Improving alcohol treatment engagement using integrated behavioral interventions in alcohol-associated liver disease: A randomized pilot trial.

INTRODUCTION: Alcohol cessation improves mortality in alcohol-associated liver disease (ALD), but few ALD patients will engage in treatment. We aimed to demonstrate the feasibility and acceptability of a mobile health intervention to increase alcohol use disorder (AUD) treatment among ALD patients. METHODS: We conducted a pilot randomized controlled trial (September 2020 to June 2022) at a single tertiary care center in adults with any stage of ALD, past 6-month drinking, and no past-month AUD treatment. Sixty participants were randomized 1:1 to a mobile health application designed to increase AUD treatment engagement through preference elicitation and matching to treatment and misconception correction. Controls received enhanced usual care. The primary outcomes were feasibility (recruitment and retention rates) and acceptability. Exploratory outcomes were AUD treatment engagement and alcohol use, measured by Timeline Followback. Outcomes were measured at 3 and 6 months. RESULTS: Baseline characteristics were balanced. The recruitment rate was 46%. Retention was 65% at 6 months. The intervention was highly acceptable to participants (91% were mostly/very satisfied; 95% felt that the intervention matched them well to AUD treatment). Secondary outcomes showed increased AUD treatment at 6 months in the intervention group (intent-to-treat: 27.3% vs. 13.3%, OR 2.3, 95% CI, 0.61-8.76). There was a trend toward a 1-level or greater reduction in World Health Organization (WHO) drinking risk levels in the intervention group (OR 2.25, 95% CI, 0.51-9.97). CONCLUSIONS: A mobile health intervention for AUD treatment engagement was highly feasible, acceptable, and produced promising early outcomes, with improved AUD treatment engagement and alcohol reduction in ALD patients.

Feasibility and early experience of a novel multidisciplinary alcohol-associated liver disease clinic.

BACKGROUND: Alcohol cessation improves mortality in alcohol-associated liver disease (ALD), but access to treatment is limited. To address this gap, implementation and early feasibility and outcomes of a multidisciplinary ALD clinic are described. METHODS: The clinic comprised a hepatologist, psychiatrist, psychologist, nurse, and social worker. Patients included those with alcohol-associated cirrhosis or acute alcoholic hepatitis who were not in the transplant evaluation process, who had less than 6 months' sobriety and willingness to engage in alcohol use treatment. Psychosocial metrics in addition to routine hepatic function labs were collected. Treatment plans were tailored based on patient preferences and needs after multidisciplinary discussion. RESULTS: 89 patients were referred from both inpatient and outpatient settings, with 51 seen during the initial year. 38 remained active in clinic (4 died, 6 discharged, 3 moved to transplant clinic). 55% were women, 88% were white, 61% had private insurance. 49% had alcoholic hepatitis. 71% were decompensated. 80% had severe alcohol use disorder (AUD) and 84% had at least 1 comorbid psychiatric or substance use disorder. 63% chose one-on-one AUD treatment, 57% were prescribed relapse prevention medications. Mean MELD-Na score improved from baseline of 14 (SD 6.6) to 11.3 at 6 months (p=0.01). Hospital utilization significantly declined when comparing 6 months before to 6 months after initial visit (emergency department visits: 0.51 to 0.20 per person-month; inpatient admission: 0.34 to 0.14 per person-month; (ß= -0.89, 95% CI -1.18 to -0.60). CONCLUSIONS: A multidisciplinary ALD clinic was feasible with encouraging early outcomes. Further research should explore ways to expand this model and increase clinic capacity.

Adherence to Depression Treatment in Primary Care: A Randomized Clinical Trial.

Importance: Nonadherence to antidepressant medication is common and leads to poor outcomes. Early nonadherence is especially problematic. Objective: To test the effectiveness of a psychosocial intervention to improve early adherence among older patients whose primary care physician newly initiated an antidepressant for depression. Design, Setting, and Participants: The Treatment Initiation and Participation Program (TIP) was offered in a 2-site randomized clinical effectiveness study between January 2011 and December 2014 at primary care practices in New York, New York, and Ann Arbor, Michigan. Analyses began in February 2016. All participants were middle-aged and older adults (aged ≥55 years) who received newly initiated depression treatment by their primary care physician and recruited within 10 days of their prescription. Analyses were intention-to-treat. Interventions: Participants were randomly assigned to the intervention (TIP) or treatment as usual. Participants in the TIP group identified and addressed barriers to adherence, including stigma, misconceptions, and fears about treatment, before developing a personalized adherence strategy. The Treatment Initiation and Participation Program was delivered in three 30-minute contacts scheduled during a 6-week period just after the antidepressant was prescribed. Main Outcomes and Measures: The primary outcome was self-reported adherence on the Brief Medication Questionnaire, with adequate early adherence defined as taking 80% or more of the prescribed doses at 6 and 12 weeks. The secondary outcome was depression severity. Results: In total, 231 middle-aged and older adults (167 women [72.3%] and 64 men [27.7%]) without significant cognitive impairment were randomly assigned to the TIP intervention (n = 115) or treatment as usual (n = 116). Participants had a mean (SD) age of 67.3 (8.4) years. Participants in the TIP group were 5 times more likely to be adherent at 6 weeks (odds ratio, 5.54; 95% CI, 2.57 to 11.96; χ21 = 19.05; P < .001) and 3 times more likely to be adherent at both 6 and 12 weeks (odds ratio, 3.27; 95% CI, 1.73 to 6.17; χ21 = 13.34; P < .001). Participants in the TIP group showed a significant earlier reduction (24.9%) in depressive symptoms (95% CI, 13.9 to 35.9; t337 = 4.46; adjusted P < .001). In both groups, participants who were 80% adherent at weeks 6 and 12 had a 15% greater improvement in depressive symptoms from baseline over the course of treatment (95% CI, -0.2 to -30; t369 = 1.93; P = .051). Conclusions and Relevance: The Treatment Initiation and Participation Program is an effective intervention to improve early adherence to pharmacotherapy. Improved adherence can promote improvement in depression. Trial Registration: clinicaltrials.gov Identifier: NCT01301859.

Mortality among older adults with opioid use disorders in the Veteran's Health Administration, 2000-2011.

BACKGROUND: The population of people with opioid use disorders (OUD) is aging. There has been little research on the effects of aging on mortality rates and causes of death in this group. We aimed to compare mortality in older (≥ 50 years of age) adults with OUD to that in younger (<50 years) adults with OUD and older adults with no history of OUD. We also examined risk factors for specific causes of death in older adults with OUD. METHODS: Using data from the Veteran's Health Administration National Patient Care Database (2000-2011), we compared all-cause and cause-specific mortality rates in older adults with OUD to those in younger adults with OUD and older adults without OUD. We then generated a Cox regression model with specific causes of death treated as competing risks. RESULTS: Older adults with OUD were more likely to die from any cause than younger adults with OUD. The drug-related mortality rate did not decline with age. HIV-related and liver-related deaths were higher among older OUD compared to same-age peers without OUD. There were very few clinically important predictors of specific causes of death. CONCLUSION: Considerable drug-related mortality in people with OUD suggests a need for greater access to overdose prevention and opioid substitution therapy across the lifespan. Elevated risk of liver-related death in older adults may be addressed through antiviral therapy for hepatitis C virus infection. There is an urgent need to explore models of care that address the complex health needs of older adults with OUD.

Violent reinjury and mortality among youth seeking emergency department care for assault-related injury: a 2-year prospective cohort study.

IMPORTANCE: Violence is a leading cause of morbidity and mortality among youth, with more than 700000 emergency department (ED) visits annually for assault-related injuries. The risk for violent reinjury among high-risk, assault-injured youth is poorly understood. OBJECTIVE: To compare recidivism for violent injury and mortality outcomes among drug-using, assault-injured youth (AI group) and drug-using, non-assault-injured control participants (non-AI group) presenting to an urban ED for care. DESIGN, SETTING, AND PARTICIPANTS: Participants were enrolled in a prospective cohort study from December 2, 2009, through September 30, 2011, at an urban level I ED and followed up for 24 months. We administered validated measures of violence and substance use and mental health diagnostic interviews and reviewed medical records at baseline and at each point of follow-up (6, 12, 18, and 24 months). EXPOSURE: Follow-up over 24 months. MAIN OUTCOMES AND MEASURES: Use of ED services for assault or mortality measured from medical record abstraction supplemented with self-report. RESULTS: We followed 349 AI and 250 non-AI youth for 24 months. Youth in the AI group had almost twice the risk for a violent injury requiring ED care within 2 years compared with the non-AI group (36.7% vs 22.4%; relative risk [RR], 1.65 [95% CI, 1.25-2.14]; P<.001). Two-year mortality was 0.8%. Poisson regression modeling identified female sex (RR, 1.30 [95% CI, 1.02-1.65]), assault-related injury (RR, 1.57 [95% CI, 1.19-2.04), diagnosis of a drug use disorder (RR, 1.29 [95% CI, 1.01-1.65]), and posttraumatic stress disorder (RR, 1.47 [95% CI, 1.09-1.97]) at the index visit as predictive of ED recidivism or death within 24 months. Parametric survival models demonstrated that assault-related injury (P<.001), diagnosis of posttraumatic stress disorder (P=.008), and diagnosis of a drug use disorder (P= .03) significantly shortened the expected waiting time until the first ED return visit for violence or death. CONCLUSIONS AND RELEVANCE: Violent injury is a reoccurring disease, with one-third of our AI group experiencing another violent injury requiring ED care within 2 years of the index visit, almost twice the rate of a non-AI comparison group. Secondary violence prevention measures addressing substance use and mental health needs are needed to decrease subsequent morbidity and mortality due to violence in the first 6 months after an assault injury.

Distal and proximal factors associated with aggression towards partners and non-partners among patients in substance abuse treatment.

Studies of violence in substance use disorder (SUD) treatment settings typically focus on partner aggression (PA) although non-partner aggression (NPA) is also a common problem. This study examines potentially distinct paths of distal and proximal risk factors related to aggression towards non-partners (NPA) and partners (PA) among a SUD treatment sample. The sample included 176 adults reporting past-year violence. Bivariate analyses indicated several distal and proximal factors were associated with NPA and PA. According to multivariate, multiple mediation analyses youth aggression history was a factor for both NPA and PA. Alcohol and cocaine use and psychological distress were associated with NPA; marijuana use was associated with PA. There also was evidence of indirect effects of distal factors on NPA and PA. The results suggest that there may be substantially different dynamics associated with NPA and PA, and have implications for developing screening, assessment and treatment protocols targeting violence among individuals in SUD treatment.

Correlates of depressive symptoms among at-risk youth presenting to the emergency department.

OBJECTIVE: The study's objective was to identify correlates of depressive symptoms among at-risk youth in an urban emergency department (ED). METHOD: A systematic sample of adolescents (ages 14-18) in the ED were recruited as part of a larger study. Participants reporting past-year alcohol use and peer aggression self-administered a survey assessing: demographics, depressive symptoms and risk/protective factors. Logistic regression identified factors associated with depressive symptoms. RESULTS: Among 624 adolescents (88% response rate) meeting eligibility criteria, 22.8% (n=142) screened positive for depressive symptoms. In logistic regression, depressive symptoms were positively associated with female gender [odds ratio (OR): 2.84, 95% confidence interval (CI): 1.78-4.51], poor academic performance (OR: 1.57, 95% CI: 1.01-2.44), binge drinking (OR: 1.88, 95% CI: 1.21-2.91), community violence exposure (OR: 2.25, 95% CI: 1.59-3.18) and dating violence (OR: 2.14, 95% CI: 1.36-3.38) and were negatively associated with same-sex mentorship (OR: 0.52, 95% CI: 0.29-0.91) and older age (OR: 0.55, 95% CI 0.34-0.89). Including gender interaction terms did not significantly change findings. CONCLUSIONS: Screening and intervention approaches for youth in the urban ED should address the co-occurrence of depressive symptoms with peer and dating violence, alcohol and nonmarijuana illicit drug use.

Trends and predictors of quality of care in VA nursing homes related to serious mental illness.

OBJECTIVE: Within Veterans Affairs (VA) nursing homes (NHs), quality issues have a tremendous impact on the population with serious mental illness (SMI), who are more likely than their non-SMI Veteran counterparts to use NH services. We examined recent trends in quality indicators (QIs) measuring poor performance of VA NHs and whether the facility-level QIs vary with SMI concentration within the facility. METHODS: From VA administrative records including Minimum Data Set assessments, we identified all residents in the 135 VA NHs between fiscal years 2005 (FY05) through FY07. We used a zero-inflated Poisson regression to assess trends in and facility-level predictors of 3 process-related QIs: depression without antidepressant therapy; bladder/bowel incontinence without a toileting plan; and physical restraint use. Facility-level predictors included collocated special care units, rurality, staffing, physical plant characteristics, SMI prevalence, and SMI admission volume. RESULTS: During FY05-FY07, restraint use declined from 1.2% to 1.1% and incontinence without a toileting plan from 25.8% to 22.1%, but untreated depression increased from 5.1% to 5.5%. Despite overall gains in quality, higher SMI prevalence was associated with higher odds of physical restraint use and lack of toileting plan. Higher SMI prevalence was also associated with higher frequency of untreated depression. Other characteristics such as complex building structure were predictive of variation in quality, but the relationships were not consistent across QI types. CONCLUSION: VA NHs had significant improvements in these examined QIs during the study period. Nonetheless, overall poorer quality was observed at sites with higher SMI concentrations.

Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial.

AIMS: To examine whether a multi-faceted intervention among older at-risk drinking primary care patients reduced at-risk drinking and alcohol consumption at 3 and 12 months. DESIGN: Randomized controlled trial. SETTING: Three primary care sites in southern California. PARTICIPANTS: Six hundred and thirty-one adults aged ≥ 55 years who were at-risk drinkers identified by the Comorbidity Alcohol Risk Evaluation Tool (CARET) were assigned randomly between October 2004 and April 2007 during an office visit to receive a booklet on healthy behaviors or an intervention including a personalized report, booklet on alcohol and aging, drinking diary, advice from the primary care provider and telephone counseling from a health educator at 2, 4 and 8 weeks. MEASUREMENTS: The primary outcome was the proportion of participants meeting at-risk criteria, and secondary outcomes were number of drinks in past 7 days, heavy drinking (four or more drinks in a day) in the past 7 days and risk score. FINDINGS: At 3 months, relative to controls, fewer intervention group participants were at-risk drinkers [odds ratio (OR) 0.41; 95% confidence interval (CI) 0.22-0.75]; they reported drinking fewer drinks in the past 7 days [rate ratio (RR) 0.79; 95% CI 0.70-0.90], less heavy drinking (OR 0.46; 95% CI 0.22-0.99) and had lower risk scores (RR 0.77 95% CI 0.63-0.94). At 12 months, only the difference in number of drinks remained statistically significant (RR 0.87; 95% CI 0.76-0.99). CONCLUSIONS: A multi-faceted intervention among older at-risk drinkers in primary care does not reduce the proportions of at-risk or heavy drinkers, but does reduce amount of drinking at 12 months.

Alcohol, tobacco, and other drugs: future directions for screening and intervention in the emergency department.

This article is a product of a breakout session on injury prevention from the 2009 Academic Emergency Medicine consensus conference on "Public Health in the ED: Screening, Surveillance, and Intervention." The emergency department (ED) is an important entry portal into the medical care system. Given the epidemiology of substance use among ED patients, the delivery of effective brief interventions (BIs) for alcohol, drug, and tobacco use in the ED has the potential to have a large public health impact. To date, the results of randomized controlled trials of interventional studies in the ED setting for substance use have been mixed in regard to alcohol and understudied in the area of tobacco and other drugs. As a result, there are more questions remaining than answered. The work group developed the following research recommendations that are essential for the field of screening and BI for alcohol, tobacco, and other drugs in the ED. 1) Screening--develop and validate brief and practical screening instruments for ED patients and determine the optimal method for the administration of screening instruments. 2) Key components and delivery methods for intervention--conduct research on the effectiveness of screening, brief intervention, and referral to treatment (SBIRT) in the ED on outcomes (e.g., consumption, associated risk behaviors, and medical psychosocial consequences) including minimum dose needed, key components, optimal delivery method, interventions focused on multiple risk behaviors and tailored based on assessment, and strategies for addressing polysubstance use. 3) Effectiveness among patient subgroups--conduct research to determine which patients are most likely to benefit from a BI for substance use, including research on moderators and mediators of intervention effectiveness, and examine special populations using culturally and developmentally appropriate interventions. 4) Referral strategies--a) promote prospective effectiveness trials to test best strategies to facilitate referrals and access from the ED to preventive services, community resources, and substance abuse and mental health treatment; b) examine impact of available community services; c) examine the role of stigma of referral and follow-up; and d) examine alternatives to specialized treatment referral. 5) Translation--conduct translational and cost-effectiveness research of proven efficacious interventions, with attention to fidelity, to move ED SBIRT from research to practice.

Symptoms of depression and anxiety (MHI) following acute medical/surgical hospitalization and post-discharge psychiatric diagnoses (DSM) in 839 geriatric US veterans.

OBJECTIVE: We addressed the relatively unexplored use of screening scores measuring symptoms of depression and/or anxiety to aid in identifying patients at increased risk for post-discharge DSM-IV Axis I diagnoses. We were unable to find such studies in the literature. METHOD: Elderly veterans without recent psychiatric diagnoses were screened for depression and anxiety symptoms upon admission to acute medical/surgical units using the Mental Health Inventory (MHI). Following discharge, those who had exceeded cut-off scores and had been randomized to UPBEAT Care (Unified Psychogeriatric Biopsychosocial Evaluation and Treatment, a clinical demonstration project) were evaluated for DSM diagnoses. We report on 839 patients, mostly male (96.3%; mean age 69.6 +/- 6.7 years), comparing three groups, i.e. those meeting screening criteria for symptoms of (i) depression only; (ii) anxiety only; and (iii) both depression and anxiety. RESULTS: Despite absence of recent psychiatric history, 58.6% of the 839 patients received a DSM diagnosis post-discharge (21.8% adjustment; 15.4% anxiety; 7.5% mood; and 14.0% other disorders). Patients meeting screening criteria for both depression and anxiety symptoms received a DSM diagnosis more frequently than those meeting criteria for anxiety symptoms only (61.9% vs 49.0%, p = 0.017), but did not differ significantly from those meeting criteria for depressive symptoms only (61.9% vs 56.8%, p = 0.174). Although exceeding the MHI screening cut-off scores for depression, anxiety, or both helped to identify patients with a post-discharge DSM diagnosis, the actual MHI screening scores failed to do so. CONCLUSION: Screening hospitalized medical/surgical patients for symptoms of depression, anxiety, and particularly for the combination thereof, may help identify those with increased risk of subsequent DSM diagnoses, including adjustment disorder.