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Background Alcoholics Anonymous (AA) is a world-wide recovery mutual-help organization that continues to arouse controversy. In large part, concerns persist because of AA's ostensibly quasi-religious/spiritual orientation and emphasis. In 1990 the United States' Institute of Medicine called for more studies on AA's effectiveness and its mechanisms of behavior change (MOBC) stimulating a flurry of federally funded research. This paper reviews the religious/spiritual origins of AA and its program and contrasts its theory with findings from this latest research. Method Literature review, summary and synthesis of studies examining AA's MOBC. Results While AA's original main text ('the Big Book', 1939) purports that recovery is achieved through quasi-religious/spiritual means ('spiritual awakening'), findings from studies on MOBC suggest this may be true only for a minority of participants with high addiction severity. AA's beneficial effects seem to be carried predominantly by social, cognitive and affective mechanisms. These mechanisms are more aligned with the experiences reported by AA's own larger and more diverse membership as detailed in its later social, cognitive and behaviorally oriented publications (e.g. Living Sober, 1975) written when AA membership numbered more than a million men and women. Conclusions Alcoholics Anonymous appears to be an effective clinical and public health ally that aids addiction recovery through its ability to mobilize therapeutic mechanisms similar to those mobilized in formal treatment, but is able to do this for free over the long term in the communities in which people live. [ABSTRACT FROM AUTHOR]

An editorial is presented which addresses the author's views about the public health aspects of electronic cigarettes (e-cigarettes), and it mentions the National Academies of Sciences' review of research papers on electronic nicotine delivery systems (ENDS), as well as the need for additional research and government regulatory action in the U.S. According to the article, ENDS may be harm-reducing for smokers who are seeking to quit and harm-creating for ex-smokers and young people.

Background and Aims: The United States Food and Drug Administration has proposed regulation to require that cigarettes contain very low nicotine content (VLNC). In contrast, reducing the number of cigarettes per day (CPD) is the most common current method to reduce nicotine. This trial aims to explore whether gradually transitioning to VLNC cigarettes plus nicotine patch or reducing CPD plus nicotine patch is more effective at decreasing nicotine dependence. Design A two‐arm, individually randomized open‐label trial. Setting Community setting, Vermont, USA. Participants: Sixty‐eight adult daily smokers (40% female) of ≥ 10 cigarettes/day who were not planning to quit in the next 30 days. Interventions: All participants smoked study cigarettes with a nicotine yield similar to most commercial cigarettes ad libitum for 1 week (baseline). Participants then gradually reduced to 70, 35, 15 and 3% of baseline nicotine over 4 weeks by either (a) transitioning to lower nicotine content cigarettes (n = 36) or (b) reducing the number of full nicotine cigarettes (n = 32). All participants received nicotine patches. Measurements The primary outcome was change in nicotine dependence assessed at baseline and weekly during the intervention with the Nicotine Dependence Syndrome Scale. Findings Dependence declined over time for both VLNC and CPD participants, but declined more for VLNC (mean decrease in Z‐score of 1.0) than CPD (mean decrease in Z‐score of 0.5) participants over time (interaction P = 0.018). Conclusions: Transitioning to very low nicotine content cigarettes reduced nicotine dependence over a 4‐week period to a greater extent than reducing cigarettes per day when both conditions were aided by nicotine patch. [ABSTRACT FROM AUTHOR]

Abstract: Background and Aims: Extended‐release naltrexone (XR‐NTX), a μ‐opioid receptor antagonist for prevention of relapse to opioid dependence, has demonstrated efficacy compared with placebo and comparative effectiveness with buprenorphine–naloxone. We report outcomes for XR‐NTX in Vivitrol's Cost and Treatment Outcomes Registry. Design: Observational, open‐label, single‐arm, multi‐center registry assessing baseline characteristics and clinical and health‐related quality‐of‐life outcomes associated with XR‐NTX treatment in clinical practice. Setting: 32 US treatment centers from 2011 to 2013. Participants: Patients with opioid dependence who were prescribed XR‐NTX treatment and then enrolled into the registry. Measurements: Monthly visits were evaluated for the full population and for patient ubgroups retrospectively, defined by injection number, focusing on the period between baseline and month 6 (1‐, 2/3‐ or 6‐XR‐NTX). Findings: Of 403 enrolled patients, 395 were analyzed. Most patients (n = 349) received out‐patient care. On average, patients received five injections (median = 3; range = 1–25). The median number of injections administered within 6 months was higher in patients who at baseline were employed (three versus two unemployed, P = 0.02) or had private insurance (five versus two self‐payment, P = 0.005; versus two state‐funded, P < 0.001). The 1‐, 2/3‐ and 6‐XR‐NTX groups had 132, 152 and 111 patients, respectively. At baseline, the 6‐XR‐NTX patients were more likely to meet normal/minimal mental illness criteria and attend school and less likely to report recent drug use. Within 6 months, the 6‐XR‐NTX group demonstrated improvements in employment, mental health and psychosocial functioning, and decreases in opioid craving, drug use and drug‐related behavior. Conclusions: Among opioid‐dependent people receiving XR‐NTX treatment, better mental health, higher education and lower recent drug use at baseline are associated with greater treatment duration; in turn, longer treatment duration is associated with lower relapse rates and improved outcomes generally. [ABSTRACT FROM AUTHOR]

Background and aims Prescription opioid overdose is a leading cause of injury-related morbidity and mortality in the United States. We aimed to identify characteristics associated with clinical severity in emergency department patients with prescription opioid overdose. Design This was a secondary data analysis of adult prescription opioid overdoses from a large prospective cohort of acute overdoses. We examined elements of a typical emergency department evaluation using a multivariable model to determine which characteristics were associated with clinical severity, specifically severe respiratory depression (SRD). Setting This study was conducted at two urban academic emergency departments in New York City, USA. Participants Adult patients who presented with acute prescription opioid overdose between 2009 and 2013 were included in the current study. We analyzed 307 patients (mean age = 44.7, 42% female, 2.0% mortality). Measurements Patient demographics, reported substances ingested, suspected intent for ingesting the substance, vital signs, laboratory data, treatments including antidotes and intubation and outcome of death were recorded by trained research assistants. Intent was categorized into four mutually exclusive categories: suicide, misuse, therapeutic error and undetermined. The primary outcome was SRD, defined as administration of either (a) naloxone or (b) endotracheal intubation (ETI). Findings A total of 109 patients suffered SRD with 90 patients receiving naloxone alone, nine ETI alone and 10 both naloxone and ETI. The most common opioids were oxycodone ( n = 124) and methadone ( n = 116). Mean age was higher in patients with SRD (51.1 versus 41.1, P < 0.001). Opioid misuse was associated with SRD in the multivariable analysis [odds ratio (OR) = 2.07, 95% confidence interval (CI) = 1.21-3.55]. The unadjusted relative risk of SRD was high for fentanyl (83.3% SRD) and lowest for codeine (3.6% SRD). Conclusion In emergency department patients in the United States with prescription opioid overdose, worse clinical severity was associated with opioid misuse, increased with age and was widely variable, depending on the specific opioid medication involved. [ABSTRACT FROM AUTHOR]

Background and aims Anhedonia-a transdiagnostic psychopathological trait indicative of inability to experience pleasure-could lead to and result from adolescent marijuana use, yet this notion has not been tested. This study aimed to estimate the association of: (1) anhedonia at age 14 with rate of change in marijuana use over an 18-month follow-up, and (2) marijuana use at age 14 with rate of change in anhedonia over follow-up. Secondary aims were to test whether gender, baseline marijuana use history and peer marijuana use moderated these associations. Design Observational longitudinal cohort repeated-measures design, with baseline (age 14 years), 6-month, 12-month and 18-month follow-up assessments. Settings Ten public high schools in Los Angeles, CA, USA, 2013-15. Participants Students [ n = 3394; 53.5% female, mean (standard deviation) age at baseline = 14.1 (0.42)]. Measurements Self-report level of anhedonia on the Snaith-Hamilton Pleasure Scale and frequency of marijuana use in the past 30 days. Findings Parallel process latent growth curve models adjusting for confounders showed that baseline anhedonia level was associated positively with the rate of increase in marijuana use frequency across follow-ups [β, 95% confidence interval (CI) = 0.115 (0.022, 0.252), P = 0.03]. Baseline marijuana use frequency was not related significantly to the rate of change in anhedonia across follow-ups [β, 95% CI = −0.015 (−0.350, 0.321), P = 0.93]. The association of baseline anhedonia with faster marijuana use escalation was amplified among adolescents with (versus without) friends who used marijuana at baseline [β, 95% CI = 0.179 (0.043, 0.334) versus 0.064 (−0.071, 0.187), interaction P = 0.04], but did not differ by gender or baseline ever marijuana use. Conclusions In mid-adolescence, anhedonia is associated with subsequent marijuana use escalation, but marijuana use escalation does not appear to be associated with subsequent anhedonia. [ABSTRACT FROM AUTHOR]

Background and Aims Recreational marijuana legalization (RML) went into effect in Oregon in July 2015. RML is expected to influence marijuana use by adolescents and young adults in particular, and by those with a propensity for substance use. We sought to quantify changes in rates of marijuana use among college students in Oregon from pre- to post-RML relative to college students in other states across the same time period. Design Repeated cross-sectional survey data from the 2012-16 administrations of the Healthy Minds Study. Setting Seven 4-year universities in the United States. Participants There were 10 924 undergraduate participants. One large public Oregon university participated in 2014 and 2016 ( n = 588 and 1115, respectively); six universities in US states where recreational marijuana use was illegal participated both in 2016 and at least once between 2012 and 2015. Measurements Self-reported marijuana use in the past 30 days (yes/no) was regressed on time (pre/post 2015), exposure to RML (i.e. Oregon students in 2016) and covariates using mixed-effects logistic regression. Moderation of RML effects by recent heavy alcohol use was examined. Findings Rates of marijuana use increased from pre- to post-2015 at six of the seven universities, a trend that was significant overall. Increases in rates of marijuana use were significantly greater in Oregon than in comparison institutions, but only among students reporting recent heavy alcohol use. Conclusions Rates of Oregon college students' marijuana use increased (relative to that of students in other states) following recreational marijuana legislation in 2015, but only for those who reported recent heavy use of alcohol. Such alcohol misuse may be a proxy for vulnerabilities to substance use or lack of prohibitions (e.g. cultural) against it. [ABSTRACT FROM AUTHOR]

Background and aims Among US high school students, alcohol consumption and cigarette smoking are associated with numerous concurrent and future harms. We tested whether multiple elementary school personality dispositions to behave impulsively can predict these addictive behaviors invariably across gender and race. Design and Setting This longitudinal design involved testing whether individual differences on impulsigenic traits in elementary school predicted drinking and smoking 4 years later in high school in 23 public schools in Kentucky, USA. Participants A total of 1897 youth, mean age 10.33 at wave 1, drawn from urban, rural and suburban backgrounds. Measurements Drinking and smoking frequency were assessed by single-item questions. The key predictors were impulsigenic traits measured with the UPPS-P Child Version impulsive behavior scale. Important covariates included were pubertal status, depression, negative affect and positive affect; each was assessed by self-report. Findings Three personality traits measured in 5th grade, each representing different dispositions to engage in impulsive behavior, predicted drinking and smoking in 9th grade above and beyond other risk factors and 5th grade drinking and smoking. Specifically, urgency ( b = 0.10, 0.13), sensation-seeking ( b = 0.13, 0.07) and low conscientiousness ( b = 0.14, 0.11) each uniquely predicted both high school drinking and smoking, respectively. There was no evidence that any trait predicted either outcome more strongly than the other traits, nor was there evidence that predictive results varied by gender or race. Conclusions Three personality traits (urgency, sensation-seeking and low conscientiousness), when measured in 11-year-old children, predict those children's drinking and smoking behavior individually at age 15. The effects are invariant across gender and race. [ABSTRACT FROM AUTHOR]

Background and Aims Criminal justice-involved individuals are highly susceptible to opioid relapse and overdose-related deaths. In a recent randomized trial, we demonstrated the effectiveness of extended-release naltrexone (XR-NTX; Vivitrol®) in preventing opioid relapse among criminal justice-involved US adults with a history of opioid use disorder. The cost of XR-NTX may be a significant barrier to adoption. Thus, it is important to account for improved quality of life and downstream cost-offsets. Our aims were to (1) estimate the incremental cost per quality-adjusted life-year (QALY) gained for XR-NTX versus treatment as usual (TAU) and evaluate it relative to generally accepted value thresholds; and (2) estimate the incremental cost per additional year of opioid abstinence. Design Economic evaluation of the aforementioned trial from the taxpayer perspective. Participants were randomized to 25 weeks of XR-NTX injections or TAU; follow-up occurred at 52 and 78 weeks. Setting Five study sites in the US Northeast corridor. Participants A total of 308 participants were randomized to XR-NTX ( n = 153) or TAU ( n = 155). Measurements Incremental costs relative to incremental economic and clinical effectiveness measures, QALYs and abstinent years, respectively. Findings The 25-week cost per QALY and abstinent-year figures were $162 150 and $46 329, respectively. The 78-week figures were $76 400/QALY and $16 371/abstinent year. At 25 weeks, we can be 10% certain that XR-NTX is cost-effective at a value threshold of $100 000/QALY and 62% certain at $200 000/QALY. At 78 weeks, the cost-effectiveness probabilities are 59% at $100 000/QALY and 76% at $200 000/QALY. We can be 95% confident that the intervention would be considered 'good value' at $90 000/abstinent year at 25 weeks and $500/abstinent year at 78 weeks. Conclusions While extended-release naltrexone appears to be effective in increasing both quality-adjusted life-years (QALYs) and abstinence, it does not appear to be cost-effective using generally accepted value thresholds for QALYs, due to the high price of the injection. [ABSTRACT FROM AUTHOR]

Aims Screening and brief intervention for harmful substance use in medical settings is being promoted heavily in the United States. To justify service provision fiscally, the field needs accurate estimates of the number and type of staff required to provide services, and thus the time taken to perform activities used to deliver services. This study analyzed the time spent in activities for the component services of the substance misuse Screening, Brief Intervention and Referral to Treatment (SBIRT) program implemented in emergency departments, in-patient units and ambulatory clinics. Design Observers timed activities according to 18 distinct codes among SBIRT practitioners. Setting Twenty-six US sites within four grantees. Participants Five hundred and one practitioner-patient interactions; 63 SBIRT practitioners. Measurements Timing of practitioner activities. Interventions Delivery of component services of SBIRT. Findings The mean (standard error) time to deliver services was 1:19 (0:06) for a pre-screen ( n = 210), 4:28 (0:24) for a screen ( n = 97) and 6:51 (0:38) for a brief intervention ( n = 66). Estimates of service duration varied by setting. Overall, practitioners spent 40% of their time supporting SBIRT delivery to patients and 13% of their time delivering services. Conclusions In the United States, support activities (e.g. reviewing the patient's chart, locating the patient, writing case-notes) for substance abuse Screening, Brief Intervention and Referral to Treatment require more staff time than delivery of services. Support time for screens and brief interventions in the emergency department/trauma setting was high compared with the out-patient setting. [ABSTRACT FROM AUTHOR]

Aims To estimate changes in the substance use behaviors of patients who received services as part of the US Substance Abuse and Mental Health Services Administration's (SAMHSA) Screening, Brief Intervention and Referral to Treatment (SBIRT) grant program. Methods We use a pre-post design and performance monitoring data collected by SBIRT organizations. For a sample of 17 575 patients, we compare pre-SBIRT substance use with substance use 6 months after receipt of SBIRT services. SBIRT's correlation with changes in substance use was estimated using generalized linear mixed models to account for the clustering of patients within health-care facility and US state. Results From pre- to post-SBIRT we found large and statistically significant decreases for almost every measure of substance use. Model-adjusted means indicate that the prevalence of alcohol use was lower 6 months later by 35.6%, heavy drinking by 43.4% and illicit drug use by 75.8%. Greater intervention intensity was associated with larger decreases in substance use. The study design does not support causal conclusions and estimated decreases in reported substance use are due, at least in part, to a well-known set of confounders and natural substance use patterns that may be unrelated to any particular SBIRT intervention. Conclusions Compared with previously published findings on the Screening, Brief Intervention and Referral to Treatment grant program, our estimates of substance use reduction were smaller, but still consistently large in absolute magnitude and within ranges of estimates from past trials of Screening, Brief Intervention and Referral to Treatment. [ABSTRACT FROM AUTHOR]

Aims To conduct a cost-effectiveness analysis (CEA) comparing the delivery of brief intervention (BI) with brief treatment (BT) within Screening, Brief Intervention and Referral to Treatment (SBIRT) programs. Design Quasi-experimental differences in observed baseline characteristics between BI and BT patients were adjusted using propensity score techniques. Incremental comparison of costs and health outcomes associated with BI and BT. Setting Health-care settings in four US states participating in Substance Abuse and Mental Health Services Administration SBIRT grant programs. Participants Ninety patients who received BT and 878 who received BI. Measurements Per-patient cost of SBIRT, patient demographics and six measures of substance use: proportion using alcohol, proportion using alcohol to intoxication, days of alcohol use, days of alcohol use to intoxication, proportion using drugs and days using drugs. Findings BI and BT were associated with better outcomes. The cost of SBIRT was significantly higher for BT patients ($75.54 versus 16.32, 95% confidence interval, P < 0.01). BT would be cost-effective if the decision-maker had a willingness to pay of $8.90 for a 1 percentage point reduction in the probability of using any alcohol. For the other five outcomes, BT was less effective and more costly, and BI would be a better use of resources. Conclusions It might be cost-effective to offer brief treatment if the goal is to abstain from alcohol. However, the higher effectiveness of brief treatment for this outcome is associated with considerable uncertainty and, because both brief intervention and brief treatment improve all outcomes, brief treatment does not appear to be a good use of resources. [ABSTRACT FROM AUTHOR]

Aims To compare three missing data strategies: (i) the latent growth model that assumes the data are missing at random ( MAR) model; (ii) the Diggle- Kenward missing not at random ( MNAR) model, where dropout is a function of previous/concurrent urinalysis ( UA) submissions; and (iii) the Wu- Carroll MNAR model where dropout is a function of the growth factors. Design Secondary data analysis of a National Drug Abuse Treatment Clinical Trials Network trial that examined a 7-day versus 28-day taper (i.e. stepwise decrease in buprenorphine/naloxone) on the likelihood of submitting an opioid-positive UA during treatment. Setting 11 out-patient treatment settings in 10 US cities. Participants A total of 516 opioid-dependent participants. Measurements Opioid UAs provided across the 4-week treatment period. Findings The MAR model showed a significant effect ( B = −0.45, P < 0.05) of trial arm on the opioid-positive UA slope (i.e. 28-day taper participants were less likely to submit a positive UA over time) with a small effect size ( d = 0.20). The MNAR Diggle- Kenward model demonstrated a significant ( B = −0.64, P < 0.01) effect of trial arm on the slope with a large effect size ( d = 0.82). The MNAR Wu- Carroll model showed a significant ( B = −0.41, P < 0.05) effect of trial arm on the UA slope that was relatively small ( d = 0.31). Conclusions This performance comparison of three missing data strategies (latent growth model, Diggle- Kenward selection model, Wu- Carrol selection model) on sample data indicates a need for increased use of sensitivity analyses in clinical trial research. Given the potential sensitivity of the trial arm effect to missing data assumptions, it is critical for researchers to consider whether the assumptions associated with each model are defensible. [ABSTRACT FROM AUTHOR]