Summary Background Methadone is an effective treatment for opioid dependence. When people who are receiving methadone maintenance treatment for opioid dependence are incarcerated in prison or jail, ...most US correctional facilities discontinue their methadone treatment, either gradually, or more often, abruptly. This discontinuation can cause uncomfortable symptoms of withdrawal and renders prisoners susceptible to relapse and overdose on release. We aimed to study the effect of forced withdrawal from methadone upon incarceration on individuals' risk behaviours and engagement with post-release treatment programmes. Methods In this randomised, open-label trial, we randomly assigned (1:1) inmates of the Rhode Island Department of Corrections (RI, USA) who were enrolled in a methadone maintenance-treatment programme in the community at the time of arrest and wanted to remain on methadone treatment during incarceration and on release, to either continuation of their methadone treatment or to usual care—forced tapered withdrawal from methadone. Participants could be included in the study only if their incarceration would be more than 1 week but less than 6 months. We did the random assignments with a computer-generated random permutation, and urn randomisation procedures to stratify participants by sex and race. Participants in the continued-methadone group were maintained on their methadone dose at the time of their incarceration (with dose adjustments as clinically indicated). Patients in the forced-withdrawal group followed the institution's standard withdrawal protocol of receiving methadone for 1 week at the dose at the time of their incarceration, then a tapered withdrawal regimen (for those on a starting dose >100 mg, the dose was reduced by 5 mg per day to 100 mg, then reduced by 3 mg per day to 0 mg; for those on a starting dose >100 mg, the dose was reduced by 3 mg per day to 0 mg). The main outcomes were engagement with a methadone maintenance-treatment clinic after release from incarceration and time to engagement with methadone maintenance treatment, by intention-to-treat and as-treated analyses, which we established in a follow-up interview with the participants at 1 month after their release from incarceration. Our study paid for 10 weeks of methadone treatment after release if participants needed financial help. This trial is registered with ClinicalTrials.gov , number NCT01874964. Findings Between June 14, 2011, and April 3, 2013, we randomly assigned 283 prisoners to our study, 142 to continued methadone treatment, and 141 to forced withdrawal from methadone. Of these, 60 were excluded because they did not fit the eligibility criteria, leaving 114 in the continued-methadone group and 109 in the forced-withdrawal group (usual care). Participants assigned to continued methadone were more than twice as likely than forced-withdrawal participants to return to a community methadone clinic within 1 month of release (106 96% of 110 in the continued-methadone group compared with 68 78% of 87 in the forced-withdrawal group; adjusted hazard ratio HR 2·04, 95% CI 1·48–2·80). We noted no differences in serious adverse events between groups. For the continued-methadone and forced-withdrawal groups, the number of deaths were one and zero, non-fatal overdoses were one and two, admissions to hospital were one and four; and emergency-room visits were 11 and 16, respectively. Interpretation Although our study had several limitations—eg, it only included participants incarcerated for fewer than 6 months, we showed that forced withdrawal from methadone on incarceration reduced the likelihood of prisoners re-engaging in methadone maintenance after their release. Continuation of methadone maintenance during incarceration could contribute to greater treatment engagement after release, which could in turn reduce the risk of death from overdose and risk behaviours. Funding National Institute on Drug Abuse and the Lifespan/Tufts/Brown Center for AIDS Research from the National Institutes of Health.
Substance‐related disorders can adversely impact quality of life. This study assessed a 12 step program on health‐related quality of life for Iranian individuals seeking to recover from substance ...use. The study used a quasi‐experimental, two group, three stage, pre‐ and post‐test design and collected data at baseline, and at 1 and 3 months’ post‐intervention. The treatment group comprised 35 participants in a 12 step program with a non‐equivalent comparison group of individuals admitted to addiction treatment centers. Physical and mental health quality‐of‐life domains were assessed using the Short Form 36 Health Survey Questionnaire. The treatment group improved in all aspects of health‐related quality of life. The treatment group improved compared to the comparison group for two of eight quality of life dimensions – physical functioning and role limitations due to emotional problems – at 1 month post‐intervention. There were additional improvements at 3 months’ follow up in six of eight quality‐of‐life subscales compared to the comparison group. The benefits to quality of life related to mental health recovery extended beyond the treatment program, indicating that the program principles were effectively implemented in daily life.
This study assessed racial-ethnic disparities in access to high-quality treatment for at-risk drinking and alcohol abuse in the United States and simulated strategies to narrow the gap.
Longitudinal ...data collected in 2001-2002 and 2004-2005 from the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed to examine racial-ethnic disparities in receipt of alcohol interventions that were provided in primary care and specialty treatment settings and that met published clinical guidelines. The sample consisted of 9,116 respondents who met criteria for at-risk drinking or alcohol abuse in 2001-2002. Simulation analyses projected how disparities in treatment services utilization might change if clinical guidelines promoted access to care in more varied health and human service settings.
Compared with whites, members of racial-ethnic minority groups had less than two-thirds the odds of receiving an alcohol intervention over the roughly four-year study period (odds ratio OR=.62, p<.05). This disparity increased after adjustment for socioeconomic confounders and frequency of heavy drinking (adjusted OR=.47, p=.003). The most pronounced disparities were between whites and U.S.-born and foreign-born Hispanics. Simulation analyses suggested that these disparities could be partially mitigated by extending care into nonmedical service venues.
Current efforts to extend evidence-based alcohol interventions into medical settings address an important need but are likely to increase racial-ethnic disparities in access to high-quality treatment. Partial solutions may be found in expanding the range and quality of alcohol-related services provided in alternative delivery sites, including faith-based and social service institutions.
Abstract
Background
In the United States, many opioid treatment programs (OTPs) do not offer viral hepatitis (VH) or human immunodeficiency virus (HIV) testing despite high prevalence among OTP ...clients. We initiated an opt-out VH and HIV testing and linkage-to-care program within our OTP.
Methods
All OTP intakes are screened for VH and HIV and evaluated for rescreening annually. A patient navigator reviews laboratory results and provides counseling in the OTP clinic. The medical record is queried to identify individuals with previously diagnosed, untreated VH or HIV. Navigation support is provided for linkage or relinkage to VH or HIV care.
Results
Between March 2018 and Februrary 2019, 532 individuals were screened for hepatitis C virus (HCV), 180 tested HCV antibody positive (34%), and 108 were HCV-ribonucleic acid (RNA) positive (20%). Sixty individuals were identified with previously diagnosed, untreated HCV. Of all HCV RNA+, 49% reported current injection drug use (82 of 168). Ninety-five individuals were seen by an HCV specialist (57% of HCV RNA+), 72 started treatment (43%), and 69 (41%) completed treatment. Individuals with primary care providers were most likely to start treatment. Four individuals were diagnosed with hepatitis B; 0 were diagnosed with HIV.
Conclusions
The implementation of an OTP-based screening and navigation protocol has enabled significant gains in the identification and treatment of VH in this high prevalence setting.
Abstract Waiting lists for methadone treatment have existed in many U.S. communities, but little is known nationally about what patient and service system factors are related to admission delays that ...stem from program capacity shortfalls. Using a combination of national data sources, this study examined patterns in capacity-related admission delays to outpatient methadone treatment in 40 U.S. metropolitan areas ( N = 28,920). Patient characteristics associated with admission delays included racial/ethnic minority status, lower education, criminal justice referral, prior treatment experience, secondary cocaine or alcohol use, and co-occurring psychiatric problems. Injection drug users experienced fewer delays, as did self-pay patients and referrals from health care and addiction treatment providers. Higher community-level utilization of methadone treatment was associated with delay, whereas delays were less common in communities with higher utilization of alternative modalities. These findings highlight potential disparities in timely admission to outpatient methadone treatment. Implications for improving treatment access and service system monitoring are discussed.
Abstract Background Few studies have examined real-world effectiveness of integrated buprenorphine maintenance treatment (BMT) programs in federally qualified health centers (FQHCs). Methods Opioid ...dependent patients ( N = 266) inducted on buprenorphine between July 2007 and December 2008 were retrospectively assessed at Connecticut's largest FQHC network. Six-month BMT retention and opioid-free time were collected longitudinally from electronic health records; 136 (51.1%) of patients were followed for at least 12 months. Results Participants had a mean age of 40.1 years, were primarily male (69.2%) and treated by family practitioners (70.3%). Co-morbidity included HCV infection (59.8%), mood disorders (71.8%) and concomitant cocaine use (59%). Retention on BMT was 56.8% at 6 months and 61.6% at 12 months for the subset observed over 1 year. Not being retained on BMT at 12 months was associated with cocaine use (AOR = 2.18; 95% CI = 1.35–3.50) while prescription of psychiatric medication (AOR = 0.36; 95% CI 0.20–0.62) and receiving on-site substance abuse counseling (AOR = 0.34; 95% CI 0.19, 0.59) improved retention. Two thirds of the participants experienced at least one BMT gap of 2 or more weeks with a mean gap length of 116.4 days. Conclusions Integrating BMT in this large FQHC network resulted in retention rates similarly reported in clinical trials and emphasizes the need for providing substance abuse counseling and screening for and treating psychiatric comorbidity.
Abstract This study examined the association between stopping smoking at 1 year after substance use treatment intake and long-term substance use outcomes. Nine years of prospective data from 1185 ...adults (39% female) in substance use treatment at a private health care setting were analyzed by multivariate logistic generalized estimating equation models. At 1 year, 14.1% of 716 participants who smoked cigarettes at intake reported stopping smoking, and 10.7% of the 469 non-smokers at intake reported smoking. After adjusting for sociodemographics, substance use severity and diagnosis at intake, length of stay in treatment, and substance use status at 1 year, those who stopped smoking at 1 year were more likely to be past-year abstinent from drugs, or in past-year remission of drugs and alcohol combined, at follow-ups than those who continued to smoke (OR = 2.4, 95% CI: 1.2–4.7 and OR = 1.6, 95% CI: 1.1–2.4, respectively). Stopping smoking at 1 year also predicted past-year alcohol abstinence through 9 years after intake among those with drug-only dependence (OR = 2.4, 95% CI: 1.2–4.5). We found no association between past-year alcohol abstinence and change in smoking status at 1 year for those with alcohol dependence or other substance use diagnoses when controlling for alcohol use status at 1 year. Stopping smoking during the first year after substance use treatment intake predicted better long-term substance use outcomes through 9 years after intake. Findings support promoting smoking cessation among smoking clients in substance use treatment.
•The MoCA and the BEARNI are screening tests for cognitive impairment in alcoholics.•The BEARNI had very high sensitivity (1.0) but very low specificity (0.04).•The MoCA had a very high sensitivity ...(0.79) and acceptable specificity (0.65).•The low BEARNI specificity results from its scoring system.•The MoCA seems more appropriate than the BEARNI for use in routine practice.
Screening of cognitive impairment is a major challenge in alcoholics seeking treatment, since cognitive dysfunction may impair the overall efficacy of rehabilitation programs and consequently increase relapse rate. We compared the performance of two screening tools: the MoCA (Montreal Cognitive Assessment), which is widely used in patients with neurological diseases and already used in patients with alcohol use disorder (AUD), and the BEARNI (Brief Evaluation of Alcohol-Related Neuropsychological Impairments), a recent test specifically developed for the alcoholic population.
We compared the sensitivity and specificity of the MoCA and the BEARNI in a sample of AUD patients with and without cognitive impairment assessed by a battery of neuropsychological tests.
Ninety patients were included. There were 67 men and 23 women aged 48.9 ± 9.6 years. According to the neuropsychological tests, 51.1% of patients had no cognitive impairment, while it was mild or moderate to severe in 31.1 and 17.8%, respectively. The BEARNI sensitivity was extremely high (1.0), since all patients with cognitive impairment were identified, but its specificity was very low (0.04). The MoCA had a lower sensitivity (0.79) than the BEARNI, but its specificity was significantly better (0.65). A detailed analysis of the BEARNI scores showed a discrepancy between the qualitative and quantitative interpretation of the test which could, at least in part, explain its low specificity.
Both the MoCA and the BEARNI are screening tools which identified alcoholic patients with cognitive impairment. However, in routine use, the MoCA appeared to be more appropriate given the low specificity of the BEARNI.
Background
Relapse is common in alcohol‐dependent individuals and can be triggered by alcohol‐related cues in the environment. It has been suggested that these individuals develop cognitive biases, ...in which cues automatically capture attention and elicit an approach action tendency that promotes alcohol seeking. The study aim was to examine whether cognitive bias modification (CBM) training targeting approach bias could be delivered during residential alcohol detoxification and improve treatment outcomes.
Methods
Using a 2‐group parallel‐block (ratio 1:1) randomized controlled trial with allocation concealed to the outcome assessor, 83 alcohol‐dependent inpatients received either 4 sessions of CBM training where participants were implicitly trained to make avoidance movements in response to pictures of alcoholic beverages and approach movements in response to pictures of nonalcoholic beverages, or 4 sessions of sham training (controls) delivered over 4 consecutive days during the 7‐day detoxification program. The primary outcome measure was continuous abstinence at 2 weeks postdischarge. Secondary outcomes included time to relapse, frequency and quantity of alcohol consumption, and craving. Outcomes were assessed in a telephonic follow‐up interview.
Results
Seventy‐one (85%) participants were successfully followed up, of whom 61 completed all 4 training sessions. With an intention‐to‐treat approach, there was a trend for higher abstinence rates in the CBM group relative to controls (69 vs. 47%, p = 0.07); however, a per‐protocol analysis revealed significantly higher abstinence rates among participants completing 4 sessions of CBM relative to controls (75 vs. 45%, p = 0.02). Craving score, time to relapse, mean drinking days, and mean standard drinks per drinking day did not differ significantly between the groups.
Conclusions
This is the first trial demonstrating the feasibility of CBM delivered during alcohol detoxification and supports earlier research suggesting it may be a useful, low‐cost adjunctive treatment to improve treatment outcomes for alcohol‐dependent patients.
In a RCT, 83 alcohol‐dependent patients received either cognitive bias modification (CBM) or sham training (controls), during inpatient withdrawal. Among the 86% followed up 2 weeks postdischarge, significantly higher rates of abstinence were reported among the CBM group relative to controls if they completed the intended protocol of four training sessions (p = 0.02). The findings demonstrate the feasibility of CBM delivered during alcohol detoxification and support earlier research suggesting it may be a useful, low‐cost adjunctive treatment to improve treatment outcomes.
Although substance use disorders (SUDs) are prevalent and associated with adverse consequences, treatment rates remain low. Unlike physical and mental health problems, treatment for SUDs is ...predominantly provided in a separate specialty sector and more heavily financed by public sources. Medicaid expansion under the Patient Protection and Affordable Care Act has the potential to increase access to treatment for SUDs but only if an infrastructure exists to serve new enrollees.
To examine the availability of outpatient SUD treatment facilities that accept Medicaid across US counties and whether counties with a higher percentage of racial/ethnic minorities are more likely to have gaps in this infrastructure.
We used data from the 2009 National Survey of Substance Abuse Treatment Services public use file and the 2011-2012 Area Resource file to examine sociodemographic factors associated with county-level access to SUD treatment facilities that serve Medicaid enrollees. Counties in all 50 states were included. We estimated a probit model with state indicators to adjust for state-level heterogeneity in demographics, politics, and policies. Independent variables assessed county racial/ethnic composition (ie, percentage black and percentage Hispanic), percentage living in poverty, percentage living in a rural area, percentage insured with Medicaid, percentage uninsured, and total population.
Dichotomous indicator for counties with at least 1 outpatient SUD treatment facility that accepts Medicaid.
Approximately 60% of US counties have at least 1 outpatient SUD facility that accepts Medicaid, although this rate is lower in many Southern and Midwestern states than in other areas of the country. Counties with a higher percentage of black (marginal effect ME, -3.1; 95% CI, -5.2% to -0.9%), rural (-9.2%; -11.1% to -7.4%), and/or uninsured (-9.5%; -13.0% to -5.9%) residents are less likely to have one of these facilities.
The potential for increasing access to SUD treatment via Medicaid expansion may be tempered by the local availability of facilities to provide care, particularly for counties with a high percentage of black and/or uninsured residents and for rural counties. Although states that opt in to the expansion will secure additional federal funds for the SUD treatment system, additional policies may need to be implemented to ensure that adequate geographic access exists across local communities to serve new enrollees.
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