HealthCall: Smartphone Enhancement of Brief Interventions to Improve HIV Medication Adherence Among Patients in HIV Care.

Heavy drinking among people living with HIV (PLWH) reduces ART adherence and worsens health outcomes. Lengthy interventions are not feasible in most HIV care settings, and patients infrequently follow referrals to outside treatment. Utilizing visual and video features of smartphone technology, we developed HealthCall as an electronic means of increasing patient involvement in a brief intervention to reduce drinking and improve ART adherence. The objective of the current study is to evaluate the efficacy of HealthCall to improve ART adherence among PLWH who drink heavily when paired with two brief interventions: the National Institute on Alcoholism and Alcohol Abuse (NIAAA) Clinician's Guide (CG) or Motivational Interviewing (MI). Therefore, we conducted a 1:1:1 randomized trial among 114 participants with alcohol dependence at a large urban HIV clinic. Participants were randomized to one of three groups: (1) CG only (n = 37), (2) CG and HealthCall (n = 38), or (3) MI and HealthCall (n = 39). Baseline interventions targeting drinking reduction and ART adherence were ~ 25 min, with brief (10-15 min) booster sessions at 30 and 60 days. The outcome was ART adherence assessed using unannounced phone pill-count method (possible adherence scores: 0-100%) at 30-day, 60-day, 3, 6, and 12 months. Analyses were conducted using generalized linear mixed models with pre-planned contrasts. Of the 114 enrolled patients, 58% were male, 75% identified as Black/African American, 28% were Hispanic, and 62% had less than a high school education. The mean age was 47.5 years (standard deviation [SD] 10 years) and the mean number of years since they were diagnosed with HIV was 18.6 (SD 7.6). Participants assigned to HealthCall to extend the CG had increased levels of ART adherence at 60-day and 6-month follow-up (compared to CG only), although there was no statistically significant difference by 12-month follow-up. Participants who were assigned to HealthCall to extend the MI never had statistically significant higher levels of ART adherence. These results suggest that the use of a smartphone app can be used to initially extend the reach of a brief drinking intervention to improve ART adherence over a short period of time; however, sustained long-term improvements in ART adherence after intervention activity ends remains a challenge.

An Intervention to Reduce Drinking Among Individuals With HIV and Hepatitis C: A Pilot Randomized Controlled Trial.

OBJECTIVE: Heavy drinking poses serious risks to individuals with HIV, hepatitis C virus (HCV), and especially HIV/HCV coinfection. We adapted the National Institute on Alcohol Abuse and Alcoholism Clinician's Guide to address HIV/HCV coinfection and paired this with the "HealthCall" smartphone app to create an intervention tailored to HIV/HCV. After formative work and pretesting with HIV/HCV coinfected heavy drinkers, we conducted a pilot trial to determine potential of this new intervention for decreasing drinking. METHOD: A sample of 31 HIV/HCV coinfected heavy drinkers were randomly assigned to either intervention (n = 16) or control (n = 15; psychoeducation and brief advice) conditions. All participants completed a 60-day program consisting of approximately 25-minute-long baseline sessions and brief 5-10-minute booster sessions at 30 and 60 days, as well as an assessment-only follow-up at 90 days. Outcomes were measured using the Timeline Followback at baseline, 30, 60, and 90 days. Generalized linear models were used for analysis. RESULTS: Intervention participants drank fewer mean drinks per drinking day at 60 days (incidence rate ratio [IRR] = 0.43, p = .03) and 90 days (IRR = 0.34, p < .01). Intervention participants also reported fewer drinking days at 90 days (mean difference = 34.5%; p < .01). Self-efficacy differed between groups during intervention (p < .05). CONCLUSIONS: Although our sample was small, our results suggested lower drinking among participants who received a modified Clinician's Guide intervention plus use of the smartphone app HealthCall, in comparison with education and advice alone. A larger study is indicated to further examine this brief, disseminable intervention for HIV/HCV coinfected drinkers.

Comparing mental and physical health of U.S. veterans by VA healthcare use: implications for generalizability of research in the VA electronic health records.

OBJECTIVE: The Department of Veterans Affairs' (VA) electronic health records (EHR) offer a rich source of big data to study medical and health care questions, but patient eligibility and preferences may limit generalizability of findings. We therefore examined the representativeness of VA veterans by comparing veterans using VA healthcare services to those who do not. METHODS: We analyzed data on 3051 veteran participants age ≥ 18 years in the 2019 National Health Interview Survey. Weighted logistic regression was used to model participant characteristics, health conditions, pain, and self-reported health by past year VA healthcare use and generate predicted marginal prevalences, which were used to calculate Cohen's d of group differences in absolute risk by past-year VA healthcare use. RESULTS: Among veterans, 30.4% had past-year VA healthcare use. Veterans with lower income and members of racial/ethnic minority groups were more likely to report past-year VA healthcare use. Health conditions overrepresented in past-year VA healthcare users included chronic medical conditions (80.6% vs. 69.4%, d = 0.36), pain (78.9% vs. 65.9%; d = 0.35), mental distress (11.6% vs. 5.9%; d = 0.47), anxiety (10.8% vs. 4.1%; d = 0.67), and fair/poor self-reported health (27.9% vs. 18.0%; d = 0.40). CONCLUSIONS: Heterogeneity in veteran sociodemographic and health characteristics was observed by past-year VA healthcare use. Researchers working with VA EHR data should consider how the patient selection process may relate to the exposures and outcomes under study. Statistical reweighting may be needed to generalize risk estimates from the VA EHR data to the overall veteran population.

Construct validity of DSM-5 cannabis use disorder diagnosis and severity levels in adults with problematic substance use.

The DSM-5 definition of cannabis use disorder (CUD) differs from DSM-IV by combining abuse and dependence criteria (without the legal criterion) and including withdrawal and craving criteria. Information on construct validity of the DSM-5 CUD diagnosis and severity levels is lacking. This study examines the associations between DSM-5 CUD and severity classification and a set of concurrent validators. Adults with problematic substance use were recruited from two settings: a research setting in an urban medical center and a suburban inpatient addiction treatment program. Participants who reported past-year cannabis use (n = 392) were included in this study and completed a semi-structured, clinician-administered diagnostic interview. Regression models estimated the associations between binary DSM-5 CUD and severity levels with a set of validators, including cannabis use variables, psychopathology, and functional impairment. DSM-5 CUD and all severity levels were associated with cannabis use validators, including number of days used, self-reporting that cannabis use was a major problem, and greater cannabis craving. DSM-5 CUD and severe CUD were associated with other psychiatric disorders and social impairment. Findings add information about the validity of DSM-5 CUD diagnosis and severity levels, with severe CUD receiving the strongest support from its association with validators across all domains, as distinct from the mild and moderate CUD measures that were associated with cannabis-specific validators alone. Severe CUD is likely to require more intensive treatment to bolster physical, psychiatric, and social functioning, whereas the mild and moderate severity thresholds provide useful information for identifying less severe disorders for prevention and brief intervention.

Diagnosing Prescription Opioid Use Disorder in Patients Using Prescribed Opioids for Chronic Pain.

OBJECTIVE: The diagnostic criteria for opioid use disorder, originally developed for heroin, did not anticipate the surge in prescription opioid use and the resulting complexities in diagnosing prescription opioid use disorder (POUD), including differentiation of pain relief (therapeutic intent) from more common drug use motives, such as to get high or to cope with negative affect. The authors examined the validity of the Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 opioid version, an instrument designed to make this differentiation. METHODS: Patients (N=606) from pain clinics and inpatient substance treatment who ever received a ≥30-day opioid prescription for chronic pain were evaluated for DSM-5 POUD (i.e., withdrawal and tolerance were not considered positive if patients used opioids only as prescribed, per DSM-5 guidelines) and pain-adjusted POUD (behavioral/subjective criteria were not considered positive if pain relief [therapeutic intent] was the sole motive). Bivariate correlated-outcome regression models indicated associations of 10 validators with DSM-5 and pain-adjusted POUD measures, using mean ratios for dimensional measures and odds ratios for binary measures. RESULTS: The prevalences of DSM-5 and pain-adjusted POUD, respectively, were 44.4% and 30.4% at the ≥2-criteria threshold and 29.5% and 25.3% at the ≥4-criteria threshold. Pain adjustment had little effect on prevalence among substance treatment patients but resulted in substantially lower prevalence among pain treatment patients. All validators had significantly stronger associations with pain-adjusted than with DSM-5 dimensional POUD measures (ratios of mean ratios, 1.22-2.31). For most validators, pain-adjusted binary POUD had larger odds ratios than DSM-5 measures. CONCLUSIONS: Adapting POUD measures for pain relief (therapeutic intent) improved validity. Studies should investigate the clinical utility of differentiating between therapeutic and nontherapeutic intent in evaluating POUD diagnostic criteria.

Validity of the DSM-5 tobacco use disorder diagnostics in adults with problematic substance use.

BACKGROUND: DSM-5 tobacco use disorder (TUD) nosology differs from DSM-IV nicotine dependence (ND) by including craving and DSM-IV abuse criteria, a lower threshold (≥ 2 criteria), and severity levels (mild; moderate; severe). We assessed concurrent and prospective validity of the DSM-5 TUD diagnosis and severity and compared validity with DSM-IV ND diagnosis. METHODS: The sample included U.S. adults with current problematic substance use and past year cigarette smoking (N = 396). Baseline assessment collected information on DSM-IV ND and DSM-5 TUD criteria, smoking-related variables, and psychopathology. Over the following 90 days, electronic daily assessments queried smoking and cigarette craving. Variables expected to be related to TUD were validators: cigarette consumption, cigarette craving scale, Fagerström Test for Nicotine Dependence, and psychiatric disorders. Regression models estimated the association of each validator with DSM-5 TUD and severity levels, and differential association between DSM-5 TUD and DSM-IV ND diagnoses. RESULTS: DSM-5 TUD and DSM-IV ND were associated with most baseline validators (p-values < 0.05), with significantly stronger associations with DSM-5 TUD for number of days smoked (p = 0.023) and cigarette craving scale (p = 0.007). Baseline DSM-5 TUD and DSM-IV ND predicted smoking and craving on any given day during follow-up, with stronger associations for DSM-5 TUD (association difference [95% CI%]: any smoking, 0.53 [0.27, 0.77]; number of cigarettes smoked, 1.36 [0.89, 1.78]; craving scale, 0.19 [0.09, 0.28]). Validators were associated with TUD severity in a dose-dependent manner. CONCLUSION: DSM-5 TUD diagnostic measures as operationalized here demonstrated concurrent and prospective validity. Inclusion of new criteria, particularly craving, improved validity and clinical relevance.

HealthCall: A randomized trial assessing a smartphone enhancement of brief interventions to reduce heavy drinking in HIV care.

INTRODUCTION: Heavy drinking among people living with HIV (PLWH) worsens their health outcomes and disrupts their HIV care. Although brief interventions to reduce heavy drinking in primary care are effective, more extensive intervention may be needed in PLWH with moderate-to-severe alcohol use disorder. Lengthy interventions are not feasible in most HIV primary care settings, and patients seldom follow referrals to outside treatment. Utilizing visual and video features of smartphone technology, we developed the "HealthCall" app to provide continued engagement after brief intervention, reduce drinking, and improve other aspects of HIV care with minimal demands on providers. We conducted a randomized trial of its efficacy. METHODS: The study recruited alcohol-dependent PLWH (n = 114) from a large urban HIV clinic. Using a 1:1:1 randomized design, the study assigned patients to: Motivational Interviewing (MI) plus HealthCall (n = 39); NIAAA Clinician's Guide (CG) plus HealthCall (n = 38); or CG-only (n = 37). Baseline MI and CG interventions took ~25 min, with brief (10-15 min) 30- and 60-day booster sessions. HealthCall involved daily use of the smartphone app (3-5 min/day) to report drinking and health in the prior 24 h. Outcomes assessed at 30 and 60 days and at 3, 6 and 12 months included drinks per drinking day (DpDD; primary outcome) and number of drinking days, analyzed with generalized linear mixed models and pre-planned contrasts. RESULTS: Study retention was excellent (85%-94% across timepoints). At 30 days, DpDD among patients in MI + HealthCall, CG + HealthCall, and CG-only was 3.80, 5.28, and 5.67, respectively; patients in MI + HealthCall drank less than CG-only and CG + HealthCall (IRRs = 0.62, 95% CI = 0.46, 0.84, and 0.64, 95% CI = 0.48, 0.87, respectively). At 6 months (end-of-treatment), DpDD was lower in CG + HealthCall (DpDD = 4.88) than MI + HealthCall (DpDD = 5.88) or CG-only (DpDD = 6.91), although these differences were not significant. At 12 months, DpDD was 5.73, 5.31, and 6.79 in MI + HealthCall, CG + HealthCall, and CG-only, respectively; DpDD was significantly lower in CG + HealthCall than CG-only (IRR = 0.71, 95% CI = 0.51, 0.98). CONCLUSIONS: During treatment, patients in MI + HealthCall had lower DpDD than patients in other conditions; however, at 12 months, drinking was lowest among patients in CG + HealthCall. Given the importance of drinking reduction and the low costs/time required for HealthCall, pairing HealthCall with brief interventions merits widespread consideration.

Psychosocial and health problems associated with alcohol use disorder and cannabis use disorder in U.S. adults.

BACKGROUND: Although the problems associated with alcohol use disorder (AUD) are well known, little is known about the psychosocial problems associated with cannabis use disorder (CUD), and the harmfulness of CUD relative to AUD. We compared the odds of psychosocial and health-related problems between individuals with DSM-5 AUD-only, CUD-only and co-occurring AUD+CUD. METHODS: The 2012-2013 NESARC-III, a nationally representative cross-sectional survey of non-institutionalized US adults (n = 36,309), assessed participants for DSM-5 AUD, CUD, and psychosocial (interpersonal, financial, legal) and health-related problems. Based on their responses, participants were categorized into mutually exclusive groups: no AUD/CUD, AUD-only, CUD-only, and AUD+CUD. Multivariable logistic regression models examined the associations between psychosocial problems and the four AUD/CUD groups, adjusting for sociodemographic characteristics. RESULTS: People with AUD-only, CUD-only, and AUD+CUD had higher odds of most interpersonal problems (adjusted odds ratio [aORs] 1.07-4.01), financial problems (aORs 1.53-4.28), legal problems (aORs 3.34-7.71), and health-related problems (aORs 1.29-1.92). The odds of psychosocial and health-related problems were similar for CUD-only and AUD-only in direct comparisons. Compared to those with AUD-only, those with AUD+CUD had higher odds of most problems examined (aORs 1.42-2.31). In contrast, there were few differences when comparing AUD+CUD with CUD-only. CONCLUSIONS: AUD and CUD were similarly associated with interpersonal, financial, and legal problems, emergency treatment and suicide attempt. People with AUD+CUD had higher odds of certain problems than individuals with either AUD-only or CUD-only. Although most people who use cannabis do not experience harms, our results indicate that CUD does not appear to be less harmful than AUD.

Agreement between DSM-5 and DSM-IV measures of substance use disorders in a sample of adult substance users.

BACKGROUND: In DSM-5, definitions of substance use disorders (SUD) were changed considerably from DSM-IV, yet little is known about how well DSM-IV and DSM-5 SUD diagnoses agree among substance users. Because data from many studies are based on DSM-IV diagnostic criteria, understanding the agreement between DSM-5 and DSM-IV SUD diagnoses and reasons for discordance between these diagnoses is crucial for comparing results across studies. MEASUREMENTS: Prevalences and chance-corrected agreement of DSM-5 SUD and DSM-IV substance dependence were evaluated in 588 substance users in a suburban inpatient addiction program and an urban medical center, using a semi-structured interview (PRISM-5). Alcohol, tobacco, cannabis, cocaine, heroin, opioid, sedative, and stimulant use disorders were examined. Cohen's kappa was used to assess agreement between DSM-5 and DSM-IV SUD (abuse or dependence), DSM-5 SUD and DSM-IV dependence, and DSM-5 moderate/severe SUD and DSM-IV dependence. RESULTS: Agreement between DSM-5 and DSM-IV SUD was excellent for all substances (κ = 0.84-0.99), except for cannabis and tobacco (κ = 0.75; 0.80, respectively). The most common reason for diagnostic discrepancies was a positive DSM-5 SUD diagnosis but no DSM-IV diagnosis, due to the lowered DSM-5 SUD threshold. Agreement between DSM-5 SUD and DSM-IV dependence was excellent for all substances (κ = 0.88-0.94), except for alcohol, tobacco, and cannabis (κ = 0.63-0.75). Agreement between moderate/severe DSM-5 SUD and DSM-IV dependence was excellent across all substances. CONCLUSION: While care should be used in interpreting results of studies using different methods, studies relying on DSM-IV or DSM-5 SUD diagnostic criteria offer similar information and thus can be compared when accumulating a body of evidence.

Assessment of Didactic Transesophageal Echocardiography Education During Anesthesia Residency.

BACKGROUND: Transesophageal echocardiography can be a useful monitor during noncardiac surgery, in patients with comorbidities and/or undergoing procedures associated with substantial hemodynamic changes. The goal of this study was to investigate if transesophageal-echocardiography-related knowledge could be acquired during anesthesia residency. METHODS: After institutional review board approval, a prospective observational study was performed in two anesthesiology residency programs. After a 41-week didactic transesophageal-echocardiography-education curriculum residents' exam scores were compared to baseline. The educators' examination was validated against the National Board of Echocardiography's Examination of Special Competence in Advanced Perioperative Transesophageal Echocardiography. RESULTS: After the 41-week course, clinical anesthesia (CA)-3 exam scores increased 12% compared to baseline (P = .03), CA-2 scores increased 29% (P = .007), and CA-1 scores increased 25% (P = .002). Pearson correlation coefficient between the educators' exam score and the special competence exam percentile rank was 0.69 (P = .006). Pearson correlation coefficient between the educators' exam score and the special competence exam scaled score was 0.71 (P = .0045). CONCLUSIONS: The 41-week course resulted in significant increases in exam scores in all 3 CA-classes. While didactic knowledge can be learned by anesthesiology residents during training, it requires significant time and effort. It is important to educate residents in echocardiography, to prepare them for board examinations and to care for the increasingly older and sicker patient population. Further work needs to be done to determine optimal methods to provide such education.

Test-retest reliability of DSM-5 substance disorder measures as assessed with the PRISM-5, a clinician-administered diagnostic interview.

AIM: In DSM-5, the definitions of substance use disorders (SUD) were changed considerably, yet little is known about the reliability of DSM-5 SUD and its new features. METHODS: The test-retest reliability of DSM-5 SUD and DSM-IV substance dependence (SD) was evaluated in 565 adult substance users, each interviewed twice by different clinician interviewers using the semi-structured Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 version (PRISM-5). DSM-5 SUD and DSM-IV SD criteria were assessed for past year and lifetime, yielding diagnoses and severity levels for alcohol, tobacco, cannabis, cocaine, heroin, opioids, sedatives, hallucinogen, and stimulant use disorders. Cohen's and intraclass correlation coefficients (ICC) assessed reliability for categorical and graded outcomes, respectively. Factors potentially influencing reliability were explored, including inpatient vs. community participant, days between interviews gender, age, race/ethnicity, and SUD severity. RESULTS: DSM-5 SUD diagnoses had substantial to excellent reliability for most substances (κ = 0.63-0.94), and moderate for others (hallucinogens, stimulants, sedatives; κ = 0.50-0.59). For graded outcomes (DSM-5 SUD mild, moderate, severe; criteria count 0-11), reliability was substantial to excellent (ICC = 0.74-0.99). Comparisons of DSM-5 SUD and DSM-IV SD reliability showed few significant differences. Reliability of the DSM-5 craving criterion was excellent for heroin (κ = 0.84-0.95) and moderate to substantial for other substances (κ = 0.49-0.76). The only factor influencing reliability of SUD was severity, with milder disorders significantly more likely to be discordant between the interviews. CONCLUSION: Reproducibility is crucial to good measurement. In a large sample using rigorous methodology, diagnoses and dimensional measures from clinician-administered interviews for DSM-5 SUD were generally highly reliable.

Modified cognitive behavioral therapy (M-CBT) for cocaine dependence: Development of treatment for cognitively impaired users and results from a Stage 1 trial.

Cognitive impairments are associated with poor outcomes when treating cocaine dependent patients, but behavioral interventions to mitigate this impact have not been developed. In this Stage 1A/1B treatment development study, several compensatory strategies (e.g., content repetition, daily logs, diaries, visual presentation) were combined to create a modified cognitive behavioral therapy (M-CBT) for treating cocaine dependence. Initially, a select group of therapists, neuropsychology experts, and patients were asked to provide input on early drafts of the treatment manual and companion patient workbook. After an uncontrolled small trial (N = 15) and two rounds of manual development (Stage 1A), a pilot randomized clinical trial (N = 102) of cocaine dependent outpatients with and without cognitive impairments was conducted (Stage 1B). Participants were randomized to M-CBT (N = 52) or CBT (N = 50). Both treatments were individually delivered over 12 weeks with assessments conducted at baseline, end-of-treatment, and 3-month follow-up. The primary outcome was frequency of cocaine use, measured by number of days used in the prior 7 days. Participants in the two treatment groups did not differ significantly on drug use reduction or retention in treatment. However, among participants who completed at least 9 weeks of treatment, those in M-CBT showed a trend toward greater reduction in cocaine use compared to those in the CBT group. M-CBT is feasible for impaired and nonimpaired cocaine dependent participants. However, M-CBT treatment did not show significant superiority over standard CBT in the present sample. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States.

Importance: No US national data are available on the prevalence and correlates of DSM-5-defined major depressive disorder (MDD) or on MDD specifiers as defined in DSM-5. Objective: To present current nationally representative findings on the prevalence, correlates, psychiatric comorbidity, functioning, and treatment of DSM-5 MDD and initial information on the prevalence, severity, and treatment of DSM-5 MDD severity, anxious/distressed specifier, and mixed-features specifier, as well as cases that would have been characterized as bereavement in DSM-IV. Design, Setting, and Participants: In-person interviews with a representative sample of US noninstitutionalized civilian adults (≥18 years) (n = 36 309) who participated in the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III). Data were collected from April 2012 to June 2013 and were analyzed in 2016-2017. Main Outcomes and Measures: Prevalence of DSM-5 MDD and the DSM-5 specifiers. Odds ratios (ORs), adjusted ORs (aORs), and 95% CIs indicated associations with demographic characteristics and other psychiatric disorders. Results: Of the 36 309 adult participants in NESARC-III, 12-month and lifetime prevalences of MDD were 10.4% and 20.6%, respectively. Odds of 12-month MDD were significantly lower in men (OR, 0.5; 95% CI, 0.46-0.55) and in African American (OR, 0.6; 95% CI, 0.54-0.68), Asian/Pacific Islander (OR, 0.6; 95% CI, 0.45-0.67), and Hispanic (OR, 0.7; 95% CI, 0.62-0.78) adults than in white adults and were higher in younger adults (age range, 18-29 years; OR, 3.0; 95% CI, 2.48-3.55) and those with low incomes ($19 999 or less; OR, 1.7; 95% CI, 1.49-2.04). Associations of MDD with psychiatric disorders ranged from an aOR of 2.1 (95% CI, 1.84-2.35) for specific phobia to an aOR of 5.7 (95% CI, 4.98-6.50) for generalized anxiety disorder. Associations of MDD with substance use disorders ranged from an aOR of 1.8 (95% CI, 1.63-2.01) for alcohol to an aOR of 3.0 (95% CI, 2.57-3.55) for any drug. Most lifetime MDD cases were moderate (39.7%) or severe (49.5%). Almost 70% with lifetime MDD had some type of treatment. Functioning among those with severe MDD was approximately 1 SD below the national mean. Among 12.9% of those with lifetime MDD, all episodes occurred just after the death of someone close and lasted less than 2 months. The anxious/distressed specifier characterized 74.6% of MDD cases, and the mixed-features specifier characterized 15.5%. Controlling for severity, both specifiers were associated with early onset, poor course and functioning, and suicidality. Conclusions and Relevance: Among US adults, DSM-5 MDD is highly prevalent, comorbid, and disabling. While most cases received some treatment, a substantial minority did not. Much remains to be learned about the DSM-5 MDD specifiers in the general population.

Heavy drinking among individuals with HIV: who drinks despite knowledge of the risk?

Heavy drinking can cause medical problems for individuals with HIV, and drinking despite medical contraindications indicates problem use. However, little is known about which individuals with HIV drink despite knowledge of health problems. This study utilizes two subsamples of individuals with HIV from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III): those reporting at least one drink (a) in their lifetime (n = 205) or (b) in the past year (n = 166). Participants reported on drinking despite health problems and psychopathology in the past year and in their lifetime, and family history of alcohol problems. Individuals with a drug use disorder (Adjusted Odds Ratios [AORs] = 3.56-12.65), major depressive disorder (AORs = 10.18-10.55), or a family history of alcohol problems (AORs = 33.60-96.01) were more likely to drink despite health problems. Anxiety and personality disorders did not increase risk. Individuals with HIV with drug use disorders or major depressive disorder are more likely to drink despite health problems. Individuals with a family history of alcohol problems were also more likely to do so, although further research is needed given large confidence intervals. Future research should consider how to help these individuals avoid alcohol-related harm.

Association between change in self-efficacy to resist drinking and drinking behaviors among an HIV-infected sample: Results from a large randomized controlled trial.

Heavy drinking among HIV-infected individuals is associated with health complications. Health-behavior self-efficacy may be characteristically low among this population or negatively affected by HIV-infected status. We assessed whether self-efficacy to resist drinking increased during brief educational and motivational drinking-reduction interventions within HIV primary care and whether increases in self-efficacy predicted drinking among HIV-infected heavy drinkers. Results indicate that increases in self-efficacy from baseline to end-of-intervention inversely predicted drinking at end-of-intervention and at follow-up. Findings suggest that brief treatment interventions within HIV primary care may promote self-efficacy and that increases in self-efficacy predict initiation and maintenance of drinking reductions among HIV patients.

HealthCall delivered via smartphone to reduce co-occurring drug and alcohol use in HIV-infected adults: A randomized pilot trial.

AIMS: Co-occurrence of drug and alcohol use among people living with HIV is linked to poor medication adherence and lack of viral suppression. HealthCall, a technological enhancement of brief Motivational Interviewing (MI), involves brief daily self-monitoring, positive reinforcement, and personalized feedback. This randomized pilot study among people living with HIV investigated the feasibility and efficacy of reducing non-injection drug and alcohol use with MI+HealthCall as adapted for smartphone technology. DESIGN: An urban, largely-minority community sample of adults living with HIV were screened for eligibility: last 30 day use of non-injection drugs (≥4days of crack/cocaine, methamphetamine, or heroin use) and binge drinking (≥1day of 4+ standard drinks). Those eligible were randomized to one of two groups: MI-only (n=21) and MI+HealthCall-S (n=21). Trained counselors delivered the brief MI at baseline. Drug and alcohol use assessments were completed at baseline, 30 and 60days (end of treatment). Primary outcomes derived from a Timeline Follow Back (TLFB) of the past 30 days included (1) total number of days used primary drug (NumDU) (2) total quantity of primary drug used (dollar amount spent per day; QuantU), (3) total number of drinking days (NumDD) and (4) mean number of drinks per day (QuantDD). Feasibility was determined by HealthCall use rates, patient satisfaction questionnaire (1-5 scale, 5 being best), and retention. FINDINGS: The median daily use rate for HealthCall was 95%, patient satisfaction was excellent (4.5) and retention was high (93%). Both treatment groups reduced drug and alcohol use by end of treatment, with MI+Healthcall-S showing significantly greater reductions than MI-only in QuantU (p=0.01) and NumDU (p=0.046). P-values for reductions in alcohol quantity and frequency in the MI+Healthcall group were 0.09-0.11. CONCLUSIONS: This proof-of-concept randomized trial indicates that HealthCall on the smartphone is a highly feasible intervention in urban, minority individuals with HIV, and suggests efficacy in reducing co-occurring drug and alcohol use. Results suggest opportunities for brief behavioral intervention that may be enhanced through interactive mobile technology to address complex alcohol and drug use patterns that interfere with HIV care, medication adherence and ultimately, viral suppression. A larger randomized trial is warranted to replicate and extend present results.

Drinking despite health problems among individuals with liver disease across the United States.

BACKGROUND: Heavy drinking is harmful for individuals with liver disease. However, some of these individuals drink despite knowledge of the risks. The current study aims to identify factors underlying drinking despite health problems among individuals with liver disease. METHODS: The current study utilizes a subsample of individuals reporting past-year liver disease and at least one drink in the past year (n=331), taken from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III), a large nationally representative survey of the United States. Participants reported on drinking despite health problems, symptoms of psychopathology, and family history of alcohol problems in a cross-sectional survey. RESULTS: Drug use disorders (Adjusted Odds Ratio [AOR]=2.68), as well as borderline, antisocial, and schizotypal personality disorders (AORs=2.50-4.10), were associated with increased likelihood of drinking despite health problems among individuals with liver disease, all ps<0.05. Any anxiety disorder trended toward significance (AOR=2.22), p=0.06, but major depressive disorder was not associated with increased risk, (AOR=0.99), ps=0.97. Individuals with a family history of alcohol problems were also more likely to drink despite health problems (AOR=2.79), p<0.05. CONCLUSIONS: Several types of psychopathology, as well as a family history of alcohol problems, increased the likelihood of drinking despite health problems among individuals with liver disease. These findings highlight the need to intervene with heavily drinking individuals with liver disease, who may be drinking due to familial risk and/or comorbid psychopathology.

US Adult Illicit Cannabis Use, Cannabis Use Disorder, and Medical Marijuana Laws: 1991-1992 to 2012-2013.

Importance: Over the last 25 years, illicit cannabis use and cannabis use disorders have increased among US adults, and 28 states have passed medical marijuana laws (MML). Little is known about MML and adult illicit cannabis use or cannabis use disorders considered over time. Objective: To present national data on state MML and degree of change in the prevalence of cannabis use and disorders. Design, Participants, and Setting: Differences in the degree of change between those living in MML states and other states were examined using 3 cross-sectional US adult surveys: the National Longitudinal Alcohol Epidemiologic Survey (NLAES; 1991-1992), the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; 2001-2002), and the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III; 2012-2013). Early-MML states passed MML between NLAES and NESARC ("earlier period"). Late-MML states passed MML between NESARC and NESARC-III ("later period"). Main Outcomes and Measures: Past-year illicit cannabis use and DSM-IV cannabis use disorder. Results: Overall, from 1991-1992 to 2012-2013, illicit cannabis use increased significantly more in states that passed MML than in other states (1.4-percentage point more; SE, 0.5; P = .004), as did cannabis use disorders (0.7-percentage point more; SE, 0.3; P = .03). In the earlier period, illicit cannabis use and disorders decreased similarly in non-MML states and in California (where prevalence was much higher to start with). In contrast, in remaining early-MML states, the prevalence of use and disorders increased. Remaining early-MML and non-MML states differed significantly for use (by 2.5 percentage points; SE, 0.9; P = .004) and disorder (1.1 percentage points; SE, 0.5; P = .02). In the later period, illicit use increased by the following percentage points: never-MML states, 3.5 (SE, 0.5); California, 5.3 (SE, 1.0); Colorado, 7.0 (SE, 1.6); other early-MML states, 2.6 (SE, 0.9); and late-MML states, 5.1 (SE, 0.8). Compared with never-MML states, increases in use were significantly greater in late-MML states (1.6-percentage point more; SE, 0.6; P = .01), California (1.8-percentage point more; SE, 0.9; P = .04), and Colorado (3.5-percentage point more; SE, 1.5; P = .03). Increases in cannabis use disorder, which was less prevalent, were smaller but followed similar patterns descriptively, with change greater than never-MML states in California (1.0-percentage point more; SE, 0.5; P = .06) and Colorado (1.6-percentage point more; SE, 0.8; P = .04). Conclusions and Relevance: Medical marijuana laws appear to have contributed to increased prevalence of illicit cannabis use and cannabis use disorders. State-specific policy changes may also have played a role. While medical marijuana may help some, cannabis-related health consequences associated with changes in state marijuana laws should receive consideration by health care professionals and the public.

Reasons for drinking as predictors of alcohol involvement one year later among HIV-infected individuals with and without hepatitis C.

INTRODUCTION: Heavy drinking can be harmful for individuals with HIV, particularly those coinfected with hepatitis C virus (HCV). HIV patients' reasons for drinking predict short-term alcohol involvement, but whether they predict longer-term involvement is unknown. Also, it remains unknown whether these motives are differentially predictive for HIV monoinfected and HIV/HCV coinfected patients. METHOD: HIV-infected heavy drinkers (n = 254) participated in a randomized trial of brief alcohol interventions, 236 (92.9%) of whom reported on baseline motives and alcohol involvement 12 months later (77.1% male, 94.9% minority, 30.6% with HCV). RESULTS: Greater endorsement of baseline drinking to cope with negative affect predicted greater alcohol dependence symptoms at 12 months (incident rate ratio [IRR] = 1.80, p < 0.05), while greater endorsement of baseline drinking due to social pressure predicted fewer drinks consumed at 12 months (IRR = 0.67, p < 0.05). Coping and social reasons were both predictive for HIV monoinfected patients, whereas only coping reasons were predictive for HIV/HCV coinfected patients. DISCUSSION: Drinking for coping and social reasons predict alcohol involvement 12 months later; however, social reasons may only be important for HIV monoinfected patients. Understanding patient reasons for drinking may help predict patient risk up to a year later. KEY MESSAGES Among HIV patients, drinking motives predict alcohol involvement 12 months later. For HIV monoinfected patients, drinking to cope and drinking for social reasons predict 12-month alcohol involvement. For HIV/Hepatitis C coinfected patients, coping (but not social) motives predict 12-month alcohol involvement.