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OBJECTIVE: In recent years, a shift has occurred from identifying variables that mediate the effects of psychosocial interventions for problematic alcohol use to trying to identify effective mechanisms of behavior change (MOBCs) that lead to better drinking-related and other outcomes. Although implementing interventions targeting specific MOBCs has considerable conceptual and intuitive appeal, it is important that strong empirical evidence be available that supports such implementation. One aim of this article is to consider some prior mediational analyses of the effects of alcohol-focused psychosocial treatments to illustrate findings and the types of evidence that typically have been presented. A second aim is to consider methodological approaches, specifically certain statistical analyses of observational data and experimental designs, that could provide more rigorous evidence regarding the causal effects of mechanisms of change (mediators) in producing desired drinking-related outcomes. RESULTS: Prior analyses that have examined the association of a mediator with an outcome, or the relationship between a mediator and an outcome with assigned treatment controlled, do not provide strong evidence regarding the causal effects of mediators on outcomes. Unfortunately, experimental designs that directly manipulate mediators seem difficult to apply in the alcohol treatment field as an approach to examine mediator/MOBC effects. CONCLUSION: To produce more compelling evidence, we need to investigate interventions that target a specific MOBC and then capitalize on random assignment to intervention/control conditions by using principal stratification or instrumental variable analyses to identify the effects of intervention-induced mediator change on outcomes.

Background Measures of substance use disorder (SUD) treatment quality are essential tools for performance improvement. The Veterans Health Administration (VHA) developed a measure of access to and engagement in intensive outpatient programs (IOPs) for SUD. However, predictive validity, or associations between this measure and treatment outcomes, has not been examined. Methods Data on veterans with SUD came from 3 samples: the Outcomes Monitoring Project ( N = 5436), a national evaluation of VHA mental health services ( N = 339,887), and patients receiving detoxification services ( N = 23,572). Propensity score–weighted mixed-effects regressions modeled associations between receiving at least 1 week of IOP treatment and patient outcomes, controlling for facility-level performance and a random effect for facility. Results Propensity score weighting reduced or eliminated observable baseline differences between patient groups. Patients who accessed IOPs versus those who did not reported significantly reduced alcohol- and drug-related symptom severity, with significantly fewer past-month days drinking alcohol ( b = 1.83, P < .001) and fewer past-month days intoxicated ( b = 1.55, P < .001). Patients who received IOP after detoxification services had higher 6-month utilization of SUD outpatient visits ( b = 2.09, P < .001), more subsequent detoxification episodes ( b = 0.25, P < .001), and lower odds of 2-year mortality (odds ratio [OR] = 0.68, 95% confidence interval [CI]: 0.61–0.75; P < .001). Conclusions Receiving at least 1 week of SUD treatment in an IOP was associated with higher follow-up utilization, improved health outcomes, and reduced mortality. These associations lend support to the predictive validity of VHA's IOP quality measure. Future research should focus on measure feasibility and validity outside of VHA, and whether predictive validity is maintained once this quality measure is tied to performance incentives.

OBJECTIVES Care coordination for substance use disorder (SUD) treatment is a persistent challenge. Timely outpatient follow-up after detoxification from alcohol and opiates is associated with improved outcomes, leading some care systems to attempt to measure and incentivize this practice. This study evaluated the predictive validity of a 7-day outpatient follow-up after detoxification quality measure used by the Veterans Health Administration (VHA). METHODS A national sample of patients who received detoxification from alcohol or opiates (N = 25,354) was identified in VHA administrative data. Propensity score-weighted mixed-effects regressions modeled associations between receiving an outpatient follow-up visit within 7 days of completing detoxification and patient outcomes, controlling for facility-level performance and clustering of patients within facilities. RESULTS Baseline differences between patients who did (39.6%) and did not (60.4%) receive the follow-up visit were reduced or eliminated with propensity score weighting. Meeting the quality measure was associated with significantly more outpatient treatment for SUD (b = 1.07 visits) and other mental health conditions (b = 0.58 visits), and higher inpatient utilization for SUD (b = 0.75 admissions) and other mental health conditions (b = 0.76 admissions). Notably, meeting the quality measure was associated with 53.3% lower odds of 2-year mortality (P

Limited empirical attention to date has focused on best practices in advanced research mentoring in the health services research domain. The authors investigated whether institutional incentives for mentoring (e.g., consideration of mentoring in promotion criteria) were associated with mentors' perceptions of mentoring benefits and costs and with time spent mentoring.The authors conducted an online survey in 2014 of a national sample of mentors of U.S. Department of Veterans Affairs (VA) Health Services Research and Development Service (HSRD) mentored career development award recipients who received an award during 2000-2012. Regression analyses were used to examine institutional incentives as predictors of perceptions of benefits and costs of mentoring and time spent mentoring.Of the 145 mentors invited, 119 (82%) responded and 110 (76%) provided complete data for the study items. Overall, mentors who reported more institutional incentives also reported greater perceived benefits of mentoring (P = .03); however, more incentives were not significantly associated with perceived costs of mentoring. Mentors who reported more institutional incentives also reported spending a greater percentage of time mentoring (P = .02). University incentives were associated with perceived benefits of mentoring (P = .02), whereas VA incentives were associated with time spent mentoring (P = .003).Institutional policies that promote and support mentorship of junior investigators, specifically by recognizing and rewarding the efforts of mentors, are integral to fostering mentorship programs that contribute to the development of early-career health services researchers into independent investigators.

Historically, mentorship has been conceived of as a dyadic relationship between a senior mentor and an early-career investigator. Models involving multiple mentors have gained favor in recent years, but empirical research on multiple-mentor models has been lacking. The current work aims to fill this gap by describing a long-standing health services research mentoring program at the U.S. Department of Veterans Affairs which has adopted a network-based approach to mentoring. As part of a broader project, we surveyed VA HSR&D Career Development Awardees who received an award between 2000 and 2012. In total, 133 awardees participated (84%). Awardees reported on the structure of mentoring relationships with their two most influential mentors. Awardees were mentored by teams consisting of one to five mentors (M = 2.7 mentors). Most often, one mentor served as primary mentor while one or more mentors played a supporting role. In most cases, an awardee's primary mentor was co-located with the awardee, with fewer secondary mentors co-located. More recently funded CDAs had more mentors and were less likely to be co-located with secondary mentors. The VA HSR&D CDA program incorporates current thinking about Developmental Network models of mentorship into a comprehensive program providing a rich mentorship experience for its awardees.

Background Over the past 60 years, the view that “alcoholism” is a disease for which the only acceptable goal of treatment is abstinence has given way to the recognition that alcohol use disorders (AUDs) occur on a continuum of severity, for which a variety of treatment options are appropriate. However, because the available treatments for AUDs are not effective for everyone, more research is needed to develop novel and more efficacious treatments to address the range of AUD severity in diverse populations. Here we offer recommendations for the design and analysis of alcohol treatment trials, with a specific focus on the careful conduct of randomized clinical trials of medications and nonpharmacological interventions for AUDs. Methods This paper provides a narrative review of the quality of published clinical trials and recommendations for the optimal design and analysis of treatment trials for AUDs. Results Despite considerable improvements in the design of alcohol clinical trials over the past 2 decades, many studies of AUD treatments have used faulty design features and statistical methods that are known to produce biased estimates of treatment efficacy. Conclusions The published statistical and methodological literatures provide clear guidance on methods to improve clinical trial design and analysis. Consistent use of state-of-the-art design features and analytic approaches will enhance the internal and external validity of treatment trials for AUDs across the spectrum of severity. The ultimate result of this attention to methodological rigor is that better treatment options will be identified for patients with an AUD.

See also page [479][1] and [www.cmaj.ca/lookup/doi/10.1503/cmaj.140849][2] As the burden of alcohol misuse — in terms of disease, trauma and social problems — grows in Canada, increased access to brief interventions is recommended. Such access forms part of a comprehensive two-tiered response

OBJECTIVE Placebo group improvement in pharmacotherapy trials has been increasing over time across several pharmacological treatment areas. However, it is unknown to what degree increasing improvement has occurred in pharmacotherapy trials for alcohol use disorders or what factors may account for placebo group improvement. This meta-analysis of 47 alcohol pharmacotherapy trials evaluated (1) the magnitude of placebo group improvement, (2) the extent to which placebo group improvement has been increasing over time, and (3) several potential moderators that might account for variation in placebo group improvement. METHOD Random-effects univariate and multivariate analyses were conducted that examined the magnitude of placebo group improvement in the 47 studies and several potential moderators of improvement: (a) publication year, (b) country in which the study was conducted, (c) outcome data source/type, (d) number of placebo administrations, (e) overall severity of study participants, and (f) additional psychosocial treatment. RESULTS Substantial placebo group improvement was found overall and improvement was larger in more recent studies. Greater improvement was found on moderately subjective outcomes, with more frequent administrations of the placebo, and in studies with greater participant severity of illness. However, even after controlling for these moderators, placebo group improvement remained significant, as did placebo group improvement over time. CONCLUSIONS Similar to previous pharmacotherapy placebo research, substantial pretest to posttest placebo group improvement has occurred in alcohol pharmacotherapy trials, an effect that has been increasing over time. However, several plausible moderator variables were not able to explain why placebo group improvement has been increasing over time.

Oral naltrexone, an opioid antagonist medication, is currently one of only four FDA-approved medications for treating alcohol use disorders (Harris et al., 2010). Although numerous studies and meta-analyses have supported its efficacy, a meta-analysis by Feinn and Kranzler (2005) found that, compared to earlier studies, more recent trials had smaller effects for relapse to heavy drinking and percent drinking days, although the trend for the latter outcome was not quite significant. In addition, multi-center trials (compared to single-site studies) had smaller medication effects on relapse to heavy drinking. Previous reviews of pharmacotherapy trials for depression and schizophrenia have come to similar conclusions (Kemp et al., 2010; Rief et al., 2009). That is, effect sizes in those trials both attenuated over time and were smaller in multi-center studies. Several factors have been pointed to that may account for these findings. The attenuation of effects in more recent pharmacotherapy trials may be attributed to (a) regression to the mean as a function of publication bias for earlier studies (Finney, 2008), (b) confounding of more recent studies with multi-center designs (Feinn and Kranzler, 2005), and (c) increasing placebo group improvement over time (Del Re et al., in submission). Multi-center studies are thought to have smaller effects due to variability in (a) study execution (e.g., varying fidelity to treatment protocol, recruitment procedures) among centers (Feinn and Kranzler, 2005) and (b) other contextual factors across sites (e.g., variation in participant and provider characteristics) which then attenuate the aggregated effect size (ES). The current review extends Feinn and Kranzler’s (2005) meta-analysis by using multivariate meta-analytic methods to examine the efficacy of naltrexone (vs. placebo) in a larger sample of single-site and multi-center studies over a longer time period. The additional studies provide more statistical power to detect the effects of potential moderators, such as time and multi- versus single-center trials. Utilizing multivariate procedures allows for simultaneous modeling of both percent days abstinent (the inverse of percent drinking days) and relapse to heavy drinking outcomes, and thus provides independent estimates for each outcome. This procedure is advantageous as it considers the correlation between the modeled outcome variables, instead of assuming independence as two separate univariate procedures do, thereby reducing the likelihood of Type I error (i.e., erroneously rejecting the null hypothesis). We hypothesize that naltrexone effect sizes continue to decrease after 2003 (the last year examined by Feinn and Kranzler), but eventually plateau (we expect that at no point in time will effect sizes average zero or less) and that multi-center trials continue to yield smaller effect sizes than single-site trials. Further extending the work of Feinn and Kranzler, we planned to examine whether placebo group improvement has been increasing over time, thus accounting for smaller medication effects over time. We also test whether the presence of a placebo run-in period moderates naltrexone effect sizes. Placebo run-in periods eliminate non-compliant participants or participants who exhibit a strong initial placebo response. Thus, studies with a placebo run-in period are expected to have stronger medication effects. Lastly, we examine the interaction between publication year and multi-center (vs. single site), to determine if there are differential effect sizes in multi-center sites versus single site studies on average (grand mean centered intercept) and over time (slope coefficient).

Studies finding weak or nonexistent relationships between hospital performance on providing recommended care and hospital-level clinical outcomes raise questions about the value and validity of process of care performance measures. Such findings may cause clinicians to question the effectiveness of the care process presumably captured by the performance measure. However, one cannot infer from hospital-level results whether patients who received the specified care had comparable, worse or superior outcomes relative to patients not receiving that care. To make such an inference has been labeled the “ecological fallacy,” an error that is well known among epidemiologists and sociologists, but less so among health care researchers and policy makers. We discuss such inappropriate inferences in the health care performance measurement field and illustrate how and why process measure-outcome relationships can differ at the patient and hospital levels. We also offer recommendations for appropriate multilevel analyses to evaluate process measure-outcome relationships at the patient and hospital levels and for a more effective role for performance measure bodies and research funding organizations in encouraging such multilevel analyses.

Aims Although debates over the efficacy of oral naltrexone and acamprosate in treating alcohol use disorders tend to focus on their global efficacy relative to placebo or their efficacy relative to each other, the underlying reality may be more nuanced. This meta-analysis examined when naltrexone and acamprosate are most helpful by testing: (1) the relative efficacy of each medication given its presumed mechanism of action (reducing heavy drinking versus fostering abstinence) and (2) whether different ways of implementing each medication (required abstinence before treatment, detoxification before treatment, goal of treatment, length of treatment, dosage) moderate its effects.

Evidence-based psychological treatments (EBPTs) are clusters of interventions, but it is unclear how providers actually implement these clusters in practice. A disaggregated measure of EBPTs was developed to characterize clinicians' component-level evidence-based practices and to examine relationships among these practices. Survey items captured components of evidence-based treatments based on treatment integrity measures. The Web-based survey was conducted with 75 U.S. Department of Veterans Affairs (VA) substance use disorder (SUD) practitioners and 149 non-VA community-based SUD practitioners. Clinician's self-designated treatment orientations were positively related to their endorsement of those EBPT components; however, clinicians used components from a variety of EBPTs. Hierarchical cluster analysis indicated that clinicians combined and organized interventions from cognitive–behavioral therapy, the community reinforcement approach, motivational interviewing, structured family and couples therapy, 12-step facilitation, and contingency management into clusters including empathy and support, treatment engagement and activation, abstinence initiation, and recovery maintenance. Understanding how clinicians use EBPT components may lead to improved evidence-based practice dissemination and implementation.

Aims: Examine whether decreases in impulsivity account for links between AA attendance and better drinking and psychosocial outcomes, and whether these mediational "effects" are conditional on age. Design: A naturalistic study in which individuals were assessed at baseline, and 1, 8, and 16 years later. Setting: Participants initiated help-seeking through the alcohol intervention system (detoxification programs, information and referral centers). Participants: Individuals with alcohol use disorders and no prior history of substance abuse treatment at baseline [N= 628; 47% women; mean age = 34.7 years (SD = 9.4)]. Measurements: Self-reports of impulsivity and drinking pattern at baseline and Year 1, duration of AA (number of weeks) in Year 1, and drinking (alcohol use problems, self-efficacy to resist drinking) and psychosocial outcomes (emotional discharge coping, social support) at baseline and follow-ups. Findings: Controlling for changes in drinking pattern, decreases in impulsivity were associated with fewer alcohol use problems, better coping, and greater social support and self-efficacy at Year 1, and better coping and greater social support at Year 8. Decreases in impulsivity statistically mediated associations between longer AA duration and improvements on all Year 1 outcomes, and indirect effects were moderated by participant age (significant only for individuals 25 years of age or younger). Conclusions: Decreased impulsivity appears to mediate reductions in alcohol-related problems over 8 years in people attending Alcoholics Anonymous. Language: en

In many evaluations of care for patients with substance use disorders (SUD), a substantial proportion of patients are abstinent from substances prior to their baseline assessment. For researchers evaluating the effect of treatments or patterns of care on follow-up abstinence, especially with non-randomized designs, this raises important conceptual and statistical questions. We discuss several ways researchers might address baseline heterogeneity in abstinence either through design or statistical approaches. For illustration, we estimate the effect of continuing care duration on follow-up abstinence in a sample of 3,181 SUD outpatients treated in 54 Veterans Health Affairs (VHA) facilities. We show that failure to separately examine individuals who are and are not abstinent at baseline overestimates the “treatment effect” on substance use outcomes for those abstinent at baseline and underestimates the treatment effect for those not abstinent at baseline. We also describe comparable findings for the effect of attendance in 12-step self-help groups.

Health care process quality measures usually are designed by expert panels attempting to synthesize nuanced clinical evidence and subsequently operationalized using administrative data. Many quality measures are then adopted without directly validating their presumed links with outcomes. Later efforts to validate process measures often yield negative results, leaving policy makers without a defensible means of measuring quality. This article presents an alternative strategy for developing and validating process quality measures. The development of an alcohol use disorder (AUD) treatment quality measure is used as an example.An expert panel generated a range of candidate process quality measures of AUD treatment derivable from administrative data that were then tested to determine which had the strongest associations with facility- and patient-level outcomes. Outcome and process data were from 2701 US Veterans Health Administration patients starting a new episode of care at 54 VA facilities.Several of the candidate process-of-care quality measures predicted facility- and patient-level outcomes. Having at least 3 visits during the first month of specialty AUD treatment was correlated with improvement on the Addiction Severity Index Alcohol composite at the facility level, r = 0.41 (95% Confidence Interval 0.16-0.61), and at the patient level, r = 0.07 (CI: 0.03-0.11).These "prevalidated" quality measures can now be judged for the extent they map onto the extant clinical literature and other design requirements. The development and validation strategy we describe should aid in efficiently producing quality measures in other areas of health care.

This study examined the patient- and facility-level associations between the continuity of care performance measure adopted by the Department of Veterans Affairs (VA) and improvements in self-administered Addiction Severity Index (ASI) composites and other indicators of problematic substance use. Up to 50 patients from each of a nationally representative sample of 109 VA substance use disorder (SUD) treatment programs at 73 VA facilities were assessed at intake and posttreatment. The continuity of care performance measure specifies that patients should receive at least two SUD outpatient visits in each of the three consecutive 30-day periods after they qualify as new SUD patients. In analyses adjusting for baseline characteristics, meeting the continuity of care performance measure was not associated with patient-level improvements in the ASI alcohol or drug composites, days of alcohol intoxication, or days of substance-related problems. Facility-level rates of continuity of care were negatively associated with improvements in ASI alcohol and drug composites. The continuity of care performance measure derived from prior patient-level evidence did not discriminate facility-level performance as predicted. Translating research into process-of-care quality measures requires postconstruction validation.

OBJECTIVE: To estimate the range and severity of distress and pain during pelvic examinations among female veterans with and without histories of sexual violence, and to examine whether posttraumatic stress disorder explains additional variance in examination-related distress and pain above that accounted for by exposure to sexual violence. METHODS: We employed a cross-sectional cohort design in which 67 selected female veterans completed self-administered questionnaires to assess history of sexual violence and experiences of distress and pain associated with the pelvic examination. A subsample of 49 completed an assessment for posttraumatic stress disorder approximately 2 weeks later. RESULTS: Distress associated with the pelvic examination was highest for women with prior sexual violence and posttraumatic stress disorder (median 5.49), next highest for women with sexual violence only (median 2.44), and lowest for women with neither (median 0), P=.015. Higher ratings of pain were also found among women with sexual violence (median 2.5) compared with those without (median 0), P=.04. However, posttraumatic stress disorder was not linked with increased pain from speculum insertion beyond that accounted for by sexual violence; limited power may have precluded detection of this effect. CONCLUSION: Distress and pain during pelvic examinations may indicate a history of previous sexual violence, particularly in those with posttraumatic stress disorder. Extra sensitivity to the special needs of this population is warranted and may contribute positively to the quality of patients' experiences. Language: en

This study examines the patient-level associations between the Health Plan Employer Data and Information Set (HEDIS) substance use disorder (SUD) treatment engagement quality indicator and improvements in clinical outcomes. Administrative and survey data from 2,789 US Department of Veterans Affairs SUD patients were used to estimate the effects of meeting the HEDIS engagement criterion on improvements in Addiction Severity Index Alcohol, Drug, and Legal composite scores. Patients meeting the engagement indicator improved significantly more in all domains than patients who did not engage, and the relationship was stronger for alcohol and legal outcomes for patients seen in outpatient settings. The benefit accrued by those who engaged was statistically significant but clinically modest. These results add to the literature documenting the clinical benefits of treatment entry and engagement. Although these findings only indirectly support the use of the HEDIS engagement measure for its intended purpose-discriminating quality at the facility or system level-they confirm that the processes of care captured by the measure are associated with important patient outcomes.

Background Illicit drug use is prevalent but under-detected among psychiatric patients. This paper reviews the need for a valid, practical screening instrument for detecting drug problems and disorders among psychiatric patients, and describes the appropriateness of existing screening instruments for this purpose. Methods Research literature on illicit drug screening instruments is reviewed. Results All existing instruments lack one or more of the following characteristics that would enable them to be used routinely in psychiatric settings: brief and easy to administer, demonstrated validity for male and female psychiatric patients, measuring illicit drug use problems without confounding with alcohol use problems, and assessing drug problems over an optimal timeframe for screening (e.g., past 12 months). Conclusion Current instruments are not appropriate for routine drug screening of psychiatric patients. A brief, easy to use drug screen should be developed and validated on male and female psychiatric patients for routine screening of drug disorders and problems.

Aims Regression to the mean (RTM) refers to the tendency for a group of cases that differ from the population mean to move (regress) towards the mean, on average, when re-assessed, if scores at the two points are less than perfectly correlated. This paper considers factors that affect the magnitude of RTM and how RTM may impact findings from primary studies and reviews of substance use disorder (SUD) treatment. Design and methods The paper is guided largely by A Primer on Regression Artifacts by Campbell and Kenny. It reviews potential RTM effects in three areas of SUD treatment research. One is the extent to which within-group improvement in comparative treatment trials, including 'placebo effects', is a function of RTM. The second is the vulnerability of treatment evaluations employing non-equivalent control group designs to RTM and biased estimates of treatment effects when matching, or statistical equating is used to adjust for pre-existing group differences. The final issue is the impact of RTM in syntheses of research findings on SUD treatments. In particular, the tendency for later studies of a particular intervention to have smaller treatment effect sizes relative to earlier studies is considered as an RTM phenomenon. Findings RTM is a pervasive, but often unrecognized phenomenon that can bias findings in SUD treatment studies and in systematic reviews of that research. Conclusion SUD treatment researchers should be aware of RTM, take any available steps to reduce it, and try to diagnose whether it is still affecting research findings.

Self-administered Addiction Severity Index (ASI) data were collected on 5,723 patients who received substance abuse treatment in 1 of 110 programs located at 73 Veterans Affairs facilities. The associations between each of three Washington Circle (WC) performance indicator scores (identification, initiation, and engagement) and their casemix-adjusted facility-level improvement in ASI drug and alcohol composites 7 months after intake were estimated. Higher initiation rates were not associated with facility-level improvement in ASI alcohol composite scores but were modestly associated with greater improvements in ASI drug composite scores. Identification and engagement rates were unrelated to 7-month outcomes. WC indicators focused on the early stages of treatment may tap necessary but insufficient processes for patients with substance use disorder to achieve good posttreatment outcomes. Ideally, the WC indicators would be supplemented with other measures of treatment quality.

Aims This study tested the hypothesis that patients with more severe substance use disorders (SUDs) at intake respond better when treated in more structured and intensive settings (i.e. in-patient/residential versus out-patient), whereas patients with less severe SUD problems have similar outcomes regardless of treatment setting. Design, setting and participants Up to 50 new patients were selected randomly from each of a random and representative sample of 50 Department of Veterans Affairs (VA) SUD treatment programs (total n = 1917 patients), and were followed-up an average of 6.7 months later (n = 1277). Measures Patients completed a brief self-report version of the Addiction Severity Index (ASI) at baseline and at follow-up. Findings In mixed-model regression analyses, baseline substance use severity predicted follow-up substance use severity and there were no main effects of treatment setting. However, interaction effects were found, such that more severe patients experienced better alcohol and drug outcomes following in-patient/residential treatment versus out-patient treatment; on the other hand, patients with lower baseline ASI drug severity had better drug outcomes following out-patient treatment than in-patient treatment. Treatment setting was unrelated to alcohol outcomes in patients with less severe ASI alcohol scores. Conclusions Results provide some support to the matching hypothesis that for patients who have higher levels of substance use severity at intake, treatment in in-patient/residential treatment settings is associated with better outcomes than out-patient treatment. More research needs to be conducted before in-patient/residential settings are further reduced as a part of the SUD continuum of care in the United States.

Historically, mentorship has been conceived of as a dyadic relationship between a senior mentor and an early‐career investigator. Models involving multiple mentors have gained favor in recent years, but empirical research on multiple‐mentor models has been lacking. The current work aims to fill this gap by describing a long‐standing health services research mentoring program at the U.S. Department of Veterans Affairs which has adopted a network‐based approach to mentoring. As part of a broader project, we surveyed VA HSR&D Career Development Awardees who received an award between 2000 and 2012. In total, 133 awardees participated (84%). Awardees reported on the structure of mentoring relationships with their two most influential mentors. Awardees were mentored by teams consisting of one to five mentors (M = 2.7 mentors). Most often, one mentor served as primary mentor while one or more mentors played a supporting role. In most cases, an awardee‘s primary mentor was co‐located with the awardee, with fewer secondary mentors co‐located. More recently funded CDAs had more mentors and were less likely to be co‐located with secondary mentors. The VA HSR&D CDA program incorporates current thinking about Developmental Network models of mentorship into a comprehensive program providing a rich mentorship experience for its awardees.

To evaluate the academic advancement and productivity of Department of Veterans Affairs Health Services Research and Development (HSRD) Career Development Award (CDA) program recipients, National Institutes of Health (NIH) K awardees in health services research (HSR), and Agency for Healthcare Research and Quality (AHRQ) K awardees.In all, 219 HSRD CDA recipients from fiscal year (FY) 1991 through FY2010; 154 NIH K01, K08, and K23 awardees FY1991-FY2010; and 69 AHRQ K01 and K08 awardees FY2000-FY2010 were included. Most data were obtained from curricula vitae. Academic advancement, publications, grants, recognition, and mentoring were compared after adjusting for years since award, and personal characteristics, training, and productivity prior to the award.No significant differences emerged in covariate-adjusted tenure-track academic rank, number of grants as primary investigator (PI), major journal articles as first/sole author, Hirsch h-index scores, likelihood of a journal editorship position or membership in a major granting review panel, or mentoring postgraduate researchers between the HSRD CDA and NIH K awardees from FY1991-FY2010, or among the three groups of awardees from FY2000 or later. Among those who reported grant funding levels, HSRD CDAs from FY1991-2010 had been PI on more grants of $100,000 than NIH K awardees. HSRD CDAs had a higher mean number of major journal articles than NIH K awardees from FY1991-2010.Findings show that all three HSR career development programs are successfully selecting and mentoring awardees, ensuring additional HSR capacity to improve the quality and delivery of high-value care.

The most effective psychosocial modalities for treating substance use disorders are cognitive-behavioral interventions, motivational interviewing and motivational enhancement, contingency management, community reinforcement, behavioral couples and family therapies, and 12-step facilitation approaches. The foci of these interventions include substance use behavior, patients’ life contexts, and their social and personal resources. Limited evidence is available for these interventions’ differential effectiveness. Brief interventions are highly effective in the treatment of alcohol use disorders. However, as stand-alone treatments, they are best suited for individuals with mild to moderate alcohol use problems. Therapists who are interpersonally skilled, empathic, and nonconfrontational, and who develop a strong therapeutic alliance, are more effective at helping patients achieve better outcomes.

Anderson et al.'s finding that states with legalized medical marijuana had lower suicide rates among young men calls to mind the work of the famous French sociologist, Emile Durkheim. In Le Suicide, published in 1897, Durkheim observed that suicide rates were lower in regions with a higher proportion of Catholics and concluded that social controls within the Catholic religion reduced the likelihood of Catholics taking their own lives. Durkheim's individual-level interpretation of his region-level data subsequently became a textbook example of the "ecological fallacy": the assumption that associations observed at a higher level of aggregation (e.g., state level) are mirrored at the individual level. (Am J Public Health. Published online ahead of print February 25, 2015: e1. doi:10.2105/AJPH.2015.302604). Language: en

Aims To examine the effectiveness of contingency management (CM) techniques in treating substance use disorders (i.e. illicit drugs, alcohol, tobacco). Design Meta-analysis was used to determine the average effect size and potential moderators in 47 comparisons of the effectiveness of CM from studies based on a treatment–control group design and published between 1970 and 2002. Findings The mean effect size (ES) of CM was positive, with a magnitude of d = 0.42 using a fixed effects model. The magnitude of the ES declined over time, following treatment. CM was more effective in treating opiate use (d = 0.65) and cocaine use (d = 0.66), compared with tobacco (d = 0.31) or multiple drugs (d = 0.42). Larger effect sizes were associated with higher researcher involvement, earlier studies and shorter treatment duration. Conclusions Study findings suggest that CM is among the more effective approaches to promoting abstinence during the treatment of substance use disorders. CM improves the ability of clients to remain abstinent, thereby allowing them to take fuller advantage of other clinical treatment components.

Although motivational readiness to change predicts alcohol use disorder (AUD) treatment outcomes, little is known about treatment aspects that are helpful for patients with low motivation. We examined whether a positive therapeutic alliance is particularly beneficial for patients entering AUD treatment with low motivation. Among Project MATCH outpatients (n = 753), we tested the influence of motivation, therapeutic alliance, and their interaction on 6-month and 1-year alcohol use. The impact of motivation on alcohol use varied depending on therapists' perceptions of alliance. Interactions involving treatment compliance did not mediate the Motivation x Alliance interaction. Thus, a positive therapeutic relationship may be particularly important for patients with low motivation, but mechanisms underlying this possible patient-treatment "match" remain to be determined.

High abstinence self-efficacy reliably predicts better treatment outcomes for patients with alcohol use disorders, but little is known about aspects of treatment that may be particularly beneficial for patients who enter treatment with low self-efficacy. This study examines whether the relationship between self-efficacy and treatment outcomes is influenced by the quality of the therapeutic alliance in Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity), a multisite clinical trial of three treatments for alcohol use disorders.Information on 785 patients in the outpatient sample of Project MATCH was used to test for an interaction between baseline self-efficacy and therapeutic alliance in relation to 1-year alcohol use outcomes.A significant interaction was found between self-efficacy and the therapists' perception of the therapeutic alliance predicting I1year drinking outcomes. Patients with low self-efficacy who established a strong treatment alliance, as judged by the therapist, experienced I1year outcomes that were superior to those of patients with low self-efficacy with poorer treatment alliance and comparable with those of patients with high self-efficacy. Therapeutic alliance was not strongly related to the outcomes of patients with high baseline self-efficacy.In patients who are treated for alcohol-use disorders, a positive therapeutic alliance may counteract the negative impact of a low baseline self-efficacy. Potential reasons why the therapist's perception of the alliance may be particularly important for patients with low self-efficacy are discussed.

This study examined the rates of sexual and physical abuse and suicide attempts among male and female patients and focused on the associations between sexual and physical abuse and recent suicide attempts among men.Data were examined for a cohort of patients aged 19 years and older who were seeking treatment for substance use disorders, other psychiatric disorders, or both from the Department of Veterans Affairs (VA) between July 1997 and September 1997. Almost all the patients in the sample (more than 99 percent) had a substance use disorder. Patients were interviewed with the Addiction Severity Index about lifetime and recent (past 30 days) sexual and physical abuse and recent suicide attempts. Because of the low prevalence of suicide attempts in the past 30 days and limited representation of female patients in this sample, the data for female patients were used only to conduct descriptive analyses to compare the prevalence of sexual and physical abuse and suicide attempts between genders.The sample comprised 34,245 patients (33,236 males and 1,009 females). Compared with male patients, female patients were ten times as likely to have been sexually abused in the past 30 days and four times as likely to have been physically abused. Among male patients, bivariate analyses showed that those who had been recently sexually or physically abused were more likely than those who had not experienced such abuse to have attempted suicide recently (odds ratios of 4.8 and 3.0, respectively). After controlling for demographic and diagnostic factors, multivariate logistic regression analyses indicated that recent sexual abuse, recent physical abuse, and lifetime sexual abuse were significantly associated with a higher likelihood of a recent suicide attempt among male patients.Female patients were more likely than their male counterparts to experience sexual and physical abuse. Recent and lifetime history of sexual abuse and recent physical abuse were independent risk factors for recent suicide attempts among men who were seeking treatment. The results suggest that clinicians who identify suicide attempts and suicidal tendencies among male patients should routinely assess for sexual or physical abuse.

This study examines the association between approach coping and better functioning outcomes and the reciprocal relationships between coping and posttraumatic stress disorder (PTSD) symptoms in patients diagnosed with PTSD. Posttraumatic stress disorder patients receiving services in five VA health care systems were randomly selected and surveyed at baseline and followed 10 months later. Analyses of longitudinal data using structural equation modeling techniques showed that more approach coping predicted better family and social functioning. Cognitive avoidance coping predicted more PTSD symptoms, and more PTSD symptoms predicted more approach coping and more behavioral avoidance coping. Approach coping may enable patients with chronic PTSD to establish and maintain better relationships with family and friends, despite continuing PTSD.

Aims To describe the eligibility criteria (i.e. study participant inclusion and exclusion rules) employed in alcohol treatment outcome research and to identify predictors of their use. Design The eligibility criteria of 683 alcohol treatment outcome studies conducted between 1970 and 1998 were coded reliably into 14 general categories. Predictors of the use of eligibility criteria were then examined. Findings Patients were most often ruled ineligible for research studies because of their level of alcohol problems (39.1% of studies), comorbid psychiatric problems (37.8%), past or concurrent utilization of alcohol treatment (31.8%), co-occurring medical conditions (31.6%), and because they were deemed non-compliant and unmotivated (31.5%). The number of eligibility criteria employed in studies increased from the 1970s through the 1990s, and was positively associated with funding from the US National Institute of Alcohol Abuse and Alcoholism (NIAAA) and from the private sector, lack of an inpatient/residential treatment condition, presence of a pharmacotherapy, and use of a randomized, multiple-condition design. Principal investigators with doctoral degrees used more eligibility criteria than those with lower degrees. Conclusion Participant eligibility criteria are extensively employed in alcohol treatment outcome research, and vary significantly across historical periods, funders and research designs. Researchers should report the details of subject eligibility criteria and excluded patients more fully, and, evaluate how eligibility criteria affect the cost, feasibility, and generalizability of treatment outcome research.

BACKGROUND:: The present study investigated whether or not the effect of treatment setting (inpatient or outpatient) on 6-mo follow-up substance use varied for suicidal and nonsuicidal patients. In particular, the study tested the hypothesis that treatment setting would have no differing effect for nonsuicidal participants, but for suicidal participants, inpatient setting would be more closely associated with positive outcomes than the outpatient setting. METHODS:: A national sample of patients presenting for treatment of substance use disorders in the Veterans Administration healthcare system was selected to participate in the study. A total of 1289 participants provided complete data on psychiatric and substance-related problems at baseline and 6-mo follow-up. RESULTS:: At baseline, 4% (n = 53) of the sample reported having made a suicide attempt within the past 30 days. Those who reported a suicide attempt were no more likely to have been treated in an inpatient setting than in an outpatient setting. A significant interaction between baseline suicide attempt and treatment setting was found, such that nonsuicidal patients reported similar patterns of substance use when treated in inpatient or outpatient settings, but suicidal patients were significantly more likely to have better substance-related outcomes at 6-mo follow-up if they were treated in inpatient compared with outpatient settings. CONCLUSIONS:: Suicidal patients displayed substantial improvement after substance use disorders treatment and seem particularly responsive to treatment in inpatient settings.

This study examined the prevalence and predictors of 5-year mortality following treatment for substance use disorders. The predictors were assessed at baseline, at discharge, and at a 1-year follow-up for 3698 male veterans, and included demographic, substance use, medical, and psychological functioning, social support, and continuing care. The annual mortality rate was 2.38%, with an observed/expected ratio of 3.05. After accounting for significant demographic, substance use, psychological, and medical conditions, not having a spouse or partner at intake independently predicted 5-year mortality. After accounting for intake variables, more depression at discharge and more medical conditions, a diagnosis of HIV or AIDS, more ounces of ethanol on a maximum drinking day, and lack of a spouse or partner at the 1-year follow-up independently predicted 5-year mortality. Unexpectedly, good quality relationships were related to a higher mortality risk. Results can be used to increase at-risk patients' motivation for recovery.

Veterans with posttraumatic stress disorder (PTSD) and substance use disorders (SUDs) demonstrate worse outcomes following treatment for SUDs than do veterans with SUDs only, and so PTSD treatment may enhance SUD outcomes for patients. A survey of current practice patterns in VA SUD treatment programs was undertaken to determine their concurrence with emerging practice guidelines for the assessment and treatment of SUD-PTSD comorbidity. Clinicians in outpatient SUD clinics and/or inpatient SUD programs were surveyed in six VA medical centers in 1999 and 2001 (respondents n = 57 and n = 39, respectively). Although one half to two thirds of clinicians working with SUD patients routinely screen for trauma exposure and PTSD, few assessments are systematically conducted using validated measures. Routine referrals to PTSD specialty and dual-diagnosis programs and to veterans' centers are made by between 35% and 60% of providers across inpatient and outpatient settings. Implications for improvement of clinical outcomes are discussed.

Background: The aim of this study was to compare women (n= 230) and men (n= 236) who had alcohol use disorders in terms of social context and coping methods and in terms of changes in these indices associated with participation in professional treatment and Alcoholics Anonymous (AA). Methods: Initially untreated problem drinkers were followed up for 8 years. Results: Women and men did not differ in regard to the type of help received, but women had longer professional treatment. At baseline, women had more stressors and fewer resources from family and relied more on avoidance coping and drinking to cope. During the next 8 years, women, more so than men, increased on approach coping and reduced their use of avoidance coping and drinking to cope. When baseline status was controlled, women had better social resource, coping, and drinking outcomes than men did at 1 year and 8 years. A longer duration of professional treatment during year 1 was associated with improved approach coping among men but not women. A longer duration of AA attendance during year 1 and the full 8 years was associated with more resources from friends, more use of approach coping, and less drinking to cope. In turn, more friends resources and approach coping and less drinking to cope were associated with better drinking outcomes. Decreases in avoidance coping and drinking to cope were more strongly associated with better drinking outcomes among men than among women. Conclusions: It may be important to target men for formal services or self-help to increase their use of approach coping in efforts to maintain abstinence. Women's strategies for improving their social context need further explication to be adapted for transfer to male problem drinkers.

Background: This article provides a historical overview of the assessment of outcome variables in alcohol treatment studies that were first published between 1968 and 1998. The review focuses on changes over time in (1) the number of outcome variables and the number of different types of outcome variables assessed, (2) the likelihood of assessing specific types of outcome variables, (3) the methods used to assess outcome variables, and (4) the status of outcome assessment in more recent studies first published between 1990 and 1998. Methods: Reports of 357 alcohol treatment trials with two or more treatment/control groups were coded with respect to the number and types of outcome variables assessed, sources of outcome data, and methodological aspects of outcome assessment. Results: Although the number of outcome variables assessed in studies, on average, did not increase significantly over time, the number of different types of outcome variables did increase. An expected decrease in the assessment of categorical abstinence was not found, but another categorical variable, global ratings of drinking improvement, did decrease over time. More recent studies were more likely to assess such continuous variables as time abstinent, alcohol consumption, time drinking, dependence symptoms, and drinking-related problems. Physiological markers of drinking/alcohol misuse also were assessed more frequently in later years. Some aspects of outcome assessment methods exhibited improvement over time; validity data were more likely to be provided or cited, and self-reports of drinking behaviors were more likely to be corroborated in studies first published in more recent years. However, the percentages of studies that provided/cited reliability data for outcome measures, indicated that follow-up data collectors were not affiliated with treatment and were unaware of respondents' treatment conditions, and reported that respondents were alcohol-free at follow-up did not rise significantly over time. Conclusions: Although the methods of outcome assessment improved between 1968 and 1998, much room for improvement remains.

We reviewed 701 alcohol treatment outcome studies reported between 1970 and 1998. Examining the nature of the research allows us to characterize this field of study, analyze trends over time, and improve upon this work in the future. For multiple-group studies, the majority of both investigators and participants were male, and participant characteristics were generally inconsistently surveyed and reported. Between the 1970s and the 1990s, research on pharmacological treatments and research conducted in outpatient settings became more common. Additionally, the types of outcome measures assessed varied more widely and were more likely to be continuous and quantifiable.

Background The primary goals in conducting clinical trials of treatments for alcohol use disorders (AUDs) are to identify efficacious treatments and determine which treatments are most efficacious for which patients. Accurate reporting of study design features and results is imperative to enable readers of research reports to evaluate to what extent a study has achieved these goals. Guidance on quality of clinical trial reporting has evolved substantially over the past 2 decades, primarily through the publication and widespread adoption of the Consolidated Standards of Reporting Trials statement. However, there is room to improve the adoption of those standards in reporting the design and findings of treatment trials for AUD. Methods This paper provides a narrative review of guidance on reporting quality in AUD treatment trials. Results Despite improvements in the reporting of results of treatment trials for AUD over the past 2 decades, many published reports provide insufficient information on design or methods. Conclusions The reporting of alcohol treatment trial design, analysis, and results requires improvement in 4 primary areas: (i) trial registration, (ii) procedures for recruitment and retention, (iii) procedures for randomization and intervention design considerations, and (iv) statistical methods used to assess treatment efficacy. Improvements in these areas and the adoption of reporting standards by authors, reviewers, and editors are critical to an accurate assessment of the reliability and validity of treatment effects. Continued developments in this area are needed to move AUD treatment research forward via systematic reviews and meta-analyses that maximize the utility of completed studies.

In a cohort of 2,595 male patients in VA intensive treatment programs for substance use disorders (SUD), we tested whether psychiatric comorbidity, outpatient care and mutual help group attendance during the first two follow-up years predicted remission status at Year 5, controlling for covariates.Logistic regression modeling of longitudinal data was used to test the hypotheses.Dual diagnosis patients were less likely to be in remission at Year 5 than SUD-only patients. Outpatient care was at best only weakly related to Year 5 remission status. By contrast, mutual help involvement substantially improved the chances of substance use remission at Year 5 for both SUD-only and dual diagnosis patients. Mutual help involvement did not, however, offset the poorer prognosis for dual diagnosis patients.Because mutual help groups specifically targeted to individuals with comorbid substance use and psychiatric disorders are currently rare, further research is recommended to investigate whether they are more effective than standard SUD mutual help groups in facilitating the recovery of persons with dual diagnoses.

Summarizing the relative effects of different treatments for alcohol use disorders is challenging because there is no standard treatment against which experimental treatments can be contrasted and comparisons to no-treatment control groups are rare. As alternative reference points, we examined outcomes and improvement for untreated participants (i.e., those in wait-list, no-treatment, and placebo conditions) in randomized trials of alcohol treatment over the last three decades. At followup, the average abstinence rate was 21% (n = 17 studies) and the mean level of alcohol consumption was 31 drinks per week (n = 29 studies). The reduction in drinking from baseline was .19 of a SD unit, or a 14% decrease from a baseline mean of 37 drinks per week (n = 17 studies). These values provide approximations of success and improvement that an active treatment for alcohol use disorders should surpass to be considered more beneficial than no treatment.

Randomized trials are widely acknowledged to be the most rigorous method to estimate the comparative efficacy of treatments. Concerns have been raised, however, about the generalizability of findings from randomized trials of alcohol treatments to actual treatment circumstances, and about the internal validity of randomized trials. The purpose of this review was to compare the participants, methodological features and posttreatment functioning in randomized and nonrandomized studies of alcohol treatment.Using systematic literature search techniques, 232 randomized and 92 nonrandomized trials published between 1970 and 1998 were identified. Each investigation was scored on a methodological quality scale, participant characteristics were recorded and participants' follow-up abstinence and improvement rates were calculated.Randomized investigations were more likely to use participant selection criteria, to use recognized diagnostic criteria to characterize participants and to stringently implement treatment and assess outcomes. Nonrandomized investigations were more likely to assess outcomes in higher proportions of participants over longer follow-up periods and to have greater statistical power t o detect treatment effects. Abstinence and improvementrates following active treatment were similar for the two types of design (proportion abstinent: 0.35 and 0.39, and proportion improved: 0.52 and 0.54, for randomized and nonrandomized trials, respectively), even when differences in study features were controlled.The contrasting strengths and weaknesses of randomized and nonrandomized studies suggest that they should be considered as complementary forms of treatment evaluation, in the alcohol treatment field and perhaps more generally.

Aims The aim of this study was to compare initially untreated women and men problem drinkers on help-utilization and outcomes over 8 years. Design and participants At the time of the 8-year follow-up, individuals (N = 466, 49% female) had self-selected into four groups: no help, Alcoholics Anonymous (AA) only, formal treatment only or formal treatment plus AA. Measurements At baseline and 1, 3 and 8 years later, participants completed measures of drinking and functioning. Findings Women were generally worse off than men on baseline drinking and functioning indices. In keeping with their poorer baseline status, women were more likely to participate in AA, and had longer in-patient stays during the next year. When women's baseline status was controlled, women had better outcomes than did men at 1 and 8 years. Generally, women and men did not differ on the extent to which obtaining help, or a particular type of help, was related to improved outcomes. Regarding drinking outcomes, women benefited more than did men from more AA attendance during years 2–8 of follow-up. Conclusions The results suggest that although alcoholism interventions were designed primarily for men, they are currently delivered in ways that are also useful to women. Problem-drinking women appear to benefit from sustained participation in AA, which emphasizes bonding with supportive peers to maintain abstinence.

Brief interventions for alcohol use disorders have been the focus of considerable research. In this meta-analytic review, we considered studies comparing brief interventions with either control or extended treatment conditions. We calculated the effect sizes for multiple drinking-related outcomes at multiple follow-up points, and took into account the critical distinction between treatment-seeking and non-treatment-seeking samples. Most investigations fell into one of two types: those comparing brief interventions with control conditions in non-treatment-seeking samples (n = 34) and those comparing brief interventions with extended treatment in treatment-seeking samples (n = 20). For studies of the first type, small to medium aggregate effect sizes in favor of brief interventions emerged across different follow-up points. At follow-up after > 3-6 months, the effect for brief interventions compared to control conditions was significantly larger when individuals with more severe alcohol problems were excluded. For studies of the second type, the effect sizes were largely not significantly different from zero. This review summarizes additional positive evidence for brief interventions compared to control conditions typically delivered by health-care professionals to non-treatment-seeking samples. The results concur with previous reviews that found little difference between brief and extended treatment conditions. Because the evidence regarding brief interventions comes from different types of investigation with different samples, generalizations should be restricted to the populations, treatment characteristics and contexts represented in those studies.

This article introduces a Special Section of the Psychology of Addictive Behaviors on "Implementing Evidence-based Interventions for Substance Use Disorders." It briefly describes the content of each of the seven manuscripts comprising the Special Section. The articles provide a overview of conceptual frameworks for, and summarize research on, the implementation of evidence-based treatments and practices for substance use disorders. Taken together, the articles make clear that successful implementation of a treatment innovation generally requires a multifaceted approach that considers: (a) features of the clinical intervention to be implemented, (b) characteristics of the individuals that are expected to adopt the clinical intervention, (c) features of the proximal and more distal environments in which the clinical intervention will be implemented, and (d) the implementation strategy to be applied.

This study’s purpose was to identify distinct publishing trajectories among 442 participants in three prominent mentored health services research career development programs (Veterans Affairs, National Institutes of Health, and Agency for Healthcare Research & Quality) in the 10 years after award receipt and to examine awardee characteristics associated with different trajectories. Curricula vitae (CVs) of researchers receiving awards between 1991 and 2010 were coded for publications, grants, and awardee characteristics. We found that awardees published at constant or increasing rates despite flat or decreasing rates of first-author publications. Senior-author publications rose concurrently with rates of overall publications. Higher overall publication trajectories were associated with receiving more grants, more citations as measured by the h-index, and more authors per article. Lower trajectory groups were older and had a greater proportion of female awardees. Career development awards supported researchers who generally published successfully, but trajectories varied across individual researchers. Researchers’ collaborative efforts produced an increasing number of articles, whereas first author articles were written at a more consistent rate. Career development awards in health services research supported the careers of researchers who published at a high rate; future research should further examine reasons for variation in publishing among early career researchers.

Accurate operationalization is a major challenge in developing quality measures for substance use disorder treatment. Specification validity is a term used to describe whether a quality measure is operationalized such that it captures the intended care processes and patients. This study assessed the specification validity of the 2009 Healthcare Effectiveness Data and Information Set (HEDIS®) substance use disorder initiation and engagement measures by examining whether encounters assumed to include relevant treatment have corroborating evidence in the clinical progress notes. The positive predictive values were excellent (>90%) for residential and outpatient records selected from addiction treatment programs but more modest for records generated in non-addiction settings, and were highly variable across facilities. Stakeholders using these measures to compare care quality should be mindful of the clinical composition of the data and determine if similar validation work has been conducted on the systems being evaluated.

Influenced by several trials and reviews highlighting positive outcomes, topiramate is increasingly prescribed as a treatment for alcohol use disorders (AUDs). The only previously published meta-analysis of topiramate for AUDs was limited by a sample of only 3 randomized, placebo-controlled trials (RCTs).A systematic search identified 7 RCTs (including a total of 1,125 participants) that compared topiramate to placebo for the treatment for AUDs. This meta-analysis estimated the overall effects of topiramate on abstinence, heavy drinking, craving, and γ-glutamyltranspeptidase (GGT) outcomes and included several sensitivity analyses to account for the small sample of studies.Overall, the small to moderate effects favored topiramate, although the effect on craving was not quite significantly different from 0. The largest effect was found on abstinence (g = 0.468, p0.01), followed by heavy drinking (g = 0.406, p0.01), GGT (g = 0.324, p = 0.02), and craving (g = 0.312, p = 0.07) outcomes. Sensitivity analyses did not change the magnitude or direction of the results, and tests did not indicate significant publication bias. The small sample size did not allow for examination of specific moderators of the effects of topiramate.Topiramate can be a useful tool in the treatment of AUDs. Its efficacy, based on the current sample of studies, seems to be of somewhat greater magnitude than that of the most commonly prescribed medications for AUDs (naltrexone and acamprosate). Further research will help to identify the contexts in which topiramate is most beneficial (e.g., dose, concurrent psychotherapy, patient characteristics).

Debate has ensued about whether substance use disorder (SUD) patients with comorbid posttraumatic stress disorder (PTSD) participate in and benefit from 12-step groups. One hundred fifty-nine SUD-PTSD and 1,429 SUD-only male patients were compared on participation in 12-step activities following an index episode of treatment. Twelve-step participation was similar for SUD patients with and without PTSD. PTSD patients with worldviews (e.g., holding disease model beliefs) that more closely matched 12-step philosophy participated more in 12-step activities. Although greater participation was associated with better concurrent functioning, participation did not prospectively predict outcomes after case mix adjustment. An exception was that greater participation predicted decreased distress among PTSD patients whose identity was more consistent with 12-step philosophy. In summary, PTSD patients participate in and benefit from 12-step participation; continuing involvement may be necessary to maintain positive benefits.