Faculty Bibliography

BACKGROUND:Studies have found that reductions in World Health Organization (WHO) drinking risk levels may be a stable outcome of treatment for alcohol use disorder (AUD) and associated with functional improvements. The aim of this study was to investigate whether posttreatment reductions in WHO drinking risk levels are stable over time among older adults and associated with a decrease in consequences of drinking and AUD symptoms and improved quality of life. METHODS:Participants. Individuals 60+ years old, suffering from DSM-5 AUD (n = 693), and seeking outpatient treatment. MEASUREMENTS:WHO drinking risk levels, prior to treatment and at all follow-up points up to 1 year after treatment start, were assessed with Form 90. Outcomes at follow-up included consequences of drinking (Drinker Inventory of Consequences), quality of life (WHOQOL-BREF), and DSM-5 AUD symptoms (Mini International Neuropsychiatric Interview). Logistic regression and linear mixed models were used to examine the probability of maintaining risk-level reductions at follow-up and the association between risk-level reductions and outcomes, respectively. RESULTS:Reductions in risk levels were maintained over time (at least 1 level: OR 5.39, 95% CI 3.43, 8.47; at least 2 levels: OR 9.30, 95% CI 6.14, 14.07). Reductions were associated with reduced consequences of drinking and number of AUD symptoms, and minor, but statistically significant, improvements in quality of life. CONCLUSIONS:Maintaining reductions in WHO risk levels appears achievable for older adults seeking treatment for AUD. The small reduction of AUD symptoms and improvement of quality of life indicates that these reductions may not be adequate as the only treatment goal.

Even with great advances in behavioral health policy in the last decade, the problems of mental illness and addiction persist in the United States-so more needs to be done. In this article, which is part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we describe the steps needed to improve outcomes, focusing on three strategies. We argue for transforming the behavioral health system to meet people where they are, decriminalizing mental illness and substance use disorders to facilitate recovery, and raising awareness of social context and social needs as essential to effective care. We call for supporting structures in the workforce and structures of accountability, outcome measurement, and more generous financing of behavioral health care. These steps have costs, but the enormous benefits of a major transformation in behavioral health policy far outweigh the expenses.

BACKGROUND:The distinct pharmacological properties and clinical uses of extended-release naltrexone (XR-NTX) and sublingual buprenorphine-naloxone (BUP-NX) present challenges in analyzing patient outcomes. METHODS:We conducted a secondary analysis of a multi-site randomized trial comparing XR-NTX with sublingual BUP-NX treatment for opioid use disorder initiated during inpatient detoxification and continued in outpatient treatment. Urine testing data for non-study opioids from the last 22 weeks of the 24-week trial were analyzed in both a per-protocol sample (n = 474 participants who received at least one dose of medication) and a completers sample (n = 211 participants who received all XR-NTX doses or all BUP-NX prescriptions). The present analyses sought to identify differences in the weekly percentages of opioid-positive urine tests between participants treated with the two medications. RESULTS:The proportion of opioid-positive tests in both conditions was less than 20 % for 21 of the 22 weeks in the per-protocol sample and all 22 weeks in the completers sample. Generalized linear mixed model analyses revealed a significant treatment (XR-NTX vs. BUP-NX) X week (weeks 3-24) interaction in the per-protocol sample but not the completers sample. In the per-protocol analysis, the BUP-NX, compared to XR-NTX, had significantly greater proportions of opioid-positive tests in 14 out of the 22 weeks. CONCLUSIONS:Longitudinal modeling approaches that utilize flexible procedures for handling missing data can offer a different perspective on study findings. Results from the present analyses suggest that XR-NTX appeared to be somewhat more effective than BUP-NX in reducing illicit opioid use in the per-protocol sample.

PURPOSE/OBJECTIVE:Young adults are disproportionately affected by the current opioid crisis. Although medications for opioid use disorder are broadly effective, with reductions in morbidity and mortality, the particular effectiveness of medications for opioid use disorder among young adults is less well understood. METHODS:This secondary analysis compared young adults (aged 18-25 years) with older adults (aged ≥26 years) in a large comparative effectiveness trial ("XBOT") that randomized subjects to extended-release naltrexone or sublingual buprenorphine-naloxone for 6 months. Opioid relapse was defined by opioid use over four consecutive weeks or seven consecutive days, using urine testing and self-report. RESULTS:Among subjects in the intention-to-treat sample (n = 570, all randomized participants), a main effect of age group was found, with higher relapse rates among young adults (70.3%) compared with older adults (58.2%), with an odds ratio of 1.72 (95% confidence interval = 1.08-2.70), p = .02. In the per-protocol sample (n = 474, only participants who started medication), relapse rates were higher among young adults (66.3%) compared with older adults (50.8%), with an odds ratio of 1.91 (95% confidence interval = 1.19-3.06). Among the intention-to-treat sample, survival analysis revealed a significant time-by-age group interaction (p = .01) with more relapse over time in young adults. No significant interactions between age and medication group were detected. CONCLUSIONS:Young adults have increased rates of relapse compared with older adults, perhaps because of vulnerabilities that increase their risk for treatment dropout and medication nonadherence, regardless of medication assignment. These results suggest that specialized, developmentally informed interventions may be needed to improve retention and successful treatment of opioid use disorder among young adults.

BACKGROUND:Relatively little is known about the prognostic value of comorbid mental disorders in alcohol use disorder (AUD) treatment for older adults (OA). AIMS/OBJECTIVE:This article aimed to investigate 1) the impact of current unipolar mood and anxiety disorders in AUD treatment success in OA, 2) the timing of this putative comorbidity impact over six months, and 3) the role of treatment length in comorbidity effects. METHODS:We analyzed baseline and one-, three-, and six-month follow-up data from the international multicenter RCT "ELDERLY-Study" (baseline n = 693, median age: 64.0 years) using mixed effects regression models. In adults aged 60+ with DSM-5 AUD "ELDERLY" compared outpatient motivational enhancement therapy (MET, four sessions) with outpatient MET plus community reinforcement approach for seniors (MET & CRA-S; up to 12 sessions). Aiming for abstinence or minimal alcohol use (AU), both conditions included CBT-elements. We assessed AU with Form 90, and mental disorders with the Mini International Neuropsychiatric Interview (M.I.N.I.). RESULTS:Mood-related disorders were associated with more drinks per day at baseline and greater reductions in drinks per day at one and six months (main effect mood disorder: Coef. 2.1, 95% CI 0.6-3.6; one month interaction effect: Coef. -1.9, 95% CI -3.3- -0.5; six months interaction effect: Coef. -2.1, 95% CI -3.5 - -0.6). These results were replicated within MET & CRA-S but not within MET. CONCLUSION/CONCLUSIONS:Comorbid mental disorders had modest effects on short-term outpatient treatment outcomes. OA with AUD and unipolar mood-related disorders may profit from short interventions based on motivational interviewing and CBT-elements. ClinicalTrials.gov:NCT02084173.