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CORK Bibliography: Health Care and Substance Abuse Treatment Utilization

69 citations. October 2010 to present

Prepared: September 2011

Agic B; Mann RE; Kobus-Matthews M. Alcohol use in seven ethnic communities in Ontario: A qualitative investigation. Drugs: Education, Prevention and Policy 18(2): 116-123, 2011. (24 refs.)

Populations in Canada represent a diverse range of cultures with different beliefs and norms regarding alcohol use and related problems. While there is very little published research on the cultural aspects of alcohol and other substance uses in Canada, in spite of the cultural diversity of the country, there are important indications that alcohol is a serious problem in many ethnic communities. In order to arrive at a more complete understanding of the issues related to providing culturally sensitive approaches that would meet the alcohol-related health promotion needs of diverse communities, focus group discussions were conducted with the key informants and community members from seven Ontario communities: the Polish, Portuguese, Russian, Tamil, Punjabi, Serbian and Somali. The results revealed that the types and sizes of alcoholic beverages consumed in each community, drinking levels that are considered 'normal' or 'excessive', as well as the perception of alcohol-related problems are largely shaped by their cultural norms and beliefs, which often differ from those of the dominant culture. Health messages that reflect the dominant culture are often not relevant to people from different cultural backgrounds. Socioeconomic disadvantages and barriers to service utilization heighten their vulnerability to alcohol problems. These findings have important implications for prevention and service provision, particularly to ethnic communities that may be unlikely to access services through more standard channels.

Allan J; Kemp M. Aboriginal and non aboriginal women in New South Wales non governmental oganisation (NGO) drug and alcohol treatment and the implications for social work: Who starts, who finishes, and where do they come from? Australian Social Work 64(1): 68-83, 2011. (47 refs.)

Limited access to care is frequently identified as a reason for poor health in Indigenous communities. This study aimed to identify the proportion of Aboriginal women accessing mainstream non government organisation (NGO) drug treatment in New South Wales (NSW) compared to non Indigenous women. Statistical analysis of two NGO subsets of the Australian Alcohol and Other Drug Treatment Services National Minimum Dataset (AODTS-NMDS) for years 2005 to 2007 was conducted. A statistically significant relationship was found between gender and Indigenous status ( 2=4.582, df=1, p=.001) in the two stages of analysis. Among NSW Aboriginal people who have accessed episodes of drug and alcohol treatment in the NGO sector, there is a significantly greater proportion of females versus males (37%F vs 63%M, n=3,080 episodes) compared to the non Indigenous service users (29%F vs 71%M, n=21,791 episodes). Aboriginal women are more likely to be referred from criminal justice settings. However, both groups of women complete treatment at the same rate. Treatment providers' perceptions of their inability to successfully intervene with Aboriginal women may be a barrier to treatment. Agency client data should be examined for both race and gender details before treatment providers decide if what they supply is accessible to Aboriginal and Torres Strait Islander populations. This study demonstrates the importance of using evidence rather than assumptions about access to and effectiveness of service provision to Aboriginal women. Analysis of agency, State, and national datasets can inform policy and practice evaluations. Social workers can then support a more hopeful future for Aboriginal women, families, and communities.

Altenburg N; Joraschky P; Barthel A; Bittner A; Pohlmann K; Rietzsch H et al. Alcohol consumption and other psycho-social conditions as important factors in the development of diabetic foot ulcers. Diabetic Medicine 28(2): 168-174, 2011. (31 refs.)

Aims: To characterize bio-psycho-social factors, particularly mental disorders and self-harm behaviour, associated with the development of diabetic foot ulcers. Methods: Two groups of diabetic patients with and without foot ulcers (n = 47 in each group) with similar sex, age and diabetes duration were assessed for mental disorders using the Composite International Diagnostic Interview. Self-harm behaviour, quality of life, depressive symptoms and self-compassion were rated using different standard questionnaires. Results: Patients from the ulcer group visited their practitioners and/or psychotherapists less frequently in the last 12 months than patients in the control group 0 vs. 13%; P = 0.026). The ulcer group patients had a history of increased alcohol consumption (43 vs. 19%; P = 0.025), lower levels of education (8 vs. 10 grades; P = 0.014) and income (1190 vs. 1535euro/month; P = 0.039). Additionally, they were less likely to be diagnosed with anxiety disorders (11 vs. 32%; P = 0.022). No significant differences in glycated haemoglobin, body mass index, smoking and direct self-harm behaviour were identified. Conclusions: Patients with foot ulcers tend to exhibit lower health-conscious behaviour, particularly higher lifetime alcohol consumption, lower utilization of medical services and less general anxiety. Practitioners should be aware of these behaviours, since early detection of diabetes patients at psycho-social risk and consecutive psychological intervention may be an effective preventive strategy in avoiding the development of foot ulcers.

Amaral G; Geierstanger S; Soleimanpour S; Brindis C. Mental health characteristics and health-seeking behaviors of adolescent school-based health center users and nonusers. Journal of School Health 81(3): 138-145, 2011. (27 refs.)

BACKGROUND: The purpose of this study is to compare the mental health risk profile and health utilization behaviors of adolescent school-based health center (SBHC) users and nonusers and discuss the role that SBHCs can play in addressing adolescent health needs. METHODS: The sample included 4640 students in grades 9 and 11 who completed the California Healthy Kids Survey between fall 2000 and spring 2005 at 4 high schools in Alameda County, California. Chi-squared tests of significance and multivariate logistic regression were used to compare characteristics of SBHC users and nonusers and identify demographic, health status, and behavioral characteristics predictive of SBHC use. RESULTS: Controlling for demographic variables and general health status, students who reported frequent feelings of sadness, trouble sleeping, suicide ideation, alcohol or marijuana use, the recent loss of a close friend or relationship, or other difficult life event were significantly more likely to seek SBHC services than their peers. Neither health insurance status nor a student's "usual" source of health care was predictive of general SBHC use, but being on public assistance or having no insurance was predictive of a student seeking SBHC mental health services. CONCLUSIONS: These findings suggest that SBHCs are able to attract students with the most serious mental health concerns and can play an important role in meeting needs that might otherwise go unmet. The provision of SBHC mental health services in particular may fill a need among adolescents with public or no insurance.

Austin J; McKellar JD; Moos R. The influence of co-occurring axis I disorders on treatment utilization and outcome in homeless patients with substance use disorders. Addictive Behaviors 36(9): 941-944, 2011. (28 refs.)

The current study examined the relationship between co-occurring substance use and Axis I psychiatric disorders and treatment utilization and outcome among homeless individuals (N = 365) who participated in an episode of intensive outpatient substance use treatment. Compared to patients without a co-occurring diagnosis, homeless patients with a diagnosis of major depressive disorder or PTSD participated in more substance use treatment. Diagnostic status did not predict 12-month alcohol or drug treatment outcome. Substance use treatment programs appear to successfully engage homeless individuals with major depressive disorder and PTSD in treatment. Such individuals appear to achieve similar benefits from standard substance use treatment as do homeless individuals without such disorders.

Back SE; Payne RL; Simpson AN; Brady KT. Gender and prescription opioids: Findings from the National Survey on Drug Use and Health. Addictive Behaviors 35(11): 1001-1007, 2010. (33 refs.)

Background: Significant gender differences in drug and alcohol use have been reported; however, little is known about gender differences in prescription opioid misuse and dependence. This study compared correlates, sources and predictors of prescription opioid non-medical use, as well as abuse or dependence among men and women in a nationally-representative sample. Methods: Participants were 55,279 (26,746 men, 28,533 women) non-institutionalized civilians aged 12 years and older who participated in the National Survey on Drug Use and Health. Results: Rates of lifetime and past-year non-medical use of prescription opiates were 13.6% and 5.1%, respectively. Significantly more men than women endorsed lifetime (15.9% vs. 11.2%) and past-year use (5.9% vs. 4.2%; ps < 0.0001). Among past-year users, 13.2% met criteria for current prescription opiate abuse or dependence, and this did not differ significantly by gender. Polysubstance use and treatment underutilization were common among both men and women, however significantly fewer women than men had received alcohol or drug abuse treatment (p = 0.001). Men were more likely than women to obtain prescription opioids for free from family or friends, and were more likely to purchase them from a dealer (ps < .01). Gender-specific predictors of use as compared to abuse/dependence were also observed. Conclusions: The findings highlight important differences between men and women using prescription opiates. The observed differences may help enhance the design of gender-sensitive surveillance, identification, prevention and treatment interventions.

Bertakis KD; Azari R. Patient gender differences in the prediction of medical expenditures26. Journal of Women's Health 19(10): 1925-1932, 2010. (26 refs.)

Aims: The prediction of individuals' use of medical services and associated costs is crucial for medical systems. We modeled a risk assessment equation that included patient sociodemographic characteristics and health risk behaviors (obesity, smoking, and alcohol abuse) to strengthen the power of self-reported health status to predict healthcare resource use. We also sought to uncover gender-specific differences in the predictive value of the models. Methods: Before their first primary care visit, 509 new patients were interviewed. Data collected included sociodemographics, self-reported health status Medical Outcomes Study Short-Form (MOS SF-36), body mass index (BMI), and screening for alcoholism and smoking. Subsequent use of healthcare services for 1 year was determined by reviewing medical and billing records. Results: Generalized linear models and two-part regressions were estimated relating the five types of charges (plus total charges) to self-reported physical health status, controlling for gender, age, education, income, obesity, smoking, alcohol abuse, and mental health status. Lower physical health status was associated with higher charges for primary care (p 0.0022), specialty care (p = 0.0141), diagnostic services (p < 0.0001), hospitalizations (p = 0.0069), and total charges (p < 0.0001). For female patients, the regression equation predicted 14% of the variation in total medical charges compared with 28% for males. Female patients had higher charges for primary care (p = 0.0019), diagnostic services (p = 0.0005), and total charges (p = 0.0180). Conclusions: Health status and patient gender were significant predictors of healthcare use and charges. The R-2 of total charges was two times higher for men vs. women. This research has policy implications for healthcare organizations in predicting the usage patterns.

Brown CH; Bennett ME; Li L; Bellack AS. Predictors of initiation and engagement in substance abuse treatment among individuals with co-occurring serious mental illness and substance use disorders. Addictive Behaviors 36(5): 439-447, 2011. (68 refs.)

Research has documented the significant challenges of engaging individuals with comorbid serious mental illness (SMI) and substance use disorders (SUDS) in substance abuse treatment. To date it is unclear which factors predict treatment initiation and engagement in this group of individuals with SUDs. In this study we conducted two analyses using data from a randomized trial of substance abuse treatment in outpatients with SMI: the first examining predictors (collected during screening) of completing an initial intake assessment and the second examining predictors (collected during the intake assessment) of becoming engaged in treatment. Results indicated that males and those with schizophrenia spectrum diagnoses were less likely to complete the intake assessment. Participants who reported more positive feelings about their family were more likely to engage in substance abuse treatment. Participants who were recently arrested were less likely to engage in treatment. Those who met criteria for current drug dependence were less likely to engage in treatment. Overall, these findings are a useful step in determining factors that predict substance abuse treatment initiation and engagement in individuals with SMI and SUDs.

Burns L; Conroy E; Mattick RP. Main reasons for hospital admissions by women with a history of methadone maintenance. Drug and Alcohol Review 29(6): 669-675, 2010. (33 refs.)

Introduction and Aims. Although clinical studies have noted that women with opioid use disorders use have high levels of mental and physical health disorders and are exposed to high levels of violence, it is not known whether this occurs at a level of severity that warrants hospital admission. Design and Methods. Administrative data from a jurisdictional methadone program were linked with hospital inpatient records from 1998 to 2002 to determine the main reasons for hospital admission for a cohort of women with a prior or ongoing history of methadone maintenance. Rates of hospital admissions by the cohort were compared with hospitalisations by all women without an opioid-related hospital diagnosis from 1998 to 2002. Results. After controlling for age, country of birth and marital status, women with a history of methadone maintenance had more frequent hospital admissions for the mental and behavioural disorders [relative risk (RR) 3.9 (95% confidence intervals (CI): 3.7, 4.0)], diseases of the skin and subcutaneous tissue [RR 2.1 (95% CI: 1.9, 2.3)]; injuries and poisonings [RR 2.0 (95% CI: 1.9, 2.1)] and infectious and parasitic diseases [RR 1.4 (95% CI: 1.2, 1.6)]. At a more detailed level of diagnostic specificity, the methadone cohort was admitted more often for hepatitis C, septicaemia and head injuries. Discussion and Conclusion. The elevated risk of hospital admission for a number of disorders suggests that women with a history of methadone maintenance experience these health events at a level of severity warranting hospital admission. Further contextual work is necessary to determine the effective preventive and management strategies.

Carlson RG; Sexton R; Wang JC; Falck R; Leukefeld CG; Booth BM. Predictors of substance abuse treatment entry among rural illicit stimulant users in Ohio, Arkansas, and Kentucky. Substance Abuse 31(1): 1-7, 2010. (23 refs.)

Illicit drug use in the rural United States is increasingly common, yet little is known about drug users' treatment-seeking behaviors. This study identifies predictors of substance abuse treatment entry over 24 months among 710 illicit stimulant users in rural areas of Ohio, Arkansas, and Kentucky. Active users of powdered cocaine, crack cocaine, and/or methamphetamine (MA) were recruited using respondent-driven sampling. Participants completed structured interviews at baseline and follow-up questionnaires every 6 months for 24 months. Data were analyzed using the Cox proportional hazards model. The paper is informed by the Anderson-Newman Model. Overall, 18.7% of the sample entered treatment. Ohio or Kentucky residence, perceived need for substance abuse treatment, higher Addiction Severity Index (ASI) legal problem composite scores, prior substance abuse treatment, and tranquilizer use were positively associated with treatment entry. Nondaily crack cocaine users and marijuana users were less likely to enter treatment. The findings can help inform rural substance abuse treatment program development and outreach.

Chartier KG; Caetano R. Trends in alcohol services utilization from 1991-1992 to 2001-2002: Ethnic group differences in the U.S. population. Alcoholism: Clinical and Experimental Research 35(8): 1485-1497, 2011. (43 refs.)

Background: During the early 1990s in the United States, changes to the provision and financing of alcohol treatment services included reductions in inpatient treatment services and in private sector spending for treatment. We investigated trends in alcohol services utilization over the 10-year period from 1991-1992 to 2001-2002 among U.S. whites, blacks, and Hispanics. Methods: Data come from 2 household surveys of the U.S. adult population. The 1991 to 1992 National Longitudinal Alcohol Epidemiologic Survey and the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions conducted face-to-face interviews with a multistage cluster sample of individuals 18 years of age and older in the continental United States. Treatment utilization represented both total utilization and the use of alcohol services. Data analyses were prevalence rates and multivariate logistic regressions for lifetime utilization with drinkers and individuals with alcohol use disorders (AUDs). Results: From 1991-1992 to 2001-2002, drinking-related emergency room and human services use increased for drinkers, while total utilization and the use of private health professional services and mutual aid decreased for individuals with AUDs. In drinkers and individuals with AUDs, blacks and Hispanics were less likely than whites to use private health professional care. Hispanics with AUDs were less likely than whites with AUDs to use alcohol or drug programs. Ethnicity interacted with alcohol severity to predict alcohol services utilization. At higher levels of alcohol severity, blacks and Hispanics were less likely than whites to ever use treatment and to use alcohol services (i.e., human services for Hispanic drinkers, mental health services for blacks with AUDs, and mutual aid for Hispanics with AUDs). Conclusions: Our findings showed increases from 1991-1992 to 2001-2002 in alcohol services utilization for drinkers, but reductions in utilization for individuals with AUDs. Blacks and Hispanics, particularly those at higher levels of alcohol severity, underutilized treatment services compared to whites. These utilization trends for blacks and Hispanics may reflect underlying disparities in healthcare access for minority groups, and language and logistical barriers to utilizing services.

Che YH; Assanangkornchai S; McNeil E; Li JH; You J; Chongsuvivatwong V. Patterns of attendance in methadone maintenance treatment program in Yunnan Province, China. American Journal of Drug and Alcohol Abuse 37(3): 148-154, 2011. (28 refs.)

Objective: To describe the patterns of patients' attendance over the first three quarters of a year under methadone maintenance treatment (MMT) clinics in Yunnan Province, China. Methods: Data were obtained from drug abuse treatment databases from five MMT clinics in Yunnan Province. Patients registered between April 2007 and December 2007 were included in the analysis. The study period was divided into three phases consisting of 3 months each. Logistic regression was used to predict factors determining whether the patients attended the clinic on each day with repetition of the patients taken into account. Results: The median number of days attending the clinics was 61 in the total treatment period, and the likelihood of a patient attending the clinic in the second and third phases was significantly less [odds ratio (OR) = .44 and .30, 95% confidence interval (CI) = .40-.49 and .26-.34] compared with the first phase. The predictors for attendance at clinic were being unmarried (OR = .63, 95% CI = .49-.82), self-employed (OR = .18, 95% CI = .11-.28), having a history of syringe sharing (OR = .67, 95% CI = .48-.92), and having been in a detoxification program (OR = 1.59, 95% CI = 1.09-2.33). Conclusion: Heroin users attended MMT programs irregularly and their periods of attendance significantly declined by duration of the time they stayed in the treatment program. Additional interventions should be employed to help patients adhere to this long-term treatment program.

Chew RB; Bryson CL; Au DH; Maciejewski ML; Bradley KA. Are smoking and alcohol misuse associated with subsequent hospitalizations for ambulatory care sensitive conditions? Journal of Behavioral Health Services & Research 38(1): 3-15, 2011. (55 refs.)

Hospitalizations for ambulatory care sensitive conditions (ACSCs) are used to assess quality of care, but studies rarely adjust for health behaviors. This study evaluated whether results of smoking or alcohol screening were associated with hospitalizations for ACSCs. Participants: included 33,273 male Veterans Affairs general medicine outpatients who returned mailed surveys. The main outcome was hospitalization with a primary discharge diagnosis for an ACSC in the year following screening. Analyses were adjusted for demographics, comorbidity, and other health behaviors. Current and previous smoking and abstaining from alcohol were associated with significantly increased risk of hospitalization for ACSCs, but alcohol misuse was not. However, severe alcohol misuse was associated with increased risk of hospitalizations with a primary or secondary ACSC discharge diagnosis. When ACSCs are used to evaluate the quality of care, health systems caring for populations with higher rates of smoking or nondrinking could falsely appear to have poorer quality care if alcohol and tobacco use are not considered.

Clinton-Sherrod AM; Barrick K; Gibbs DA. Soldier characteristics, alcohol abuse risk, and mental health risk as treatment predictors. Military Psychology 23(1): 22-35, 2011. (42 refs.)

Combat exposure and other factors associated with military service may place soldiers at increased risk of substance use and mental health issues. We examine the importance of soldier characteristics and risk for alcohol abuse and mental health issues in predicting entry into treatment for alcohol abuse and treatment for mental health issues among active duty soldiers (n = 43,342). Results indicated that soldiers were more likely to be referred for mental health issues than alcohol abuse issues and that marital status, race/ethnicity, and pay grade were predictive of the likelihood of entering treatment. We discuss the implications of our findings with regard to the referral and treatment of alcohol abuse and mental health issues within the military environment.

Comhair SAA; Gaston BM; Ricci KS; Hammel J; Dweik RA; Teague WG et al. Detrimental effects of environmental tobacco smoke in relation to asthma severity. PLoS ONE 6(5), 2011. (64 refs.)

Background: Environmental tobacco smoke (ETS) has adverse effects on the health of asthmatics, however the harmful consequences of ETS in relation to asthma severity are unknown. Methods: In a multicenter study of severe asthma, we assessed the impact of ETS exposure on morbidity, health care utilization and lung functions; and activity of systemic superoxide dismutase (SOD), a potential oxidative target of ETS that is negatively associated with asthma severity. Findings: From 2002-2006, 654 asthmatics (non-severe 366, severe 288) were enrolled, among whom 109 non-severe and 67 severe asthmatics were routinely exposed to ETS as ascertained by history and validated by urine cotinine levels. ETS-exposure was associated with lower quality of life scores; greater rescue inhaler use; lower lung function; greater bronchodilator responsiveness; and greater risk for emergency room visits, hospitalization and intensive care unit admission. ETS-exposure was associated with lower levels of serum SOD activity, particularly in asthmatic women of African heritage. Interpretation: ETS-exposure of asthmatic individuals is associated with worse lung function, higher acuity of exacerbations, more health care utilization, and greater bronchial hyperreactivity. The association of diminished systemic SOD activity to ETS exposure provides for the first time a specific oxidant mechanism by which ETS may adversely affect patients with asthma.

Cunningham CO; Sohler NL; Cooperman NA; Berg KM; Litwin AH; Arnsten JH. Strategies to improve access to and utilization of health care services and adherence to antiretroviral therapy among HIV-Infected drug users. Substance Use & Misuse 46(2-3): 218-232, 2011. (112 refs.)

We review five innovative strategies to improve access, utilization, and adherence for HIV-infected drug users and suggest areas that need further attention. In addition, we highlight two innovative programs. The first increases access and utilization through integrated HIV and opioid addiction treatment with buprenorphine in a community health center, and the second incorporates adherence counseling for antiretroviral therapy in methadone programs. Preliminary evaluations demonstrated that these strategies may improve both HIV and opioid addiction outcomes and may be appropriate for wider dissemination. Further refinement and expansion of strategies to improve outcomes of HIV-infected drug users is warranted.

de Wit M; Zilberberg MD; Boehmler JM; Bearman GM; Edmond MB. Outcomes of patients with alcohol use disorders experiencing healthcare-associated infections. Alcoholism: Clinical and Experimental Research 35(7): 1368-1373, 2011. (48 refs.)

Background: Healthcare-associated infections (HAI) affect 1.7 million patients annually in the United States, and patients with alcohol use disorders (AUD) are at increased risk of developing HAI. HAI have been shown to substantially increase the hospital length of stay, mortality, and cost. In a cohort of patients with HAI, we sought to determine mortality, cost, and hospital length of stay attributable to AUD. Methods: Using the Nationwide Inpatient Sample for the year 2007, the largest all-payer database of hospitalized patients comprising approximately 1,000 hospitals, we performed a retrospective cohort study of all patients who developed healthcare-associated pneumonia or sepsis. We excluded patients who were transferred from another healthcare facility, who were diagnosed with community-acquired infections, immunosuppression, or cancer. Logistic regression was computed to calculate attributable mortality. Linear regression analyses were computed to determine cost and hospital length of stay alpha - 10(-10). Results: A total of 149,892 patients developed HAI, and 8,830 (5.9%) had a codiagnosis of AUD. Patients with AUD were younger, more likely to be men, less likely to be Asian, and more likely to be Hispanic. Patients with AUD were more likely to have tobacco dependence, less likely to be electively admitted to the hospital, and less likely to undergo surgery. They also had lower severity of illness, lower income, and were more likely to be in academic medical centers. Logistic regression revealed that AUD was an independent predictor of increased mortality: Odds ratio = 1.71, 95% confidence interval (CI) [1.626; 1.799], p < 10(-10). Linear regression demonstrated that AUD independently predicted increased hospital length of stay by 2 days: Patients with AUD had a length of stay of 13 days, 95% CI [12.4; 13.6] compared with 11 days, 95% CI [11.1; 11.4] for patients without AUD, p < 10(-10). Linear regression also revealed that patients with AUD had a higher hospital cost: $ 34,826, 95% CI [32,415.71; 37,416.52] for patients with AUD compared with $ 27,167, 95% CI [25,703.18; 28,714.05] for patients without AUD, p < 10(-10). Conclusions: Patients with AUD who experience HAI have worse outcomes compared with patients without AUD. Patients with AUD have higher mortality, longer hospital length of stay, and higher costs. Studies aimed at decreasing the morbidity and mortality of HAI in patients with AUD are warranted.

Deering KN; Kerr T; Tyndall MW; Montaner JSG; Gibson K; Irons L et al. A peer-led mobile outreach program and increased utilization of detoxification and residential drug treatment among female sex workers who use drugs in a Canadian setting. Drug and Alcohol Dependence 113(1): 46-54, 2011. (70 refs.)

Background: The objectives of this study were to examine the determinants of using a peer-led mobile outreach program (the Mobile Access Project [MAP]) among a sample of street-based female sex workers (FSWs) who use drugs in an urban Canadian setting and evaluate the relationship between program exposure and utilizing addiction treatment services. Methods: A detailed questionnaire was administered at baseline and bi-annual follow-up visits over 18 months (2006-2008) to 242 FSWs in Vancouver, Canada. We used bivariate and multivariate logistic regression with generalized estimating equations for both objectives, reporting unadjusted and adjusted odds ratios (AOR) with 95% confidence intervals (CIs). Results: Over 18 months, 42.2% (202) reports of peer-led mobile outreach program use were made. High-risk women, including those servicing a higher weekly client volume (10+ compared to <10; AOR: 1.7, 95%CIs: 1.1-2.6) and those soliciting clients in deserted, isolated settings (AOR: 1.7, 95%CIs: 1.1-2.7) were more likely to use the program. In total, 9.4% (45) reports of using inpatient addiction treatment services were made (7.5% detoxification; 4.0% residential drug treatment), and 33.6% (161) using outpatient treatment (28.8% methadone; 9.6% alcohol/drug counsellor). Women who used the peer-led mobile outreach were more likely to use inpatient addiction treatment (AOR: 4.2, 95%CIs: 2.1-8.1), even after adjusting for drug use, environmental-structural factors, and outpatient drug treatment. Discussion: Our findings demonstrate that FSWs at higher risk for sexually transmitted infections and violence are more likely to access this peer-led mobile outreach program and suggest that the program plays a critical role in facilitating utilization of detoxification and residential drug treatment.

Delucchi KL; Kaskutas LA. Following problem drinkers over eleven years: Understanding changes in alcohol consumption. Journal of Studies on Alcohol and Drugs 71(6): 831-836, 2010. (26 refs.)

Objective: Much of what we know about the course of alcohol consumption in problem and dependent drinkers comes from studies of in-treatment populations. Less is known about the natural course of alcohol consumption among such drinkers in the general population and what predicts how much they drink. Method: This study examined alcohol consumption over the course of 11 years in a randomly selected sample of 672 problem and dependent drinkers from a single, heterogeneous U.S. county. Results: Alcohol consumption declined and leveled off over time but did not decrease to the average general U.S. population level. Several indicators of ongoing problems with drinking are associated with high levels of drinking over time: having a heavy-drinking network, receiving suggestions to do something about one's drinking, and going to treatment. Factors associated with less drinking include having contact with community agencies and going to Alcoholics Anonymous (AA). Conclusions: Results suggest that problem and dependent drinkers continue to drink at an elevated level over the course of years. Gatekeepers, family members, and policymakers should encourage and facilitate contact with social service agencies and with AA for problem drinkers. Suggestions from others to do something about one's drinking and seeking specialty care occur more often in those with more severe problems and do not appear to be linked to less drinking over time.

Ding K; Yang JZ; Cheng G; Schiltz T; Summers KM; Skinstad AH. Hospitalizations and hospital charges for co-occurring substance use and mental disorders. Journal of Substance Abuse Treatment 40(4): 366- 375, 2011. (33 refs.)

Most published studies have examined co-occurring disorders among mental health patients. Our objective was to compare the length of stay and hospital charges between hospitalized patients with alcohol- or substance-related disorders with and without co-occurring disorders. We analyzed nationally representative hospital discharge data (Nationwide Inpatient Sample, 2003-2007) and examined factors associated with length of stay and hospital charges. Forty-four percent of patients who were hospitalized with alcohol- or substance-related disorders were diagnosed with co-occurring mental disorders, representing 979,421 such disorders nationwide between 2003 and 2007. Females, those of White race, those who paid with insurance, and those who stayed in large, rural, nonteaching, and Midwest region hospitals had a high prevalence of co-occurring disorders. Co-occurring disorders were associated with longer hospital stays, but there were mixed results with hospital charges per discharge. An increase in co-occurring disorders among hospitalized patients with substance-related disorder may be due to the improvement in diagnosis and clinical attention.

Drake RE; Caton CLM; Xie HY; Hsu E; Gorroochurn P; Samet S et al. A prospective 2-year study of emergency department patients with early-phase primary psychosis or substance-induced psychosis. American Journal of Psychiatry 168(7): 742-748, 2011. (32 refs.)

Objective: The authors examined treatment utilization and outcomes over 2 years among patients admitted to emergency departments with early-phase primary or substance-induced psychosis. The main hypothesis was that patients with substance-induced psychosis would have a more benign course of illness than those with primary psychosis. Method: Using a prospective naturalistic cohort study design, the authors compared 217 patients with early-phase primary psychosis plus substance use and 134 patients with early-phase substance-induced psychosis who presented to psychiatric emergency departments at hospitals in Upper Manhattan. Assessments at baseline and at 6, 12, 18, and 24 months included psychiatric diagnoses, service use, and institutional outcomes using the Psychiatric Research Interview for Substance and Mental Disorders; psychiatric symptoms using the Positive and Negative Syndrome Scale; social, vocational, and family functioning using the World Health Organization Psychiatric Disability Assessment Schedule; and life satisfaction using the Quality of Life Interview. Longitudinal analyses were conducted using generalized estimating equations. Results: Participants with primary psychosis were more likely to receive antipsychotic and mood-stabilizing medications, undergo hospitalizations, and have outpatient psychiatric visits; those with substance-induced psychosis were more likely to receive addiction treatments. Only a minority of each group received minimally adequate treatments. Both groups improved significantly over time on substance dependence, psychotic symptoms, homelessness, and psychosocial outcomes, and few group-by-time interactions emerged. Conclusions: Patients presenting to Upper Manhattan emergency departments with either early-phase primary psychosis or substance-induced psychosis improved steadily over 2 years despite minimal use of mental health and substance abuse services.

El-Bassel N; Terlikbaeva A; Pinkham S. HIV and women who use drugs: Double neglect, double risk. (editorial). Lancet 376(9738): 312-314, 2010. (11 refs.)

Farrelly MC; Davis KC; Nonnemaker JM; Kamyab K; Jackson C. Promoting calls to a quitline: Quantifying the influence of message theme, strong negative emotions and graphic images in television advertisements. Tobacco Control 20(4): 279-284, 2011. (28 refs.)

Objective. To understand the relative effectiveness of television advertisements that differ in their thematic focus and portrayals of negative emotions and/or graphic images in promoting calls to a smokers' quitline. Methods. Regression analysis is used to explain variation in quarterly media market-level per smoker calls to the New York State Smokers' Quitline from 2001 to 2009. The primary independent variable is quarterly market-level delivery of television advertisements measured by target audience rating points (TARPs). Advertisements were characterised by their overall objective-promoting cessation, highlighting the dangers of secondhand smoke (SHS) or other-and by their portrayals of strong negative emotions and graphic images. Results. Per smoker call volume is positively correlated with total TARPs (p<0.001), and cessation advertisements are more effective than SHS advertisements in promoting quitline call volume. Advertisements with graphic images only or neither strong negative emotions nor graphic images are associated with higher call volume with similar effect sizes. Call volume was not significantly associated with the number of TARPs for advertisements with strong negative emotions only (p=0.71) or with both graphic images and strong emotions (p=0.09). Conclusions. Exposure to television advertisements is strongly associated with quitline call volume, and both cessation and SHS advertisements can be effective. The use of strong negative emotions in advertisements may be effective in promoting smoking cessation in the population but does not appear to influence quitline call volume. Further research is needed to understand the role of negative emotions in promoting calls to quitlines and cessation more broadly among the majority of smokers who do not call quitlines.

Fleury MJ; Grenier G; Bamvita JM; Perreault M; Jean-Caron. Typology of adults diagnosed with mental disorders based on socio-demographics and clinical and service use characteristics. BMC Psychiatry 11: e-article 67, 2011. (78 refs.)

Background: Mental disorder is a leading cause of morbidity worldwide. Its cost and negative impact on productivity are substantial. Consequently, improving mental health-care system efficiency -especially service utilisation - is a priority. Few studies have explored the use of services by specific subgroups of persons with mental disorder; a better understanding of these individuals is key to improving service planning. This study develops a typology of individuals, diagnosed with mental disorder in a 12-month period, based on their individual characteristics and use of services within a Canadian urban catchment area of 258,000 persons served by a psychiatric hospital. Methods: From among the 2,443 people who took part in the survey, 406 (17%) experienced at least one episode of mental disorder (as per the Composite International Diagnostic Interview (CIDI)) in the 12 months pre-interview. These individuals were selected for cluster analysis. Results: Analysis yielded four user clusters: people who experienced mainly anxiety disorder; depressive disorder; alcohol and/or drug disorder; and multiple mental and dependence disorder. Two clusters were more closely associated with females and anxiety or depressive disorders. In the two other clusters, males were over-represented compared with the sample as a whole, namely, substance abuses with or without concomitant mental disorder. Clusters with the greatest number of mental disorders per subject used a greater number of mental health-care services. Conversely, clusters associated exclusively with dependence disorders used few services. Conclusion: The study found considerable heterogeneity among socio-demographic characteristics, number of disorders, and number of health-care services used by individuals with mental or dependence disorders. Cluster analysis revealed important differences in service use with regard to gender and age. It reinforces the relevance of developing targeted programs for subgroups of individuals with mental and/or dependence disorders. Strategies aimed at changing low service users' attitude (youths and males) or instituting specialised programs for that particular clientele should be promoted. Finally, as concomitant disorders are frequent among individuals with mental disorder, psychological services and/or addiction programs must be prioritised as components of integrated services when planning treatment.

French MT; Fang H; Balsa AI. Longitudinal analysis of changes in illicit drug use and health services utilization. Health Services Research 46(3): 877- 899, 2011. (44 refs.)

Objective: To analyze the relationships between illicit drug use and three types of health services utilization: emergency room utilization, hospitalization, and medical attention required due to injury(s). Data: Waves 1 and 2 (11,253 males and 13,059 females) from the National Epidemiology Survey on Alcohol and Related Conditions (NESARC). Study Design: We derive benchmark estimates by employing standard cross-sectional data models to pooled waves of NESARC data. To control for potential bias due to time-invariant unobserved individual heterogeneity, we reestimate the relationships with fixed-effects models. Principal Findings: The cross-sectional data models suggest that illicit drug use is positively and significantly related to health services utilization in almost all specifications. Conversely, the only significant (p <.05) relationships in the fixed-effects models are the odds of receiving medical attention for an injury and the number of injuries requiring medical attention for men, and the number of times hospitalized for men and women. Conclusions: Failing to control for time-invariant individual heterogeneity could lead to biased coefficients when estimating the effects of illicit drug use on health services utilization. Moreover, it is important to distinguish between types of drug user (casual versus heavy) and estimate gender-specific models.

Fussell HE; Rieckmann TR; Quick MB. Medicaid reimbursement for screening and brief intervention for substance misuse. Psychiatric Services 62(3): 306- 309, 2011. (7 refs.)

Objectives: Effective January 2008, state Medicaid plans may reimburse for screening and brief intervention for alcohol and drug misuse. This study assessed state Medicaid activity to implement Healthcare Common Procedure Code System codes and pay for screening and brief intervention. Methods: State and District of Columbia Medicaid representatives (N=44) participated in semistructured telephone interviews (N=37) or provided e-mail correspondence (N=7) about implementation of reimbursement codes. Confirmatory Web searches of Medicaid fee schedules supplemented findings and provided information for the remaining seven states. Results: More than half the states (N=28) list designated screening and brief intervention codes in their state Medicaid fee schedules; 19 of those states are capable of reimbursing for the codes. Qualitative analysis examined the challenges in choosing codes, assigning reimbursement rates, and working within constrained Medicaid budgets. Conclusions: Implementation of billing codes appears to be an insufficient policy mechanism to promote utilization of screening and brief intervention for treating substance use.

Gibson JE; Murray RL; Borland R; Cummings KM; Fong GT; Hammond D; McNeill A. The impact of the United Kingdom's national smoking cessation strategy on quit attempts and use of cessation services: Findings from the International Tobacco Control Four Country Survey. Nicotine & Tobacco Research 12(Supplement 1): s64-s71, 2010. (19 refs.)

The World Health Organization Framework Convention on Tobacco Control recommends that provision of cessation support should be included in national tobacco control strategies. This study examines the impact of the United Kingdom's national smoking cessation strategy on quit attempts, use of treatment and short-term abstinence, relative to the United States, Canada, and Australia where less support is provided. Data on quitting behavior and use of support were obtained for all smokers enrolled in the International Tobacco Control 4 Country Survey between 2002 and 2005. Generalized estimating equations were used to calculate the relative odds (adjusted by age, sex, and Heaviness of Smoking Index) that smokers in each country made quit attempts, used behavioral or pharmacological support, and to compare rates of short-term (28 days) abstinence between countries and users of different forms of support. U.K. smokers were less likely to have attempted to quit smoking than those in Australia (odds ratio [OR] = 1.25, 95% CI: 1.12-1.40), Canada (OR = 1.50, 95% CI: 1.34-1.67), and the United States (OR = 1.25, 95% CI: 1.11-1.40) but were more likely to use pharmacotherapy and/or support from a clinic, helpline, or health professional when attempting to quit than smokers in the other countries. U.K. smokers making quit attempts were significantly more likely to achieve 28-day abstinence than those in Australia (OR = 0.59, 95% CI: 0.49-0.71), Canada (OR = 0.72, 95% CI: 0.61-0.87), and the United States (OR = 0.51, 95% CI: 0.42-0.62). U.K. smokers report fewer quit attempts but are more likely to use support when quitting and to achieve short-term abstinence.

Glass JE; Bucholz KK. Concordance between self-reports and archival records of physician visits: A case-control study comparing individuals with and without alcohol use disorders in the community. Drug and Alcohol Dependence 116(1-3): 57-63, 2011. (24 refs.)

Objective: The accuracy of self-reported healthcare use among individuals with alcohol use disorders (AUD) has been questioned. The present study attempts to compare the accuracy of self-reported physician visits for individuals who differ with respect to their history of AUDs. Methods: Our data source was a 14-year follow-up of individuals interviewed at the St. Louis site of the 1981-1983 Epidemiologic Catchment Area Study (ECA). We used a case-control design (n = 237) to compare the accuracy of self-reports among ECA participants with stably diagnosed AUDs (cases; n = 75) to two comparison groups: those with problem/very heavy drinking (n = 81) and those unaffected by alcohol (n = 81). Intraclass correlation coefficients (ICC) described the concordance between self-reports and archival records of physician visits in the prior six months. We used multinomial logistic regression to identify characteristics associated with under-reporting and over-reporting, and zero-truncated Poisson regression to identify characteristics associated with discordance severity. Results: Self-reports of cases had substantial concordance with physician records (ICC = 0.74, Cl = 0.61-0.83). As compared to cases, those with problem/very heavy drinking had a significantly higher ICC, and those who were unaffected by alcohol had a significantly lower ICC. However, differences in concordance disappeared when using regression models that adjusted for factors known to affect the accuracy of self-reported healthcare use. Utilization frequency was a strong predictor of inaccurate reporting. Conclusions: These findings suggest AUD status may not independently affect the accuracy of self-reports. Counts of physician visits for those with AUD may be considered accurate when utilization frequency is low.

Goebert D; Nishimura S. Comparison of substance abuse treatment utilization and preferences among Native Hawaiians, Asian Americans and Euro Americans. Journal of Substance Use 16(2): 161-170, 2011. (49 refs.)

Use and preferences for substance abuse treatment can vary by ethnicity. However, little is known about use and preferences among Native Hawaiians and Asian Americans. Interviews from 192 admitted multi-ethnic residents from two treatment facilities in Hawaii were conducted. More similarities than differences were found. The most utilized treatments were Alcoholics Anonymous and the emergency department, with no significant ethnic differences. However, Native Hawaiians and Asian Americans were significantly less likely to have spoken to a mental health provider about alcohol problems (32%%, 39%%, respectively vs. 69%% of Euro Americans) and to have seen a physician for a drinking-related problem (21%% of Native Hawaiians and 19%% of Asian Americans vs. 41%% of Euro Americans). Native Hawaiians were significantly more likely to consider marriage counselling to be an effective form of treatment (33%% vs. 11%% of Asian Americans and 9%% of Euro Americans). Implications for substance abuse treatment are discussed. The findings suggest that it is important to integrate the field of substance abuse in multiple systems; including substance abuse, medical, criminal, social service and community settings to ensure treatment preferences are met. Ethnic differences may also have implications for expanding and tailoring services.

Hauri DD; Lieb CM; Rajkumar S; Kooijman C; Sommer HL; Roosli M. Direct health costs of environmental tobacco smoke exposure and indirect health benefits due to smoking ban introduction. European Journal of Public Health 21(3): 316-322, 2011. (38 refs.)

Background: Introducing comprehensive smoke-free policies to public places is expected to reduce health costs. This includes prevented health damages by avoiding environmental tobacco smoke (ETS) exposure as well as indirect health benefits from reduced tobacco consumption. Methods: The aim of this study was to estimate direct health costs of ETS exposure in public places and indirect health benefits from reduced tobacco consumption. We calculated attributable hospital days and years of life lost (YLL), based on the observed passive smoking and disease rates in Switzerland. The exposure-response associations of all relevant health outcomes were derived by meta-analysis from prospective cohort studies in order to calculate the direct health costs. To assess the indirect health benefits, a meta-analysis of smoking ban studies on hospital admissions for acute myocardial infarction was conducted. Results: ETS exposure in public places in Switzerland causes 32 000 preventable hospital days (95% CI: 10 000-61 000), 3000 YLL (95% CI: 1000-5000), corresponding to health costs of 330 Mio CHF. The number of hospital days for ischaemic heart disease attributable to passive smoking is much larger if derived from smoking ban studies (41 000) than from prospective cohort studies (3200), resulting in additional health costs of 89 Mio CHF, which are attributed to the indirect health benefits of a smoking ban introduction. Conclusion: The example of smoking ban studies on ischaemic heart disease hospitalization rates suggests that total health costs that can be prevented with smoking bans are considerably larger than the costs arising from the direct health impact of ETS exposure in public places.

Herttua K; Makela P; Martikainen P. The effects of a large reduction in alcohol prices on hospitalizations related to alcohol: A population-based natural experiment. Addiction 106(4): 759-767, 2011. (50 refs.)

Aims: Finland experienced a large reduction in alcohol prices in 2004 due to in the lowering of alcohol taxes by about one-third and the abolition of duty-free allowances for travellers from the European Union. We examined the effects of these changes on alcohol-related hospitalizations. Design and participants: Time-series intervention analyses of monthly aggregations of hospitalization for acute and chronic causes among men and women aged 15-39, 40-49, 50-69 and more than 69 years. Setting: Finland, 1996-2006. Findings: After the price reduction the chronic hospitalization rate for men increased among those below age 70 years. It was largest among those aged 50-69 years: 22%, which implies an increase of 18.0 monthly hospitalizations per 100 000 person-years, and there was an 11% and 16% (11.5 and 4.8 monthly hospitalizations) increase among those aged 40-49 and 15-39, respectively. Among the women the rate increased by 23% (4.0 monthly hospitalizations) in the 50-69-year-olds, and decreased in the under-40s. The increase in all the population groups was due mainly to an increase in mental and behavioural disorders due to alcohol. Acute hospitalizations increased by 17% and 20% (6.2 and 7.0 per month) among men aged 40-49 and 50-69 years, respectively, and by 38% among women aged 50-69 years (2.3 per month). Conclusions: The results, obtained in a natural experimental setting when trends and seasonal variation had been taken into account, suggest that the reduction in alcohol prices led to increases in alcohol-related hospitalization in certain population groups, mainly among 50-69-year-olds, in Finland.

Hickert AO; Taylor MJ. Supportive housing for addicted, incarcerated homeless adults. Journal of Social Service Research 37(2): 136-151, 2011. (38 refs.)

Homeless populations often suffer from mental illness, substance abuse, and criminality. Interventions, such as supportive housing, can have positive impacts, although benefits can be limited. This study examined outcomes for clients (N = 102) of a new supportive housing intervention. Use of formal treatment, jail contact, and community stability were compared pre- and post-housing. Jail bookings and residential substance abuse treatment significantly declined post-housing, while clients improved in income level, access to food, and housing stability. Results from official justice and treatment system data suggest that supportive housing can lead to significant changes. Future research is necessary to understand the relationship between client characteristics and outcomes.

Holmes WJM; Hold P; James MI. The increasing trend in alcohol-related burns: It's impact on a tertiary burn centre. Burns 36(6): 938-943, 2010. (32 refs.)

Introduction: The incidence of alcohol-related hospital admissions is a worldwide problem and currently costs the UK National Health Service approximately 4% of its annual budget. 40% of men and 22% of women drink over the recommended UK weekly allowance. The purpose of our study was to examine the trend in alcohol-related admissions to a tertiary burns unit over a 5-year period. Methodology: All patients admitted were documented for alcohol-related burn, and history of alcohol dependence. Results: 1293 patients admitted between 2003 and 2008 were included in the study. The number of alcohol-related burns were as follows: 2003: 6%; 2004: 10%; 2005: 16%; 2006: 9%; 2007: 19%; 2008: 19%. This increasing trend was highly significant (p < 0.0001). Alcohol-related burns had a higher incidence of flame injury (60%) and a subsequent longer length of stay (12.5 vs. 7.9, p = 0.04). Alcohol dependence was noted in 54% of all alcohol-related burns and in 5% of the non-alcohol-related burns. Discussion: The number of alcohol-related burns admitted to a tertiary burn unit is increasing and now comprises of nearly 20% of all admissions. This highlights the growing burden of alcohol on health and the need to address it at both a national and regional level.

Huebner RB; Kantor LW. Advances in alcoholism treatment. Alcohol Research & Health 33(4): 295-299, 2011. (7 refs.)

Researchers are working on numerous and varied approaches to improving the accessibility, quality, effectiveness, and cost-effectiveness of treatment for alcohol use disorders (AUDs). This overview article summarizes the approaches reviewed in this issue, including potential future developments for alcoholism treatment, such as medications development, behavioral therapy, advances in technology that are being used to improve treatment, integrated care of patients with AUDs and co-occurring disorders, the role of 12-step programs in the broader realm of treatment, treating patients with recurring and chronic alcohol dependence, strategies to close the gap between treatment need and treatment utilization, and how changes in the health care system may affect the delivery of treatment. This research will not only reveal new medications and behavioral therapies but also will contribute to new ways of approaching current treatment problems.

Hvidtfeldt UA; Rasmussen S; Gronbaek M; Becker U; Tolstrup JS. Influence of smoking and alcohol consumption on admissions and duration of hospitalization. European Journal of Public Health 20(4): 376-382, 2010. (39 refs.)

Background: Previous studies have linked smoking and alcohol consumption to a considerable disease burden and large healthcare expenditures. However, findings from studies based on individual level data are sparse and inconclusive. Our objective was to assess the association between alcohol consumption, smoking and patterns of hospitalization, defined as admission and duration of hospitalization. Methods: The study was based on 12 698 men and women, aged 20 years or more, enrolled in the Copenhagen City Heart Study. We related smoking and alcohol to hospital admission from any cause, smoking-and alcohol-related diseases and duration of hospitalization in a two-part random effects model. Results: Smoking status was strongly associated with admission and duration of hospitalization. For smoking-related admissions, odds ratios (OR) of 2.77 (95% CI 2.13-3.59) in men and 6.30 (95% CI 4.80-8.26) in women were observed among smokers of >20 g/day compared to never-smokers. For any admission (excl. smoking-related causes), corresponding ORs were 1.32 (95% CI 1.15-1.51) and 1.80 (95% CI 1.58-2.06), respectively. In men, a U-shaped association between alcohol consumption and risk of admission was found, both regarding any admission and admissions due to alcohol-related diseases. Alcohol was associated with alcohol-related admissions in women but not with duration of hospitalization. Conclusions: Smoking was associated with increased risk of hospital admission and duration of hospitalization. A U-shaped relation was observed for alcohol consumption and risk of hospitalization in men, but no effect on duration was observed. In women, however, alcohol consumption was only vaguely associated with admission and duration of hospitalization.

Ilgen MA; Price AM; Burnett-Zeigler I; Perron B; Islam K; Bohnert ASB et al. Longitudinal predictors of addictions treatment utilization in treatment-naive adults with alcohol use disorders. Drug and Alcohol Dependence 113(2-3): 215-221, 2011. (43 refs.)

Background: Despite the substantial prevalence of alcohol use disorders (AUDs), prior research indicates that most people with AUDs never utilize either formal or informal treatment services. Several prior studies have examined the characteristics of individuals with AUDs who receive treatment; however, limited longitudinal data are available on the predictors of receiving AUD services in treatment-naive individuals with AUDs. Methods: This study utilized data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) to identify adults in Wave 1 who met criteria for an AUD within the last 12 months and reported no prior lifetime alcohol treatment (N = 2760). These individuals were surveyed again at Wave 2, approximately 3-4 years later (N = 2170). This study examined the Wave 1 demographic and psychiatric conditions that were associated with receipt of AUD treatment services between Waves 1 and 2. Results: In multivariable analyses, use of AUD treatment services between Waves 1 and 2 was significantly more likely among those who were male, non-Caucasian, younger, had lower income, and who had health insurance. Additionally, those who met criteria for a baseline drug use disorder, anxiety disorder or a personality disorder were more likely to receive AUD treatment. Conclusions: Treatment was more often utilized in those who had more severe baseline psychopathology and in those with fewer economic resources. These findings highlight the need to broaden the types of care available to individuals with AUDs to increase the appeal of AUD services.

Ireys HT; Barrett AL; Buck JA; Croghan TW; Au M; Teich JL. Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 States, 2003. Psychiatric Services 61(9): 871-877, 2010. (15 refs.)

Objective: This study identified Medicaid beneficiaries using mental health or substance abuse services in fee-for-service plans in 13 states in 2003 (N=1,380,190) and examined their use of medical services. Methods: Administrative and fee-for-service claims data from Medicaid Analytic eXtract files were analyzed to identify mutually exclusive groups of beneficiaries who used either mental health or substance abuse services and to describe patterns of medical service use. Results: Overall, 11.7% of Medicaid beneficiaries were identified as using mental health or substance abuse services (10.9% and.7% used each of these services, respectively), with substantial variation across age and eligibility groups. Among beneficiaries using mental health services, 47.4% had visited an emergency room for any reason, 7.8% were treated for their disorder in inpatient settings, 13.8% received inpatient treatment for problems other than their mental or substance use disorders, and 70.4% received prescriptions for psychotropic medications. Among beneficiaries using substance abuse services, 60.7% had visited an emergency room, 12.6% were treated for their disorder in inpatient settings, 24.7% received other inpatient treatment, and 46.1% received prescriptions for psychotropic medications. Among beneficiaries not using either mental health or substance use services, 29.0% had visited an emergency room, 12.7% received inpatient treatment, and 10.1% received prescriptions for psychotropic medications. Conclusions: Beneficiaries who used mental health or substance abuse services entered general inpatient settings and visited emergency rooms more frequently than other beneficiaries.

Kenny P; Harney A; Lee NK; Pennay A. Treatment utilization and barriers to treatment: Results of a survey of dependent methamphetamine users. Substance Abuse, Treatment, Prevention and Policy 6: article 3, 2011. (23 refs.)

Background: Australia has one of the highest rates of methamphetamine use in the world; however, treatment access for methamphetamine is comparatively low. This descriptive study aimed to identify patterns of treatment utilization and perceived barriers to accessing treatment among dependent methamphetamine users in the hope that such information will enable services to more appropriately respond to this group. Methods: One hundred and twenty-six methamphetamine users who had a current or past history of methamphetamine dependence were interviewed about their experiences of, and perceived barriers to, treatment. Results: Treatment utilization among methamphetamine users was reportedly low. One of the main reasons cited for not accessing treatment was that methamphetamine users did not perceive their drug use to be a problem (despite apparent levels of dependence). Self-detoxification with the use of other licit and illicit drugs was high among this group. Participants identified a lack of confidence in the ability of treatment services to address methamphetamine dependence and the 'opiate-centric' nature of treatment services as significant blocks to treatment entry. Suggestions for improvement by participants included operating specialist services for methamphetamine users, placing an emphasis on responsiveness and routinely involving case management services for this group. Discussion and Conclusions: To improve service delivery, treatment services should reorient their services to better address the needs of methamphetamine users by making small changes such as specific opening times for methamphetamine users or using a dedicated space for methamphetamine treatment. Alternative options such as online treatments and specialist methamphetamine clinics should be considered for methamphetamine users.

Kerfoot KE; Petrakis IL; Rosenheck RA. Dual diagnosis in an aging population: Prevalence of psychiatric disorders, comorbid substance abuse, and mental health service utilization in the Department of Veterans Affairs. Journal of Dual Diagnosis 7(1-2): 4- 13, 2011. (16 refs.)

Objective: In the context of an aging baby boom cohort with higher rates of substance use disorders than previous cohorts, the abuse of substances and dual diagnosis represent growing areas of concern among older adults. The aims of this study were to determine the current treated prevalence of major psychiatric illnesses, substance use disorders, and dual diagnosis across multiple age groups in a national sample of mental health patients and to examine associated service utilization. Methods: Using administrative data from specialty mental health clinics in the Department of Veterans Affairs (N = 911,725), treated prevalence of major psychiatric illnesses, substance use disorders, and dual diagnosis across multiple age groups were determined over a 1-year interval (FY 2009). Associated mental health service utilization was examined. Results: Treated prevalence of almost all major psychiatric and substance use disorders decreased with age, while dementias increased with age. Across all major psychiatric illnesses, documented comorbid substance abuse decreased with age. Those with dual diagnoses had higher utilization of outpatient services compared to those without substance use disorders. With older age, patients had fewer outpatient visits and reduced likelihood of psychiatric hospitalization, but incurred more inpatient days per episode. Conclusions: Treated prevalence of substance use disorders and dual diagnosis decreases with age, falling to approximately 10% in those older than 65. Questions remain regarding the possibility of underdiagnosis of substance use disorders in the elderly.

Kuramoto SJ; Martins SS; Ko JY; Chilcoat HD. Past year treatment status and alcohol abuse symptoms among US adults with alcohol dependence. Addictive Behaviors 36(6, special issue): 648- 653, 2011. (25 refs.)

Objective: We tested whether the number and type of alcohol abuse symptoms were associated with an increased likelihood of treatment seeking among respondents with alcohol dependence. Methods: Data from 4027 adult respondents from 2006 and 2007 National Survey on Drug Use and Health (NSDUH) who met DSM-IV criteria for the past year alcohol dependence were used. Respondents were classified according to the number of past year alcohol abuse symptoms endorsed, as well as type of abuse symptom. Associations were estimated using weighted multivariate logistic regressions that controlled for severity of alcohol dependence, other drug use disorders and other characteristics. Results: Twenty-eight percent of individuals with alcohol dependence had one alcohol abuse symptom, 20% had two and 19% had three or four. Individuals with more alcohol abuse symptoms differed from those without alcohol abuse symptoms in a number of sociodemographic characteristics and severity of alcohol and drug dependence. Even after adjusting for these factors, individuals with three or four alcohol abuse symptoms had 2.67 times increased odds of treatment seeking, as compared to those without alcohol abuse symptoms [95% CI = 1.65-4.30] However, individuals with one or two alcohol abuse symptoms were no more likely to seek treatment than those without alcohol abuse symptoms. Majority of those with one or two alcohol abuse symptoms endorsed the hazardous abuse symptom. Conclusion: Alcohol abuse symptoms are important factors for treatment seeking in individuals with alcohol dependence, but only among certain subset of individuals with three or four alcohol abuse symptoms. Examining structural and psychosocial differences across these subgroups may help inform and reduce barriers to treatment seeking among this population.

Leider HL; Dhaliwal J; Davis EJ; Kulakodlu M; Buikema AR. Healthcare costs and nonadherence among chronic opioid users. American Journal of Managed Care 17(1): 32-40, 2011. (39 refs.)

Objectives: To assess the health economic burden of chronic opioid users and to determine whether opioid regimen nonadherence contributes to increased healthcare costs. Study Design: Retrospective claims-based analysis of patients with long-term prescription opioid use (>120 days of supply over 6 months). Methods: Twelve-month healthcare utilization and costs were compared for chronic opioid users (n = 49,425) and, among chronic opioid users with urine drug-monitoring results ( n = 2100), between adherent patients versus patients with evidence of nonadherence to their opioid regimen. Likely nonadherence was based on urine test results indicating absence of the prescribed drug, higher or lower than expected drug levels based on a proprietary algorithm, or presence of unprescribed or illegal drugs. The influence of nonadherence on total healthcare costs was assessed using multivariate models. Results: Prevalence of chronic opioid use was 1.3%. Chronic opioid users had significantly greater healthcare utilization and costs than matched nonusers ($23,049 vs $4975; P<.001). Adherent patients ( n = 442) had lower total healthcare costs than likely nonadherent patients ( n = 1658; $23,160 vs $26,433; P=.036). After adjustment for demographics, likely nonadherence was significantly associated with elevated total healthcare costs ( cost ratio [CR] 1.136;95% confidence interval [CI] 1.00, 1.29; P=.048). When adjusting for other types of nonadherence, the presence of higher than expected levels of the prescribed opioid was associated with significantly elevated costs ( CR 1.121; 95% CI 1.01, 1.25; P=.039). Conclusions: Chronic opioid users represent a substantial cost burden relative to similar patients without evidence of chronic pain. Among likely nonadherent chronic opioid users, those with evidence of opioid overuse had significantly elevated healthcare costs.

Levy DE; Rigotti NA; Winickoff JP. Medicaid expenditures for children living with smokers. BMC Health Services Research 11(e-article 125), 2011. (30 refs.)

Background: Children's exposure to secondhand smoke is associated with increased morbidity. We estimated Medicaid expenditures for children living with smokers compared to those living with no smokers in the United States. Methods: Data were overall and service-specific (i.e., inpatient, ambulatory, emergency department, prescription drug, and dental) annual Medicaid expenditures for children 0-11 years old from the 2000-2007 Medical Expenditures Panel Surveys. Smokers' presence in households was determined by adult respondents' self reports. There were 25,835 person-years of observation. We used multivariate analyses to adjust for child, parent, and geographic characteristics. Results: Children with Medicaid expenditures were nearly twice as likely to live with a smoker as other children in the U.S. population. Adjusted analyses revealed no detectable differences in children's overall Medicaid expenditures by presence of smokers in the household. Medicaid children who lived with smokers on average had $10 (95% CI $3, $18) higher emergency department expenditures per year than those living with no smokers. Conclusions: Living with at least one smoker (a proxy for secondhand smoke exposure) is unrelated to children's overall short-term Medicaid expenditures, but has a modest impact on emergency department expenditures. Additional research is necessary to understand the relationship between secondhand smoke exposure and long-term health and economic outcomes.

Liang W; Chikritzhs T; Pascal R; Binns CW. Mortality rate of alcoholic liver disease and risk of hospitalization for alcoholic liver cirrhosis, alcoholic hepatitis and alcoholic liver failure in Australia between 1993 and 2005. Internal Medicine Journal 41(1A): 34-41, 2011. (21 refs.)

Background: Alcoholic liver disease (ALD) is an important contributor to the total burden of alcohol-related harm; however, the morbidity of different types of ALD in Australia has not been described. The aim of this study was to investigate recent trends in hospital admission rates among alcoholic liver cirrhosis, alcoholic hepatic failure and alcoholic hepatitis in Australia, as well as the mortality of ALD. Method: This is a population-based cohort study including the total 15+ years Australian population. Data were obtained from the Australian Bureau of Statistics and the Australian Institute of Health and Welfare. Main outcome measures: (i) trend of standardized mortality rates and trend of standardized hospital admission rates for males and females for 1993/1994-2004/2005 (fiscal year), (ii) relative risk of alcoholic liver cirrhosis, alcoholic hepatic failure and alcoholic hepatitis hospital admissions for 1999/2000-2004/2005. Results: The mortality rate of ALD decreased significantly. Significant increases in hospital admissions for alcoholic hepatic failure among older adults and alcoholic hepatitis among younger age groups were observed. There is a significant 10-fold increase in the risk of hospital admissions of alcoholic cirrhosis in 2002/2003 for the 20-29 years population. Conclusion: Reductions in overall ALD mortality observed are likely the result of advances in disease management. Significant increase in hospital admissions suggests an increase in the prevalence of ALD among the Australian population. Dramatic increases in hospital admissions for alcoholic cirrhosis in 2002/2003 for the 20-29 years population may have been due to an increase in screening of alcohol-related harms in primary care settings.

Luchins DJ; McCarthy JF; Mach JJ; Jordan N. Quantifying the contribution of VA service-connected disability pensions to the "Check Effect". Psychiatric Services 62(5): 551- 553, 2011. (10 refs.)

Objective: The study attempted to quantify the effect of receiving a disability pension check at the beginning of the month on the timing of substance-related hospitalizations in Department of Veterans Affairs (VA) facilities. Methods: All substance-related hospitalizations during fiscal year 2005 were identified in the VA National Psychosis Registry (13,402 hospitalizations among 8,813 individuals) and in a random sample of VA patients without serious mental illness (689 hospitalizations among 508 individuals). Multivariable logistic regression examined the impact of pension check receipt on timing of hospitalizations while controlling for other predictors of substance-related hospitalizations. Results: Receipt of a service-connected pension was associated with an increased risk of admission during the first two weeks of the month (odds ratio = 1.08; 95% confidence interval = 1.01-1.16). Conclusions: Staggering the disbursement of VA disability pensions (sending half the checks at the beginning and half in the middle of the month) might modestly reduce peak demand for substance-related inpatient services.

Magnus A; Cadilhac D; Sheppard L; Cumming T; Pearce D; Carter R. Economic benefits of achieving realistic smoking cessation targets in Australia. American Journal of Public Health 101(2): 321-327, 2011. (30 refs.)

Objectives. We estimated the economic impact of reductions in the prevalence of tobacco smoking on health, production, and leisure in the 2008 Australian population. Methods. We selected a prevalence target of 15%. Cohort lifetime health benefits were modeled as fewer incident cases of tobacco-related diseases, deaths, and disability-adjusted life-years. We estimated production gains by comparing surveyed participation and absenteeism rates of adult smokers and ex-smokers valued according to the human capital and friction cost approaches. We estimated household production and leisure gains from time use surveys and valued these gains with the appropriate proxy. Results. In the 2008 Australian population, an absolute reduction in smoking prevalence of 8% would result in 158000 fewer incident cases of disease, 5000 fewer deaths, 2.2 million fewer lost working days, and 3000 fewer early retirements and would reduce health sector costs by AUD 491 million. The gain in workforce production was AUD 415 million (friction cost) or AUD 863 million (human capital), along with gains of 373000 days of household production and 23000 days of leisure time. Conclusions. Lowering smoking prevalence rates can lead to substantial economic savings and health benefits.

Murphy DA; Shetty V; Zigler C; Researchell J; Yamashita DD. Willingness of facial injury patients to change causal substance using behaviors. Substance Abuse 31(1): 35-42, 2010. (21 refs.)

Many injuries due to interpersonal violence among patients presenting to urban trauma centers for treatment are preventable, with alcohol and illicit drug use presenting as common antecedent risk factors. However, many patients with such problems do not seek treatment. Substance use patients were surveyed to determine how many recognized they had a problem and whether they had previously received treatment for substance use problems. Almost 60% of the patients treated for a facial injury screened for problem alcohol use, and slightly more than 25% screened for problem drug use. Only approximately one third of patients indicated any movement towards dealing with these problems and of these, only 20% had actually sought treatment. Employment had an effect on treatment seeking, with fewer employed patients seeking help. Utilizing the critical window of opportunity for emergency department (ED) personnel to make referrals may have an impact on treatment seeking for problem level substance use.

Nakamura K; Okamura T; Hayakawa T; Kanda H; Okayama A; Ueshima H. Medical expenditures of men with hypertension and/or a smoking habit: A 10-year follow-up study of National Health Insurance in Shiga, Japan. Alcohol Research & Health 33(8): 802-807, 2010. (43 refs.)

Hypertension and smoking are major causes of disability and death, especially in the Asia-Pacific region, where there is a high prevalence of a combination of these two risk factors. We attempted to measure the medical expenditures of a Japanese male population with hypertension and/or a smoking habit over a 10-year period of follow-up. A cohort study was conducted that investigated the medical expenditures due to a smoking habit and/or hypertension during the decade of the 1990s using existing data on physical status and medical expenditures. The participants included 1708 community-dwelling Japanese men, aged 40-69 years, who were classified into the following four categories: 'neither smoking habit nor hypertension', 'smoking habit alone', 'hypertension alone' or 'both smoking habit and hypertension.' Hypertension was defined as a systolic blood pressure of >= 140mmHg, a diastolic blood pressure of >= 90mmHg or taking antihypertensive medications. In the study cohort, 24.9% had both a smoking habit and hypertension. During the 10-year follow-up period, participants with a smoking habit alone (18 444 Japanese yen per month), those with hypertension alone (21 252 yen per month) and those with both a smoking habit and hypertension (31 037 yen per month) had increased personal medical expenditures compared with those without a smoking habit and hypertension (17 418 yen per month). Similar differences were observed even after adjustment for other confounding factors (P<0.01). Japanese men with both a smoking habit and hypertension incurred higher medical expenditures compared with those without a smoking habit, hypertension or their combination.

Oser CB; Leukefeld CG; Tindall MS; Garrity TF; Carlson RG; Falck R et al. Rural drug users: Factors associated with substance abuse treatment utilization. International Journal of offender Therapy and Comparative Criminology 55(4): 567-586, 2011. (80 refs.)

The purpose of this study is to use a modified version of Andersen's Behavioral Model of Health Services Use to identify the correlates of the number of substance abuse treatment episodes received by rural drug users. Data were collected from face-to-face interviews with 711 drug users in rural areas of Ohio, Arkansas, and Kentucky. Descriptive analyses examine rural drug users' substance use histories and retrospective substance abuse treatment service utilization patterns. A negative binomial regression model indicated that selected predisposing, historical health, and enabling factors were significantly associated with the utilization of substance abuse treatment among rural drug users. Despite high levels of recent and lifetime self-reported substance use among these rural drug users, treatment services were underutilized. Future studies are needed to examine the impact of the health care system and characteristics of the external environment associated with rural substance abuse treatment in order to increase utilization among drug users.

Palepu A; Milloy MJ; Kerr T; Zhang R; Wood E. Homelessness and adherence to antiretroviral therapy among a cohort of HIV-Infected Injection drug users. Journal of Urban Health 88(3): 545-555, 2011. (59 refs.)

Homelessness is prevalent among HIV-infected injection drug users (IDU) and may adversely affect access and adherence to antiretroviral therapy (ART). There are limited descriptions of the effect of homelessness on adherence to ART in long-term cohorts of HIV-infected IDU. We used data from a community-recruited prospective cohort of HIV-infected IDU, including comprehensive ART dispensation records, in a setting where HIV care is free. We examined the relationship between the homelessness measured longitudinally, and the odds of a parts per thousand yen95% adherence to ART using generalized estimating equations logistic regression modeling adjusting for sociodemographics, drug use, and clinical variables. Between May 1996 and September 2008, 545 HIV-infected IDU were recruited and eligible for the present study. The median follow-up duration was 23.8 months (IQR 8.5-91.6 months) contributing 2,197 person-years of follow-up. At baseline, homeless participants were slightly younger (35.8 vs. 37.9 years, p = 0.01) and more likely to inject heroin at least daily (37.1% vs. 24.6%. p = 0.004) than participants who had housing. The multivariate model revealed that homelessness (adjusted odds ratio [AOR] 0.66; 95% CI: 0.53-0.84) and frequent heroin use (AOR 0.40; 95% CI: 0.30-0.53) were significantly and negatively associated with ART adherence, whereas methadone maintenance was positively associated (AOR 2.33; 95% CI: 1.86-2.92). Sub-optimal ART adherence was associated with homelessness and daily injection heroin use among HIV-infected IDU. Given the survival benefit of ART, it is critical to develop and evaluate innovative strategies such as supportive housing and methadone maintenance to address these risk factors to improve adherence.

Perron BE; Mowbray OP; Glass JE; DelvaJ; Vaughn MG; Howard MO. Differences in service utilization and barriers among Blacks, Hispanics, and Whites with drug use disorders. Substance Abuse Treatment, Prevention and Policy 5(e-journal 3), 2010. (33 refs.)

Background: Treatment for drug use disorders (DUD) can be effective, but only a small proportion of people with DUD seek or receive treatment. Research on racial and ethnic treatment differences and disparities remains unclear. Understanding racial and ethnic differences and disparities in drug treatment is necessary in order to develop a more effective referral system and to improve the accessibility of treatment. The purpose of the current study was to explore the role of race and ethnicity in service utilization. Methods: Using data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), this study examined racial and ethnic differences in use of 14 types of treatment services for DUD and 27 different treatment barriers among persons who met lifetime criteria for a DUD. Multivariate logistic regression analyses were used to examine service utilization and barriers among the racial and ethnic groups, while adjusting for other sociodemographic and clinical variables. Results and discussion: Among Blacks, Hispanics and Whites in the overall NESARC sample, approximately 10.5% met criteria for at least one lifetime drug use disorder. Approximately 16.2% of persons with a lifetime DUD received at least one type of service. Overall, this study indicated that Whites were less likely to report receiving help for drug-related problems than Blacks, Blacks used a greater number of different types of services, and no racial and ethnic differences were observed with respect to perceived barriers to drug treatment. However, by examining types of services separately, a complex picture of racial and ethnic differences emerges. Most notably, Whites were most likely to use professional services, whereas Blacks were most likely to use 12-step and clergy. The service use pattern of Hispanics most resembled that of Whites. Conclusion: While structural barriers to accessing treatment were observed, broad-based educational programs and interventions that are appropriately targeted to racial and ethnic groups remains an important area for prevention and treatment.

Reavley NJ; Cvetkovski S; Jorm AF; Lubman DI. Help-seeking for substance use, anxiety and affective disorders among young people: Results from the 2007 Australian National Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry 44(8): 729-735, 2010. (24 refs.)

Objective: To provide a more detailed analysis of the relationship between type and severity of mental disorders (substance use, anxiety and affective disorders) and help-seeking in those aged 16-24 years compared to those aged 25-44 and 45-85 years. Method: Data from the National Survey of Mental Health and Wellbeing (NSMHWB) which was conducted in 2007. The survey sample comprised residents of private dwellings across Australia aged 16-85 years. Results: More than one in four Australians aged 16-24 years experienced a mental disorder in the preceding 12 months. This compared to one in five in those aged 16-85 years. Fewer than one in four 16-24-year-olds with a 12-month mental disorder accessed health services in a 12-month period compared with just over one in three of those aged 16-85. The gap in help-seeking was primarily related to higher rates of substance use disorders and low help-seeking associated with these, particularly in young men. Conclusions: Findings from the 2007 NSMHWB show that the gap in help-seeking in young people with mental health problems is largely due to high rates of substance use disorders and the low rates of help-seeking associated with these. In order to address this gap there is a need for better coordination and integration of mental health and alcohol and drug services within primary care settings. Population health approaches that tackle erroneous beliefs about alcohol and related harms and improve overall mental health literacy are also needed.

Rehm J; Patra J; Gnam WH; Sarnocinska-Hart A; Popova S. Avoidable cost of alcohol abuse in Canada. European Addiction Research 17(2): 72-79, 2011. (15 refs.)

Aims: To estimate avoidable burden and avoidable costs of alcohol abuse in Canada for the year 2002. Methods: A policy effectiveness approach was used. The impact of six effective and cost-effective alcohol policy interventions aimed to reduce alcohol consumption was modeled. In addition, the effect of privatized alcohol sales that would increase alcohol consumption and alcohol-attributable costs was also modeled. The effects of these interventions were compared with the baseline (aggregate) costs obtained from the second Canadian Study of Social Costs Attributable to Substance Abuse. Results: It was estimated that by implementing six cost-effective policies from about 900 million to two billion Canadian dollars per year could be saved in Canada. The greatest savings due to the implementation of these interventions would be achieved in the lowering of productivity losses, followed by health care, and criminality. Substantial increases in burden and cost would occur if Canadian provinces were to privatize alcohol sales. Conclusion: The implementation of proven effective population-based interventions would reduce alcohol-attributable burden and its costs in Canada to a considerable degree.

Roudsari B; Caetano R; Field C. Alcohol intoxication/dependence, ethnicity and utilisation of health care resources in a level I trauma center. injury 42(1): 66-71, 2011. (44 refs.)

Objective: To evaluate the potential influence of acute intoxication and dependence to alcohol on extra-utilisation of health care resources by ethnic minority trauma patients in a level I trauma center. Methods: We analysed the data of 1493 patients enrolled in a study that evaluated the effectiveness of brief alcohol intervention among ethnic minority trauma patients. The database included detailed demographic, injury-related and drinking-related characteristics (including acute intoxication and alcohol dependency status). Patients were categorised into the following groups: non-intoxicate/non-dependent (NI/ND), non-intoxicated/dependent (NI/D), intoxicated/non-dependent (I/ND) and intoxicated/dependent (I/D). We compared utilisation of several diagnostic and therapeutic procedures among these four categories. We placed special emphasis on ethnicity as a potential effect modifier. Results: Relative to NI/ND trauma patients, I/ND patients (relative risk (RR): 1.8, 95% CI: 1.2-2.8) and I/D patients (RR: 2.4, 95% CI: 1.6-3.6) had significantly higher chance of being evaluated by abdominal ultrasound during the first 24 h of hospital arrival. Similar pattern was observed for head CT scan (with the corresponding RRs of 2.1 and 2.6, respectively). Chance of admission to the intensive care unit (ICU) was not associated with intoxication/dependence status. Length of hospital stay was negatively associated with drinking status with the shortest length of stay for I/D. Including ethnicity in the models, did not change the results and conclusions. Discussion: Acute intoxication and dependence to alcohol are both associated with more frequent utilisation of selected health care resources and the utilisation pattern was not associated with patient ethnicity. This emphasises on the importance of routine screening for drinking problems among all trauma patients, regardless of their blood alcohol level in the ED.

Sara G; Burgess P; Malhi G; Whiteford H. Amphetamine availability and admissions for psychosis in New South Wales, 2001-2009. Australian and New Zealand Journal of Psychiatry 45(4): 317-324, 2011. (14 refs.)

Objective: Clinicians have raised concerns about the impact of amphetamines on demand for mental health services. However, evidence for this link is limited. This study explores whether changes in the availability of amphetamines in NSW in the last decade have been associated with variations in admission to mental health units for amphetamine related conditions and for psychoses more generally. Method: The study examined admissions from community settings to NSW acute mental health units from 2000 to 2009. Quarterly rates of hospital admission with primary or comorbid diagnoses of stimulant use disorders, stimulant-induced psychoses and non-drug-related psychoses were compared to quarterly rates of criminal incidents of amphetamine possession and use, which provide an indirect measure of the community availability of amphetamines. Analysis was confounded by increases in mental health beds over the period. Linear regression predicted admission rates on the basis of amphetamine availability, adjusting for changing mental health bed numbers. Results: Amphetamine availability and admissions for psychoses increased steadily from 2000 to a peak in early 2007, but have declined since. Regression models including both amphetamine availability and bed numbers predicted 34% of variation in stimulant use disorders admission rates and 50% of variation in stimulant induced psychoses admission rates. There was no significant effect of amphetamine availability on admissions for schizophrenia and other non-drug-induced psychoses after controlling for changing bed numbers. Conclusions: Increased amphetamine availability appears to have been one factor increasing demand for mental health admission in NSW over the last decade. However, there appears to have been a recent downward trend in both amphetamine availability and amphetamine-related admissions. Policies which reduce the community availability of amphetamines may result in reduced admissions for amphetamine-related mental health conditions, including amphetamine-induced psychoses. Further research is needed regarding effects of amphetamine availability on admissions for schizophrenia.

Schwartz RP; Kelly SM; O'Grady KE; Mitchell SG; Brown BS. Antecedents and correlates of methadone treatment entry: A comparison of out-of-treatment and in-treatment cohorts. Drug and Alcohol Dependence 115(1-2): 23-29, 2011. (57 refs.)

Background: The majority of opioid-dependent individuals in the US in need of drug treatment are not receiving it. It would be useful to understand the characteristics of individuals entering and failing to enter methadone treatment. Methods: Participants were opioid-dependent adults in Baltimore Maryland recruited from new admissions to one of six methadone treatment programs (n = 351) and from the streets from among non-treatment seekers (n = 164). At study enrollment, participants were administered the Addiction Severity Index, AIDS Risk Assessment, Community Assessment Inventory, Attitudes toward Methadone Scale, Motivation for Treatment Scale and a urine drug test. A series of logistic regression analyses were conducted to determine the best model to predict treatment entry. Results: The final logistic regression analysis showed that predictors of treatment entry included: being African-American, being on parole or probation, having lower rates of self-reported cocaine use and criminal activity, higher employment functioning, and greater perceptions of support from family and community for behavioral change. In addition, in-treatment participants were more likely to have a more extensive prior history of drug abuse treatment, greater desire to seek help in coping with their drug problem, and more positive view of methadone. Conclusions: The distinctions between those entering and those not pursuing MTP entry have significance for the structure of outreach programs and reaffirm the need to supplement the current practices of voluntary and coerced treatment entry with one of encouraged treatment entry through outreach.

Seguin M; Boyer R; Lesage A; McGirr A; Suissa A; Tousignant M et al. Suicide and gambling: Psychopathology and treatment-seeking. Psychology of Addictive Behaviors 24(3): 541-547, 2010. (46 refs.)

The aim of this study was to evaluate suicides with a history of problem gambling (PG) and others with no such history (NPG) and to compare the two on mental health problems and service utilization. Data on a sample of 49 PG suicides and 73 NPG suicides were obtained front informants and hospital records. Psychopathology was prevalent in both groups, but problem gamblers were twice as likely to have a personality disorder. Moreover, PG suicides were less in contact with mental health services in their last month, their last year, and their lifetime. NPG suicides consulted specialized services from 3 (last month and last year) to 13 times (lifetime) as often as their PG counterparts. Lower service utilization associated with PG suicides argues in favor of stepping up detection, engagement in care and treatment with respect to problem gambling, especially when comorbidity is present.

Sheffer CE; Brackman SL; Cottoms N; Olsen M. Understanding the barriers to use of free, proactive telephone counseling for tobacco dependence. Qualitative Health Research 21(8): 1075-1085, 2011. (47 refs.)

We sought to gain an empirical and practical understanding of the barriers experienced by residents of the Mississippi River Delta in Arkansas to using the free, proactive telephone counseling (quitline) for tobacco dependence. Barriers included a lack of appropriate telephone service, lack of knowledge about the quitline, and lack of trust in the providers, as well as multiple root causes to seeking and achieving abstinence from tobacco, including stress related to the poor socioeconomic context and concerns about negative health effects of quitting. A strong belief in the role of faith was expressed. Participants suggested strategies for increasing knowledge and trust levels, but were not hopeful about addressing root causes. Given the considerable resources being allocated to quitlines and the burden of tobacco use and disease in lower socioeconomic and minority groups, understanding utilization of quitlines by these groups has implications for policy development, the promotion of quitlines, and the provision of alternate tobacco treatment services.

Staiger PK; Thomas AC; Ricciardelli LA; Mccabe MP; Cross W; Young G. Improving services for individuals with a dual diagnosis: A qualitative study reporting on the views of service users. Addiction Research & Theory 19(1): 47-55, 2011. (35 refs.)

Individuals with high prevalence mental health (HPMH) and concurrent alcohol and/or drug disorders are vulnerable to falling 'between the gaps' of existing service systems. The aim of the current qualitative study was to explore service experiences (barriers to treatment and suggestions for improvements) from the perspective of those with this type of dual diagnosis. Of the individuals, 44 with a HPMH dual diagnosis participated in qualitative interviews. Thematic analysis was conducted on the data and major themes from the analysis presented. Barriers to treatment related primarily to knowledge (not knowing that services existed; breakdowns in referrals) and structure (delays in response; system inflexibility). Suggestions for improvements to services targeted barriers but took a holistic view including the need for worker and community education, addressing issues beyond the illness and the importance of relationships. The complex interaction between the disorders means that navigating either of the specialist systems has pitfalls not faced by people with a single disorder. Service user input is vital to minimise gaps and ensure service provision meets the needs of this group. These findings can now be used to inform service system redesign so that services are better able to meet the needs of this group.

Tucker JA; Simpson CA. The recovery spectrum from self-change to seeking treatment. Alcohol Research & Health 33(4): 371+, 2011. (82 refs.)

Recent innovations in alcohol-focused interventions are aimed at closing the gap between population need and the currently uncommon use of alcohol treatment services. Guided by population data showing the heterogeneity of alcohol problems and the occurrence of natural remissions from problem drinking without treatment, alcohol services have begun to expand beyond clinical treatment to offer the untreated majority of individuals with alcohol-related problems accessible, less-intensive services that use the tools of public health practice. These services often are opportunistic, meaning they can be provided in primary-care or other unspecialized health care or community settings. They also can be delivered by nonspecialists, or can be used by people themselves to address problems with alcohol without entering the health care system. This developing spectrum of services includes screening and brief interventions, guided self-change programs, and telehealth options that often are targeted and tailored for high-risk groups (e.g., college drinkers). Other efforts aimed at reducing barriers to care and increasing motivation to seek help have utilized individual, organizational, and public health strategies. Together, these efforts have potential for helping the treatment field reach people who have realized that they have a drinking problem but have not yet experienced the severe negative consequences that may eventually drive them to seek treatment. Although the evidence supporting several innovations in alcohol services is preliminary, some approaches are well established, and collectively they form an emerging continuum of care for alcohol problems aimed at increasing service availability and improving overall impact on population health.

Wisdom JP; Cavaleri M; Gogel L; Nacht M. Barriers and facilitators to adolescent drug treatment: Youth, family, and staff reports. Addiction Research & Theory 19(2): 179-188, 2011. (72 refs.)

Many adolescents with substance abuse problems do not obtain treatment, and there has been no systematic exploration of perceived barriers to starting care from multiple stakeholders. This article describes adolescent, parent, and treatment staff perceptions of barriers and facilitators to treatment. We interviewed 87 adolescents, their parents, and agency staff from three residential substance abuse treatment agencies in two states to explore barriers and facilitators to care in seeking, finding, and initiating substance abuse treatment. Youth, parent, and staff reports of barriers to treatment (n = 128) far outnumbered facilitators to treatment (n = 6). Staff perceived primarily family barriers to seeking treatment (e. g., denial, stigma); parents stated challenges finding treatment (e. g., lack of knowledge), and all three groups reported barriers to initiating treatment (e. g., lack of motivation). Findings suggest structural and perceptual barriers to adolescent services vary by respondent and by the reference point on the help-seeking continuum.

Wong NS; Lee SS; Lin H. Assessing the spatial distribution of methadone clinic clients and their access to treatment. Harm Reduction Journal 7: 1-6, 2010. (9 refs.)

Using Geographic Information System (GIS), the spatial distribution of methadone clinic clients and their utilization of a treatment service in Hong Kong was analysed. A majority (93.7%) of the 63 methadone users recruited were residing in the same district, of which 84.1% spent not more than 15 minutes for traveling. Walking (55.6%) was the commonest transport mode followed by cycling (30.2%). There was no distance decay effect on traveling time, but an association between distance and transport selection could be demonstrated. The residence locations displayed a compact distribution, merging with the general population without any evidence of clustering. Though the distribution of methadone users could have been shaped by the location of clinic, it can also be concluded that methadone clinics at convenient locations are needed if maintenance is a key determinant of service effectiveness.

Woodman J; Brandon M; Bailey S; Belderson P; Sidebotham P; Gilbert R. Healthcare use by children fatally or seriously harmed by child maltreatment: Analysis of a national case series 2005-2007. Archives of Disease in Childhood. Fetal and Neonatal Edition 96(3): 270- 275, 2011. (31 refs.)

Aim To determine antecedent patterns of healthcare use by children fatally or seriously harmed by maltreatment. Methods The authors analysed recorded healthcare use for children who were the subject of a serious case review (SCR) in England in 2005-2007. The SCRs were initiated when a child under 18 years old died or was seriously harmed, maltreatment (abuse or neglect) was a factor, and there were lessons for interagency working. The authors analysed a purposive sample (N=40), similar in key demographics to all 189 SCRs in England in 2005-2007. Results: Children had extensive recorded contact with universal (N= 34/40; 85%) and secondary (N= 26/40; 65%) healthcare services and children's social care (N=21/40; 53%). Thirty-one children (78%) had recorded health visitor and/or school nurse contact. Fourteen children (35%) had missed appointments. Almost three-quarters (N=29) had complex family problems recorded (parental domestic violence, alcohol/drug and/or mental health problems). Data quality regarding healthcare use was poor, and the extent and type of 'missing data' varied by age. Conclusions: Complex paediatric and family problems and a high level of contact with services preceded serious adverse events. Universal health services are likely to be well placed for giving ongoing and family-orientated support to vulnerable families. The absence of standardised data collection and any control group limits how far the Biennial Analyses of SCRs can meet their stated objective of identifying national trends and patterns. Linking SCRs to healthcare databases would provide a control group, improve understanding of the population context and diminish demands for data from professionals delivering care.

Worley MJ; Trim RS; Tate SR; Hall JE; Brown SA. Service utilization during and after outpatient treatment for comorbid substance use disorder and depression. Journal of Substance Abuse Treatment 39(2): 124-131, 2010. (49 refs.)

Patients with comorbid substance use disorder (SUD) and depression incur greater treatment costs than those with either disorder alone. Integrated treatment targeting both issues concurrently has been shown to reduce substance use and depression in this population, but little is known about the effects of such treatment on the utilization of costly health services. This study compared 18-month patterns of service utilization for 236 veterans with comorbid SUD depression randomly assigned to 6 months of either Integrated Cognitive Behavioral Therapy (ICBT) or Twelve-Step Facilitation Therapy. Treatment group differences were found for the utilization of psychotropic medication services and inpatient hospitalization. Higher rates of therapy attendance, lower baseline depression, and receiving ICBT all predicted shorter admissions for those hospitalized during treatment. Ethnicity and gender predicted medication service use both during and following treatment. The findings provide evidence supporting the long-term cost-effectiveness of integrated treatment for this high-risk population.

Wu LT; Blazer DG. Illicit and nonmedical drug use among older adults: A review. (review). Journal of Aging and Health 23(3): 481-504, 2011. (54 refs.)

Objective: Substance abuse among older adults is a looming public health concern. The number of Americans aged 50+ years with a substance use disorder is projected to double from 2.8 million in 2002-2006 to 5.7 million in 2020. The authors provide a review of epidemiological findings for this understudied area of research by focusing on illicit drug use disorders and nonmedical use of prescription drugs among adults aged 50+ years. Method: MEDLINE and PsychInfo were searched using keywords drug use, drug abuse, drug misuse, substance use disorder, and prescription drug abuse. Using the related-articles link, additional articles were screened for inclusion. This review included articles published between 1990 and 2010. Result: Results from multiple sources indicated a much higher rate of illicit drug use and nonmedical use of prescription drugs and drug-related treatment admissions for persons 50 to 64 years of age compared with adults 65+ years of age. Rates of treatment admissions involving primary use of illicit and misuse of prescription drugs have increased, while rates involving primary use of alcohol only have decreased. Alcohol, opioids/heroin, and cocaine were more likely than other substances to be associated with treatment use. Limited research data suggested the effectiveness of treatments, especially for women. Furthermore, older adults appeared to be less likely than younger adults to perceive substance use as problematic or to use treatment services. Discussion: There is robust evidence showing that an increased number of older adults will need substance abuse care in the coming decades. Increasing demands on the substance abuse treatment system will require expansion of treatment facilities and development of effective service programs to address emerging needs of the aging drug-using population.

Xie HY; Drake RE; McHugo GJ; Xie L; Mohandas A. The 10-year course of remission, abstinence, and recovery in dual diagnosis. Journal of Substance Abuse Treatment 39(2): 132-140, 2010. (26 refs.)

This study examined the frequency, stability, predictors, and long-term outcomes of 6-month remissions of alcohol use disorders among 116 adults with co-occurring severe mental illnesses followed up prospectively for 10 years. Remission was defined as 6 months without meeting syndromal criteria for alcohol abuse or dependence. Most participants (86%) experienced at least one 6-month remission, and these remissions were relatively durable. One third did not relapse during follow-up, and two thirds relapsed on average 3 years after remission. Six-month remissions were preceded by increased participation in substance abuse treatments, reductions in alcohol and drug use, decreases in psychiatric symptoms, increases in competitive employment, and increases in life satisfaction. Following remissions, participants improved in multiple domains of adjustment: reductions of psychiatric symptoms, decreases in alcohol and drug use, increases in work and social contacts with nonabusers, decreases in hospitalizations and incarcerations, increases in independent living, and increases in life satisfaction. Participants with alcohol dependence rather than alcohol abuse were less likely to attain 6-month remissions and more likely to relapse after attaining remissions.

Yang L; Sung HY; Mao ZZ; Hu TW; Rao KQ. Economic costs attributable to smoking in China: Update and an 8-year comparison, 2000-2008. Tobacco Control 20(4): 266-272, 2011. (40 refs.)

Objective. To estimate the health-related economic costs attributable to smoking in China for persons aged 35 and older in 2003 and in 2008 and to compare these costs with the respective results from 2000. Methods. A prevalence-based, disease-specific approach was used to estimate smoking-attributable direct and indirect economic costs. The primary data source was the 2003 and 2008 China National Health Services Survey, which contains individual participant's smoking status, healthcare use and expenditures. Results. The total economic cost of smoking in China amounted to $17.1 billion in 2003 and $28.9 billion in 2008 (both measured in 2008 constant US$). Direct smoking-attributable healthcare costs in 2003 and 2008 were $4.2 billion and $6.2 billion, respectively. Indirect economic costs in 2003 and 2008 were $12.9 billion and $22.7 billion, respectively. Compared to 2000, the direct costs of smoking rose by 72% in 2003 and 154% in 2008, while the indirect costs of smoking rose by 170% in 2003 and 376% in 2008. Conclusions. The economic burden of cigarette smoking has increased substantially in China during the past decade and is expected to continue to increase as the national economy and the price of healthcare services grow. Stronger intervention measures against smoking should be taken without delay to reduce the health and financial losses caused by smoking.

Yanos PT; Czaja SJ; Widom CS. A prospective examination of service use by abused and neglected children followed up into adulthood. Psychiatric Services 61(8): 796-802, 2010. (26 refs.)

Objective: This study sought to determine whether abused and neglected children are more likely than those without childhood maltreatment to use health and social services as adults and whether psychiatric status mediates or moderates the relationship. Methods: A prospective cohort design was used. Individuals with documented cases of physical and sexual abuse and neglect (ages 0-10) and nonvictimized children matched on age, sex, and race-ethnicity were interviewed in adulthood (mean age 41 years). Past-year service use (general medical, mental health, substance abuse, and social) was assessed during 2003-2004 interviews (maltreated group, N=458; control group, N=349). Psychiatric status (posttraumatic stress disorder [PTSD], drug abuse, and major depressive disorder) was assessed during 1989-1995 (mean age 29) by structured interview. Results: Individuals with histories of childhood abuse and neglect were significantly more likely than their control group counterparts to use mental health services (odds ratio [OR]=1.60, 95% confidence interval [CI]=1.04-2.45) and social services (OR=2.95, CI=2.19-3.97) in adulthood. Psychiatric status in young adulthood (PTSD and major depressive disorder) partially mediated the relationship between childhood maltreatment and use of mental health services, whereas major depression and drug abuse moderated the relationship between maltreatment and use of any services and general medical services. Conclusions: In adulthood, individuals with documented histories of childhood abuse and neglect are more likely than persons without such histories to use some types of services, and psychiatric status mediates and moderates these relationships. Findings have implications for the provision of services to persons with childhood abuse and neglect.

Zbikowski SM; Jack LM; McClure JB; Deprey M; Javitz HS; McAfee TA et al. Utilization of services in a randomized trial testing phone- and web-based interventions for smoking cessation. Nicotine & Tobacco Research 13(5): 319- 327, 2011. (33 refs.)

Introduction: Phone counseling has become standard for behavioral smoking cessation treatment. Newer options include Web and integrated phone-Web treatment. No prior research, to our knowledge, has systematically compared the effectiveness of these three treatment modalities in a randomized trial. Understanding how utilization varies by mode, the impact of utilization on outcomes, and predictors of utilization across each mode could lead to improved treatments. Methods: One thousand two hundred and two participants were randomized to phone, Web, or combined phone-Web cessation treatment. Services varied by modality and were tracked using automated systems. All participants received 12 weeks of varenicline, printed guides, an orientation call, and access to a phone supportline. Self-report data were collected at baseline and 6-month follow-up. Results: Overall, participants utilized phone services more often than the Web-based services. Among treatment groups with Web access, a significant proportion logged in only once (37% phone-Web, 41% Web), and those in the phone-Web group logged in less often than those in the Web group (mean = 2.4 vs. 3.7, p = .0001). Use of the phone also was correlated with increased use of the Web. In multivariate analyses, greater use of the phone- or Web-based services was associated with higher cessation rates. Finally, older age and the belief that certain treatments could improve success were consistent predictors of greater utilization across groups. Other predictors varied by treatment group. Conclusions: Opportunities for enhancing treatment utilization exist, particularly for Web-based programs. Increasing utilization more broadly could result in better overall treatment effectiveness for all intervention modalities.

Zhu SH; Gardiner P; Cummins S; Anderson C; Wong S; Cowling D et al. Quitline utilization rates of African-American and white smokers: The California experience. American Journal of Health Promotion 25(5, Supplement S): S51-S58, 2011. (42 refs.)

Purpose. To compare the utilization rate of a statewide tobacco quitline by African-American smokers to that of white smokers. Design, Setting, and Subjects. Observational study of 18 years of state quitline operation in California. Subjects were 61,096 African-American and 279,042 white smokers who called the quitline from August 1992 to December 2009. Data from six California Tobacco Surveys, 1993, 1996, 1999, 2002, 2005, and 2008 were also used. Measure. Callers' answers' to the question how they heard about the quitline were grouped into four categories: media, health care providers, friends/family, and others. Analysis. The averaged annual quitline call volume fir each ethnic group was divided by the total number of smokers in that group, based on California Tobacco Surveys, to produce the annual quitline utilization rate. Results. In five out of six periods of comparison, African-American smokers had a higher annual utilization rate than white smokers. The odds ratios [ORs] ranged from 1.44 to 2.40 (all p < .05). In the 1996 comparison, the OR was .90 (p < .05). The difference in utilization rates that is attributed to media, accounts for most of the difference in total utilization rates between the two ethnic groups. Conclusions. Within the context of California's comprehensive tobacco control program, which includes a strong media campaign, African-American smokers were significantly more likely to call the state quitline than white smokers were. Promoting the quitline as part of antismoking media campaigns can help reduce disparity in cessation service utilization.