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

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

Low bone mineral density (BMD) is common in people living with HIV infection (PLWH), increasing fracture risk. Alcohol use is also common in PLWH and is a modifiable risk factor for both HIV disease progression and low BMD. In PLWH, alcohol's effect on BMD is not well understood.We studied adult PLWH with substance dependence. We measured lifetime alcohol use (kg) and recent (i.e., past 30-day) alcohol use (categorized as: abstinent, low risk, or high risk). In adjusted multivariable regression analyses, we tested associations between lifetime and recent alcohol use and (i) mean BMD (g/cm) at the femoral neck, total hip, and lumbar spine and (ii) low BMD diagnosis (i.e., osteopenia or osteoporosis). We also examined associations between 2 measures of past alcohol use (i.e., total consumption [kg] and drinking intensity [kg/year]) and BMD outcome measures during 3 periods of the HIV care continuum: (i) period before first positive HIV test, (ii) period from first positive HIV test to antiretroviral therapy (ART) initiation, and (iii) period following ART initiation.We found no significant associations between lifetime alcohol use and mean femoral neck (β -0.000, P = .62), total hip (β -0.000, P = .83) or lumbar spine (β 0.001, P = .65) BMD (g/cm), or low BMD diagnosis (adjusted odds ratio [aOR] = 0.98, 95% Confidence Interval [CI]: 0.95-1.01). There was no significant correlation between past 30-day alcohol use and mean BMD (g/cm). Past 30-day alcohol use was associated with low BMD diagnosis (P = .04); compared to abstainers, the aOR for high risk alcohol use was 1.94 (95% CI: 0.91-4.12), the aOR for low risk alcohol use was 4.32 (95% CI: 1.30-14.33). Drinking intensity (kg/year) between first positive HIV test and ART initiation was associated with lower mean BMD (g/cm) at the femoral neck (β -0.006, P = .04) and total hip (β -0.007, P = .02) and increased odds of low BMD (aOR = 1.18, 95% CI = 1.03-1.36).In this sample of PLWH, we detected no association between lifetime alcohol use and BMD. However, recent drinking was associated with low BMD diagnosis, as was drinking intensity between first positive HIV test and ART initiation. Longitudinal studies should confirm these associations.

Background: HIV infection leads to chronic inflammation and alterations in levels of inflammatory cytokines. The association between cytokine levels and mortality in HIV infection is not fully understood., Methods: We analyzed data from a cohort of HIV-infected adults with alcohol problems who were recruited in 2001-2003, and were prospectively followed until 2010 for mortality using the National Death Index. The main independent variables were inflammatory biomarkers [interleukin-6 (IL-6), IL-10, tumor necrosis factor-α, C-reactive protein, serum amyloid A, monocyte chemotactic protein-1, and cystatin-C], measured at baseline in peripheral blood and categorized as high (defined as being in the highest quartile) vs. low. A secondary analysis was conducted using inflammatory burden score, defined as the number of biomarkers in the highest quartile (0, 1, 2 or ≥ 3). Cox models were used to assess the association between both biomarker levels and inflammatory burden with mortality adjusting for potential confounders., Results: Four hundred HIV-infected patients were included (74.8% men, mean age 42 years, 50% hepatitis C virus-infected). As of 31 December 2009, 85 patients had died. In individual multivariable analyses for each biomarker, high levels of IL-6 and C-reactive protein were significantly associated with mortality [hazard ratio=2.49 (1.69-5.12), P<0.01] and [hazard ratio=1.87 (1.11-3.15), P=0.02], respectively. There was also a significant association between inflammatory burden score and mortality [hazard ratio=2.18 (1.29-3.66) for ≥ 3 vs. 0, P=0.04]. In the fully adjusted multivariable analysis, high levels of IL-6 remained independently associated with mortality [hazard ratio=2.57 (1.58-4.82), P<0.01]., Conclusion: High IL-6 levels and inflammatory burden score were associated with mortality in a cohort of HIV-infected adults with alcohol problems.

The Current Opioid Misuse Measure (COMM), a self-report assessment of past-month aberrant medication-related behaviors, has been validated in specialty pain management patients. The performance characteristics of the COMM were evaluated in primary care (PC) patients with chronic pain. It was hypothesized that the COMM could identify patients with prescription drug use disorder (PDD). English-speaking adults awaiting PC visits at an urban, safety-net hospital, who had chronic pain and had received any opioid analgesic prescription in the past year, were administered the COMM. The Composite International Diagnostic Interview served as the "gold standard," using DSM-IV criteria for PDD and other substance use disorders (SUDs). A receiver operating characteristic (ROC) curve demonstrated the COMM's diagnostic test characteristics. Of the 238 participants, 27 (11%) met DSM-IV PDD criteria, whereas 17 (7%) had other SUDs, and 194 (82%) had no disorder. The mean COMM score was higher in those with PDD than among all others (ie, those with other SUDs or no disorder, mean 20.4 [SD 10.8] vs 8.4 [SD 7.5], P<.0001). A COMM score of⩾13 had a sensitivity of 77% and a specificity of 77% for identifying patients with PDD. The area under the ROC curve was 0.84. For chronic pain patients prescribed opioids, the development of PDD is an undesirable complication. Among PC patients with chronic pain-prescribed prescription opioids, the COMM is a promising tool for identifying those with PDD. Among primary care patients with chronic pain-prescribed opioids, the validated Current Opioid Misuse Measure (COMM) is a promising tool for identifying patients with prescription opioid use disorder., (Copyright © 2010 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.)

Background: Trauma exposure and post-traumatic stress disorder (PTSD) increase healthcare utilization in veterans, but their impact on utilization in other populations is uncertain., Objectives: To examine the association of trauma exposure and PTSD with healthcare utilization, in civilian primary care patients., Research Design: Cross-sectional study., Subjects: English speaking patients at an academic, urban primary care clinic., Measures: Trauma exposure and current PTSD diagnoses were obtained from the Composite International Diagnostic Interview. Outcomes were nonmental health outpatient and emergency department visits, hospitalizations, and mental health outpatient visits in the prior year from an electronic medical record. Analyses included bivariate unadjusted and multivariable Poisson regressions adjusted for age, gender, income, substance dependence, depression, and comorbidities., Results: Among 592 subjects, 80% had > or =1 trauma exposure and 22% had current PTSD. In adjusted regressions, subjects with trauma exposure had more mental health visits [incidence rate ratio (IRR), 3.9; 95% confidence interval (CI), 1.1-14.1] but no other increased utilization. After adjusting for PTSD, this effect of trauma exposure was attenuated (IRR, 3.2; 95% CI, 0.9-11.7). Subjects with PTSD had more hospitalizations (IRR, 2.2; 95% CI, 1.4-3.7), more hospital nights (IRR, 2.6; 95% CI, 1.4-5.0), and more mental health visits (IRR, 2.2; 95% CI, 1.1-4.1) but no increase in outpatient and emergency department visits., Conclusions: PTSD is associated with more hospitalizations, longer hospitalizations, and greater mental healthcare utilization in urban primary care patients. Although trauma exposure is independently associated with greater mental healthcare utilization, PTSD mediates a portion of this association.

Objective: To assess the impact of recent heavy alcohol use, heroin/cocaine use, and homelessness on short-term mortality in HIV-infected persons., Methods: Survival in a longitudinal cohort of 595 HIV-infected persons with alcohol problems was assessed at 6-month intervals in 1996-2005. The time-varying main independent variables were heavy alcohol use (past 30 days), heroin/cocaine use (past 6 months), and homelessness (past 6 months). Date of death was determined using the Social Security Death Index. Outcomes were limited to deaths occurring within 6 months of last assessment to ensure recent assessments of the main independent variables. Cox proportional hazards models were fit to the data., Results: Death within 6 months of their last assessment occurred in 31 subjects (5.2%). Characteristics at study entry included mean age 41 years, 25% female, 41% African-American, 24% with CD4 cell count < 200 cells/mul; 41% taking antiretroviral therapy, 30% heavy alcohol use, 57% heroin or cocaine use, and 28% homelessness. Heroin or cocaine use [hazard ratio (HR), 2.43; 95% confidence interval (CI), 1.12-5.30)] and homelessness (HR, 2.92; 95% CI, 1.32-6.44), but not heavy alcohol use (HR, 0.57; 95% CI, 0.23-1.44), were associated with increased mortality in analyses adjusted for age, injection drug use ever, CD4 cell count, and current antiretroviral therapy., Conclusions: Recent heroin or cocaine use and homelessness are associated with increased short-term mortality in HIV-infected patients with alcohol problems. Optimal management of HIV-infected patients requires regular assessments for drug use and homelessness and improved access to drug treatment and housing.

Objective: To examine the association between hepatitis C and prevalent cardiovascular disease (CVD) among HIV-infected individuals., Design: A cross-sectional analysis of data from the HIV-Longitudinal Interrelationships of Viruses and Ethanol (HIV-LIVE) cohort, a prospective cohort of HIV-infected individuals with current or past alcohol problems., Methods: We analysed health questionnaire and laboratory data from 395 HIV-infected individuals (50.1% co-infected with hepatitis C) using logistic regression to estimate the odds ratio (OR) for the prevalence of CVD among those co-infected with hepatitis C and HIV compared with those infected with HIV alone., Results: The prevalence of CVD was higher among those co-infected with hepatitis C compared with those with HIV alone (11.1 versus 2.5%, respectively). After adjusting for age, the OR for the prevalence of CVD was significantly higher among those with hepatitis C co-infection (adjusted OR 4.65, 95% confidence interval 1.70-12.71). The relationship between hepatitis C and CVD persisted when adjusting for age and other sociodemographic characteristics, substance use, and cardiovascular risk factors in separate regression models., Conclusion: Co-infection with hepatitis C among a cohort of HIV-infected individuals was associated with a higher age-adjusted odds for the prevalence of CVD. These data suggest that hepatitis C infection may be associated with an increased risk of CVD among those co-infected with HIV.

Background: Preference-based utility ratings for health conditions are important components of cost-utility analyses and population burden of disease estimates. However, utility ratings for alcohol problems have not been determined., Objectives: The objectives of this study were to directly measure utility ratings for a spectrum of alcohol-related health states and to compare different methods of utility measurement., Design, Setting, and Subjects: The authors conducted a cross-sectional interview of 200 adults from a clinic and community sample., Methods: Subjects completed computerized visual analog scale (VAS), time tradeoff (TTO), and standard gamble (SG) utility measurement exercises for their current health, a blindness scenario, and for 6 alcohol-related health state scenarios presented in random order. The main outcome measures were the utility ratings, scaled from 0 to 1, and anchored by death (0) and perfect health (1)., Results: The 200 subjects were middle-aged (mean, 41 +/- 14 years), 61% women, and racially diverse (48% black, 43% white). Utility ratings decreased as the severity of the alcohol-related health state increased, but differed significantly among the VAS, TTO, and SG methods within each health state. Adjusted mean (95% confidence interval) utility ratings for alcohol dependence (VAS, 0.38 [0.34-0.41]; TTO, 0.54 [0.48-0.60]; SG, 0.68 [0.63-0.73]) and alcohol abuse (VAS, 0.53 [0.49-0.56]; TTO, 0.71 [0.65-77]; SG, 0.76 [0.71-0.81]) were significantly lower than utility ratings for nondrinking, moderate drinking, at-risk drinking, current health, and blindness., Conclusions: Utility ratings for alcohol-related health states decrease as the severity of alcohol use increases. The low utility ratings for alcohol abuse and alcohol dependence are similar to those reported for other severe chronic medical conditions.