Surviving drug addiction: the effect of treatment and abstinence on mortality

Objectives. We examined the relationships between substance abuse treatment, abstinence, and mortality in a sample of individuals entering treatment. We also estimated overall mortality rates and the extent to which they varied according to demographic, clinical severity, and treatment variables.Methods. We used data from a 9-year longitudinal study of 1326 adults entering substance abuse treatment on the west side of Chicago, of whom 131 died (11.0 per 1000 person-years). Baseline predictors, initial and long-term treatment response, and substance use patterns were used to predict mortality rates and time to mortality.Results. Older age, health problems, and substance use were associated with an increased risk of mortality, and higher percentages of time abstinent and longer durations of continuous abstinence were associated with a reduced risk of mortality. Treatment readmission in the first 6 months after baseline was related to an increased likelihood of abstinence, whereas readmission after 6 months was related to a decreased likelihood of abstinence, suggesting that treatment timing is significant.Conclusions. Our findings suggest the need to shift the addiction treatment field from an acute care model to a chronic disease management paradigm and the need for more aggressive screening, intervention, and addiction management over time.The strong association of illicit drug use with other prominent causes of mortality (e.g., tobacco and alcohol use, accidents, and high-risk sexual behaviors), as well as its contribution to significant chronic health problems (e.g., cancer, heart disease, liver disease, and respiratory illness), renders it one of the most fundamental mortality risks.^1,2 The statistics are staggeringly clear: individuals with a drug dependence diagnosis die on average 22.5 years earlier than those without such a diagnosis.³ Furthermore, mortality in the subgroup of individuals with substance use disorders who enter substance abuse treatment is 3 or more times higher than that in the US population as a whole after adjustment for age.^4–15How should US public health officials address the insidious mortality risk associated with illicit drug use, which currently threatens the approximately 6.9 million people (2.8% of the US population) who meet the diagnostic criteria for substance use disorders?^2,16 Before a coherent and effective public health strategy to address the mortality risk associated with drug use can be formulated, the research community must achieve a greater understanding of the specific mechanisms that drive the association between addiction treatment and reduced mortality.Although the relationship between addiction treatment, abstinence, and mortality is complex, we do know that the variables that may affect this relationship include the point in their addiction career at which people enter treatment and the amount of treatment they receive. A large number of studies as well as expert reviews of the literature in the past 2 decades have consistently concluded that participation in substance abuse treatment increases the likelihood of short-term abstinence.^17–25 Particularly, more intense initial treatment, higher cumulative treatment dosage, and early reintervention have been associated with sustained abstinence over multiple years.^26–29 A smaller body of evidence also indicates that those who enter treatment sooner and stay in longer are less at risk for mortality.^26,30In addition, the US Preventive Services Task Force, which is charged with evaluating the benefits of strategies that address the leading causes of mortality, found “good evidence” that drug use is related to mortality and that various treatments designed to reduce illicit drug use in the short term are effective.³¹ Nevertheless, it concluded that insufficient evidence exists to link treatment to longer term improvements in morbidity (prevalence and duration of abstinence) and, consequently, reduced mortality.A rigorous examination of the relationships between illicit drug use, treatment, and long-term outcomes, including mortality, requires consideration of the variables that affect these relationships not only in the short term but also in the long term. One such group of variables consists of an individual''s characteristics upon entering treatment: age, gender, living arrangements, employment, criminal justice history, substance use history, and preexisting health conditions.^6,7,32–34In addition to this first set of variables, results from a range of studies indicate the need to consider various aspects of treatment participation. Because substance use disorders are best conceptualized as chronic conditions, a number of addiction scientists have argued that research in this area adopt a life course, developmental perspective to assess the role of treatment in substance use and related outcomes.^35–39 From this perspective, mortality risk among substance users may be related to their initial response to treatment and their cumulative duration of abstinence. Duration of sustained abstinence may also play a role in mortality risk.Finally, previous studies have shown that longer periods of abstinence (% of days whether consecutive or not) and longer durations of sustained abstinence (consecutive days only) yield benefits in a wide array of physical, psychological, and social functioning domains, including social network improvements, increased vocational involvement, and better mental health.^{27,28,40–43} Despite the knowledge that such changes represent an increase in recovery capital that may be related to a wide range of health outcomes with an impact on mortality risk, it remains unclear whether characteristics of an individual''s abstinence (e.g., timing or duration), the proximal goal of treatment, mediate that association.Capitalizing on a 9-year longitudinal investigation of individuals presenting to community-based substance abuse treatment facilities, we addressed 2 research questions in this study: (1) What are the overall mortality rates in this sample, and how do they vary according to demographic, clinical severity, and treatment variables? and (2) How and to what extent do treatment and abstinence (i.e., the proximal outcome of treatment) mediate these relationships?     

Day versus inpatient treatment for cocaine dependence: An experimental comparison

This study was designed to explore the question of whether day treatment is a viable alternative to inpatient treatment for cocaine-dependent patients. Inpatient subjects were compared with day-treatment subjects in a randomized, prospective study design. Treatment outcome was evaluated at three and six months posttreatment. At three months posttreatment, the inpatient group had a statistically significant higher rate of total abstinence than the day-treatment group, but the difference at six months was not statistically significant. The two groups also were statistically comparable at six months posttreatment in terms of “current” abstinence and in terms of other measures. Average costs for day-treatment subjects was 48–61% of the cost for inpatient subjects. The results of this study support the use of day treatment as a clinically and economically effective alternative to inpatient treatment for many cocaine-dependent patients, especially when steps are taken to minimize drop out.     

Unplanned admissions to inpatient psychiatric treatment and services received prior to admission

BackgroundInpatient bed numbers are continually being reduced but are not being replaced with adequate alternatives in primary health care. There is a considerable risk that eventually all inpatient treatment will be unplanned, because planned or elective treatments are superseded by urgent needs when capacity is reduced.Aims of the studyTo estimate the rate of unplanned admissions to inpatient psychiatric treatment facilities in Norway and analyse the difference between patients with unplanned and planned admissions regarding services received during the three months prior to admission as well as clinical, demographical and socioeconomic characteristics of patients.MethodUnplanned admissions were defined as all urgent and involuntary admissions including unplanned readmissions. National mapping of inpatients was conducted in all inpatient treatment psychiatric wards in Norway on a specific date in 2012. Binary logit regressions were performed to compare patients who had unplanned admissions with patients who had planned admissions (i.e., the analyses were conditioned on admission to inpatient psychiatric treatment).ResultsPatients with high risk of unplanned admission are suffering from severe mental illness, have low functional level indicated by the need for housing services, high risk for suicide attempt and of being violent, low education and born outside Norway.ConclusionSpecialist mental health services should support the local services in their efforts to prevent unplanned admissions by providing counselling, short inpatient stays, outpatient treatment and ambulatory outpatient psychiatry services.Implications for health policiesThis paper suggests the rate of unplanned admissions as a quality indicator and considers the introduction of economic incentives in the income models at both service levels.     

Associations between admissions factors and the need for remediation

Advances in Health Sciences Education - This study examines the way in which student characteristics and pre-admissions measures are statistically associated with the likelihood a student will...     

Substance abuse treatment cost offsets vary with gender, age, and abstinence likelihood.

The cost-offset effect has been promoted as a way for substance abuse treatment to pay for itself by generating reductions in health care utilization in other areas. Clients (n = 5,434) that were abstinent for 24 months following substance abuse treatment had lower posttreatment utilization than clients that had relapsed. An examination of cost offsets revealed a complex interplay between gender, age, and type of utilization (medical versus psychiatric). Cost offsets were especially pronounced for women over 40 years old.     

Mothering and anxiety: Social support and competence as mitigating factors for first-time mothers

This study investigated anxiety as a phenomenon distinct from depression and evaluated several variables that influence anxiety in first-time mothers. This explored the relationship between maternal sense of competence (both of mothering and efficacy) and perceived social support (from family, friends, and significant others) and first-time mothers’ postpartum anxiety, when depression, socioeconomic status (SES), and marital status were controlled for. The population studied were 86 first-time mothers made up of women with children 24 months or younger in two populations of Kentucky and Michigan. The constructs of maternal sense of competence and perceived social support were found to be significant in explaining first-time mothers’ anxiety. The study concluded that a combined association of perceived social support and maternal sense of competence were associated with a 34% (change in R-squared = .339) decrease of a first-time mothers’ anxiety. However, not all types of social support, or maternal competence appeared to be equally important with regards to maternal anxiety: social support from friends and family and maternal sense of competence in regard to productivity appeared to be most significant. Lastly, some recommendations for health practitioners who work with mothers are provided.     

Patterns of eating and abstinence in women treated for bulimia nervosa

OBJECTIVE: The current study sought to determine whether there is an optimal pattern of eating leading to cessation of binge eating and purging in bulimic women. METHOD: Data on the number of meals and snacks consumed were obtained from the Eating Disorders Examination (EDE) pretreatment and posttreatment, for individuals participating in a randomized controlled study comparing cognitive-behavioral therapy and interpersonal therapy. Records were available for 158 participants. RESULTS: The numbers of meals and snacks eaten from pretreatment to posttreatment increased significantly. A pattern of eating with at least 80 meals combined with at least 21 afternoon snacks within a 28-day period was associated with an abstinence rate of 70%. In contrast, for subjects having 72-80 meals, those having greater than 11 evening snacks have an abstinence rate of 4%. CONCLUSION: The critical elements of the pattern of eating related to abstinence appear to be the total number of meals consumed and the timing of snacks.     

Predicting response to treatment: differentiating active-factor and non-specific effects

An important step in providing treatment is prediction of which treatments will be effective for which patients. Common methods for prediction of efficacy, however, are inconsistent with the assumptions of the standard placebo-control paradigm for establishment of efficacy. This is because in prediction of the observed response, one ignores the distinction between response attributable to non-specific factors and that attributable to active-treatment factors. This paper presents a paradigm for the use of log-linear analysis that allows for the development of predictive methods that take into account this distinction. An example with simulated data demonstrates how, if this distinction is ignored, one can reach misleading conclusions and make non-optimal treatment decisions as a result of an inaccurate cost-benefit analysis of the treatment.     

Risk factors for hospital admissions among asthmatic children and adolescents

OBJECTIVE: To assess the prevalence rate and risk factors for hospital admissions among asthma children and to evaluate care delivered to these patients. METHODS: Three-hundred and twenty-five asthmatic children attending a public outpatient reference clinic were studied. Of them, 202 were hospitalized. Care was evaluated using a questionnaire covering general aspects of hospital stay and biological, demographics, socioeconomic and asthma-related factors. Univariate and multivariate analyses were performed to measure the association between hospital admissions and selected independent variables. RESULTS: Of the total, 62.2% had already been hospitalized due to asthma, 64.9% developed asthma episodes, and 60.9% were hospitalized in their first year of life. Most (76.0%) had moderate to severe asthma. Despite that, 94.2% were not on anti-inflammatory drugs and were treated only during isolated acute episodes. None of these were regularly seen in primary health care centers for a periodic control of their steroid inhalants. Most parents (97.8%) referred not to know how to take care of asthma children. Symptoms onset is normally seen before the age of 12 months (OR=3.20; 95%CI 1.55-6,61) or between 12 and 24 months (OR=3.89; 95%CI 1.62-9.36). Mothers have attended school for less than 7 years (OR=3.06; 95%CI 1.62-5.76). Disease severity (OR=2.32; 95%CI 1.24-3.88), 2 or more monthly visits to emergency wards (OR=2.19; 95%CI 1.24-3.88), and referred recurrent pneumonia (OR=2.00; 95%IC 1.06-3.80) were the main risk factors for hospital admissions. CONCLUSIONS: Organizing health care services is crucial to reduce hospital admissions and provide adequate care for asthma children and adolescents, especially those less than 2 years old.     

Acute ethanol dependence or long-term ethanol treatment and abstinence do not reduce hippocampal responses to carbachol

In the hippocampus of human alcoholics, prolonged ethanol treatment reduces the number of muscarinic ligand binding sites present at autopsy suggesting a decrease in functional muscarinic receptors. Whether these changes are due to alcohol-induced brain damage or ethanol dependence and represent a reduced level of cholinergic function is unknown. The present studies tested the impact of ethanol dependence or long-term ethanol treatment and subsequent withdrawal on the function of pre- and postsynaptic muscarinic receptors in the CA1 region of the rat hippocampus. Field excitatory postsynaptic potentials (EPSPs) were inhibited in a concentration-dependent manner by 0.1–100 μM carbachol. This presynaptic inhibitory action of carbachol involving muscarinic receptors was not significantly reduced either by ethanol treatment (12 days), causing physical dependence, or by long-term ethanol treatment (97–120 days) and abstinence (3–6 months). Postspike after hyperpolarizations (AHPs) were inhibited in a concentration-dependent manner by carbachol (6–2000 nM). This postsynaptic excitatory action of muscarinic receptors also was not significantly reduced either by 12-day ethanol treatment or by long-term ethanol treatment. Taken together, these results suggest that neither pre- nor postsynaptic muscarinic receptor function measured electrophysiologically is reduced by either ethanol dependence or long-term ethanol consumption and abstinence in the rat as suggested by reduced muscarinic ligand binding in the hippocampus of human alcoholics.