Mary Jo Larson

Quality of Life Assessments by Adult Substance Abusers Receiving Publicly Funded Treatment in Massachusetts

Purpose. Quality of life (QOL) has become an important endpoint in clinical trials and studies of medical interventions for many chronic diseases, but has not been widely studied in the substance abuse field. The purpose of this study was to measure QOL in a large sample of adult substance abusers (SA), to compare QOL ratings with those for other chronic diseases, and to assess factors influencing QOL levels in this population. Methods. Hour-long personal interviews were administered to 570 randomly selected substance abuse clients in six detoxification centers and seven outpatient facilities in Massachusetts. Two QOL instruments—the Multidimensional Index of Life Quality (MILQ) and the SF-12—were used to measure QOL. Substance use problems were measured by the Addiction Severity Index Drug and Alcohol composite scores. QOL scores were compared to those for patients with other chronic diseases. Multivariable regression analysis was used to estimate the influence of demographic characteristics, co-morbidities, and substance use on QOL summary scores. Results. SA clients reported significantly lower QOL scores than patients about to undergo heart surgery on seven of the nine MILQ domains as well as the MILQ QOL summary index. SA clients also had much lower mean scores than the general population on both the SF-12s Mental Health (ES=−1.80) and Physical Health (ES=−0.58) component scales. SF-12 physical component scores were similar to those for other chronic diseases, but mental component scores were markedly lower and comparable on average to clinically depressed groups. In the regression model, MILQ Index scores were significantly lower for dual diagnosis and detoxification cases. Index scores were negatively associated with ASI drug composite scores, but not with ASI alcohol scores. Implications. The results of this study suggest that the physical functioning of adult substance abusers is similar to the levels for patients diagnosed with other serious chronic diseases, but that mental functioning is much lower. QOL provides information about functioning and well-being that is not captured by traditional measures of substance use, and may soon begin to play a more prominent role in evaluating the effectiveness of treatment services for substance abusers.

Homeless Chronicity and Health-related Quality of Life Trajectories Among Adults With Addictions

Background:New federal initiatives target funds toward chronically homeless as distinct from other homeless persons. Few data exist, however, to substantiate the implications of chronic homelessness for major health outcomes. Objectives:Using data from a 2-year cohort of addicted persons, we tested whether changes in mental and physical health-related quality of life (HRQOL) differed according to homeless chronicity. Methods:Using self-reported homelessness, we classified subjects as chronically homeless (CH; n = 60), transitionally homeless (TRANS; n = 108), or as housed comparison subjects (HSD; n = 106). The Short Form-36 Health Survey, administered at baseline and 2 follow-ups over a period of 2 years, provided a Mental Component Summary (MCS) and a Physical Component Summary (PCS) for HRQOL. Mixed model linear regression was used to test the association between housing status, MCS, and PCS. Additional models assessed whether medical, psychiatric, addiction, and social support measures could account for HRQOL differences. Results:All subjects had low MCS scores at study entry (mean, 31.2; SD, 12.6). However, there was a significant housing status-by-time interaction (P = 0.01). At final follow-up, CH and TRANS subjects had lower adjusted MCS scores than HSD subjects (33.4, 38.8, and 43.7 for the 3 groups, respectively; all P ≤ 0.01). By contrast, housing status and PCS were not significantly associated (P = 0.19). Medical, psychiatric, addiction, and social support variables had significant associations with MCS, and their inclusion in the regression reduced the apparent effect of housing status on MCS. Conclusions:Chronic homelessness was associated with especially poor mental but not physical HRQOL over time. These findings reinforce a new typology of homelessness.

The Case for Chronic Disease Management for Addiction

Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care—elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CDM has been proven effective.

Military Combat Deployments and Substance Use: Review and Future Directions

Iraq and Afghanistan veterans experience extreme stressors and injuries during deployments, witnessing and participating in traumatic events. The military has organized prevention and treatment programs as a result of increasing rates of suicide and posttraumatic stress disorder among troops; however, there is limited research on how to intervene with alcohol misuse and drug use that accompany these problems. This review presents statistics about postdeployment substance use problems and comorbidities, and it discusses the militarys dual role (a) in enforcing troop readiness with its alcohol and drug policies and resiliency-building programs and (b) in seeking to provide treatment to troops with combat-acquired problems, including substance abuse.

Need and non-need factors associated with addiction treatment utilization in a cohort of homeless and housed urban poor.

Background:Research on addiction treatment utilization in indigent samples mainly has been retrospective, without measures of addictive consequences, social network influences, and motivation. Prospective assessment of factors influencing utilization could inform policy and clinical care. Objective:We sought to identify factors associated with utilization of addiction treatment and mutual help groups among substance-dependent persons with high rates of homelessness. Research and Methods:This was a prospective cohort of patients detoxified from alcohol or drugs at baseline who were followed for 2 years in a randomized clinical trial of linkage to primary care (n = 274). Outcomes included utilization of Inpatient/Residential, Outpatient, Any Treatment, and Mutual Help Groups. Predictor variables in longitudinal regression analyses came from the literature and clinical experience, organized according to theoretical categories of Need, and non-Need (eg, Predisposing and Enabling). Results:Many subjects used Inpatient/Residential (72%), Outpatient (62%), Any Treatment (88%) or Mutual Help Groups (93%) at least once. In multivariable analyses, addictive consequences (odds ratio [OR] 1.38, 95% confidence interval [CI] 1.12–1.71), motivation (OR 1.32, 95% CI 1.09–1.60), and female gender (OR 1.80, 95% CI 1.13–2.86) were associated with most treatment types (ORs are for Any Treatment). Homelessness was associated with Residential/Inpatient (for Chronically Homeless vs. Housed, OR 1.75, 95% CI 1.04–2.94). Living with ones children (OR 0.51, 95% CI 0.31–0.84) and substance-abusing social environment (OR 0.65, 95% CI 0.43–0.98) were negatively associated with Any Treatment. Conclusions:In this cohort of substance-dependent persons, addictive consequences, social network variables, and motivation were associated with treatment utilization. Non-need factors, including living with ones children and gender, also were significant.

Physical health burdens of women with trauma histories and co-occurring substance abuse and mental disorders

This article documents the physical health burdens of participants in a large, federally funded cross-site study of specialized services for women with histories of trauma (physical or sexual abuse) and co-occurring substance abuse and mental health disorders. Nearly half of the 2729 women in the study (48%) reported serious physical illnesses that frequently limited their daily life activities or required them to use special equipment. Nearly half (46%) rated their health status as only fair or poor. Given the prevalence of physical illnesses in this population, behavioral service providers should discuss with clients their overall health and how it might hinder their participation in treatment for trauma, substance abuse, and mental illness, and policymakers should consider this need when designing behavioral health requirements, setting reimbursement rates, and allocating funds.

Supportive Housing Approaches in the Collaborative Initiative to Help End Chronic Homelessness (CICH)

The Federal Collaborative Initiative to Help End Chronic Homelessness funded 11 sites to expand permanent housing and offer supportive services to persons experiencing chronic homelessness and suffering from mental and substance use disorders. This study examines qualitative data on how the projects used US Department of Housing and Urban Development funding and three housing approaches (scattered units, congregate/clustered, or a combination) for rapid placement of clients. Each housing approach called for adaptations by the services teams and property personnel in order to support clients with independent living skills, prevent housing loss, and promote their overall health in line with Initiative goals. Property personnel reported taking on new roles with clients and forming new collaborative arrangements with services teams. The authors discuss the lessons reported by sites that were associated with housing configuration, type of lease, and role of property personnel.

A Case for Enhanced Linkage of Substance Abusers to Primary Medical Care

Abstract Alcohol and drug abuse continue to be problems of major significance throughout the United States. Although experts have advocated linking substance abusers with primary medical care to help achieve both individual and public health goals, few successful and generalizable methods for linkage have been developed. Specific potential benefits for such linkage include HIV testing and initiation of therapy, treatment of tuberculosis and sexually transmitted diseases, appropriate immunizations, cervical cancer screening, promotion of healthy behaviors regarding sexual and drug practices, and encouragement of cessation of substance use. Distributive or decentralized models linking patients receiving addiction treatment to existing primary medical care services need evaluation, as they may be more generalizable and cost-effective compared with on-site integrated programs. Health care providers and policy makers need to explore innovative approaches to bring substance abusers into a medical care system in...

Frequent binge drinking after combat-acquired traumatic brain injury among active duty military personnel with a past year combat deployment

Objective:To determine whether combat-acquired traumatic brain injury (TBI) is associated with postdeployment frequent binge drinking among a random sample of active duty military personnel. Participants:Active duty military personnel who returned home within the past year from deployment to a combat theater of operations and completed a survey health assessment (N = 7155). Methods:Cross-sectional observational study with multivariate analysis of responses to the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel, an anonymous, random, population-based assessment of the armed forces. Main Measures:Frequent binge drinking: 5 or more drinks on the same occasion, at least once per week, in the past 30 days. TBI-AC: self-reported altered consciousness only; loss of consciousness (LOC) of less than 1 minute (TBI-LOC <1); and LOC of 1 minute or greater (TBI-LOC 1+) after combat injury event exposure. Results:Of active duty military personnel who had a past year combat deployment, 25.6% were frequent binge drinkers and 13.9% reported experiencing a TBI on the deployment, primarily TBI-AC (7.5%). In regression models adjusting for demographics and positive screen for posttraumatic stress disorder, active duty military personnel with TBI had increased odds of frequent binge drinking compared with those with no injury exposure or without TBI: TBI-AC (adjusted odds ratio, 1.48; 95% confidence interval, 1.18–1.84); TBI-LOC 1+ (adjusted odds ratio, 1.67; 95% confidence interval, 1.00–2.79). Conclusions:Traumatic brain injury was significantly associated with past month frequent binge drinking after controlling for posttraumatic stress disorder, combat exposure, and other covariates.

Boston Consortium of Services for Families in Recovery: A Trauma-Informed Intervention Model for Women's Alcohol and Drug Addiction Treatment

SUMMARY Through collaboration among the service agencies collectively known as the Boston Consortium of Services for Families in Recovery, the Boston Public Health Commission implemented an integrated model of trauma-informed services that is culturally and linguistically appropriate to its service population of primarily poor urban Latina and African American women. The enhanced intervention was implemented in five Consortium-affiliated alcohol and drug addiction treatment programs providing outpatient, residential, and methadone services. Programs adopted trauma-informed service system enhancements and offered study participants a package of trauma-specific and trauma-informed clinical services. The assessment and consensus-building processes, enhanced model components, implementation process, challenges and lessons learned are described.