Derek D. Satre

Age and Gender Trends in Long-Term Opioid Analgesic Use for Noncancer Pain

OBJECTIVES We describe age and gender trends in long-term use of prescribed opioids for chronic noncancer pain in 2 large health plans. METHODS Age- and gender-standardized incident (beginning in each year) and prevalent (ongoing) opioid use episodes were estimated with automated health care data from 1997 to 2005. Profiles of opioid use in 2005 by age and gender were also compared. RESULTS From 1997 to 2005, age-gender groups exhibited a total percentage increase ranging from 16% to 87% for incident long-term opioid use and from 61% to 135% for prevalent long-term opioid use. Women had higher opioid use than did men. Older women had the highest prevalence of long-term opioid use (8%-9% in 2005). Concurrent use of sedative-hypnotic drugs and opioids was common, particularly among women. CONCLUSIONS Risks and benefits of long-term opioid use are poorly understood, particularly among older adults. Increased surveillance of the safety of long-term opioid use is needed in community practice settings.

Short-term alcohol and drug treatment outcomes predict long-term outcome.

INTRODUCTION Although addiction is recognized as a chronic, relapsing condition, few treatment studies, and none in a commercially insured managed care population, have measured long-term outcomes. We examined the relationship of 6-month treatment outcomes to abstinence 5 years post-treatment, and whether the predictors of abstinence at 5 years were different for those who were, and were not, abstinent at 6 months. METHODS The sample (N=784) is from an outpatient (day hospital and traditional outpatient) managed care chemical dependency program. Subjects were interviewed at baseline, 6 months, and 5 years. Logistic regression analysis was used to assess which individual, treatment and extra-treatment characteristics predicted alcohol and drug abstinence at 5 years. RESULTS Abstinence at 6 months was an important predictor of abstinence at 5 years. Among those abstinent at 6 months, predictors of abstinence at 5 years were older age, being female, 12-step meeting attendance, and recovery-oriented social networks. Among those not abstinent at 6 months, being alcohol dependent rather than drug dependent, 12-step meeting attendance, treatment readmission, and recovery-oriented social networks predicted abstinence at 5 years. CONCLUSION Our findings demonstrate a clear association between short-term and long-term treatment success. In addition, these results strongly support the importance of recovery-oriented social networks for those with good short-term outcomes, and the beneficial impact of readmission for those not initially successful in treatment.

Cognitive Behavioral Interventions with Older Adults: Integrating Clinical and Gerontological Research

Psychotherapeutic interventions utilizing cognitive–behavioral strategies have been used widely with older adults. To appropriately adapt these techniques, characteristics unique to older adults must be taken into account. These factors include aspects of the social environment, cohort effects, cognitive changes with aging, personality, and emotional development, which have been described in an emerging body of research literature from the field of gerontology. In addition, clinical studies have examined the efficacy of cognitive–behavioral interventions in treating older clients for anxiety, depression, insomnia, and other disorders. This review describes current empirical evidence in gerontology and treatment outcome research that informs the practice of psychotherapy in this population and provides recommendations for conducting therapy with older adults.

The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients.

INTRODUCTION Health problems are prevalent in chemical dependency (CD) treatment populations, and often precede reductions in substance use among untreated populations. Few studies have examined whether medical problems predict better long-term outcomes in treated individuals, or how primary care utilization and CD/primary care service integration affects long-term outcomes among those with health problems. METHOD In a sample of 598 CD patients in a private health plan, logistic regression models examined whether substance abuse-related medical conditions (SAMCs), integrated medical and CD care, and on-going primary care predicted remission of CD problems at 5 years. RESULTS Those with SAMCs were no more likely than others to be remitted at 5 years except among young adults and those with medical, but not psychiatric SAMCs. Higher levels of medical problem severity at intake and receiving integrated CD and primary care in the index treatment episode predicted remission in the full sample and among those with SAMCs. Among those with SAMCs, individuals with ongoing medical care - 2-10 primary care visits - in the 5 years following intake were more likely to be remitted at 5 years than those with fewer visits. CONCLUSIONS This study highlights the potentially important role of medical services in the long-term treatment of CD disorders. CD treatment may benefit from a disease management approach similar to that recommended for other chronic medical problems: specialty care when the condition is severe followed by services in primary care when the condition is stabilized.

Cigarette Smoking and Long-Term Alcohol and Drug Treatment Outcomes: A Telephone Follow-Up at Five Years

This prospective study examined the relationship between cigarette smoking and five-year substance abuse treatment outcomes. Of 749 individuals who began private outpatient treatment, 598 (80%) were re-interviewed by telephone at five years. At five-year follow-up, 53% reported smoking cigarettes in the prior 30 days. Smokers were less likely to be abstinent from alcohol and drugs in the prior 30 days (48.3% vs. 64.0%), and had higher Addiction Severity Index (ASI) scores in employment, alcohol, drug, psychiatric, and family/social problems; worse self-reported health; and greater self-reported depression. Findings inform understanding of long-term substance abuse treatment outcomes and potential service needs of smokers.

Gender Differences in Seven-Year Alcohol and Drug Treatment Outcomes among Older Adults

This study examined participants at seven-year follow-up to assess long-term outcomes of older women (n = 25) and men (n = 59) ages 55 and over in an outpatient addiction program. It measured demographic characteristics, alcohol and drug use, psychiatric symptoms, Addiction Severity Index, treatment length, and outcomes. At seven years, 76.0% of women reported abstinence in the prior 30 days versus 54.2% of men, p = .05. Logistic regression analysis found that longer treatment stay predicted abstinence. Findings indicate that older women have better long-term addiction outcome than older men, but treatment length is more significant than gender in predicting outcome.

Excess Mortality Among HIV-Infected Patients Diagnosed With Substance Use Dependence or Abuse Receiving Care in a Fully Integrated Medical Care Program

BACKGROUND We examined the association between substance use (SU) disorder and mortality among HIV-infected patients in a large, private medical care program. METHODS In a retrospective cohort design, HIV-infected patients (≥14 years old) from a large health plan (Northern California) were studied to examine mortality associated with diagnosis of SU dependence or abuse over an 11-year period. RESULTS At study entry or during follow-up, 2,279 (25%) of 9,178 HIV-infected patients had received a diagnosis of SU disorder. Diagnoses were categorized as alcohol dependence/abuse only, illicit drugs only, or both. Cause of death differed by the category of SU diagnosis. Mortality rates ranged from 35.5 deaths per 1,000 person-years in patients with an SU disorder to 17.5 deaths among patients without an SU disorder. Regression results indicated mortality risk was significantly higher in all categories of SU disorder compared to no SU diagnosis (hazard ratios ranging from 1.65 to 1.67) after adjustment for SU treatment and confounders. CONCLUSIONS A diagnosis of SU dependence/abuse is associated with higher mortality among HIV-infected patients for whom access to medical services is not a significant factor.

Alcohol expectancies and their relationship to alcohol use: age and sex differences.

Previous studies have demonstrated a correlation between expectancies that adolescents and young adults hold about the effects of alcohol and the amount of alcohol they consume. This study examined age and sex differences in expectancies and alcohol consumption in a sample of 92 older and 83 younger adults. The two groups were administered self-report questionnaires for quantity and frequency of alcohol consumption, and for positive and negative expectancies regarding the effects of alcohol. Results found lower quantities of alcohol consumption per occasion in older adults, but higher frequency of drinking occasions. Older adults reported significantly lower levels of both positive and negative expectancies when compared with the younger sample. Among older women, regression analyses found a significant relationship between negative expectancies and lower alcohol consumption. For older men, positive expectancies showed a positive relationship to consumption, while negative expectancies showed a negative relationship to consumption. For younger women, positive expectancies were related to increased consumption. These findings suggest different strategies based on age and sex in treatment models, which identify expectancies as important components of drinking behavior.

Mortality After Diagnosis of Psychiatric Disorders and Co-Occurring Substance Use Disorders Among HIV-Infected Patients

We examined the associations between psychiatric diagnoses, substance use disorders, health services, and mortality among 9751 HIV-infected patients (≥14 years old) in a large, private medical care program, in a retrospective cohort design over a 12-year period. All study data were extracted from computerized clinical and administrative databases. Results showed that 25.4% (n = 2472) of the 9751 study subjects had received a psychiatric diagnosis (81.1% had major depression, 17.1% had panic disorder, 14.2% had bipolar disorder, and 8.1% had anorexia/bulimia); and 25.5% (n = 2489) had been diagnosed with substance use disorder; 1180 (12.1%) patients had received both psychiatric and substance diagnoses. In comparison to patients with neither a psychiatric diagnosis nor a SU diagnosis, the highest risk of death was found among patients with dual psychiatric and substance use diagnoses who had no psychiatric treatment visits and no substance treatment (relative hazards [RH] = 4.17, 95% confidence interval [CI] = 2.35 to 7.40). Among dually diagnosed patients, receiving psychiatric and/or substance use disorder treatment somewhat reduced the risk of death compared to patients with neither diagnosis. The lowest risks of death were observed among patients with a single diagnosis who had received corresponding treatment. Our study findings suggest that screening for psychiatric and substance problems at the initiation and during the course of HIV/AIDS treatment and providing psychiatric and substance use disorder treatment may extend life for these vulnerable patients.

Patterns of Alcohol and Drug Use Among Depressed Older Adults Seeking Outpatient Psychiatric Services

OBJECTIVE Alcohol and drug use and related problems may compromise depression treatment, and older adults may be especially at risk for poor outcomes. However, alcohol and drug use among older adults have not been studied in settings in which depression treatment is provided. This study examined the prevalence and clinical and demographic correlates of alcohol and drug use and misuse of prescription drugs among adults with depression seeking outpatient psychiatric care (excluding chemical dependency treatment). METHODS The sample included 154 older adults (age 60 years and older who scored ≥10 on the Beck Depression Inventory-II [BDI-II] at intake). Participants also completed alcohol and drug use questions and the Short Michigan Alcohol Screening Test. RESULTS Recent alcohol and drug use, heavy episodic drinking, and history of alcohol-related problems were common. Alcohol use in the prior 30 days was reported by 53% of men and 50% of women. Cannabis use in the prior 30 days was reported by 12% of men and 4% of women; and misuse of sedatives in the prior 30 days was reported by 16% of men and 9% of women. In exact logistic regression, higher BDI-II score was associated with cannabis use (odds ratio = 15.8, 95% confidence interval = 2.0-734.0, exactp = 0.003). CONCLUSIONS Older adults with depression are likely to present for treatment with a range of concurrent alcohol and drug use patterns, including cannabis use and misuse of prescription medication. Clinicians should evaluate depressed patients for substance use and related problems and consider appropriate interventions.