomes. Thus, despite the presence of pre-treatment gender differences in this population, once the study treatment was initiated, women and men exhibited similar opioid use outcomes.

Beyond drug use: a systematic consideration of other outcomes in evaluations of treatments for substance use disorders

Across the addictions field, the primary outcome in treatment research has been reduction in drug consumption. A comprehensive view of the impact of substance use disorders on human functioning suggests that effective treatments should address the many consequences and features of addiction beyond drug use, a recommendation forwarded by multiple expert panels and review papers. Despite recurring proposals, and a compelling general rationale for moving beyond drug use as the sole standard for evaluating addiction treatment, the field has yet to adopt any core set of 'other' measures that are routinely incorporated into treatment research. Among the many reasons for the limited impact of previous proposals has been the absence of a clear set of guidelines for selecting candidate outcomes. This paper is the result of the deliberations of a panel of substance abuse treatment and research experts convened by the National Institute on Drug Abuse to discuss appropriate outcome measures for clinical trials of substance abuse treatments. This paper provides an overview of previous recommendations and outlines specific guidelines for consideration of candidate outcomes. A list of outcomes meeting those guidelines is described and illustrated in detail with two outcomes: craving and quality of life. The paper concludes with specific recommendations for moving beyond the outcome listing offered in this paper to promote the programmatic incorporation of these outcomes into treatment research.

The relationship of self-efficacy expectancies to relapse among alcohol dependent men and women: a prospective study

OBJECTIVE

We studied the relationship of self-efficacy expectancies measured during inpatient alcohol treatment and time to first drink and time to relapse following hospitalization. We also examined whether the relationship of in-hospital self-efficacy and posttreatment drinking outcome differed by gender.

METHOD

We measured self-efficacy expectancies using the Situational Confidence Questionnaire (SCQ) in 100 subjects (59 men) during inpatient treatment for alcohol dependence. We followed subjects monthly for 1 year and examined the relationship of their in-hospital SCQ scores to posttreatment drinking behavior, as measured by time to first drink, time to relapse and percent abstinent days.

RESULTS

Self-efficacy during hospitalization was related to relapse during the 12 months following hospitalization. Survival analysis demonstrated that in-hospital SCQ scores greater than 45 were predictive of better drinking outcomes. The median number of days to relapse after treatment were 30 and 135, respectively, in those with in-hospital SCQ scores less than or equal to 45 compared with those with SCQ scores greater than 45. There were no gender differences in self-efficacy measured during hospitalization, nor were there gender differences in the relationship of self-efficacy to time to relapse. However, men with SCQ scores less than or equal to 45 had fewer abstinent days during follow-up.

CONCLUSIONS

Among both men and women being treated for alcohol dependence, a cut-off score of 45 on the SCQ may be especially important in helping clinicians assess patients who are at high risk for more rapid return to drinking after hospitalization.

Concurrent validity of the Alcohol Use Disorders Identification Test (AUDIT) and AUDIT zones in defining levels of severity among out-patients with alcohol dependence in the COMBINE study

AIMS

To examine among alcohol-dependent out-patient clients the concurrent validity of the Alcohol Use Disorders Identification Test (AUDIT) total score and 'zones' suggested by the World Health Organization for defining levels of severity of alcohol use problems.

DESIGN

Participants were classified into AUDIT zones (AUDIT total score = 8-15, 16-19, 20-40) and compared on measures of demographics, treatment goals, alcohol consumption, alcohol-related consequences, severity of dependence, physiological dependence, tolerance, withdrawal and biomarkers of alcohol use.

SETTING

Eleven out-patient academic clinical research centers across the United States. Participants Alcohol dependent individuals (n = 1335) entering out-patient treatment in the Combined Pharmacotherapies and Behavioral Interventions (COMBINE) study.

MEASUREMENTS

The AUDIT was administered as part of an initial screening. Baseline measures used for concurrent validation included the Structured Clinical Interview for Diagnostic and Statistical Manual, 4th edition (DSM-IV) Disorders, the Alcohol Dependence Scale, the Drinker Inventory of Consequences, the Obsessive-Compulsive Drinking Scale, the University of Rhode Island Change Assessment, the Thoughts about Abstinence Scale, the Form-90, %carbohydrate-deficient transferrin and gamma-glutamyl transferase. Findings Indicators of severity of dependence and alcohol-related problems increased linearly with total score and differed significantly across AUDIT zones. The highest zone, with scores of 20 and above, was markedly different with respect to severity from the other two zones and members of this group endorsed an abstinence goal more strongly.

CONCLUSIONS

The AUDIT total score is a brief measure that appears to provide an index of severity of dependence in a sample of alcohol-dependent individuals seeking out-patient treatment, extending its potential utility beyond its more traditional role as a screening instrument in general populations.

A randomized trial of integrated group therapy versus group drug counseling for patients with bipolar disorder and substance dependence

OBJECTIVE

Although bipolar disorder and substance use disorder frequently co-occur, there is little information on the effectiveness of behavioral treatment for this population. Integrated group therapy, which addresses the two disorders simultaneously, was compared with group drug counseling, which focuses on substance use. The authors hypothesized that patients receiving integrated group therapy would have fewer days of substance use and fewer weeks ill with bipolar disorder.

METHOD

A randomized controlled trial compared 20 weeks of integrated group therapy or group drug counseling with 3 months of posttreatment follow-up. Sixty-two patients with bipolar disorder and current substance dependence, treated with mood stabilizers for >or=2 weeks, were randomly assigned to integrated group therapy (N=31) or group drug counseling (N=31). The primary outcome measure was the number of days of substance use. The primary mood outcome was the number of weeks ill with a mood episode.

RESULTS

Intention-to-treat analysis revealed significantly fewer days of substance use for integrated group therapy patients during treatment and follow-up. Groups were similar in the number of weeks ill with bipolar disorder during treatment and follow-up, although integrated group therapy patients had more depressive and manic symptoms.

CONCLUSIONS

Integrated group therapy, a new treatment developed specifically for patients with bipolar disorder and substance dependence, appears to be a promising approach to reduce substance use in this population.

Patterns and predictors of treatment seeking after onset of a substance use disorder

BACKGROUND

We studied survey respondents aged 18 through 54 years to determine consistent predictors of treatment seeking after onset of a DSM-III-R substance use disorder.

METHODS

Survey populations included a regional sample in Ontario (n = 6261), a national sample in the United States (n = 5388), and local samples in Fresno, Calif (n = 2874) and Mexico City, Mexico (n = 1734). The analysis examined the effects of demographics, symptoms, and types of substances on treatment seeking.

RESULTS

Between 50% (Ontario) and 85% (Fresno) of people with substance use disorders seek treatment but the time lag between onset and treatment seeking averages a decade or more. Consistent predictors of treatment seeking include: (1) late onset of disorder (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.6-5.6 for late [> or =30 years] vs early [1-15 years] age at first symptom of disorder); (2) recency of cohort (OR, 3.4; 95% CI, 2.3-5.0 for most recent [aged 15-24 years at interview] vs earliest [aged > or =45 years] cohorts); (3) 4 specific dependence symptoms (using larger amounts than intended, unsuccessful attempts to cut down use, tolerance, and withdrawal symptoms), with ORs ranging between 1.6 (95% CI, 1.3-2.0) and 2.7 (95% CI, 2.1-3.6) for people with vs without these symptoms; and (4) use vs nonuse of cocaine (OR, 2.1; 95% CI, 1.6-2.7) and heroin (OR, 2.6; 95% CI, 1.1-6.0).

CONCLUSIONS

Although most people with substance use disorders eventually seek treatment, treatment seeking often occurs a decade or more after the onset of symptoms of disorder. While treatment seeking has increased in recent years, it is not clear whether this is because of increased access, increased demand, increased societal pressures, or other factors.

Women and alcohol use disorders

Although substance abuse and dependence have been increasing among women in the United States for some time, only during the past two decades have researchers started to focus on women and alcohol use disorders. In the past all-male samples were generally used because they were much more easily available; when mixed-gender populations were examined, women were often underrepresented. Gender bias was evident in research on alcohol dependence even in the early 1990s. A critical review of addiction specialty journals in 1995 concluded that researchers still commonly used male populations and generalized the findings to both sexes. Recent studies on gender differences in alcohol use disorders have found that compared to men, women become intoxicated after drinking half as much, metabolize alcohol differently, develop cirrhosis of the liver more rapidly, and have a greater risk of dying from alcohol-related accidents. This article reviews the existing literature, focusing on four central questions: (1) Are alcohol use disorders becoming increasingly prevalent in women, thereby closing the gender gap between men and women? (2) Do the physical effects of alcohol differ by gender, and if so, why? (3) Do men and women differ in frequency and type of treatment services sought for alcohol use disorders? (4) What role does gender play in the process of recovery from alcohol dependence?

Medication compliance among patients with bipolar disorder and substance use disorder

BACKGROUND

This study examined patterns of medication compliance and reasons for noncompliance among patients with bipolar disorder and substance use disorder.

METHOD

Forty-four patients with current bipolar disorder and substance use disorder were administered a structured interview regarding lifetime compliance with prescribed psychotropic medications.

RESULTS

Patients who were prescribed both lithium and valproate were significantly (p = .03) more likely to report full compliance with valproate than with lithium. Side effects were the most common reason for lithium noncompliance, but were not cited as a reason for valproate noncompliance. Also, a common pattern of noncompliance among patients prescribed benzodiazepines, neuroleptics, and tricyclic antidepressants was the use of more medication than prescribed.

CONCLUSION

Valproate may have greater acceptability than lithium among patients with bipolar disorder and substance use disorder. Clinicians should also be aware that these patients may take higher doses of medication than prescribed.

The Women's Recovery Group Study: a Stage I trial of women-focused group therapy for substance use disorders versus mixed-gender group drug counseling

The aim of this Stage I Behavioral Development Trial was to develop a manual-based 12-session Women's Recovery Group (WRG) and to pilot test this new treatment in a randomized controlled trial against a mixed-gender Group Drug Counseling (GDC), an effective manual-based treatment for substance use disorders. After initial manual development, two pre-pilot groups of WRG were conducted to determine feasibility and initial acceptability of the treatment among subjects and therapists. In the pilot stage, women were randomized to either WRG or GDC. No significant differences in substance use outcomes were found between WRG and GDC during the 12-week group treatment. However, during the 6-month post-treatment follow-up, WRG members demonstrated a pattern of continued reductions in substance use while GDC women did not. In addition, pilot WRG women with alcohol dependence had significantly greater reductions in average drinks/drinking day than GDC women 6 months post-treatment (p<.03, effect size=0.81). While satisfaction with both groups was high, women were significantly more satisfied with WRG than GDC (p<.009, effect size=1.11). In this study, the newly developed 12-session women-focused WRG was feasible with high satisfaction among participants. It was equally effective as mixed-gender GDC in reducing substance use during the 12-week in-treatment phase, but demonstrated significantly greater improvement in reductions in drug and alcohol use over the post-treatment follow-up phase compared with GDC. A women-focused single-gender group treatment may enhance longer-term clinical outcomes among women with substance use disorders.

Group therapy for patients with bipolar disorder and substance dependence: results of a pilot study

BACKGROUND

The authors' goal was to pilot test a newly developed manual-based group psychotherapy, called Integrated Group Therapy (IGT), for patients with bipolar disorder and substance dependence.

METHOD

In this open trial, patients with DSM-IV bipolar disorder and substance dependence (N = 45) were recruited in sequential blocks to receive either group therapy (N = 21) or 6 monthly assessments, but no experimental treatment (N = 24).

RESULTS

When compared with patients who did not receive group therapy, patients who received IGT had significantly better outcomes on the Addiction Severity Index drug composite score (p < .03), percentage of months abstinent (p < .01), and likelihood of achieving 2 (p < .002) or 3 (p < .004) consecutive abstinent months.

CONCLUSION

IGT is a promising treatment for patients with bipolar disorder and substance dependence, who have traditionally had poor outcomes. It is unclear, however, how much of the improvement among the group therapy patients is attributable to the specific content of the treatment. A study comparing this treatment with another active psychotherapy treatment is warranted.

Topiramate in the treatment of substance-related disorders: a critical review of the literature

OBJECTIVE

To critically review the literature on topiramate in the treatment of substance-related disorders.

DATA SOURCES

A PubMed search of human studies published in English through January 2009 was conducted using the following search terms: topiramate and substance abuse, topiramate and substance dependence, topiramate and withdrawal, topiramate and alcohol, topiramate and nicotine, topiramate and cocaine, topiramate and opiates, and topiramate and benzodiazepines.

STUDY SELECTION

26 articles were identified and reviewed; these studies examined topiramate in disorders related to alcohol, nicotine, cocaine, methamphetamine, opioids, Ecstasy, and benzodiazepines.

DATA EXTRACTION

Study design, sample size, topiramate dose and duration, and study outcomes were reviewed.

DATA SYNTHESIS

There is compelling evidence for the efficacy of topiramate in the treatment of alcohol dependence. Two trials show trends for topiramate's superiority over oral naltrexone in alcohol dependence, while 1 trial suggests topiramate is inferior to disulfiram. Despite suggestive animal models, evidence for topiramate in treating alcohol withdrawal in humans is slim. Studies of topiramate in nicotine dependence show mixed results. Human laboratory studies that used acute topiramate dosing show that topiramate actually enhances the pleasurable effects of both nicotine and methamphetamine. Evidence for topiramate in the treatment of cocaine dependence is promising, but limited by small sample size. The data on opioids, benzodiazepines, and Ecstasy are sparse.

CONCLUSIONS

Topiramate is efficacious for the treatment of alcohol dependence, but side effects may limit widespread use. While topiramate's unique pharmacodynamic profile offers a promising theoretical rationale for use across multiple substance-related disorders, heterogeneity both across and within these disorders limits topiramate's broad applicability in treating substance-related disorders. Recommendations for future research include exploration of genetic variants for more targeted pharmacotherapies.

Gender differences in cocaine dependent patients: a 6 month follow-up study

This 6-month follow-up study compared 64 men and 37 women hospitalized for cocaine dependence. Drug histories, sociodemographic characteristics, psychiatric diagnoses, and Addiction Severity Index (ASI) scores were compared during hospitalization; cocaine use and ASI scores were compared at 6 months. During hospitalization, women had significantly more severe family and social problems; men had more antisocial personality disorder. At follow-up, significantly more women had remained abstinent: family/social problem severity no longer differed. This replicates previous research showing better treatment outcome for cocaine dependent women. This may be related to specific characteristics of women who enter mixed-gender cocaine treatment programs.

Validity of substance use self-reports in dually diagnosed outpatients

OBJECTIVE

The purpose of this study was to assess the validity of self-reports of substance use among outpatients dually diagnosed with substance use disorder and either bipolar disorder or posttraumatic stress disorder.

METHOD

Self-reports of substance use were compared with supervised urine samples collected on the same day for 55 subjects.

RESULTS

Self-reports were highly valid. Only 4.7% of cases involved subjects not reporting substance use detected by urine screens.

CONCLUSIONS

Self-reports of substance use may be highly valid in nonpsychotic, dually diagnosed outpatients under certain conditions, i.e., when patients are in treatment, when urine samples are collected with patients' prior knowledge, when patients are well-known to staff, and when honest self-reporting is encouraged.

Does report of craving opioid medication predict aberrant drug behavior among chronic pain patients?

OBJECTIVE

To examine the relationship between the self-report of craving prescription medication and subsequent opioid misuse among chronic pain patients prescribed opioids for pain.

METHODS

Six hundred thirteen patients taking opioid medication for chronic noncancer pain were asked how often they have felt a craving for their medication on a scale from 0=never to 4=very often. All participants completed a series of baseline questionnaires. After 6 months the participants were administered a structured prescription drug use interview (Prescription Drug Use Questionnaire), and submitted a urine sample for toxicology assessment. Their treating physicians also completed a substance misuse behavior checklist (Prescription Opioid Therapy Questionnaire).

RESULTS

Three hundred thirty-seven participants (55.0%) reported that they never felt a craving for their medication, whereas 276 (45.0%) reported some degree of craving their medication (seldom to very often). Those who reported craving their medication were significantly more often male (P<0.01), unmarried (P<0.05), had lower scores on social desirability (P<0.001), and had been prescribed opioids for a longer time (P<0.05) than those who did not report craving medication. At 6-month follow-up, those who reported craving their medication showed higher scores on the Prescription Drug Use Questionnaire (P<0.001), had a higher incidence of physician-rated aberrant drug behavior on the Prescription Opioid Therapy Questionnaire (P<0.05), showed a higher frequency of abnormal urine toxicology screens (P<0.001), and more often had a positive Aberrant Drug Behavior Index (P<0.001).

DISCUSSION

These results suggest that self-reported craving is a potential marker for identification of those at risk for opioid medication misuse.

What is "women-focused" treatment for substance use disorders?

Over the past three decades research has highlighted gender differences in substance use disorders and substance abuse treatment participation. Programs devoted to addressing women's treatment needs, broadly encompassed in the term "women-focused treatment," have multiplied. This column examines the rationale for women-focused treatment and describes some of its components. The authors cite the need to evaluate women-focused treatment by developing validated measures of the processes embodied in such treatment and by conducting empirically sound research on clinical outcomes, treatment effectiveness, cost-effectiveness, and the optimal means of providing services to women with substance use disorders.

The effect of comorbid substance use disorders on the course of bipolar disorder: a review

Population-based studies have documented that among all patients with major psychiatric disorders, those with bipolar disorder have the highest prevalence of comorbid substance abuse and dependence. The cause of this high comorbidity rate has not been clearly established, and the relationship is probably bidirectional. Articles published in English from 1980 through 1997 containing the terms comorbidity, mania, outcome, and substance use were identified by searching Medline and then the bibliographies of the articles identified in this search. The literature review showed several risk factors to be associated with comorbid substance use disorders in bipolar disorder patients: early age of onset, gender, family history of substance use disorders, and presence of mixed mania. Methodological enhancements that have helped to advance understanding in this area include distinguishing between primary and secondary disorders, between the different subtypes of bipolar disorder, and between first and subsequent episodes of illness. In order to determine the temporal sequence of onset, longitudinal studies initiated at the onset of either illness need to be pursued. Increased understanding of the association between bipolar disorder and comorbid substance use disorder will facilitate improved detection and intervention, as well as more-effective preventive measures that could improve outcome for patients with bipolar disorder.

Effect of the Affordable Care Act's young adult insurance expansions on hospital-based mental health care

OBJECTIVE

Insurance coverage for young adults has increased since 2010, when the Affordable Care Act (ACA) required insurers to permit children to remain on parental policies until age 26 as dependents. This study estimated the association between the dependent coverage provision and changes in young adults' use of hospital-based services for substance use disorders and non-substance use psychiatric disorders.

METHOD

The authors conducted a quasi-experimental comparison of a national sample of non-childbirth-related inpatient admissions to general hospitals (a total of 2,670,463 admissions, 430,583 of which had primary psychiatric diagnoses) and California emergency department visits with psychiatric diagnoses (N=11,139,689), using data spanning 2005 to 2011. Analyses compared young adults who were targeted by the ACA dependent coverage provision (19- to 25-year-olds) and those who were not (26- to 29-year-olds), estimating changes in utilization before and after implementation of the dependent coverage provision. Primary outcome measures included quarterly inpatient admissions for primary diagnoses of any psychiatric disorder per 1,000 population; emergency department visits with any psychiatric diagnosis per 1,000 population; and payer source.

RESULTS

Dependent coverage expansion was associated with 0.14 more inpatient admissions for psychiatric diagnoses per 1,000 for 19- to 25-year-olds (targeted by the ACA) than for 26- to 29-year-olds (not targeted by the ACA). The coverage expansion was associated with 0.45 fewer psychiatric emergency department visits per 1,000 in California. The probability that inpatient admissions nationally and emergency department visits in California were uninsured decreased significantly.

CONCLUSIONS

ACA dependent coverage provisions produced modest increases in general hospital psychiatric inpatient admissions and higher rates of insurance coverage for young adults nationally. Lower rates of emergency department visits were observed in California.

Craving of prescription opioids in patients with chronic pain: a longitudinal outcomes trial

Little is known about whether patients with chronic pain treated with opioids experience craving for their medications, whether contextual cues may influence craving, or if there is a relationship between craving and medication compliance. We hypothesized that craving for prescription opioids would be significantly correlated with the urge for more medication, preoccupation with the next dose, and current mood symptoms. We studied craving in 62 patients with chronic pain who were at low or high risk for opioid misuse, while they were enrolled in an RCT to improve prescription opioid medication compliance. Using electronic diaries, patients completed ratings of craving at monthly clinic visits and daily during a 14-day take-home period. Both groups consistently endorsed craving, whose levels were highly correlated (P < .001) with urge, preoccupation, and mood. The intervention to improve opioid compliance in the high-risk group was significantly associated with a rate of decrease in craving over time in comparison to a high-risk control group (P < .05). These findings indicate that craving is a potentially important psychological construct in pain patients prescribed opioids, regardless of their level of risk to misuse opioids. Targeting craving may be an important intervention to decrease misuse and improve prescription opioid compliance.

PERSPECTIVE

Patients with noncancer pain can crave their prescription opioids, regardless of their risk for opioid misuse. We found craving to be highly correlated with the urge to take more medication, fluctuations in mood, and preoccupation with the next dose, and to diminish with a behavioral intervention to improve opioid compliance.

Gender differences in alcohol treatment: an analysis of outcome from the COMBINE study

BACKGROUND

Relatively few studies have examined gender differences in the effectiveness of specific behavioral or pharmacologic treatment of alcohol dependence. The aim of this study is to assess whether there were gender differences in treatment outcomes for specific behavioral and medication treatments singly or in combination by conducting a secondary analysis of public access data from the national, multisite NIAAA-sponsored COMBINE study.

METHODS

The COMBINE study investigated alcohol treatment among 8 groups of patients (378 women, 848 men) who received medical management (MM) with 16 weeks of placebo, naltrexone (100 mg/day), acamprosate (3 g/day), or their combination with or without a specialist-delivered combined behavioral intervention. We examined efficacy measures separately for men and women, followed by an overall analysis that included gender and its interaction with treatment condition in the analyses. These analyses were performed to confirm whether the findings reported in the parent trial were also relevant to women, and to more closely examine secondary outcome variables that were not analyzed previously for gender effects.

RESULTS

Compared to men, women reported a later age of onset of alcohol dependence by approximately 3 years, were significantly less likely to have had previous alcohol treatment, and drank fewer drinks per drinking day. Otherwise, there were no baseline gender differences in drinking measures. Outcome analyses of 2 primary (percent days abstinent and time to first heavy drinking day) and 2 secondary (good clinical response and percent heavy drinking days) drinking measures yielded the same overall pattern in each gender as that observed in the parent COMBINE study report. That is, only the naltrexone by behavioral intervention interaction reached or approached significance in women as well as in men. There was a naltrexone main effect that was significant in both men and women in reduction in alcohol craving scores with naltrexone-treated subjects reporting lower craving than placebo-treated subjects.

CONCLUSIONS

This gender-focused analysis found that alcohol-dependent women responded to naltrexone with COMBINE's Medical Management, similar to the alcohol-dependent men, on a wide range of outcome measures. These results suggest that clinicians can feel comfortable prescribing naltrexone for alcohol dependence in both men and women. In this study, it is also notable that fewer women than men reported receiving any alcohol treatment prior to entry into the COMBINE study. Of note, women tend to go to primary health care more frequently than to specialty substance abuse programs for treatment, and so the benefit we confirm for women of the naltrexone and MM combination has practical implications for treating alcohol-dependent women.

Childhood abuse in first-episode psychosis

Of 38 adult patients admitted for first-episode psychosis, 20 reported childhood abuse, with equal prevalence in men and women. Patients with histories of childhood abuse had significantly more dissociative symptoms, but not more severe psychiatric symptoms. Childhood abuse was not related to rate of recovery and was only marginally related to longer stays in hospital. Although childhood abuse did not affect recovery during first-episode psychosis, it may contribute to a chronic course in some patients.