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Bickel WK, Witkiewitz K, Athamneh LN, Kuhlemeier A. Recovery from alcohol use disorder: Reinforcer pathology theory, measurement, and methods. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2024; 48:1626-1636. [PMID: 39155126 DOI: 10.1111/acer.15406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 06/28/2024] [Indexed: 08/20/2024]
Abstract
Recovery from alcohol use disorder (AUD) is a dynamic process that often entails periods of drinking but has been defined primarily by abstinence. Recently, a broader interpretation of recovery was developed, including meeting the Diagnostic and Statistical Manual of Mental Disorders (DSM) remission criteria and improved psychosocial functioning. This new understanding of recovery has facilitated the development of novel theories and methodologies. This paper reviews a new theoretical perspective of recovery, Reinforcer Pathology, and two novel methodological approaches in light of this broader view of recovery. Using this theoretical framework as a foundation, we propose an alternative perspective to explain the recovery process as it relates to environmental factors and valuation of the future; we suggest that changing the environment in which substances are available (e.g., increasing non-alcohol-related activities) and extending one's temporal window are associated with improved recovery outcomes (e.g., remission and quality of life). In this review, we discuss two novel methodological approaches. The first uses latent profile analysis to show that using a measure of Relative Reinforcement Value of Alcohol-Free Activities is associated with a greater likelihood of belonging to a high functioning/infrequent heavy drinking recovery profile. The second developed an online national sample and used an accelerated longitudinal design to study longer-term recovery of up to 12 years over a 5-year study period. Reinforcer Pathology theory, novel methods, and measures may further our understanding of recovery and begin to address critical questions for future studies. Subsequent randomized clinical trials should examine whether the suggested targets and interventions based on the theoretical model improve recovery outcomes prospectively. Measuring and promoting alcohol-free activity engagement may facilitate improved recovery outcomes, while novel methodologies permit an understanding of returning to use or remission across different recovery durations.
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Affiliation(s)
- Warren K Bickel
- Addiction Recovery Research Center, Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, Virginia, USA
| | | | - Liqa N Athamneh
- Addiction Recovery Research Center, Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, Virginia, USA
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Young AS, Reboussin BA, Riehm K, Mojtabai R, Green KM, O'Gorman ET, Susukida R, Amin-Esmaeili M, Crum RM. Associations between mental health & substance use treatment and alcohol use progression and recovery among US women drinkers. PLoS One 2024; 19:e0306820. [PMID: 38976705 PMCID: PMC11230554 DOI: 10.1371/journal.pone.0306820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 06/24/2024] [Indexed: 07/10/2024] Open
Abstract
BACKGROUND Alcohol use has profound public health impact on women; however, modifiable factors that may influence alcohol use progression/recovery, including health service utilization, are understudied in women. OBJECTIVE To investigate the association between mental health (MH) and substance use (SU) treatment with alcohol use progression and recovery among women who currently use alcohol or have in the past. METHODS This study is a secondary data analysis of prospective data from waves 1 (2001-2002) and 2 (2004-2005) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; a US-nationally representative sample of adults). The analytic sample was limited to women who reported past or current alcohol use at wave 1 (N = 15,515). Latent transition analysis (LTA) examined whether receiving SU/MH treatment in the year prior to wave 1 was associated with transitioning between three empirically-derived stages of alcohol involvement (no, moderate, and severe problems classes), between Waves 1 and 2 adjusting for possible confounders using propensity score weight. RESULTS Compared to White female drinkers, female drinkers who were from Black, Hispanic, or other races were less likely to receive SU/MH treatment (p-values ≤. 001). SU/MH treatment in the year prior to wave 1 was associated with transitioning from the moderate problems class to the no problems class between Waves 1 and 2 (p-value = .04). CONCLUSION Receipt of SU or MH treatment among women, was associated with a higher likelihood of remission from moderate alcohol use problems to no problems over time. Future research, including investigation into treatment characteristics (e.g., frequency, duration, type) should further explore why women initially experiencing severe alcohol use problems did not experience similar remission.
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Affiliation(s)
- Andrea S Young
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Beth A Reboussin
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina, United States of America
| | - Kira Riehm
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Ramin Mojtabai
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kerry M Green
- Department of Behavioral and Community Health, University of Maryland School of Public Health, College Park, Maryland, United States of America
| | - Emily T O'Gorman
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Ryoko Susukida
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Masoumeh Amin-Esmaeili
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Rosa M Crum
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Lai D, Kuo SIC, Wetherill L, Aliev F, Zhang M, Abreu M, Schwantes-An TH, Dick D, Francis MW, Johnson EC, Kamarajan C, Kinreich S, Kuperman S, Meyers J, Nurnberger JI, Liu Y, Edenberg HJ, Porjesz B, Agrawal A, Foroud T, Schuckit M, Plawecki MH, Bucholz KK, McCutcheon VV. Associations between alcohol use disorder polygenic score and remission in participants from high-risk families and the Indiana Biobank. ALCOHOL, CLINICAL & EXPERIMENTAL RESEARCH 2024; 48:283-294. [PMID: 38054532 PMCID: PMC10922306 DOI: 10.1111/acer.15239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND In the United States, ~50% of individuals who meet criteria for alcohol use disorder (AUD) during their lifetimes do not remit. We previously reported that a polygenic score for AUD (PGSAUD ) was positively associated with AUD severity as measured by DSM-5 lifetime criterion count, and AUD severity was negatively associated with remission. Thus, we hypothesized that PGSAUD would be negatively associated with remission. METHODS Individuals of European (EA) and African ancestry (AA) from the Collaborative Study on the Genetics of Alcoholism (COGA) who met lifetime criteria for AUD, and two EA cohorts ascertained for studies of liver diseases and substance use disorders from the Indiana Biobank were included. In COGA, 12-month remission was defined as any period of ≥12 consecutive months without meeting AUD criteria except craving and was further categorized as abstinent and non-abstinent. In the Indiana Biobank, remission was defined based on ICD codes and could not be further distinguished as abstinent or non-abstinent. Sex and age were included as covariates. COGA analyses included additional adjustment for AUD severity, family history of remission, and AUD treatment history. RESULTS In COGA EA, PGSAUD was negatively associated with 12-month and non-abstinent remission (p ≤ 0.013, βs between -0.15 and -0.10) after adjusting for all covariates. In contrast to the COGA findings, PGSAUD was positively associated with remission (p = 0.004, β = 0.28) in the Indiana Biobank liver diseases cohort but not in the Indiana Biobank substance use disorder cohort (p = 0.17, β = 0.15). CONCLUSIONS PGSAUD was negatively associated with 12-month and non-abstinent remission in COGA EA, independent of behavioral measures of AUD severity and family history of remission. The discrepant results in COGA and the Indiana Biobank could reflect different ascertainment strategies: the Indiana Biobank participants were older and had higher rates of liver disease, suggesting that these individuals remitted due to alcohol-related health conditions that manifested in later life.
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Affiliation(s)
- Dongbing Lai
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Sally I-Chun Kuo
- Department of Psychiatry, Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - Leah Wetherill
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Fazil Aliev
- Department of Psychiatry, Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | - Michael Zhang
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Marco Abreu
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Tae-Hwi Schwantes-An
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Danielle Dick
- Department of Psychiatry, Robert Wood Johnson Medical School, Rutgers University, Piscataway, NJ
| | | | - Emma C. Johnson
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Chella Kamarajan
- Henri Begleiter Neurodynamics Lab, Department of Psychiatry, SUNY Downstate Health Science University, NY
| | - Sivan Kinreich
- Henri Begleiter Neurodynamics Lab, Department of Psychiatry, SUNY Downstate Health Science University, NY
| | - Samuel Kuperman
- Department of Psychiatry, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, IA
| | - Jacquelyn Meyers
- Henri Begleiter Neurodynamics Lab, Department of Psychiatry, SUNY Downstate Health Science University, NY
| | - John I Nurnberger
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - Yunlong Liu
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Howard J Edenberg
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
- Department of Biochemistry and Molecular Biology, Indiana University School of Medicine, Indianapolis, IN
| | - Bernice Porjesz
- Henri Begleiter Neurodynamics Lab, Department of Psychiatry, SUNY Downstate Health Science University, NY
| | - Arpana Agrawal
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Tatiana Foroud
- Department of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis, IN
| | - Marc Schuckit
- Department of Psychiatry, University of California, San Diego Medical School, San Diego, CA
| | - Martin H. Plawecki
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN
| | - Kathleen K. Bucholz
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Vivia V. McCutcheon
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
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Ruderman SA, Drumright LN, Delaney JAC, Webel AR, Fitzpatrick AL, Whitney BM, Nance RM, Hahn AW, Ma J, Mixson LS, Eltonsy S, Willig AL, Mayer KH, Napravnik S, Greene M, McCaul M, Cachay E, Kritchevsky SB, Austad SN, Landay A, Saag MS, Kitahata MM, Lau B, Lesko C, Chander G, Crane HM, Odden MC. Evaluating the Sick Quitting Hypothesis for Frailty Status and Reducing Alcohol Use Among People With HIV in a Longitudinal Clinical Cohort Study. J Assoc Nurses AIDS Care 2024; 35:5-16. [PMID: 38150572 DOI: 10.1097/jnc.0000000000000441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
ABSTRACT "Sick quitting," a phenomenon describing reductions in alcohol consumption following poor health, may explain observations that alcohol appears protective for frailty risk. We examined associations between frailty and reductions in drinking frequency among people with HIV (PWH). At six Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) sites between January 2012 and August 2021, we assessed whether frailty, measured through validated modified frailty phenotype, precedes reductions in drinking frequency. We associated time-updated frailty with quitting and reducing frequency of any drinking and heavy episodic drinking (HED), adjusted for demographic and clinical characteristics in Cox models. Among 5,654 PWH reporting drinking, 60% reported >monthly drinking and 18% reported ≥monthly HED. Over an average of 5.4 years, frail PWH had greater probabilities of quitting (HR: 1.56, 95% confidence interval [95% CI] [1.13-2.15]) and reducing (HR: 1.35, 95% CI [1.13-1.62]) drinking frequency, as well as reducing HED frequency (HR: 1.58, 95% CI [1.20-2.09]) versus robust PWH. Sick quitting likely confounds the association between alcohol use and frailty risk, requiring investigation for control.
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Affiliation(s)
- Stephanie A Ruderman
- Stephanie A. Ruderman, PhD, MPH, is a Research Scientist, School of Medicine, University of Washington, Seattle, Washington, USA. Lydia N. Drumright, PhD, MPH, is a Clinical Assistant Professor, School of Nursing, University of Washington, Seattle, Washington, USA. Joseph A. C. Delaney, PhD, is a Research Associate Professor, College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada, and School of Medicine, University of Washington, Seattle, Washington, USA. Allison R. Webel, RN, PhD, is an Associate Dean for Research, School of Nursing, University of Washington, Seattle, Washington, USA. Annette L. Fitzpatrick, PhD, is a Research Professor, Department of Epidemiology, University of Washington, Seattle, Washington, USA. Bridget M. Whitney, PhD, MPH, is a Senior Research Scientist, School of Medicine, University of Washington, Seattle, Washington, USA. Robin M. Nance, PhD, is a Research Scientist, School of Medicine, University of Washington, Seattle, Washington, USA. Andrew W. Hahn, MD, is a Clinical Assistant Professor, School of Medicine, University of Washington, Seattle, Washington, USA. Jimmy Ma, MD, is an Infectious Disease Specialist, School of Medicine, University of Washington, Seattle, Washington, USA. L. Sarah Mixson, MPH, is a Research Scientist, School of Medicine, University of Washington, Seattle, Washington, USA. Sherif Eltonsy, PhD, is an Assistant Professor, College of Pharmacy, University of Manitoba, Winnipeg, Manitoba, Canada. Amanda L Willig, PhD, RD, is an Associate Professor, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. Kenneth H. Mayer, MD, is a Professor, Harvard Medical School, Fenway Institute, Boston, Massachusetts, USA. Sonia Napravnik, PhD, MPH, is an Associate Professor, Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, USA. Meredith Greene, MD, is an Associate Professor, Department of Medicine, University of California San Francisco, San Francisco, California, USA. Mary McCaul, PhD, is a Professor, School of Medicine, Johns Hopkins University, Baltimore, Maryland, USA. Edward Cachay, MD, is a Professor, Department of Medicine, University of California San Diego, San Diego, California, USA. Stephen B. Kritchevsky, PhD, is a Professor, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA. Steven N. Austad, PhD, is a Distinguished Professor, Department of Biology, University of Alabama at Birmingham, Birmingham, Alabama, USA. Alan Landay, PhD, is a Professor, Department of Internal Medicine, Rush University, Chicago, Illinois, USA. Michael S. Saag, MD, is a Professor and Associate Dean, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA. Mari M. Kitahata, MD, MPH, is a Professor, School of Medicine, University of Washington, Seattle, Washington, USA. Bryan Lau, PhD, is a Professor, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA. Catherine Lesko, PhD, MPH, is an Assistant Professor, Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland, USA. Geetanjali Chander, MD, MPH, is a Professor, School of Medicine, University of Washington, Seattle, Washington, USA. Heidi M. Crane, MD, MPH, is a Professor, School of Medicine, University of Washington, Seattle, Washington, USA. Michelle C. Odden, PhD, is an Associate Professor, Department of Epidemiology, Stanford University, Stanford, California, USA
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Evaluating the Sick Quitting Hypothesis for Frailty Status and Reducing Alcohol Use Among People With HIV in a Longitudinal Clinical Cohort Study. J Assoc Nurses AIDS Care 2024; 35:e1-e2. [PMID: 38150573 PMCID: PMC10753926 DOI: 10.1097/jnc.0000000000000445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
“Sick quitting”, a phenomenon describing reductions in alcohol consumption following poor health, may explain observations that alcohol appears protective for frailty risk. We examined associations between frailty and reductions in drinking frequency among people with HIV (PWH). At six Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) sites between January 2012 and August 2021, we assessed whether frailty, measured via validated modified frailty phenotype, precedes reductions in drinking frequency. We associated time-updated frailty with quitting and reducing frequency of any drinking and heavy episodic drinking (HED), adjusted for demographic and clinical characteristics in Cox models. Among 5,654 PWH reporting drinking, 60% reported >monthly drinking and 18% reported ≥monthly HED. Over an average of 5.4 years, frail PWH had greater probabilities of quitting (HR:1.56, 95%CI:1.13–2.15) and reducing (HR:1.35, 95%CI:1.13–1.62) drinking frequency, as well as reducing HED frequency (HR:1.58, 95%CI:1.20–2.09) vs. robust PWH. Sick quitting likely confounds the association between alcohol use and frailty risk, requiring investigation for control.
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Kaur A, Lal R, Sen MS, Sarkar S. Comparison of Recovery Capital in Patients with Alcohol and Opioid Dependence - An Exploratory Study. ADDICTION & HEALTH 2022; 14:105-114. [PMID: 36544508 PMCID: PMC9743817 DOI: 10.22122/ahj.2022.196722.1314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Accepted: 01/12/2022] [Indexed: 12/24/2022]
Abstract
Background Recovery capital helps in the assessment of the personal strengths and challenges that exist in an individual with substance use which may have an impact on recovery process. This study aims at finding out the factors which help such individuals to sustain their recovery and how these factors differ across the two groups of people suffering from Alcohol Dependence Syndrome and Opioid Dependence Syndrome. Methods A cross-sectional observational was designed where sociodemographic and clinical variables, the recovery capital ARC (Assessment of Recovery Capital) Scale and Severity of substance use SDS (Severity of Dependence) Scale of patients diagnosed with Alcohol Dependence Syndrome (ADS group) and those with Opioid Dependence Syndrome (ODS group) were assessed among patients not reporting withdrawal symptoms. Findings A total of 49 subjects in the ODS group and 30 subjects in the ADS group were enrolled. The majority of the subjects in both groups were married, belonged to urban areas, practiced Hinduism, and were living in nuclear families. There was a significant difference between the educational status (p<0.001), religion practiced (p<0.001), age of onset of dependence (p<0.001), severity of dependence (p=0.11), and duration of abstinence (p<0.001) between the ADS and ODS groups. The mean scores on ARC Scale were 45.9 (S.D. =3.5) in the ODS group and 47.4 (S.D. =4.3) in the ADS group. ADS group had higher scores in Social Support Domain (p=0.034) and Housing and Safety domain (p=0.025). Other domains like global health, citizenship, meaningful activities, risk-taking, coping, and recovery experience did not significantly differ between the groups. Conclusion This study aims at comparing the recovery capital of ADS patients with ODS patients. It also suggests that tailored treatment plans for people with ADS and ODS especially in housing and social support and common treatment approach in other domains of recovery will help them sustain the state for a longer term.
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Affiliation(s)
- Apinderjit Kaur
- Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Lal
- Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
| | - Mahadev Singh Sen
- Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India,Correspondence to: Mahadev Singh Sen; Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India;
| | - Siddharth Sarkar
- Department of Psychiatry and NDDTC, All India Institute of Medical Sciences, New Delhi, India
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Farmer RF, Gau JM, Seeley JR, Kosty DB. Family-Based Predictors of Alcohol Use Disorder (AUD) Recurrence and New Non-Alcohol Substance Use Disorder Onset Following Initial AUD Recovery. J Stud Alcohol Drugs 2022; 83:239-247. [PMID: 35254247 PMCID: PMC8909923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
OBJECTIVE Knowledge of factors that predict alcohol use disorder (AUD) recurrence or the subsequent switching to a different substance use disorder (SUD) after initial AUD recovery is especially crucial for preventive efforts that seek to alter life courses dominated by problematic substance use. This study evaluated whether the proportions (or densities) of first-degree relatives with AUD and non-alcohol substance use disorder (NASUD) histories predicted AUD recurrence or a new NASUD onset in a family member (i.e., proband) following initial AUD episode recovery. METHOD This research is based on a prospective and multigenerational data set collected as part of the Oregon Adolescent Depression Project (OADP). The initial proband cohort was selected randomly from nine high schools in western Oregon. The sample for this research consisted of OADP probands with histories of AUD who recovered from their first AUD episode by age 30 (n = 244). Lifetime SUD histories were also assessed for first-degree adult relatives of probands (n = 790). RESULTS In unadjusted and partially adjusted analyses, family densities of AUD predicted AUD recurrence among probands, and family densities of NASUDs predicted the onset of a new NASUD following first-episode AUD recovery. In fully adjusted analyses, the effect for AUD family histories on proband AUD recurrence remained, whereas the effect for family NASUD histories on new NASUD emergence was not maintained. CONCLUSIONS Family SUD histories have predictive relevance for the course of AUD following initial recovery as well as some specificity for the type of SUD recurrence subsequently experienced.
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Affiliation(s)
- Richard F. Farmer
- Oregon Research Institute, Eugene, Oregon,Correspondence may be sent to Richard F. Farmer at the Oregon Research Institute, 1776 Millrace Dr., Eugene, OR 97403, or via email at:
| | - Jeff M. Gau
- Oregon Research Institute, Eugene, Oregon,University of Oregon, College of Education, Eugene, Oregon
| | - John R. Seeley
- Oregon Research Institute, Eugene, Oregon,University of Oregon, College of Education, Eugene, Oregon
| | - Derek B. Kosty
- Oregon Research Institute, Eugene, Oregon,University of Oregon, College of Education, Eugene, Oregon
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Farmer RF, Gau JM, Seeley JR, Kosty DB. Family-Based Predictors of Alcohol Use Disorder (AUD) Recurrence and New Non-Alcohol Substance Use Disorder Onset Following Initial AUD Recovery. J Stud Alcohol Drugs 2022; 83:239-247. [PMID: 35254247 PMCID: PMC8909923 DOI: 10.15288/jsad.2022.83.239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/16/2021] [Indexed: 01/17/2024] Open
Abstract
OBJECTIVE Knowledge of factors that predict alcohol use disorder (AUD) recurrence or the subsequent switching to a different substance use disorder (SUD) after initial AUD recovery is especially crucial for preventive efforts that seek to alter life courses dominated by problematic substance use. This study evaluated whether the proportions (or densities) of first-degree relatives with AUD and non-alcohol substance use disorder (NASUD) histories predicted AUD recurrence or a new NASUD onset in a family member (i.e., proband) following initial AUD episode recovery. METHOD This research is based on a prospective and multigenerational data set collected as part of the Oregon Adolescent Depression Project (OADP). The initial proband cohort was selected randomly from nine high schools in western Oregon. The sample for this research consisted of OADP probands with histories of AUD who recovered from their first AUD episode by age 30 (n = 244). Lifetime SUD histories were also assessed for first-degree adult relatives of probands (n = 790). RESULTS In unadjusted and partially adjusted analyses, family densities of AUD predicted AUD recurrence among probands, and family densities of NASUDs predicted the onset of a new NASUD following first-episode AUD recovery. In fully adjusted analyses, the effect for AUD family histories on proband AUD recurrence remained, whereas the effect for family NASUD histories on new NASUD emergence was not maintained. CONCLUSIONS Family SUD histories have predictive relevance for the course of AUD following initial recovery as well as some specificity for the type of SUD recurrence subsequently experienced.
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Affiliation(s)
| | - Jeff M. Gau
- Oregon Research Institute, Eugene, Oregon
- University of Oregon, College of Education, Eugene, Oregon
| | - John R. Seeley
- Oregon Research Institute, Eugene, Oregon
- University of Oregon, College of Education, Eugene, Oregon
| | - Derek B. Kosty
- Oregon Research Institute, Eugene, Oregon
- University of Oregon, College of Education, Eugene, Oregon
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Palzes VA, Kline-Simon AH, Satre DD, Sterling S, Weisner C, Chi FW. Predictors of early and sustained cessation of heavy drinking over 5 years among adult primary care patients. Addiction 2022; 117:82-95. [PMID: 34159681 PMCID: PMC8664973 DOI: 10.1111/add.15612] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 03/11/2021] [Accepted: 06/09/2021] [Indexed: 01/03/2023]
Abstract
AIMS To identify factors asociated with early and sustained cessation of heavy drinking. DESIGN Retrospective cohort study over 5 years. SETTING Kaiser Permanente Northern California, United States. PARTICIPANTS Adults reporting heavy drinking during primary care-based alcohol screening between 1 June 2013 and 31 May 2014. The sample (n = 85 434) was 40.7% female and 33.8% non-white; mean age was 50.3 years (standard deviation = 18.1). MEASUREMENTS Following US guidelines, early and sustained cessation of heavy drinking was defined as reporting lower-risk drinking or abstinence at 1 year and to 5 years after achieving early cessation, respectively. Associations between patient characteristics and service use and cessation outcomes were examined using logistic regression with inverse probability weights addressing attrition. FINDINGS Nearly two-thirds of participants achieved early cessation of heavy drinking. Women [odds ratio (OR) = 1.39, 95% confidence interval (CI) = 1.35, 1.44], middle-age (35-64 years: ORs = 1.16-1.19), non-white race/ethnicity (ORs = 1.03-1.57), medical conditions (OR = 1.05, 95% CI = 1.04, 1.06), psychiatric (OR = 1.10, 95% CI = 1.06, 1.15) and drug use disorders (OR = 1.35, 95% CI = 1.17, 1.56) and addiction treatment (OR = 1.19, 95% CI = 1.09, 1.30) were associated with higher odds of early cessation, while older age (≥ 65 years: OR = 0.91, 95% CI = 0.86, 0.96), smoking (OR = 0.81, 95% CI = 0.77, 0.84), higher index drinking levels (exceeding both daily and weekly limits: OR = 0.30, 95% CI = 0.29, 0.32) and psychiatric treatment (OR = 0.91, 95% CI = 0.84, 0.99) were associated with lower odds. Among those who achieved early cessation (n = 19 200), 60.0% sustained cessation. Associations between patient factors and sustained cessation paralleled those observed in analyses of early cessation. Additionally, routine primary care (OR = 1.57, 95% CI = 1.44, 1.71) and addiction treatment post-1 year (OR = 1.41, 95% CI = 1.19, 1.66) were associated with higher odds of sustained cessation. Lower-risk drinking versus abstinence at 1 year was associated with lower odds of sustained cessation (OR = 0.62, 95% CI = 0.57, 0.66). CONCLUSIONS Nearly two-thirds of a large, diverse sample of patients who reported heavy drinking in a Californian health-care system achieved early and sustained cessation of heavy drinking. Vulnerable subgroups (i.e. non-white patients and those with psychiatric disorders), patients who received routine primary care and those who received addiction treatment were more likely to sustain cessation of heavy drinking than other participants.
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Affiliation(s)
- Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | | | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Stacy Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
- Department of Psychiatry and Behavioral Sciences, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
| | - Felicia W Chi
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
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10
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Maintaining recovery from alcohol use disorder during the COVID-19 pandemic: The importance of recovery capital. Drug Alcohol Depend 2021; 229:109142. [PMID: 34775185 PMCID: PMC8552632 DOI: 10.1016/j.drugalcdep.2021.109142] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Revised: 10/08/2021] [Accepted: 10/09/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The potential impact of the COVID-19 pandemic on recovery from alcohol use disorder (AUD) has received scant attention to date. In response, we investigated the stability of recovery and identified correlates of relapse, with particular interest in differences between women and men. METHODS Data were obtained in a national survey of adults with resolved alcohol use disorder who were not drinking heavily (n = 1492). We calculated summary statistics and modeled odds of mild relapse (i.e., resolved at the time of data collection), overall and stratified by gender. RESULTS Equivalent large majorities of women and men reported that the COVID-19 pandemic had not affected their recovery at all (88.9% and 88.8%, respectively). Mild relapse events were infrequent, with only 45 participants (3.1%) reporting a resumption of drinking after being abstinent and 35 participants (2.7%) reporting an increase from previously moderated drinking, with no differences in prevalence between men and women. Recovery capital showed consistent and comparable protective effects for both women and men (adjusted odds ratio [aOR] 0.90; 95% confidence interval [95% CI] 0.84, 0.97; and aOR 0.93; 95% CI 0.88, 0.98, respectively). We did not find any effect of pandemic-related stressors; however, there were a number of distinct correlates of mild relapse for women and men. CONCLUSIONS Recovery capital showed a consistently protective effect and may serve as a highly suitable intervention target as it is modifiable. Given gender differences, assessments of other key factors and tailored interventions targeting women and men may be necessary to ensure stable recovery.
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11
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Yoshimura A, Kimura M, Matsushita S, Yoneda JI, Maesato H, Komoto Y, Nakayama H, Sakuma H, Yumoto Y, Takimura T, Tohyama T, Iwahara C, Mizukami T, Yokoyama A, Higuchi S. Alcohol dependence severity determines the course of treatment-seeking patients. Alcohol Clin Exp Res 2021; 45:2335-2346. [PMID: 34585408 DOI: 10.1111/acer.14707] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 08/05/2021] [Accepted: 08/28/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND While accumulating evidence suggests a relation between the severity of alcohol dependence and the risk of its recurrence, the impact of dependence severity on the course of the disorder has not been carefully evaluated. The present study examined the impact of several severity indices of alcohol dependence on the drinking course after inpatient treatment. METHODS This prospective study was conducted over a 12-month period following alcohol treatment at a specialized hospital. A total of 712 consecutively admitted alcohol-dependent patients were targeted for enrollment at the time of their hospitalization, with 637 patients registered and followed. The characteristics and severity of the subjects were assessed using multiple methods at admission, with their course after discharge followed continuously using mailed questionnaires that queried them regarding their drinking behavior. RESULTS Greater severity of dependence, assessed using the number of ICD-10 diagnostic criteria met, was associated with a lower rate of abstinence during the study period (p = 0.035). The rate of abstinence also decreased significantly as the baseline blood gamma-glutamyl transferase value and Alcohol Dependence Scale (ADS) score increased (p = 0.031 and p = 0.0002, respectively). In multivariate Cox proportional hazards analyses, the group with the most severe ADS scores had a significantly greater risk of relapse to drinking than the group with the least severe scores (HR = 2.67, p = 0.001). Dependence severity also associated with the drinking pattern; participants in both the controlled drinking group and the abstinence group had lower ADS scores at admission and a later age at first drinking (p = 0.001 and p < 0.001, respectively) than those with poorer drinking outcomes. CONCLUSIONS The present study showed that more severe alcohol dependence predicts a poorer course after alcohol treatment, as reflected by findings on multiple measures. These results suggest that assessing the dependence severity at the outset of treatment could be useful both in predicting treatment outcome and targeting interventions to alcohol-dependent individuals who need additional support in their recovery.
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Affiliation(s)
- Atsushi Yoshimura
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan.,Division of Psychiatry, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Mitsuru Kimura
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Sachio Matsushita
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Jun-Ichi Yoneda
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Hitoshi Maesato
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | | | - Hideki Nakayama
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan.,Hokujinkai Asahiyama Hospital, Sapporo, Japan
| | - Hiroshi Sakuma
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Yosuke Yumoto
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Tsuyoshi Takimura
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Tomomi Tohyama
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Chie Iwahara
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Takeshi Mizukami
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Akira Yokoyama
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
| | - Susumu Higuchi
- National Hospital Organization, Kurihama Medical and Addiction Center, Yokosuka, Japan
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12
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Palzes VA, Kline-Simon AH, Satre DD, Sterling S, Weisner C, Chi FW. Remission From Unhealthy Drinking Among Patients With an Alcohol Use Disorder: A Longitudinal Study Using Systematic, Primary Care-Based Alcohol Screening Data. J Stud Alcohol Drugs 2020. [PMID: 32800079 DOI: 10.15288/jsad.2020.81.436] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Using electronic health record (EHR) data from a systematic, primary care-based alcohol screening, brief intervention, and referral to treatment (SBIRT) initiative within a health system, we examined correlates of remission from unhealthy drinking among patients with an alcohol use disorder (AUD). METHOD We conducted a longitudinal study of 4,078 adults with AUD who screened positive for unhealthy drinking between October 1, 2015, and September 30, 2016. We extracted EHR data up to 3 years after screening until October 1, 2018. We used survival analysis to examine associations between remission (i.e., reporting abstinence or low-risk drinking at a subsequent screening) and patient characteristics, comorbidities, and treatment utilization. RESULTS The median time to remission from unhealthy drinking was 1.7 years. Factors significantly associated with greater odds of remitting from unhealthy drinking during follow-up were female gender; older age (50-64 years); Black or Latino/Hispanic race/ethnicity; having more medical comorbidities; not having a comorbid drug use disorder; lower alcohol consumption levels; and receiving addiction medicine treatment before the index screening. In the first follow-up year, individuals with mental health comorbidities were more likely to remit, but those in psychiatric treatment were less likely. Receiving addiction treatment during follow-up was not associated with remission. CONCLUSIONS Ethnic minorities and individuals with mental illness were more likely to remit, which is encouraging given the health disparities observed among these clinically important subgroups and warrants further research. Our findings may inform research on AUD recovery and clinical practice, as remission from unhealthy drinking is a crucial component of the early stages of recovery.
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Affiliation(s)
- Vanessa A Palzes
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Andrea H Kline-Simon
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Derek D Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, California.,Department of Psychiatry, Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, California
| | - Stacy Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland, California.,Department of Psychiatry, Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, California
| | - Felicia W Chi
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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13
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Stefanovics EA, Gavriel-Fried B, Potenza MN, Pietrzak RH. Current drinking patterns in US veterans with a lifetime history of alcohol use disorder: Results from the National Health and Resilience in Veterans Study. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2020; 46:784-794. [PMID: 32975444 DOI: 10.1080/00952990.2020.1803893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Background: Although more than 40% of US military veterans have lifetime histories of alcohol use disorder (AUD), little is known about the prevalence and correlates of current drinking patterns (i.e., abstinent, subthreshold, hazardous drinking) in this population. Objectives: To characterize the prevalence and key correlates of abstinence, subthreshold drinking, and hazardous drinking in a nationally representative sample of US veterans with lifetime AUD. Methods: Data from 1,282 veterans with lifetime AUD who participated in the National Health and Resilience in Veterans Study were analyzed using analyses of variance, chi-square analyses, and multinomial regression models. Results: Of the 1,282 veterans with lifetime AUD (of which 94.7% were males), 674 (48.2%) were past-year subthreshold drinkers, 317 (28.0%) were abstinent and 291 (23.8%) were hazardous drinkers. Abstinent veterans were older, less educated, less socially engaged, and had higher levels of religiosity than subthreshold and hazardous drinkers. They were also more likely to smoke, screen positive for PTSD, reported greater somatic symptoms than subthreshold drinkers, and had more physical difficulties and lifetime trauma than hazardous drinkers. Subthreshold drinkers were more likely than hazardous drinkers to be female and report physical health problems and less likely to smoke and be depressed. Conclusion: More than three-quarters of US veterans with lifetime AUD are currently abstinent or subthreshold drinkers. Factors associated with abstinence included older age, health problems, religiosity and social engagement. Results suggest a "J-shaped" relationship between current drinking patterns and health and psychosocial factors in veterans, with subthreshold drinkers generally having better health than abstinent and hazardous drinkers.
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Affiliation(s)
- Elina A Stefanovics
- Department of Psychiatry, Yale School of Medicine , New Haven, CT, USA.,U.S. Department of Veterans Affairs (VA) New England Mental Illness Research and Education, Clinical Center (MIRECC), VA Connecticut Healthcare System , West Haven, CT, USA
| | - Belle Gavriel-Fried
- The Bob Shapell School of Social Work, Tel Aviv University , Tel Aviv, Israel
| | - Marc N Potenza
- Department of Psychiatry, Yale School of Medicine , New Haven, CT, USA.,The Connecticut Council on Problem Gambling , Wethersfield, CT, USA.,The Connecticut Mental Health Center , New Haven, CT, USA.,Department of Neuroscience and Child Study Center, Yale School of Medicine , New Haven, CT, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale School of Medicine , New Haven, CT, USA.,U.S. Department of Veterans Affairs (VA) National Center for Posttraumatic Stress Disorder, VA Connecticut Healthcare System , West Haven, CT, USA
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14
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Heyman GM. How individuals make choices explains addiction's distinctive, non-eliminable features. Behav Brain Res 2020; 397:112899. [PMID: 32926908 DOI: 10.1016/j.bbr.2020.112899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/14/2020] [Accepted: 09/03/2020] [Indexed: 11/24/2022]
Abstract
In keeping with the goals of this Special Issue, this paper poses the following questions: What are addiction's non-eliminable features and can they be explained by one or more general principles? I have added the qualifier "distinctive" to these goals, as in "distinctive non-eliminable features." The result is a highly heterogeneous list, which includes features of addiction's natural history, such as its high remission rates, its unique idioms (e.g., "kicking the habit"), and its patented interventions, such as Alcoholics Anonymous. I show that each of these distinctive features reflects how individuals make choices. In particular, they reflect the competing claims of two basic choice processes: global maximizing of the sort assumed in introductory economics textbooks and Herrnstein's matching law, which has empirical rather than theoretical roots. These are basic choice processes, which apply to all decision making, not just drugs and not just addicts. Nevertheless, they can result in addiction when one of the options has the capacity to undermine the value of competing interests and undermine global maximizing. Conversely, the analyses also show that the two basic choice processes combine so as to predict that addiction is a semi-stable state that is biased to resolve in favor of remission. These predictions are supported by the high rates of addiction, by the high rates of remission from addiction, and by the fact that remission is often unassisted or "spontaneous." The analyses fail to support the idea that pathological psychological processes lead to addiction. Rather they show that addiction emerges from the interactions of normal choice processes and the behaviorally toxic effects of drugs.
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Affiliation(s)
- Gene M Heyman
- Department of Psychology & Neuroscience, Boston College, Chestnut Hill, MA 02467, United States.
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15
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Palzes VA, Kline-Simon AH, Satre DD, Sterling S, Weisner C, Chi FW. Remission From Unhealthy Drinking Among Patients With an Alcohol Use Disorder: A Longitudinal Study Using Systematic, Primary Care-Based Alcohol Screening Data. J Stud Alcohol Drugs 2020; 81:436-445. [PMID: 32800079 PMCID: PMC7437559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 01/07/2020] [Indexed: 03/30/2024] Open
Abstract
OBJECTIVE Using electronic health record (EHR) data from a systematic, primary care-based alcohol screening, brief intervention, and referral to treatment (SBIRT) initiative within a health system, we examined correlates of remission from unhealthy drinking among patients with an alcohol use disorder (AUD). METHOD We conducted a longitudinal study of 4,078 adults with AUD who screened positive for unhealthy drinking between October 1, 2015, and September 30, 2016. We extracted EHR data up to 3 years after screening until October 1, 2018. We used survival analysis to examine associations between remission (i.e., reporting abstinence or low-risk drinking at a subsequent screening) and patient characteristics, comorbidities, and treatment utilization. RESULTS The median time to remission from unhealthy drinking was 1.7 years. Factors significantly associated with greater odds of remitting from unhealthy drinking during follow-up were female gender; older age (50-64 years); Black or Latino/Hispanic race/ethnicity; having more medical comorbidities; not having a comorbid drug use disorder; lower alcohol consumption levels; and receiving addiction medicine treatment before the index screening. In the first follow-up year, individuals with mental health comorbidities were more likely to remit, but those in psychiatric treatment were less likely. Receiving addiction treatment during follow-up was not associated with remission. CONCLUSIONS Ethnic minorities and individuals with mental illness were more likely to remit, which is encouraging given the health disparities observed among these clinically important subgroups and warrants further research. Our findings may inform research on AUD recovery and clinical practice, as remission from unhealthy drinking is a crucial component of the early stages of recovery.
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Affiliation(s)
- Vanessa A. Palzes
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | | | - Derek D. Satre
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Department of Psychiatry, Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, California
| | - Stacy Sterling
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Constance Weisner
- Division of Research, Kaiser Permanente Northern California, Oakland, California
- Department of Psychiatry, Weill Institute of Neurosciences, University of California, San Francisco, San Francisco, California
| | - Felicia W. Chi
- Division of Research, Kaiser Permanente Northern California, Oakland, California
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16
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Stein E, Witkiewitz K. Trait self-control predicts drinking patterns during treatment for alcohol use disorder and recovery up to three years following treatment. Addict Behav 2019; 99:106083. [PMID: 31430618 DOI: 10.1016/j.addbeh.2019.106083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/06/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
Abstract
To more fully understand recovery from alcohol use disorder, we must consider several ways in which reductions in drinking and improvements in psychosocial functioning may occur. Previous research has demonstrated various patterns of drinking and functioning during and after behavioral treatment for alcohol use disorder, including groups of individuals who consume alcohol at low-risk levels and those that report occasional heavy drinking yet good psychosocial functioning. This study aimed to identify whether trait self-control, which has previously been associated with alcohol treatment outcomes, was a predictor of drinking patterns during treatment as well as three years following treatment. Latent variable mixture modeling was used to identify seven classes of drinking patterns during treatment and four profiles of drinking and psychosocial function after treatment. We found that membership in the low-risk drinking class was predicted by greater trait self-control than several of the other classes, including the consistent abstinence class. Furthermore, we found that greater trait self-control predicted membership in two high-functioning recovery profiles at three years following treatment, including a high functioning occasional heavy drinking profile. These findings suggest that self-control is an important predictor of recovery, particularly for a non-abstinent recovery.
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17
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Fan AZ, Chou SP, Zhang H, Jung J, Grant BF. Prevalence and Correlates of Past-Year Recovery From DSM-5 Alcohol Use Disorder: Results From National Epidemiologic Survey on Alcohol and Related Conditions-III. Alcohol Clin Exp Res 2019; 43:2406-2420. [PMID: 31580502 DOI: 10.1111/acer.14192] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 08/21/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Little is known about remission, recovery, and other outcomes of alcohol use disorder (AUD) as defined by the DSM-5. METHODS Data from a large representative sample of the United States was used to examine correlates of past-year AUD status among individuals with prior-to-past-year AUD: persistent AUD, symptomatic high-risk drinking, asymptomatic high-risk drinking, symptomatic low-risk drinking, asymptomatic low-risk drinking (nonabstinent recovery, NAR), and abstainer (abstinent recovery, AR). Multiple logistic regression analyses were conducted to compare: (i) AR and NAR with persistent AUD, (ii) AR with NAR, and (iii) asymptomatic and symptomatic high-risk drinking with AR and NAR. RESULTS Among individuals with AUD prior to past year (n = 7,785), 34.2% were classified with persistent AUD, 8.8 and 1.6% were symptomatic high-risk and symptomatic low-risk drinkers, respectively, 21.5% were asymptomatic high-risk drinkers, 17.9% were asymptomatic low-risk drinkers, and 16.0% were abstainers. One-quarter of individuals with AUD prior to past year achieved AR or NAR without the benefit of treatment, while a much greater percentage of individuals achieving AR (43.2%) reported receiving treatment relative to those with NAR (12.3%). The number of lifetime AUD symptoms was greater among those achieving AR (among the treated) and lower among those achieving NAR relative to persistent AUD. The number of AUD symptoms was also greater among those achieving AR than NAR and lower among asymptomatic and symptomatic risk drinkers relative to those achieving AR and NAR. Consumption was greater among those achieving AR relative to those achieving NAR and greater among asymptomatic and symptomatic risk drinkers relative to AR and NAR. Odds of achieving AR or NAR relative to persistent AUD were generally lower among non-Hispanic Blacks and those with higher education, greater among women and married individuals, and lower among illicit drug users and individuals with histories of a personality disorder or mood/anxiety disorder. CONCLUSIONS There appears to be a substantial level of recovery from AUD. Information on specific factors associated with AUD outcomes can be useful in targeting appropriate treatment efforts.
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Affiliation(s)
- Amy Z Fan
- From the, Epidemiology and Biometry Branch, (AZF, SPC, HZ, JJ), National Institute on Alcohol Abuse and Alcoholism, National Institute of Health, Bethesda, Maryland
| | - Sanchen Patricia Chou
- From the, Epidemiology and Biometry Branch, (AZF, SPC, HZ, JJ), National Institute on Alcohol Abuse and Alcoholism, National Institute of Health, Bethesda, Maryland
| | - Haitao Zhang
- From the, Epidemiology and Biometry Branch, (AZF, SPC, HZ, JJ), National Institute on Alcohol Abuse and Alcoholism, National Institute of Health, Bethesda, Maryland
| | - Jeesun Jung
- From the, Epidemiology and Biometry Branch, (AZF, SPC, HZ, JJ), National Institute on Alcohol Abuse and Alcoholism, National Institute of Health, Bethesda, Maryland
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18
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Developing the Spirituality in Recovery Framework: The Function of Spirituality in 12-Step Substance Use Disorder Recovery. JOURNAL OF HUMANISTIC PSYCHOLOGY 2019. [DOI: 10.1177/0022167819871742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A large portion of substance use disorder recovery research has incorporated the study of mutual-aid 12-Step programs and faith-based programs. However, spirituality as a centerpiece of substance use disorder recovery, as an actionable or operationalized means of transformative change, is not well studied. As many individuals in recovery point to spirituality as the chief means by which they have overcome their substance use disorder, this represents a significant gap in the current literature. Though spirituality is difficult to operationalize and measure, several previous studies have examined aspects of the role of spirituality in the recovery process. This current article puts forth a theoretical framework in which leading articles involving spirituality in recovery are synthesized in order to inform a functional, theoretical model of change that can be utilized in future research design.
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19
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Sliedrecht W, de Waart R, Witkiewitz K, Roozen HG. Alcohol use disorder relapse factors: A systematic review. Psychiatry Res 2019; 278:97-115. [PMID: 31174033 DOI: 10.1016/j.psychres.2019.05.038] [Citation(s) in RCA: 179] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/12/2022]
Abstract
A relapsing-remitting course is very common in patients with an Alcohol Use Disorder (AUD). Understanding the determinants associated with alcohol resumption remains a formidable task. This paper examines relapse determinants based on a systematic review of recent alcohol literature (2000-2019). Relevant databases were consulted for articles that contained information about specific relapse determinants and reported statistical significance of each relapse determinant in predicting relapse. Relapse was broadly defined based on the characterization in the included articles. From the initial identified 4613 papers, a total of 321 articles were included. Results encompass multiple relapse determinants, which were ordered according to biopsychosocial and spiritual categories, and presented, using a descriptive methodology. Psychiatric co-morbidity, AUD severity, craving, use of other substances, health and social factors were consistently significantly associated with AUD relapse. Conversely, supportive social network factors, self efficacy, and factors related to purpose and meaning in life, were protective against AUD relapse. Despite heterogeneity in different methods, measures, and sample characteristics, these findings may contribute to a better therapeutic understanding in which specific factors are associated with relapse and those that prevent relapse. Such factors may have a role in a personalized medicine framework to improve patient outcomes.
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Affiliation(s)
- Wilco Sliedrecht
- De Hoop GGZ, Provincialeweg 70, 3329 KP Dordrecht, the Netherlands.
| | - Ranne de Waart
- Mentrum/Arkin, Wisselwerking 46-48, 1112 XR Diemen, the Netherlands.
| | - Katie Witkiewitz
- The University of New Mexico (UNM), MSC 03-2220, Univ of New Mexico, Albuquerque, NM 87131, USA.
| | - Hendrik G Roozen
- The University of New Mexico (UNM), Center on Alcoholism, Substance Abuse, and Addictions (CASAA), MSC 11 6280, 1 Univ of New Mexico, Albuquerque, NM 87106, USA.
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20
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Witkiewitz K, Wilson AD, Pearson MR, Montes KS, Kirouac M, Roos CR, Hallgren KA, Maisto SA. Profiles of recovery from alcohol use disorder at three years following treatment: can the definition of recovery be extended to include high functioning heavy drinkers? Addiction 2019; 114:69-80. [PMID: 30063267 PMCID: PMC6289769 DOI: 10.1111/add.14403] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/29/2018] [Accepted: 07/20/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS Recovery from alcohol use disorder (AUD) is often narrowly defined by abstinence from alcohol and improvements in functioning (e.g. mental health, social functioning, employment). This study used latent profile analysis to examine variability in recovery outcomes, defined by alcohol use, alcohol-related problems and psychosocial functioning at 3 years following treatment. Secondary analysis investigated pre-treatment, post-treatment and 1- and 3-year post-treatment covariate predictors of the latent profiles. DESIGN Secondary analysis of data from a randomized clinical trial. SETTING United States. PARTICIPANTS We used data from the out-patient arm of Project MATCH (n = 806; 29.7% female, 22.2% non-white). MEASUREMENTS Recovery was defined by latent profile analyses including measures of psychosocial functioning and life satisfaction (Psychosocial Functioning Inventory), unemployment and mental health (Addiction Severity Index), alcohol and other drug use (Form 90) and alcohol-related consequences (Drinker Inventory of Consequences) 3 years following treatment. Mixture modeling was used to examine correlates of profiles. FINDINGS We identified four profiles at 3 years following treatment: (1) poor functioning frequent heavy drinkers, (2) poor functioning infrequent heavy drinkers, (3) high functioning occasional heavy drinkers and (4) high-functioning infrequent non-heavy drinkers. There were relatively few differences on indicators of functioning and treatment-related variables between the high functioning infrequent non-heavy drinkers and the high-functioning occasional heavy drinkers, other than high-functioning occasional heavy drinkers having lower alcohol dependence severity [odds ratio (OR) = 0.94, 95% confidence interval (CI) = 0.90, 0.98], fewer post-treatment coping skills (OR = 0.54, 95% CI = 0.32, 0.90) and lower 3-year post-treatment abstinence self-efficacy (OR = 0.37, 95% CI = 0.28, 0.49) and Alcoholics Anonymous (AA) involvement (OR = 0.87, 95% CI = 0.85, 0.99). The two high-functioning profiles showed the greatest improvements in functioning from baseline through the 3-year follow-up, whereas the low-functioning profiles showed the least amount of improvement. High-functioning occasional heavy drinkers had higher purpose in life than the poor-functioning profiles. CONCLUSIONS Some individuals who engage in heavy drinking following treatment for alcohol use disorder may function as well as those who are mostly abstinent with respect to psychosocial functioning, employment, life satisfaction and mental health.
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21
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Seeley JR, Farmer RF, Kosty DB, Gau JM. Prevalence, incidence, recovery, and recurrence of alcohol use disorders from childhood to age 30. Drug Alcohol Depend 2019; 194:45-50. [PMID: 30399499 PMCID: PMC7018515 DOI: 10.1016/j.drugalcdep.2018.09.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 09/13/2018] [Accepted: 09/17/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Little is known about the course of alcohol use disorders (AUDs) in representative samples during high-risk periods of adolescence and early adulthood. The primary objective of this research is to describe the prevalence and course of initial AUD episodes experienced between childhood and age 30 in a regionally representative cohort sample. METHODS Study data are from an epidemiological study of 816 youth. Participants were initially selected at random from nine high schools in western Oregon, USA. Four waves of data collection were conducted between ages 16 and 30. AUD course milestones are referenced to participants' age. RESULTS Results indicated that male participants (43%) were significantly more likely to be diagnosed with a lifetime AUD than female participants (28%), OR [CI95] = 1.97 [1.47-2.65], and rate of first incidence was especially high between ages 18 and 24.9, a developmental period that also corresponded to the peak interval in prevalence rates. The rate of first AUD incidence substantially diminished beginning around age 25. Among those with an initial AUD episode, 87% recovered by age 30 and, of these, the average episode length was 23 months. Among recovered cases, 33% went on to experience a second AUD episode (i.e., a recurrence) after a minimum 12-month asymptomatic recovery period. Risk for recurrence remained relatively high within the 5 years following initial AUD offset. CONCLUSIONS AUDs are common lifetime conditions in representative samples, whereby most affected individuals by age 30 experience a time-limited course rather than a recurring or persistent course.
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Affiliation(s)
- John R. Seeley
- University of Oregon, College of Education, 1215 University St., Eugene, OR, 97403, USA,Oregon Research Institute, 1776 Millrace Drive, Eugene, OR, 97403, USA
| | - Richard F. Farmer
- Oregon Research Institute, 1776 Millrace Drive, Eugene, OR, 97403, USA
| | - Derek B. Kosty
- Oregon Research Institute, 1776 Millrace Drive, Eugene, OR, 97403, USA
| | - Jeff M. Gau
- Oregon Research Institute, 1776 Millrace Drive, Eugene, OR, 97403, USA
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L’addictologie de liaison : outils et spécificités. Encephale 2018; 44:354-362. [DOI: 10.1016/j.encep.2017.12.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 12/14/2017] [Accepted: 12/18/2017] [Indexed: 11/22/2022]
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Farmer RF, Seeley JR, Gau JM, Klein DN, Merikangas KR, Kosty DB, Duncan SC, Lewinsohn PM. Clinical features associated with an increased risk for alcohol use disorders among family members. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2018; 32:628-638. [PMID: 30160501 PMCID: PMC11771953 DOI: 10.1037/adb0000388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study evaluated the risk for alcohol use disorders (AUDs) among first-degree relatives depending on whether a specific family member (proband) had an AUD history. For probands with AUD histories, we also evaluated whether certain clinical features were associated with higher rates of AUDs in family members as a means for identifying markers that signify a more familial form of AUD. The proband sample was recruited from high schools in Western Oregon communities at Age 16 and followed longitudinally until Age 30. Structured psychiatric histories of 2,414 first-degree relatives of 732 probands were ascertained when the proband was Age 24. For the full sample, a significant association was observed between proband AUD history and the density (proportion) of first-degree relatives with AUD histories. Univariate analyses indicated that several clinical features among probands with AUD histories were significantly associated with AUD family density. In multivariate analyses, proband AUD episode recurrence and anxiety disorder history features emerged as trend-level or statistically significant unique predictors of AUD family density. One of these features, AUD episode recurrence, demonstrated a significant association with AUD family density once other forms of psychopathology among first-degree relatives were controlled. No evidence of gender moderation of effects was observed. Findings overall indicate that the familial risk for AUDs is related to probands' AUD history status and clinical features they exhibit. (PsycINFO Database Record
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Schuckit MA, Smith TL, Danko G, Kramer J, Bucholz KK, McCutcheon V, Chan G, Kuperman S, Hesselbrock V, Dick DM, Hesselbrock M, Porjesz B, Edenberg HJ, Nureberger JI, Gregg M, Schoen L, Kawamura M, Mendoza LA. A 22-Year Follow-Up (Range 16 to 23) of Original Subjects with Baseline Alcohol Use Disorders from the Collaborative Study on Genetics of Alcoholism. Alcohol Clin Exp Res 2018; 42:1704-1714. [PMID: 29975427 DOI: 10.1111/acer.13810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 06/03/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Recent reports indicate higher-than-expected problematic drinking in older populations. However, few data describe how to predict which older individuals are most likely to demonstrate alcohol-related problems, including those with earlier alcohol use disorders (AUDs). These analyses evaluate predictors of alcohol outcomes in individuals with earlier AUDs in the Collaborative Study on Genetics of Alcoholism (COGA). METHODS Original COGA participants with baseline AUDs at about age 40 were interviewed 13 to 26 years later and placed into clinically derived outcome categories. Chi-square and analysis of variance evaluated baseline differences across 4 outcome groups, with significant items entered into binary logistic regression backwards elimination analyses predicting outcomes. RESULTS Low-Risk Drinkers (N = 100) at follow-up were predicted by baseline higher levels of response to alcohol (high LRs), lower histories of alcohol treatment, experience with fewer types of illicit drugs, and were more likely to have been widowed. At follow-up, Problem Drinkers (N = 192) differed from High-Risk Drinkers (N = 93) who denied multiple alcohol problems by exhibiting baseline lower LRs, higher Sensation Seeking, and a higher proportion who were widowed. Abstinent (N = 278) outcomes were predicted by a history of higher baseline AUD treatments, higher alcohol problems, lower usual drinks, as well as older age and European American heritage. Thirty-four subjects (4.9%) could not be classified and were not included in these analyses. CONCLUSIONS These results generated from AUD individuals from both treatment and nontreatment settings reinforce low probabilities of recent Low-Risk Drinking in individuals with AUDs, but also suggest many individuals with AUDs demonstrate good outcomes 2 decades later.
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Affiliation(s)
- Marc A Schuckit
- Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - Tom L Smith
- Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - George Danko
- Department of Psychiatry, University of California, San Diego, La Jolla, California
| | | | | | | | - Grace Chan
- University of Connecticut, Farmington, Connecticut
| | | | | | | | | | | | | | | | - Marcy Gregg
- Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - Lara Schoen
- Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - Mari Kawamura
- Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - Lee Anne Mendoza
- Department of Psychiatry, University of California, San Diego, La Jolla, California
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Gonçalves PD, Schuckit MA, Smith TL. Drinking Status Between Ages 50 and 55 for Men From the San Diego Prospective Study Who Developed DSM-IV Alcohol Abuse or Dependence in Prior Follow-Ups. J Stud Alcohol Drugs 2018; 78:512-520. [PMID: 28728633 DOI: 10.15288/jsad.2017.78.512] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVE Although alcohol use disorders (AUDs) are prevalent among older individuals, few studies have examined the course and predictors of AUDs from their onset into the person's 50s. This study describes the AUD course from ages 50 to 55 in participants who developed AUDs according to criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), during the San Diego Prospective Study (SDPS). METHOD Among the 397 university students in the SDPS who were followed about every 5 years from age 20 (before AUD onset), 165 developed AUDs, 156 of whom were interviewed at age 55. Age 50-55 outcomes were compared regarding age 20-50 characteristics. Variables that differed significantly across outcome groups were evaluated using binary logistic regression analyses predicting each outcome type. RESULTS Between ages 50 and 55, 16% had low-risk drinking, 36% had high-risk drinking, 38% met DSM-5 AUD criteria, and 10% were abstinent. Baseline predictors of outcome at ages 50-55 included earlier low levels of response to alcohol predicting DSM-5 AUDs and abstinence, higher drinking frequency predicting DSM-5 diagnoses and lower predicting low-risk drinking, higher participation in treatment and/or self-help groups predicting abstinence and lower predicting DSM-5 AUDs, later ages of AUD onset predicting high-risk drinking, and cannabis use disorders predicting abstinent outcomes. CONCLUSIONS Despite the high functioning of these men, few were abstinent or maintained low-risk drinking during the recent 5 years, and 38% met DSM-5 AUD criteria. The data may be helpful to both clinicians and researchers predicting the future course of AUDs in their older patients and research participants.
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Affiliation(s)
- Priscila Dib Gonçalves
- Department of Psychiatry, University of California, San Diego, La Jolla, California.,Institute of Psychiatry, Psychology and Neuropsychology Service and Institute of Psychiatry, Interdisciplinary Group of Studies on Alcohol and Drugs (GREA), University of São Paulo, São Paulo, Brazil
| | - Marc A Schuckit
- Department of Psychiatry, University of California, San Diego, La Jolla, California
| | - Tom L Smith
- Department of Psychiatry, University of California, San Diego, La Jolla, California
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Baldassarre M, Caputo F, Pavarin RM, Bossi MM, Bonavita ME, Caraceni P, Grignaschi A, Balloni M, Cavazza M, Bernardi M, Domenicali M. Accesses for alcohol intoxication to the emergency department and the risk of re-hospitalization: An observational retrospective study. Addict Behav 2018; 77:1-6. [PMID: 28918344 DOI: 10.1016/j.addbeh.2017.08.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 08/13/2017] [Accepted: 08/29/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Alcohol use disorders (AUD) are a frequent cause of admission to emergency departments (EDs) for acute alcohol intoxication (AAI). Patients with AUD present a higher risk of readmission to EDs for AAI than the general population, however, the distinction between sporadic AAI and AAI in the context of AUD in the ED setting is difficult. AIMS To analyze the epidemiological characteristics of patients admitted to EDs because of AAI and to identify factors associated with repeated admissions in order to develop a risk stratification system for patients with AUD based on objective data that can be easily applied in an ED setting. METHODS An observational retrospective study was performed. All patients with diagnosis of AAI at admission in 2014 were enrolled. RESULTS Five hundred and sixty-five patients were enrolled, of which 92 (16%) were admitted more than once to the ED. At multivariate analysis, factors associated with readmission were past episodes of alcohol abuse, social discomfort, previous traumas and psychiatric disorders. Basing on this parameter, a risk-score for re-hospitalization was developed. This score has a high predictive power for the risk of readmission to the ED (AROC 0.837, 95%CI 0.808-0.866), moreover, the cumulative probability of readmission within one year, increased in parallel with score value, being highest in patients presenting 3 or more risk factors. CONCLUSION The present study demonstrates that several risk factors stratify the risk of re-hospitalization in patients admitted to EDs for AAI, allowing the identification of those presenting more severe conditions and who would likely benefit from multidisciplinary intervention.
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McCutcheon VV, Schuckit MA, Kramer JR, Chan G, Edenberg HJ, Smith TL, Bender AK, Hesselbrock V, Hesselbrock M, Bucholz KK. Familial association of abstinent remission from alcohol use disorder in first-degree relatives of alcohol-dependent treatment-seeking probands. Addiction 2017; 112:1909-1917. [PMID: 28556494 PMCID: PMC5633502 DOI: 10.1111/add.13890] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/05/2017] [Accepted: 05/22/2017] [Indexed: 01/24/2023]
Abstract
BACKGROUND AND AIMS Studies that have included family history of alcohol use disorder (AUD) as a predictor of remission from AUD have yielded few significant results. The goals of this study were to estimate the association of persistent AUD, non-abstinent remission and abstinent remission ('AUD/remission status') in a proband with AUD/remission status in a relative and to test whether this association differed in related and unrelated proband-relative pairs. DESIGN High-risk family study of alcohol dependence. Probands were recruited from treatment settings and relatives were invited to participate. Baseline assessments occurred between 1991 and 1998 with follow-up between 1996 and 2005. Half of probands were matched with a biological 1st-degree relative with life-time AUD (related group) and half of probands were paired with an unrelated individual with life-time AUD (unrelated group). SETTING Brooklyn, New York; Indianapolis, Indiana; Iowa City, Iowa; San Diego, California; Farmington, Connecticut; and St Louis, Missouri, USA. PARTICIPANTS A total of 606 probands (25.7% female, mean age 37.7) with baseline and follow-up data and 606 of their 1st-degree relatives who had life-ime AUDs (45.8% female, mean age 36.2 years). MEASUREMENTS Persistent AUD, non-abstinent remission and abstinent remission were based on self-report interview data on most recent AUD symptoms and alcohol consumption. Dependent variable was relatives' AUD/remission status. Independent variable was probands' AUD/remission status. FINDINGS A total of 34.6% of probands and 20.6% of relatives were abstinent and 11.1% of probands and 22.8% of relatives were in non-abstinent remission. AUD/remission status was correlated significantly in related (r = 0.23, P = 0.0037) but not in unrelated pairs. A significant interaction of probands' abstinent remission with a variable representing related (versus unrelated, P = 0.003) pairs suggested a familial association for abstinent remission. In related pairs, individuals with an abstinent proband were more likely to be abstinent themselves than were individuals whose proband had persistent AUD [relative risk ratio = 3.27, 95% confidence interval (CI) = 1.56-6.85, P = 0.002]; this association was not significant in unrelated pairs. CONCLUSIONS The likelihood of abstinent remission among people with alcohol use disorder appears to be more than three times greater for individuals who are related to an abstinent proband versus those related to a proband with persistent alcohol use disorder.
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Affiliation(s)
- Vivia V. McCutcheon
- Washington University School of Medicine, Dept. of Psychiatry, St. Louis, MO 63110
| | - Marc A. Schuckit
- University of California, San Diego, Dept. of Psychiatry, San Diego, CA 92093
| | | | - Grace Chan
- University of Connecticut School of Medicine, Dept. of Psychiatry, Farmington, CT 06030
| | - Howard J. Edenberg
- Indiana University School of Medicine, Dept. of Biochemistry and Molecular Biology, Indianapolis, IN 46202
| | - Tom L. Smith
- University of California, San Diego, Dept. of Psychiatry, San Diego, CA 92093
| | - Annah K. Bender
- University of Missouri, College of Nursing, St. Louis, MO 63121
| | - Victor Hesselbrock
- University of Connecticut School of Medicine, Dept. of Psychiatry, Farmington, CT 06030
| | - Michie Hesselbrock
- University of Connecticut School of Medicine, Dept. of Psychiatry, Farmington, CT 06030
| | - Kathleen K. Bucholz
- Washington University School of Medicine, Dept. of Psychiatry, St. Louis, MO 63110
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Hasin DS, Wall M, Witkiewitz K, Kranzler HR, Falk D, Litten R, Mann K, O'Malley SS, Scodes J, Robinson RL, Anton R. Change in non-abstinent WHO drinking risk levels and alcohol dependence: a 3 year follow-up study in the US general population. Lancet Psychiatry 2017; 4:469-476. [PMID: 28456501 PMCID: PMC5536861 DOI: 10.1016/s2215-0366(17)30130-x] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 02/02/2017] [Accepted: 02/28/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Alcohol dependence is often untreated. Although abstinence is often the aim of treatment, many drinkers prefer drinking reduction goals. Therefore, if supported by evidence of benefit, drinking reduction goals could broaden the appeal of treatment. Regulatory agencies are considering non-abstinent outcomes as efficacy indicators in clinical trials, including reduction in WHO drinking risk levels-very high, high, moderate, and low-defined in terms of mean ethanol consumption (in grams) per day. We aimed to study the relationship between reductions in WHO drinking risk levels and subsequent reduction in the risk of alcohol dependence. METHODS In this population-based cohort study, we included data from 22 005 drinkers who were interviewed in 2001-02 (Wave 1) and re-interviewed 3 years later (2004-05; Wave 2) in the US National Epidemiologic Survey on Alcohol and Related Conditions. Alcohol consumption (WHO drinking risk levels) and alcohol dependence (at least three of seven DSM-IV criteria in the previous 12 months) were assessed at both waves. We used logistic regression to test the relationship between change in WHO drinking risk levels between Waves 1 and 2, and alcohol dependence at Wave 2. FINDINGS At Wave 1, 2·5% (weighted proportion) of the respondents were very-high-risk drinkers, 2·5% were high-risk drinkers, 4·8% were moderate-risk drinkers, and most (90·2%) were low-risk drinkers. Reduction in WHO drinking risk level predicted significantly lower odds of alcohol dependence at Wave 2, particularly among very-high-risk drinkers (adjusted odds ratios 0·27 [95% CI 0·18-0·41] for reduction by one level, 0·17 [0·10-0·27] for two levels, and 0·07 [0·05-0·10] for three levels) and high-risk drinkers (0·64 [0·54-0·75] for one level and 0·12 [0·09-0·15] for two levels), and among those with alcohol dependence at Wave 1 (0·29 [0·15-0·57] for one level, 0·06 [0·04-0·10] for two levels, and 0·04 [0·03-0·06] for three levels in very-high-risk drinkers). INTERPRETATION Our results support the use of reductions in WHO drinking risk levels as an efficacy outcome in clinical trials. Because these risk levels can be readily translated into standard drink equivalents per day of different countries, the WHO risk levels could also be used internationally to guide treatment goals and clinical recommendations on drinking reduction. FUNDING US National Institute on Alcohol Abuse and Alcoholism, New York State Psychiatric Institute, the Alcohol Clinical Trials Initiative.
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Affiliation(s)
- Deborah S Hasin
- Columbia University, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA.
| | - Melanie Wall
- Columbia University, New York, NY, USA; New York State Psychiatric Institute, New York, NY, USA
| | - Katie Witkiewitz
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | - Henry R Kranzler
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA; Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA
| | - Daniel Falk
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Raye Litten
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Karl Mann
- Central Institute of Mental Health, Mannheim, Germany
| | | | | | | | - Raymond Anton
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
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Lin CC, Tsai YF, Yeh WL, Kao JT, Chen CY. Perceptions of problem-drinker patients' family members about their own hazardous-drinking behaviours in Chinese general hospitals: a qualitative study. BMC Psychiatry 2017; 17:189. [PMID: 28521730 PMCID: PMC5437516 DOI: 10.1186/s12888-017-1348-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/05/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Excessive alcohol use has been associated with health, social and legal problems. Alcohol-related problems have been studied primarily in problem-drinker patients, with few studies on their family members, particularly about their own hazardous or harmful alcohol-drinking behaviours. METHOD In this qualitative descriptive study, participants were recruited from three hospitals randomly selected from northern and central Taiwan (2:1). Hazardous-drinker patients and their family members were screened using the Chinese version Alcohol Use Disorders Identification Test (scores ≥8 indicate harmful or hazardous drinkers). Data were collected in individual, audiotaped, in-depth interviews using an interview guide. Verbatim interview transcripts were analysed using ATLAS.ti, version WIN 7.0. RESULTS The sample of 35 family members with hazardous or harmful drinking behaviours perceived that their own alcohol-drinking behaviours were related to six major patterns: family habits, leisure activities with friends, work pressures, personal taste, a way to forget one's problems and to express happiness. CONCLUSION We recommend that programmes targeting harmful or hazardous drinking among problem-drinker patients' family members should educate participants about the standard amounts of alcohol in alcoholic beverages, recommended amounts of alcohol consumption for males and females, the long-term effects of excessive alcohol consumption; address sources of risk factors at work; offer strategies to resist social pressures to drink; and build positive strategies for coping with stress.
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Affiliation(s)
- Chen-Chun Lin
- Department of Hepato-Gastroenterology, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan
| | - Yun-Fang Tsai
- School of Nursing, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
- Department of Nursing, Chang Gung University of Science and Technology, Tao-Yuan, Taiwan
- Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Wen-Ling Yeh
- Department of Traumatology Orthopedics, Chang Gung Memorial Hospital at Linkou, Tao-Yuan, Taiwan
| | - Jung-Ta Kao
- School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
- Department of Internal Medicine, Division of Hepato-Gastroenterology, China Medical University Hospital, Taichung, Taiwan
| | - Ching-Yen Chen
- Department of Psychiatry, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
- College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
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Kline-Simon AH, Chi FW, Mertens JR, Weisner C. Trajectories of remission and mortality over 13 years after intake to substance use treatment. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2017. [PMID: 28635344 DOI: 10.1080/00952990.2016.1271883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Little is known about the relationships between long-term patterns of substance use and mortality risk among substance use disorder (SUD) patients. OBJECTIVE To determine distinct patterns of remission and relapse of SUD over time and examine their relationship with mortality. METHODS The study site was Kaiser Permanente of Northern California. Data for 997 adults who entered substance use treatment between 1994 and 1996 and 4,241 non-SUD patients with similar demographic distributions (35% women in both groups) were analyzed. Latent class growth analysis identified distinct remission trajectory groups over 13 years among SUD patients, and survival analyses were conducted to examine the risk of death between remission trajectory groups, and SUD and non-SUD patients within each remission trajectory group. RESULTS Three distinct remission trajectory groups were identified among SUD patients: 1) early relapse-low remission probabilities; 2) declining remission-decreasing remission probabilities; and 3) stable remission-stable remission probabilities across all time points. Among the SUD patients, the early relapse group had a higher risk of death than those stably remitted; stable and declining remission groups did not differ. Comparisons within each remission trajectory group showed that SUD patients in the early relapse and stable remission groups had higher risks of death compared with non-SUD patients; there were no differences within the declining group. CONCLUSIONS SUD patients in the stable remission group had lower survival rates compared with non-SUD patients. These findings underline the importance of continuously addressing healthcare needs of individuals with SUD, even in the presence of long-term remission.
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Affiliation(s)
- Andrea H Kline-Simon
- a Division of Research , Kaiser Permanente Northern California , Oakland , CA , USA
| | - Felicia W Chi
- a Division of Research , Kaiser Permanente Northern California , Oakland , CA , USA
| | - Jennifer R Mertens
- b Aurora Public Schools Division of Accountability and Research , Aurora , CO , USA
| | - Constance Weisner
- a Division of Research , Kaiser Permanente Northern California , Oakland , CA , USA.,c Department of Psychiatry , University of California , San Francisco , CA , USA
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Fleury MJ, Djouini A, Huỳnh C, Tremblay J, Ferland F, Ménard JM, Belleville G. Remission from substance use disorders: A systematic review and meta-analysis. Drug Alcohol Depend 2016; 168:293-306. [PMID: 27614380 DOI: 10.1016/j.drugalcdep.2016.08.625] [Citation(s) in RCA: 109] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This paper presents a systematic review and meta-analysis of available evidence on remission rates for substance use disorders (SUDs), providing weighted mean estimates of SUD remission rates. The review also explores study-level characteristics that may explain variations in remission rates across studies. METHODS A comprehensive search strategy identified studies published between 2000 and 2015 with follow-up periods of at least three years or reported lifetime remission outcomes for potential inclusion in the review. Remission was defined as not meeting diagnostic criteria for abuse or dependence for a minimum period of six months, as of final follow-up. A single-group summary meta-analysis was performed. Pooled estimated annual remission rates (PEARRs) were calculated. Meta-regression techniques and subgroup analyses were used to explore the association between study remission rates and key selected variables. RESULTS Of 8855 studies identified, 21 met the eligibility criteria. The results suggested that 35.0% to 54.4% of individuals with SUDs achieved remission, and this occurred after a mean follow-up period of 17 years. The PEARRs projected few cases of SUD remission, between 6.8% and 9.1% in any given year. Studies that reported higher remission rates had longer follow-up periods, and lower sample retention rates. CONCLUSIONS Results support the contention that SUDs are more likely to be "chronic" or long term disorders than acute disorders for a substantial number of individuals. However, more longitudinal research is required. Treatment geared to chronicity, such as assertive community treatment and intensive case management, needs to be more readily available for SUD populations.
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Affiliation(s)
- M-J Fleury
- Department of Psychiatry, McGill University, Montreal, Canada.
| | - Akram Djouini
- Centre de recherche et d'expertise en dépendance du Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal (Addiction Rehabilitation Center-University Institute), Montreal, Canada.
| | - Christophe Huỳnh
- Centre de recherche et d'expertise en dépendance du Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Centre-Sud-de-l'Île-de-Montréal (Addiction Rehabilitation Center-University Institute), Montreal, Canada.
| | - Joël Tremblay
- Department of Psycho-education, Université du Québec à Trois-Rivières, Trois-Rivières, Canada.
| | - Francine Ferland
- Centre de réadaptation en dépendance du CIUSSS de la Capitale-Nationale (Addiction Rehabilitation Center), Université Laval, Québec, Canada.
| | - J-M Ménard
- CIUSSS de-la-Mauricie-et-du-Centre-du-Québec (Addiction Rehabilitation Center), Trois-Rivières, Canada.
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Abstract
PURPOSE OF REVIEW Illicit drugs, alcohol, and tobacco use disorders contribute substantially to the global burden of disease. Knowledge about the major elements of the natural history of substance use disorders (incidence, remission, persistence, and relapse) is crucial to a broader understanding of the course and outcomes of substance use disorders. RECENT FINDINGS Prospective cohort studies in nonclinical samples indicate that externalizing psychopathology in earlier life, including early disordered substance use, delinquency, and personality disorders, are related to substance use disorders later in life and chronic course. Externalizing psychopathology may be initiated by early adverse experiences, for example, childhood maltreatment and stressful life events. After controlling for confounders, 'age at first use' as a causal factor for alcohol use disorder later in life and the 'drug substitution' hypothesis are not supported in general population data. SUMMARY Future research should focus on elaborating the causal framework that leads to the development and persistence of severe substance use disorders, with an emphasis on identifying modifiable factors for intervention by policy makers or health professionals. More research is needed on the natural history of substance use disorders in low-income and middle-income countries.
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Conde K, Lichtenberger A, Santángelo P, Cremonte M. Natural recovery from alcohol use disorders in Argentinean university students. JOURNAL OF SUBSTANCE USE 2016. [DOI: 10.3109/14659891.2015.1082160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Witkiewitz K, McCallion E, Kirouac M. Religious Affiliation and Spiritual Practices: An Examination of the Role of Spirituality in Alcohol Use and Alcohol Use Disorder. Alcohol Res 2016; 38:55-8. [PMID: 27159812 PMCID: PMC4872613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
AIMS To assess the prevalence and correlates of remission from cannabis use disorders (CUDs), focusing on the proportion of individuals with CUDs that remit without abstaining from cannabis use. DESIGN Three-year longitudinal study. SETTING Wave 1 (2001) and wave 2 (2004) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative sample of US adults aged 18 years and over. PARTICIPANTS Our sample included 444 individuals diagnosed with DSM-IV cannabis abuse and/or dependence during the 12 months prior to wave 1 of the NESARC. MEASUREMENTS Baseline socio-demographic and clinical correlates were analysed for possible outcomes of CUDs after 3 years: abstinent remission, non-abstinent remission and sustained disorder. FINDINGS Approximately two-thirds (67%) of individuals with baseline CUD remitted at follow-up. Approximately 37% of those who remitted were non-abstinent. Remission was associated with Hispanic ethnicity [odds ratio (OR)=2.59; 95% confidence interval (CI)=1.27-4.87], baseline daily or almost daily use of cannabis (OR=1.91; 95% CI=1.15-3.16), baseline use of other drugs (OR=1.63; 95% CI=1.04-2.56) and two or more medical conditions at baseline (OR=8.40; 95% CI=2.67-26.41). Non-abstinent remission was associated with baseline daily or almost daily use of cannabis (OR=1.92; 95% CI=1.05-3.51). CONCLUSIONS A substantial level of remission from cannabis use disorders (CUDs), including non-abstinent remission, suggests that the nature of CUDs may be more unstable than reported previously.
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Affiliation(s)
- Daniel Feingold
- Ariel University, Ariel, Israel.,Addiction Medicine and Dual Diagnosis Services, Department of Psychiatry, Sheba Medical Center, Tel Hashomer, Israel
| | - Jonah Fox
- New York State/American Program, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jürgen Rehm
- Social and Epidemiological Research Department, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Shaul Lev-Ran
- Addiction Medicine and Dual Diagnosis Services, Department of Psychiatry, Sheba Medical Center, Tel Hashomer, Israel.,Social and Epidemiological Research Department, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Hasin DS, Grant BF. The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings. Soc Psychiatry Psychiatr Epidemiol 2015; 50:1609-40. [PMID: 26210739 PMCID: PMC4618096 DOI: 10.1007/s00127-015-1088-0] [Citation(s) in RCA: 295] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/28/2015] [Indexed: 01/12/2023]
Abstract
PURPOSE The NESARC, a "third-generation" psychiatric epidemiologic survey that integrated detailed measures of alcohol and drug use and problems has been the data source for over >850 publications. A comprehensive review of NESARC findings and their implications is lacking. METHOD NESARC was a survey of 43,093 participants that covered alcohol, drug and psychiatric disorders, risk factors, and consequences. Wave 1 of the NESARC was conducted in 2001-2002. Three years later, Wave 2 follow-up re-interviews were conducted with 34,653 of the original participants. Scopus and Pubmed were used to search for NESARC papers, which were sorted into topic areas and summarized. RESULT The most common disorders were alcohol and posttraumatic stress disorders, and major depression. Females had more internalizing disorders and males had more externalizing disorders, although the preponderance of males with alcohol disorders (the "gender gap") was less pronounced than it was in previous decades. A race/ethnic "paradox" (lower risk among disadvantaged minorities than whites) remains unexplained. Younger participants had higher risk for substance and personality disorders, but not unipolar depressive or anxiety disorders. Psychiatric comorbidity was extensive and often formed latent trans-diagnostic domains. Since 1991-1992, risk for marijuana and prescription drug disorders increased, while smoking decreased, although smoking decreases were less pronounced among those with comorbidity. A nexus of comorbidity, social support, and stress predicted transitions in diagnostic status between Waves 1 and 2. Childhood maltreatment predicted psychopathology. Alcohol and drug use disorders were seldom treated; attitudinal barriers (little perceived need, perceived alcoholism stigma, pessimism about efficacy) were more important in predicting non-treatment than financial barriers. CONCLUSIONS Understanding comorbidity and the effects of early stressors will require research incorporating biologic components, e.g., genetic variants and brain imaging. The lack of treatment for alcohol and drug disorders, predicted by attitudinal rather than financial variables, suggests an urgent need for public and professional education to reduce the stigma associated with these disorders and increase knowledge of treatment options.
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Affiliation(s)
- Deborah S Hasin
- Department of Psychiatry, College of Physicians and Surgeons, New York, NY, 10032, USA
- Mailman School of Public Health, Columbia University, New York, NY, 10032, USA
- New York State Psychiatric Institute, New York, NY, 10032, USA
| | - Bridget F Grant
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, 5635 Fishers Lane, Room 3077, Rockville, MD, 20852, USA.
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Simioni N, Rolland B, Cottencin O. Interventions for Increasing Alcohol Treatment Utilization Among Patients with Alcohol Use Disorders from Emergency Departments: A Systematic Review. J Subst Abuse Treat 2015. [DOI: 10.1016/j.jsat.2015.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Dom G, Peuskens H. Addiction specialist's role in liver transplantation procedures for alcoholic liver disease. World J Hepatol 2015; 7:2091-2099. [PMID: 26301051 PMCID: PMC4539402 DOI: 10.4254/wjh.v7.i17.2091] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2015] [Revised: 07/09/2015] [Accepted: 08/11/2015] [Indexed: 02/06/2023] Open
Abstract
Although liver transplantation (LT) is performed increasingly for patients with end-stage alcoholic liver disease (ALD), the topic remains controversial. Traditionally, the role of an addiction specialist focused on the screening and identification of patients with a high risk on relapse in heavy alcohol use. These patients were in many cases subsequently excluded from a further LT procedure. Recently, awareness is growing that not only screening of patients but also offering treatment, helping patients regain and maintain abstinence is essential, opening up a broader role for the addiction specialist (team) within the whole of the transplant procedure. Within this context, high-risk assessment is proposed to be an indication of increasing addiction treatment intensity, instead of being an exclusion criterion. In this review we present an overview regarding the state of the art on alcohol relapse assessment and treatment in patients with alcohol use disorders, both with and without ALD. Screening, treatment and monitoring is suggested as central roles for the addiction specialist (team) integrated within transplant centers.
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Grant BF, Goldstein RB, Saha TD, Chou SP, Jung J, Zhang H, Pickering RP, Ruan WJ, Smith SM, Huang B, Hasin DS. Epidemiology of DSM-5 Alcohol Use Disorder: Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry 2015; 72:757-66. [PMID: 26039070 PMCID: PMC5240584 DOI: 10.1001/jamapsychiatry.2015.0584] [Citation(s) in RCA: 1898] [Impact Index Per Article: 189.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE National epidemiologic information from recently collected data on the new DSM-5 classification of alcohol use disorder (AUD) using a reliable, valid, and uniform data source is needed. OBJECTIVE To present nationally representative findings on the prevalence, correlates, psychiatric comorbidity, associated disability, and treatment of DSM-5 AUD diagnoses overall and according to severity level (mild, moderate, or severe). DESIGN, SETTING, AND PARTICIPANTS We conducted face-to-face interviews with a representative US noninstitutionalized civilian adult (≥18 years) sample (N = 36 309) as the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III). Data were collected from April 2012 through June 2013 and analyzed in October 2014. MAIN OUTCOMES AND MEASURES Twelve-month and lifetime prevalences of AUD. RESULTS Twelve-month and lifetime prevalences of AUD were 13.9% and 29.1%, respectively. Prevalence was generally highest for men (17.6% and 36.0%, respectively), white (14.0% and 32.6%, respectively) and Native American (19.2% and 43.4%, respectively), respondents, and younger (26.7% and 37.0%, respectively) and previously married (11.4% and 27.1%, respectively) or never married (25.0% and 35.5%, respectively) adults. Prevalence of 12-month and lifetime severe AUD was greatest among respondents with the lowest income level (1.8% and 1.5%, respectively). Significant disability was associated with 12-month and lifetime AUD and increased with the severity of AUD. Only 19.8% of respondents with lifetime AUD were ever treated. Significant associations were found between 12-month and lifetime AUD and other substance use disorders, major depressive and bipolar I disorders, and antisocial and borderline personality disorders across all levels of AUD severity, with odds ratios ranging from 1.2 (95% CI, 1.08-1.36) to 6.4 (95% CI, 5.76-7.22). Associations between AUD and panic disorder, specific phobia, and generalized anxiety disorder were modest (odds ratios ranged from 1.2 (95% CI, 1.01-1.43) to 1.4 (95% CI, 1.13-1.67) across most levels of AUD severity. CONCLUSIONS AND RELEVANCE Alcohol use disorder defined by DSM-5 criteria is a highly prevalent, highly comorbid, disabling disorder that often goes untreated in the United States. The NESARC-III data indicate an urgent need to educate the public and policy makers about AUD and its treatment alternatives, to destigmatize the disorder, and to encourage those who cannot reduce their alcohol consumption on their own, despite substantial harm to themselves and others, to seek treatment.
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Affiliation(s)
- Bridget F. Grant
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland
| | - Risë B. Goldstein
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland
| | - Tulshi D. Saha
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland
| | - S. Patricia Chou
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland
| | - Jeesun Jung
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland
| | - Haitao Zhang
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland
| | - Roger P. Pickering
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland
| | - W. June Ruan
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland
| | - Sharon M. Smith
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland
| | - Boji Huang
- Laboratory of Epidemiology and Biometry, Division of Intramural Clinical and Biological Research, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Rockville, Maryland
| | - Deborah S. Hasin
- Department of Psychiatry, College of Physicians and Surgeons, Mailman School of Public Health, Columbia University, New York, New York3New York State Psychiatric Institute, New York
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40
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Simioni N, Cottencin O, Rolland B. Interventions for Increasing Subsequent Alcohol Treatment Utilisation Among Patients with Alcohol Use Disorders from Somatic Inpatient Settings: A Systematic Review. Alcohol Alcohol 2015; 50:420-9. [DOI: 10.1093/alcalc/agv017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 02/17/2015] [Indexed: 11/13/2022] Open
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Abstract
Drug and alcohol use disorders account for a high and potentially preventable proportion of overall disability and mortality. This article reviews published data on the distribution of alcohol and drug abuse and dependence in the USA. Published data shows that alcohol use disorders are more prevalent than illegal drug use disorders, although the persistence of both disorders was similar over a three-year follow-up period. Significant variability exists within sex, racial/ethnic, and age groups. Men, Native Americans, and young adults, aged 18 to 25, are at a higher risk of substance dependence. Environmental correlates of disorder include early environmental factors, political environment, and social contextual factors. Systematically identifying, and measuring variability across demographic populations, will guide prevention and intervention efforts. Future research will expand understanding of the complex interplay between individual and environmental factors that serve to initiate and sustain alcohol and drug use disorders.
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Affiliation(s)
- Erin Delker
- New York State Psychiatric Institute, 722 West 168th Street, New York, NY 10032, USA
| | - Qiana Brown
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Deborah Hasin
- New York State Psychiatric Institute, 722 West 168th Street, New York, NY 10032, USA
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Jessup MA, Ross TB, Jones AL, Satre DD, Weisner CM, Chi FW, Mertens JR. Significant life events and their impact on alcohol and drug use: a qualitative study. J Psychoactive Drugs 2015; 46:450-9. [PMID: 25364998 DOI: 10.1080/02791072.2014.962715] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
This study used a life-course perspective to identify and understand life events related to long-term alcohol and other drug (AOD) use trajectories across the life span. Using a purposive sample, we conducted semi-structured telephone interviews with 48 participants (n = 30 abstinent and 18 non-abstinent) from a longitudinal study of AOD outcomes 15 years following outpatient AOD treatment. A content analysis was conducted using ATLAS.ti software to identify events and salient themes. Caregiving for an ill or dependent family member was related to better AOD outcomes by reinforcing abstinence and reduced drinking, and contributing to alcohol cessation in most individuals who cited caregiving as a pivotal event. Grandparenting and parenting an adult child were motivational for sustaining abstinence and reduced drinking. Findings were mixed on death of a loved one, which was related to abstinence in some and relapse in others. Redemption and mutual fulfillment as caregivers, reconciliations with adult children, and legacy-building as grandparents were themes associated with maintaining abstinence and reduced drinking. AOD treatment has the opportunity to employ motivational interventions for relapse prevention that address the meaning and lifelong reach of intimate relationships for individuals and their AOD use across the life span.
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Affiliation(s)
- Martha A Jessup
- a Professor Emerita, Institute for Health & Aging, School of Nursing, University of California, San Francisco, CA; and Senior Research Consultant, Division of Research, Kaiser Permanente Northern California , Oakland , CA
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43
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Ahacic K, Kennison RF, Kåreholt I. Alcohol abstinence, non-hazardous use and hazardous use a decade after alcohol-related hospitalization: registry data linked to population-based representative postal surveys. BMC Public Health 2014; 14:874. [PMID: 25150844 PMCID: PMC4153888 DOI: 10.1186/1471-2458-14-874] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 08/18/2014] [Indexed: 12/20/2022] Open
Abstract
Background Although there is evident association between alcohol-related hospitalization and alcohol use, the relationship has not been well examined. This study analyzed the extent of alcohol abstinence, non-hazardous use and hazardous use among people who had experienced alcohol-related hospitalization during the preceding decade. Method Registry data concerning alcohol-related hospitalizations between 1996 and 2007 were linked to two representative surveys, in 2006 and 2007, of residents of Stockholm County. Relevant contrasts were modeled, using logistic regression, in the pooled sample (n = 54 955). Ages were 23–84 years at follow-up. Results Among persons previously hospitalized (n = 576), half reported non-hazardous use. Non-hazardous use was less prevalent than in the general population – and the extent of non-hazardous use did not change over time following hospitalization. There were no significant age differences, but non-hazardous use was less frequent among people with repeated episodes of care. One in six was abstinent. Abstinence was more common among the old, while hazardous use (exceeding 14 drinks per week for men, and 9 drinks per week for women) decreased with age. Abstinence also increased over time; among persons hospitalized ten years ago, the abstinence rate was twice that of the general population. Associations with hazardous use over time were less conclusive. Hazardous use among those previously hospitalized decreased over time in one sample but not in the other. After pooling the data, there were indications of a decrease over time following hospitalization, but more prevalent hazardous use than in the general population. Conclusions Following alcohol-related hospitalization, abstinence increased, and there was no evidence of regression towards the mean, i.e., towards non-hazardous use. Abstinence was also more widespread among previously hospitalized persons of older ages. With advancing age, changing hazardous alcohol habits among previously hospitalized appears to yield a trend towards promotion of abstinence.
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Affiliation(s)
- Kozma Ahacic
- Department of Public Health Sciences, Karolinska Institutet, Tomtebodavägen 18A, 171 77 Stockholm, Sweden.
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Tuithof M, ten Have M, van den Brink W, Vollebergh W, de Graaf R. Alcohol consumption and symptoms as predictors for relapse of DSM-5 alcohol use disorder. Drug Alcohol Depend 2014; 140:85-91. [PMID: 24793368 DOI: 10.1016/j.drugalcdep.2014.03.035] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Revised: 03/24/2014] [Accepted: 03/28/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Alcohol consumption levels and alcohol use disorder (AUD) symptoms may serve as easily quantifiable markers for AUD relapse after remission and might help prevention workers identify at-risk individuals. We investigated the predictive value of alcohol consumption and AUD symptoms on relapse. METHODS Data are from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2). We selected 506 people in ≥12-month DSM-5 AUD remission at baseline and assessed their status at 3-year follow-up. AUD symptoms and drinking patterns were assessed using the Composite International Diagnostic Interview 3.0. Time since remission was assessed retrospectively at baseline and ranged from 1 to 48 years. Predictors for relapse were examined using Cox regression analysis. RESULTS Cumulative AUD relapse rate was 5.6% at 5 years, 9.1% at 10 years and 12.0% at 20 years. Relapse was predicted by both medium (15-28/22-42 drinks weekly for women/men) and high (≥29/43) past alcohol intake, 6+ lifetime AUD symptoms, 'impaired control over use', and at-risk (≥8/15) current intake. The risk of relapse was especially high when medium or high past intake or 6+ lifetime symptoms coincided with current at-risk drinking. CONCLUSIONS Only a minority of people in DSM-5 AUD remission relapsed, but the risk of relapse increased substantially with the presence of at least one of the risk factors. Moreover, at-risk current drinking coupled with other risk factors substantially increased the likelihood of relapse. Therefore, current drinking may provide an adequate reference point for relapse prevention.
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Affiliation(s)
- Marlous Tuithof
- Netherlands Institute of Mental Health and Addiction, PO Box 725, 3500 AS Utrecht, The Netherlands.
| | - Margreet ten Have
- Netherlands Institute of Mental Health and Addiction, PO Box 725, 3500 AS Utrecht, The Netherlands
| | - Wim van den Brink
- Department of Psychiatry, Academic Medical Centre, University of Amsterdam, PO Box 22660, 1100 DD Amsterdam, The Netherlands
| | - Wilma Vollebergh
- Department of Interdisciplinary Social Science, Utrecht University, PO Box 80140, 3508 TC Utrecht, The Netherlands
| | - Ron de Graaf
- Netherlands Institute of Mental Health and Addiction, PO Box 725, 3500 AS Utrecht, The Netherlands
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McCutcheon VV, Kramer JR, Edenberg HJ, Nurnberger JI, Kuperman S, Schuckit MA, Heath AC, Bucholz KK. Social contexts of remission from DSM-5 alcohol use disorder in a high-risk sample. Alcohol Clin Exp Res 2014; 38:2015-23. [PMID: 24942361 DOI: 10.1111/acer.12434] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 03/26/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Measures of social context, such as marriage and religious participation, are associated with remission from alcohol use disorders (AUDs) in population-based and treatment samples, but whether these associations hold among individuals at high familial risk for AUD is unknown. This study tests associations of measures of social context and treatment with different types of remission from DSM-5 AUD in a high-risk sample. METHODS Subjects were 686 relatives of probands (85.7% first-degree) who participated in a high-risk family study of alcohol dependence. All subjects met criteria for AUD at baseline and were re-interviewed 5 years later. Follow-up status was categorized as persistent AUD, high-risk drinking, remitted low-risk drinking, and abstinence. Social context measures were defined as stable or changing from baseline to follow-up, and their bivariate and multivariate associations with follow-up status were tested. RESULTS At follow-up, 62.8% of subjects had persistent AUD, 6.4% were high-risk drinkers, 22.2% were remitted low-risk drinkers, and 8.6% were abstinent. Birth of first child during the interval was the only measure of social context associated with remitted low-risk drinking and was significant for women only. Abstinent remission was characterized by being stably separated or divorced for women, new marriage for both sexes, experiencing low levels of family support and high levels of friend support, and receiving treatment. High-risk drinkers were more likely than individuals with persistent AUD to have a stable number of children and to have been recently unemployed. CONCLUSIONS The social contexts accompanying different types of remission in this high-risk sample resemble those found in population-based and clinical samples. Low-risk drinkers resemble natural remitters from population-based samples who change their drinking habits with life transitions. Abstainers resemble clinical samples in marital context, support from friends, and treatment. High-risk drinkers appear to continue to experience negative consequences of heavy drinking.
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Affiliation(s)
- Vivia V McCutcheon
- Department of Psychiatry , Midwest Alcoholism Research Center, Washington University School of Medicine, St. Louis, Missouri
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Dawson DA. Commentary on Tuithof et al. (2013): Implications of the DSM-5 revision for the analysis of persistence/remission of alcohol use disorder. Addiction 2013; 108:2100-1. [PMID: 24237899 PMCID: PMC4098938 DOI: 10.1111/add.12351] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Deborah A. Dawson
- Senior Scientist, Kelly Government Services and Contractor, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda Maryland, USA
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Tuithof M, Ten Have M, van den Brink W, Vollebergh W, de Graaf R. Predicting persistency of DSM-5 alcohol use disorder and examining drinking patterns of recently remitted individuals: a prospective general population study. Addiction 2013; 108:2091-9. [PMID: 23889861 DOI: 10.1111/add.12309] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 06/06/2013] [Accepted: 07/17/2013] [Indexed: 12/18/2022]
Abstract
AIMS To establish the 3-year persistency rate of alcohol use disorder (AUD) and its predictors, and to examine drinking patterns of recently remitted individuals. DESIGN AND SETTING The Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2) surveyed a nationally representative sample of adults (aged 18-64 years) at baseline (response = 65.1%) and 3-year follow-up (response = 80.4%). PARTICIPANTS People with AUD at baseline, as defined by DSM-5 (n = 198). MEASUREMENTS AUD, drinking patterns and mental disorders were assessed using the Composite International Diagnostic Interview 3.0. Other predictors were assessed with an additional questionnaire. Predictors of persistency were examined with univariable and multivariable logistic regression analyses. RESULTS The AUD persistency rate was 29.5% [95% confidence intervals (CI) = 20.0-39.0]. In the multivariable model, the older (25-34 and 35-44) age groups had lower AUD persistency [odds ratio (OR) = 0.05; 95% CI = 0.00-0.49 and OR = 0.14; 95% CI = 0.02-0.79, respectively] than the youngest age group (18-24). A higher number of weekly drinks and a comorbid anxiety disorder predicted AUD persistency (OR = 1.03; 95% CI = 1.00-1.07 and OR = 4.56; 95% CI = 1.04-20.06, respectively). Furthermore, remission was associated with a reduction of six drinks per week between T0 and T1 . It should be noted, however, that 35.8% (95% CI = 22.4-49.2) of people in diagnostic remission still drank more than the recommended maximum (more than seven/14 drinks weekly for women/men). CONCLUSIONS Only a minority of people in the Netherlands with alcohol use disorder as defined by DSM-5 still have the disorder 3 years later. Factors that help to identify people at risk of alcohol use disorder persistence are: younger age, a higher number of weekly drinks and a comorbid anxiety disorder. A substantial number of people recently in diagnostic remission still drink above the maximum recommended level.
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Affiliation(s)
- Marlous Tuithof
- Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
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Remission from substance dependence: differences between individuals in a general population longitudinal survey who do and do not seek help. Drug Alcohol Depend 2013; 133:146-53. [PMID: 23791039 PMCID: PMC3786033 DOI: 10.1016/j.drugalcdep.2013.05.019] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 04/10/2013] [Accepted: 05/19/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Only a minority of individuals who have substance use disorders receives treatment, and those who do typically have more severe disorders. The current study examines the relationship of help-seeking with remission from alcohol and/or drug dependence and other outcomes. METHODS Data from the Wave 1 (2001-2002) and Wave 2 (2004-2005) National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) were used to examine remission at Wave 2 among respondents who had past-year substance dependence disorders at Wave 1 (N=1262). Multi-group structural equation modeling was used to compare individuals with (n=356) and without (n=906) prior help-seeking at Wave 1 on subsequent help-seeking and other factors that influence outcomes. RESULTS Baseline help-seekers sought help at higher levels over the follow-up period (31% vs. 8%) and had lower rates of remission (50% vs. 68%), as compared with those without prior help-seeking, respectively. Among baseline help-seekers, there were stronger relationships between baseline stress and mental disorders and having sought help since baseline; age and past-year level of stress at follow-up; level of stress and health status at follow-up; and social support and mental disorders at follow-up. Among baseline non-help-seekers, there were stronger relationships between being female and past-year stress at follow-up, and between having sought help since baseline and physical health status at follow-up. CONCLUSIONS Findings extend our understanding of the factors associated with recovery from substance dependence, including "natural recovery", use of services outside of addiction treatment, and gender differences in help-seeking and remission.
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Vergés A, Haeny AM, Jackson KM, Bucholz KK, Grant JD, Trull TJ, Wood PK, Sher KJ. Refining the notion of maturing out: results from the national epidemiologic survey on alcohol and related conditions. Am J Public Health 2013; 103:e67-73. [PMID: 24134383 DOI: 10.2105/ajph.2013.301358] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Our aim was to determine if the decrease in drug use disorders with age is attributable to changes in persistence, as implied by the notion of maturing out. Also, we examined the association between role transitions and persistence, recurrence, and new onset of drug use disorders. METHODS We performed secondary analysis of the 2 waves of the National Epidemiologic Survey on Alcohol and Related Conditions data (baseline assessment 2001-2002, follow-up conducted 2004-2005). We conducted logistic regressions and multinomial logistic regression to determine the effect of age on wave 2 diagnosis status, as well as the interaction between age and role transitions. RESULTS Rates of persistence were stable over the life span, whereas rates of new onset and recurrence decreased with age. Changes in parenthood, marital, and employment status were associated with persistence, new onset, and recurrence. We found an interaction between marital status and age. CONCLUSIONS Our findings challenge commonly held notions that the age-related decrease in drug use disorders is attributable to an increase in persistence, and that the effects of role transitions are stronger during young, compared with middle and older, adulthood.
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Affiliation(s)
- Alvaro Vergés
- Alvaro Vergés, Angela M. Haeny, Timothy J. Trull, Phillip K. Wood, and Kenneth J. Sher are with the Department of Psychological Sciences, University of Missouri-Columbia. Kristina M. Jackson is with the Department of Community Health, Brown University, Providence, RI. Kathleen K. Bucholz and Julia D. Grant are with the School of Medicine, Washington University, St Louis, MO
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Burdick BV, Adinoff B. A proposal to evaluate mechanistic efficacy of hallucinogens in addiction treatment. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2013; 39:291-7. [DOI: 10.3109/00952990.2013.811513] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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