Medical-surgical patients with untreated hazardous drinking: Randomized controlled trial of the DO-MoST intervention to improve health outcomes over 12-month follow-up.

INTRODUCTION: High prevalence and harmful consequences of hazardous drinking among medical-surgical patients underscore the importance of intervening with drinking to improve patients' health. This study evaluated a novel intervention, "Drinking Options - Motivate, Shared Decisions, Telemonitor" (DO-MoST). METHODS: In a randomized design, 155 medical-surgical patients with untreated hazardous drinking were assigned to enhanced usual care or DO-MoST, and followed 3, 6, and 12 months later. We conducted intent-to-treat and per-protocol analyses. RESULTS: For the primary outcome, percent days of alcohol abstinence in the past 30 days, intent-to-treat analyses did not find superior effectiveness of DO-MoST. However, per-protocol analyses found abstinence increased between 3 and 12 months among participants assigned to DO-MoST who engaged with the intervention (n=46). Among DO-MoST-assigned participants who did not engage (n=27), abstinence stayed stable during follow-up. Group comparisons showed an advantage on abstinence for Engaged compared to Non-Engaged participants on change over time. Intent-to-treat analyses found that DO-MoST was superior to usual care on the secondary outcome of physical health at 12 months; per-protocol analyses found that Engaged DO-MoST-assignees had better physical health at 12 months than Non-Engaged DO-MoST-assignees. DO-MoST-assignees had lower odds of receiving substance use care during follow-up than usual care-assignees. DISCUSSION: Patients engaged in DO-MoST showed a greater degree of abstinence and better physical health relative to the non-engaged or usual care group. DO-MoST may be a source of alcohol help in itself rather than only a linkage intervention. Work is needed to increase DO-MoST engagement among medical-surgical patients with untreated hazardous drinking.

Hazardous Drinking Interventions Delivered During Medical-Surgical Care: Patient and Provider Views.

Addressing hazardous drinking during medical-surgical care improves patients' health. This formative evaluation examined patients' consideration of options to change drinking and engage in treatment. It explored whether interventions such as "DO-MoST" overcome treatment barriers. We interviewed 20 medical-surgical patients with hazardous drinking in a trial of DO-MoST, and 16 providers. Analyses used a directed content approach. Patients were receptive to and comfortable discussing drinking during medical-surgical care. Interventions like DO-MoST (patient-centered, motivational approach to shared decision making) addressed some treatment barriers. Patients and providers viewed such interventions as helpful by building a relationship with a psychologist who facilitated self-awareness of drinking behaviors, and discussing connections between alcohol- and physical health-related problems and potential strategies to address drinking. However, both groups expressed concerns about individual and system-level barriers to long-term change. Interventions like DO-MoST bridge the gap between the patient's medical treatment episode and transition to other health care settings. TRIAL REGISTRATION: The study is registered on ClinicalTrials.gov (ID: NCT03258632).

Patient-Concerned Other Dyads' 12-Step Involvement and Patients' Substance Use: A Latent Class Growth Model Analysis.

OBJECTIVE: This study aimed to inform clinical practice by identifying subgroups of patient-concerned other (CO) dyads. Patients with alcohol use disorders (AUDs) were characterized on Alcoholics Anonymous (AA) involvement and substance use together with COs' Al-Anon involvement. Predictors and recovery maintenance outcomes of subgroup membership were examined. METHOD: Participants were 279 patient-CO dyads. Patients were in residential treatment for AUD. Parallel latent class growth model analysis characterized 12-step involvement and substance use at treatment entry and 3-, 6-, and 12-month follow-ups. RESULTS: Three classes were as follows: 38% Low AA/Low Al-Anon (patients' low AA and COs' low Al-Anon involvement, and patients' high-to-moderate substance use), 10% High AA/High Al-Anon (patients' high AA and COs' high Al-Anon involvement, and patients' moderate-to-low substance use), and 52% High AA/Low Al-Anon (patients' high AA and COs' low Al-Anon involvement, and patients' moderate-to-low substance use). At follow-up, the Low AA/Low Al-Anon classes' patients were less likely to have spirituality as recovery support, confidence about staying abstinent, and satisfaction with recovery progress. The High AA classes' COs had less concern about patients' drinking and scored higher on positive aspects of relationships with patients. CONCLUSIONS: Clinicians should encourage patients' and COs' 12-step group involvement (12-step practices' engagement). Among patients treated for AUD, AA involvement was related to better outcomes, and to COs' lessened concern about the patients' drinking. COs' Al-Anon involvement was associated with having a more positive view of their relationship with the patient. That more than one third of dyads had low 12-step group involvement suggests that treatment programs may need to facilitate involvement in non-12-step mutual-help groups.

Patient and Provider Perspectives on Benefits and Harms of Continuing, Tapering, and Discontinuing Long-Term Opioid Therapy.

BACKGROUND: Given efforts to taper patients off long-term opioid therapy (LTOT) because of known harms, it is important to understand if patients and providers align in LTOT treatment goals. OBJECTIVE: To investigate patient and provider perceptions about the harms and benefits of continuing and discontinuing LTOT. DESIGN: Qualitative study PARTICIPANTS: Patients and providers with experiences with LTOT for pain in two Veterans Health Affairs regions. APPROACH: We conducted semi-structured interviews and analyzed data using rapid qualitative analysis to describe patient and provider preferences about LTOT continuation and discontinuation and non-opioid pain treatments. KEY RESULTS: Participants (n=43) included 28/67 patients and 15/17 providers. When discussing continuing LTOT, patients emphasized the benefits outweighed the harms, whereas providers emphasized the harms. Participants agreed on the benefits of continuing LTOT for improved physical functioning. Provider-reported benefits of continuing LTOT included maintaining the status quo for patients without opioid alternatives or who were at risk for illicit drug use. Participants were aligned regarding the harms of negative side-effects (e.g., constipation) from continued LTOT. In contrast, when discussing LTOT tapering and discontinuation, providers underscored how benefits outweighed the harms, citing patients' improved well-being and pain management with tapering or alternatives. Patients did not foresee benefits to potential LTOT tapers or discontinuation and were worried about pain management in the absence of LTOT. When discussing non-opioid pain treatments, participants emphasized that they were adjunctive to opioid therapy rather than a replacement (except for cannabis). Providers described the importance of mental health services to manage pain, which differed from patients who focused on treatments to improve strength and mobility and reduce pain. CONCLUSIONS: Patients emphasized the benefits of continuing LTOT for pain management and well-being, which differed from providers' emphasis on the benefits of discontinuing LTOT. Patient and provider differences are important for informing patient-centered care and decisions around continuing, tapering, or discontinuing LTOT.

Caregivers of people with substance use or mental health disorders in the US.

Background: Caregiving for persons with substance use and/or mental health disorders (SU/MHD) and other conditions places significant strains on caregivers. Methods: The present study used Behavioral Risk Factor Surveillance System (a US health survey) data to (1) compare caregivers of recipients with SU/MHD to those of recipients with other conditions on demographic and caregiving characteristics and health outcomes and (2) examine demographic and caregiving characteristics that were associated with poorer health outcomes among caregivers of persons with SU/MHD. Results: Caregivers of people with SU/MHD were more likely than other caregiver groups (of recipients with medical, cognitive, developmental disability, and old age-related conditions) to report poor general health, physical health, and mental health, as well as activities limitations, having been diagnosed with depression, and binge drinking. Among the group of caregivers of recipients with SU/MHD, those caring for a parent were more likely to report poor physical health, poor mental health, depression, and binge drinking than those caring for a friend, relative, child, or spouse. In addition, caregivers who provided SU/MHD-related caregiving for a longer duration and for whom caregiving included household help were less likely to report poor mental health, depression, or binge drinking. Conclusions: Findings underscore the importance of the substance use disorder treatment system developing improved institutional and structural support for caregivers of recipients with SU/MHD.

Long-Term Benzodiazepine Use and Discontinuation Among Patients in the U.S. Veterans Health Administration.

Objective: Although long-term benzodiazepine use is not recommended, patients are often prescribed benzodiazepines for >30 days (long-term use). Data from the Veterans Health Administration (VHA) may inform efforts to discontinue such use. This study sought to describe benzodiazepine use and discontinuation among VHA patients and compared patients who continued and discontinued use. Methods: The study used nationwide electronic health record data for all VHA-enrolled patients (age ≥18) from fiscal year (FY) 2019 (N=6,032,613). The primary outcome, benzodiazepine discontinuation, was defined as no prescription refill for 120 days. Results: In FY2019, 3.5% of VHA enrollees were prescribed benzodiazepines for >30 days, which was 72.0% of those prescribed benzodiazepines. One-third of veterans prescribed long-term benzodiazepines discontinued use. Continuation was more likely among patients who were older, not Black, taking benzodiazepines longer, and taking higher doses. When demographic factors were controlled, patients who continued long-term use were more likely to have a diagnosis of anxiety, posttraumatic stress disorder (PTSD), bipolar disorder, or psychosis and less likely to have depression or an alcohol or drug use disorder. Continuation was associated with a lower likelihood of sleep and cardiopulmonary disorders and of dementia. Conclusions: Higher discontinuation prevalence among patients with substance use disorders, dementia, or cardiopulmonary disorders is encouraging. However, the challenge remains of discontinuing long-term use among patients who are White, older, or diagnosed as having anxiety, PTSD, bipolar disorder, or psychosis. There is a need to identify provider, patient, and contextual factors driving long-term benzodiazepine use in these patient groups to effectively apply evidence-based discontinuation strategies.

Development and field testing of primary care screening tools for harms of long-term opioid therapy continuation and tapering to discontinuation: a study protocol.

INTRODUCTION: Despite calls for screening tools to help providers monitor long-term opioid therapy (LTOT) harms, and identify patients likely to experience harms of discontinuation, such screening tools do not yet exist. Current assessment tools are infeasible to use routinely in primary care and focus mainly on behaviours suggestive of opioid use disorder to the exclusion of other potential harms. This paper describes a study protocol to develop two screening tools that comprise one integrated instrument, Screen to Evaluate and Treat (SET). SET1 will indicate if LTOT may be harmful to continue (yes or no), and SET2 will indicate if tapering to discontinue opioids may be harmful to initiate (yes or no). Patients receiving LTOT who screen positive on the SET tools should receive subsequent additional assessment. SET will give providers methods that are feasible to implement routinely to facilitate more intensive and comprehensive monitoring of patients on LTOT and decision-making about discontinuation. METHODS AND ANALYSIS: We will develop the screening tools, SET1 and SET2, concurrently. Tool development will be done in stages: (1) comprehensive literature searches to yield an initial item pool for domains covered by each screening tool; (2) qualitative item analyses using interviews, expert review and cognitive interviewing, with subsequent item revision, to yield draft versions of each tool; and (3) field testing of the draft screening tools to assess internal consistency, test-retest reliability and convergent and discriminant validity. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Institutional Review Boards of Stanford University and the University of California, San Francisco for the VA Palo Alto Health Care System, and the VA San Francisco Healthcare System, respectively. Findings will be disseminated through peer-reviewed manuscripts and presentations at research conferences.

Concerned others' help utilization and patients' alcohol treatment outcomes.

BACKGROUND: This study of dyads composed of patients in treatment for alcohol use disorders (AUDs) and their Concerned Others (COs) examined (1) COs' attendance at three types of help (educational sessions, treatment sessions with the patient, and treatment sessions without the patient) during a 3-month period after patients' admission, and (2) whether COs' use of help was associated with better treatment outcomes reported by COs about patients, and patients about themselves. METHODS: Dyads (n = 277) were assessed when patients entered AUD treatment and 3 months later (80 %). COs rated their patient's AUD, and patients rated their own AUD, on the Brief Addiction Monitor. At 3-month follow-up, COs answered three items about help (education, treatment with patient, treatment without patient) from their patient's treatment program. Main analyses were analyses of covariance to examine associations between COs' help use and patients' outcomes. RESULTS: At 3-month follow-up, COs who had obtained one type of help were significantly more likely to have also obtained the other two types of help. However, relatively few COs (39 %) obtained any type of help. COs who obtained help rated their patient as having more protection against future substance use. And, when COs had obtained help, patients rated themselves as having less risk of future substance use, and had attended a greater number of AA meetings, than when COs had not obtained help. CONCLUSIONS: Findings suggest that COs' use of help can benefit patients in AUD treatment. Clinicians and researchers should increase the availability and use of help among COs.

Patients With Alcohol Use Disorders and Their Concerned Others: Concordance of Lived Experience as a Moderator of Treatment Outcomes.

OBJECTIVE: Growing up with an adult with an alcohol use disorder (AUD) is common and negatively affects adult functioning. This study examined two questions concerning the lived experience of growing up in a home with AUD. METHOD AND RESULTS: The first question asked how adults entering AUD treatment (n = 402) who had this lived experience (58%) compared to those who did not (42%) on indicators of alcohol use severity. Patients with lived experience reported alcohol use at a younger age, more times having been arrested and charged, and greater risk for future substance use. The second question examined concordance between patients and their concerned others on this lived experience (n = 277 dyads) and patients' treatment outcomes 3 months later. The associations between patients' lived experience and better treatment outcomes were stronger when patients' concerned others had a concordant lived experience. When patient-concerned other dyads reported concordant lived experiences at baseline, patients had lower substance use and risk scores at the 3-month follow-up than when the dyads reported discordant lived experiences with regard to growing up in a home with AUD; effect sizes were small. CONCLUSIONS: Concordance and discordance on this lived experience could be considered in treatment planning for patients with AUD and their concerned others. Providers could ask about each member's childhood and aim interventions at helping dyads discuss their childhoods in ways that validate each other's needs and provide emotional support, without stigmatization. Delivery may consider relationship type (spousal or other) and be in educational or treatment sessions that include the dyad or one member.

Engaging Hmong adults in genomic and pharmacogenomic research: Toward reducing health disparities in genomic knowledge using a community-based participatory research approach.

Advancing precision medicine relies in part on examining populations that may exhibit unique genetic variants that impact clinical outcomes. Failure to include diverse populations in genomic-based research represents a health disparity. We implemented a community-based participatory research (CBPR) process with the Hmong community in Minnesota, who were refugees from Laos, in order to assess the feasibility of conducting genomic and pharmacogenomic-based research for genetic variants that are relevant to the Hmong community. Our Hmong Genomics Board, consisting of Hmong and non-Hmong professionals, used CBPR principles and built on previous formative research to create and implement culturally and linguistically appropriate informed consent processes for Hmong people at six community venues. The Board chose genetic variants for diabetes risk and warfarin response as relevant to the community. The Institutional Review Board approved aggregate but not individual return of results. Two hundred thirty-seven Hmong participants with mean (range) age of 30.2 (18-81) years and diverse levels of education (22% without and 75% with high-school education) provided saliva for genetic (DNA) analyses. Eighty-five percent of participants agreed to store DNA for future analyses, 82% agreed to share DNA with other researchers, and 78% agreed to be contacted for future studies. Twenty-five elders refused to participate because they wanted individual results. Aggregate results were shared with all participants. This CBPR approach proved highly successful to obtain informed consent and recruit a sample from the Hmong community for a genomic and pharmacogenomic study. Investment in the CBPR process may prove successful to address the gap of genomic information in under-represented communities.