The phenotype of recovery VI: The association between life-history strategies, delay discounting, and maladaptive health and financial behaviors among individuals in recovery from alcohol use disorders.

BACKGROUND: The life-history theory is a well-established framework that predicts behaviors and explains how and why organisms allocate effort and resources to different life goals. Delay discounting (DD) is associated with risky behaviors and has been suggested as a candidate behavioral marker of addiction. Thus, we investigated the relationship between DD, life-history strategies, and engagement in risky behaviors among individuals in recovery from alcohol use disorder (AUD). METHODS: Data from 110 individuals in recovery from addiction from The International Quit & Recovery Registry, an ongoing online registry designed to understand recovery phenotype, were included in the analysis. The association between life-history strategies, DD, engagement in risky behaviors, and remission status were assessed. RESULTS: Life-history strategy scores were significantly associated with DD rates and finance, health, and personal development behaviors after controlling for age, sex, race, ethnicity, years of education, marital status, smoking status, and history of other substance use. Remission status was significantly associated with life-history strategy, DD, drug use, fitness, health, and safe driving after controlling for age, sex, race, years of education, marital status, and smoking status. In addition, a mediation analysis using Hayes' methods revealed that the discounting rates partially mediated the association between remission status and life-history strategy scores. CONCLUSIONS: Life-history strategies and remission status are both significantly associated with DD and various health and finance behaviors among individuals in recovery from AUD. This finding supports the characterizations of DD as a candidate behavioral marker of addiction that could help differentiate subgroups needing special attention or specific interventions to improve the outcomes of their recovery. Future longitudinal studies are warranted to understand the relationships between changes in life-history strategies, DD, maladaptive health behaviors, and remission status over time.

A pilot economic evaluation of computerized cognitive behavioral therapy for alcohol use disorder as an addition and alternative to traditional therapy.

BACKGROUND: Computer-based delivery of cognitive behavioral therapy (CBT) may be a less costly approach to increase dissemination and implementation of evidence-based treatments for alcohol use disorder (AUD). However, comprehensive evaluations of costs, cost-effectiveness, and cost-benefit of computer-delivered interventions are rare. METHODS: This study used data from a completed randomized clinical trial to evaluate the cost-effectiveness and cost-benefit of a computer-based version of CBT (CBT4CBT) for AUD. Sixty-three participants were randomized to receive one of the following treatments at an outpatient treatment facility and attended at least one session: (1) treatment as usual (TAU), (2) CBT4CBT plus treatment as usual (CBT4CBT+TAU), or (3) CBT4CBT plus brief monitoring. RESULTS: Median protocol treatment costs per participant differed significantly between conditions, Kruskal-Wallis H(2) = 8.40, p = 0.02, such that CBT4CBT+TAU and CBT4CBT+monitoring each cost significantly more per participant than TAU. However, when nonprotocol treatment costs were included, total treatment costs per participant did not differ significantly between conditions. Median incremental cost-effective ratios (ICERs) revealed that CBT4CBT+TAU was more costly and more effective than TAU. It cost $35.08 to add CBT4CBT to TAU to produce a reduction of one additional drinking day per month between baseline and the end of the 8-week treatment protocol: CBT4CBT+monitoring cost $33.70 less to produce a reduction of one additional drinking day per month because CBT4CBT+monitoring was less costly than TAU and more effective at treatment termination, though not significantly so. Net benefit analyses suggested that costs of treatment, regardless of condition, did not offset monthly costs related to healthcare utilization, criminal justice involvement, and employment disruption between baseline and 6-month follow-up. Benefit-cost ratios were similar for each condition. CONCLUSIONS: Results of this pilot economic evaluation suggest that an 8-week course of CBT4CBT may be a cost-effective addition and potential alternative to standard outpatient treatment for AUD. Additional research is needed to generate conclusions about the cost-benefit of providing CBT4CBT to treatment-seeking individuals participating in standard outpatient treatment.

COVID-19 impacts on drinking and mental health in emerging adults: Longitudinal changes and moderation by economic disruption and sex.

BACKGROUND: There are significant concerns that the COVID-19 pandemic may have negative effects on substance use and mental health, but most studies to date are cross-sectional. In a sample of emerging adults, over a two-week period during the pandemic, the current study examined: (1) changes in drinking-related outcomes, depression, anxiety, and posttraumatic stress disorder and (2) differences in changes by sex and income loss. The intra-pandemic measures were compared to pre-pandemic measures. METHODS: Participants were 473 emerging adults (Mage  = 23.84; 41.7% male) in an existing longitudinal study on alcohol misuse who were assessed from June 17 to July 1, 2020, during acute public health restrictions in Ontario, Canada. These intra-pandemic data were matched to participant pre-pandemic reports, collected an average of 5 months earlier. Assessments included validated measures of drinking, alcohol-related consequences, and mental health indicators. RESULTS: Longitudinal analyses revealed significant decreases in heavy drinking and adverse alcohol consequences, with no moderation by sex or income loss, but with substantial heterogeneity in changes. Significant increases in continuous measures of depression and anxiety were present, both of which were moderated by sex. Females reported significantly larger increases in depression and anxiety. Income loss >50% was significantly associated with increases in depression. CONCLUSIONS: During the initial phase of the pandemic, reductions in heavy drinking and alcohol consequences were present in this sample of emerging adults, perhaps due to restrictions on socializing. In contrast, there was an increase in internalizing symptoms , especially in females, highlighting disparities in the mental health impacts of the pandemic.

Specialist alcohol inpatient treatment admissions and non-specialist hospital admissions for alcohol withdrawal in England: an inverse relationship.

AIMS: We assessed the relationship between specialist and non-specialist admissions for alcohol withdrawal since the introduction of the UK government Health and Social Care Act in 2012. METHODS: Using publicly available national data sets from 2009 to 2019, we compared the number of alcohol withdrawal admissions and estimated costs in specialist and non-specialist treatment settings. RESULTS: A significant negative correlation providing strong evidence of an association was observed between the fall in specialist and rise in non-specialist admissions. Significant cost reductions within specialist services were displaced to non-specialist settings. CONCLUSIONS: The shift in demand from specialist to non-specialist alcohol admissions due to policy changes in England should be reversed by specialist workforce investment to improve outcomes. In the meantime, non-specialist services and staff must be resourced and equipped to meet the complex needs of these service users.

Twenty Years Socioeconomic Trajectories in Older Adults with Varying Alcohol Use: A Register-Based Cohort Study.

AIMS: The objective of this paper was to examine 20-year trends of the socioeconomic status (SES) measures income and employment and their association with current alcohol use behaviors in Danish adults aged 60-70. METHODS: Data from The Danish National Health Survey 2013 and the baseline assessment of the Elderly Study (2013-2016) were combined to form four groups from the general population with various drinking patterns, but with no recent treatment for alcohol use disorder (AUD), and one group seeking treatment: Abstinent (n = 691), low- (n = 1978), moderate- (n = 602), and high-risk (HR) drinkers (n = 467), and DSM-5 AUD seeking treatment (n = 262). For all groups, Danish national register data were linked at the individual level obtain find annual information on income and employment during the 20 years prior to interview. Mixed effects models were utilized to model trajectories of income and employment for the five groups. RESULTS: Lower income and employment status was observed from middle-aged adulthood when comparing 12-month abstinence or AUD to individuals with low or moderate alcohol consumption. At the end of the study period, moderate-risk drinkers experienced an increase, and HR drinkers a decrease, in income and rate of employment relative to the low-risk drinkers. CONCLUSIONS: Alcohol use behaviors observed in older adults are related to distinct long-term trajectories regarding income and employment status, which are observable already in middle-aged adulthood.

Current diagnosis-related group-based bundling for upper-extremity arthroplasty: a case of insufficient risk adjustment and misaligned incentives.

BACKGROUND: The current Centers for Medicare & Medicaid Services diagnosis-related group (DRG) bundled-payment model for upper-extremity arthroplasty does not differentiate between the type of arthroplasty (anatomic total shoulder arthroplasty [ATSA] vs. reverse total shoulder arthroplasty vs. total elbow arthroplasty [TEA] vs. total wrist arthroplasty) or the diagnosis and indication for surgery (fracture vs. degenerative osteoarthritis vs. inflammatory arthritis). METHODS: The 2011-2014 Medicare 5% Standard Analytical Files (SAF5) database was queried to identify patients undergoing upper-extremity arthroplasty under DRG-483 and -484. Multivariate linear regression modeling was used to assess the marginal cost impact of patient-, procedure-, diagnosis-, and state-level factors on 90-day reimbursements. RESULTS: Of 6101 patients undergoing upper-extremity arthroplasty, 3851 (63.1%) fell under DRG-484 and 2250 (36.9%) were classified under DRG-483. The 90-day risk-adjusted cost of an ATSA for degenerative osteoarthritis was $14,704 ± $655. Patient-level factors associated with higher 90-day reimbursements were male sex (+$777), age 75-79 years (+$740), age 80-84 years (+$1140), and age 85 years or older (+$984). Undergoing a TEA (+$2175) was associated with higher reimbursements, whereas undergoing a shoulder hemiarthroplasty (-$1000) was associated with lower reimbursements. Surgery for a fracture (+$2354) had higher 90-day reimbursements. Malnutrition (+$10,673), alcohol use or dependence (+$6273), Parkinson disease (+$4892), cerebrovascular accident or stroke (+$4637), and hyper-coagulopathy (+$4463) had the highest reimbursements. In general, states in the South and Midwest had lower 90-day reimbursements associated with upper-extremity arthroplasty. CONCLUSIONS: Under the DRG-based model piloted by the Centers for Medicare & Medicaid Services, providers and hospitals would be reimbursed the same amount regardless of the type of surgery (ATSA vs. hemiarthroplasty vs. TEA), patient comorbidity burden, and diagnosis and indication for surgery (fracture vs. degenerative pathology), despite each of these factors having different resource utilization and associated reimbursements. Lack of risk adjustment for fracture indications leads to strong financial disincentives within this model.

Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal.

BACKGROUND: Evidence shows benefits of psychological treatments in low-resource countries, yet few government health systems include psychological services.AimEvaluating the clinical value of adding psychological treatments, delivered by community-based counsellors, to primary care-based mental health services for depression and alcohol use disorder (AUD), as recommended by the Mental Health Gap Action Programme (mhGAP). METHOD: Two randomised controlled trials, separately for depression and AUD, were carried out. Participants were randomly allocated (1:1) to mental healthcare delivered by mhGAP-trained primary care workers (psychoeducation and psychotropic medicines when indicated), or the same services plus individual psychological treatments (Healthy Activity Program for depression and Counselling for Alcohol Problems). Primary outcomes were symptom severity, measured using the Patient Health Questionnaire - 9 item (PHQ-9) for depression and the Alcohol Use Disorder Identification Test for AUD, and functional impairment, measured using the World Health Organization Disability Assessment Schedule (WHODAS), at 12 months post-enrolment. RESULTS: Participants with depression in the intervention arm (n = 60) had greater reduction in PHQ-9 and WHODAS scores compared with participants in the control (n = 60) (PHQ-9: M = -5.90, 95% CI -7.55 to -4.25, ß = -3.68, 95% CI -5.68 to -1.67, P < 0.001, Cohen's d = 0.66; WHODAS: M = -12.21, 95% CI -19.58 to -4.84, ß = -10.74, 95% CI -19.96 to -1.53, P= 0.022, Cohen's d = 0.42). For the AUD trial, no significant effect was found when comparing control (n = 80) and intervention participants (n = 82). CONCLUSION: Adding a psychological treatment delivered by community-based counsellors increases treatment effects for depression compared with only mhGAP-based services by primary health workers 12 months post-treatment.Declaration of interestNone.

The Effect of Contextual Risk Factors on the Effectiveness of Brief Personality-Targeted Interventions for Adolescent Alcohol Use and Misuse: A Cluster-Randomized Trial.

BACKGROUND: A range of school-based prevention programs has been developed and used to prevent, delay, or reduce alcohol use among adolescents. Most of these programs have been evaluated at the community-level impact. However, the effect of contextual risk factors has rarely been considered in the evaluation of these programs. The aim of this study was to investigate the potential moderating effects of 2 important contextual risk factors (i.e., socioeconomic status [SES] and peer victimization) on the effectiveness of the school-based personality-targeted interventions (Preventure program) in reducing adolescent alcohol use over a 2-year period using a cluster-randomized trial. METHODS: High-risk adolescents were identified using personality scores on the Substance Use Risk Profile Scale and randomized to intervention and control groups. Two 90-minute cognitive behavioral therapy-based group sessions targeted 1 of 4 personality risk profiles: Anxiety Sensitivity, Hopelessness, Impulsivity, or Sensation Seeking. Multilevel linear modeling of alcohol use, binge drinking, and drinking-related harm was conducted to assess the moderating effect of baseline peer victimization and SES. RESULTS: Results indicated that the Preventure program was equally beneficial to all adolescents, regardless of SES and victimization history, in terms of their alcohol outcomes and related harm. Receiving the intervention was additionally beneficial for adolescents reporting peer victimization regarding their alcohol-related harm compared to nonvictimized youth (ß = -0.29, SE = 0.11, p = 0.014). CONCLUSIONS: Findings suggest that the content of personality-targeted interventions is beneficial for all high-risk youth regardless of their SES or experience of peer victimization. The current study suggests that using targeted approaches, such as targeting underlying personality risk factors, may be the most appropriate substance use prevention strategy for high-risk youth, as it is beneficial for all high-risk youth regardless of their contextual risk factors.

Equity in household spending on alcoholic beverages in South Africa: assessing changes between 1995 and 2011.

BACKGROUND: Globally, alcohol consumption accounts for a substantial burden of disease, which translates into high social and economic costs. To address this burden, several policies (e.g. age and trading hour restrictions, increasing alcohol taxation) were implemented. Despite the existence of these policies evidence shows that alcohol misuse and alcohol-related harms have increased in South Africa over recent years. The objective of this paper is to assess progressivity and the changes in progressivity of alcohol expenditure at the household level in South Africa using datasets that span 15 years. METHODS: Data come from the 1995, 2000, 2005/06 and 2010/11 South Africa Income Expenditure Survey. Distribution of spending on alcoholic beverages were analyzed using standard methodologies. Changes in progressivity between 1995 and 2000, and between 2005/06 and 2010/11 were also assessed using the Kakwani index. RESULTS: Alcohol spending was regressive between 1995 and 2011 as the fraction of poorer households' expenditure spent on alcohol beverage exceeds that for the richest households. Also, the difference in Kakwani indexes of progressivity indicates that spending on alcoholic beverages has become less regressive between the same time periods. CONCLUSION: The results show no evidence that alcohol policy including taxation increased regressivity. Thus, there is an opportunity to further reduce the regressivity using coherent alcohol policies. This paper concludes that there is a need for further research to unpack why alcohol spending became less regressive over the years that goes beyond just looking at changes in the distribution of alcohol expenditure.

Social Inequalities in Harmful Drinking and Alcohol-Related Problems Among Swedish Adolescents.

AIMS: The study aims to examine how socio-economic status (SES) among youth is related to binge-drinking and alcohol-related problems using three SES indicators: (i) SES of origin (parental education level), (ii) SES of the school environment (average parental education level at student's school) and (iii) SES of destination (academic orientation). METHODS: Cross-sectional data on upper secondary students (n= 4448) in Sweden. Multilevel logistic and negative binomial regression were used to estimate the relationship between each SES indicator and binge-drinking and alcohol-related problems, respectively. RESULTS: Only SES of destination was significantly associated with binge-drinking, with higher odds for students in vocational programmes (OR= 1.42, 95% CI= 1.13-1.80). For the second outcome, SES of destination (rr=1.25; 95%CI=1.08-1.45) and SES of the school environment (rr=1.19, 95% CI=1.02-1.39) indicated more alcohol-related problems in vocational programmes and in schools with lower-educated parents. After adjustment for drinking patterns, the relationship remained for SES of the school environment, but became non-significant for SES of destination. CONCLUSION: Our results suggest that the SES gradient among youth is stronger for alcohol-related problems than for harmful drinking. By only focusing on SES differences in harmful alcohol use, researchers may underestimate the social inequalities in adverse alcohol-related outcomes among young people. Our findings also support the notion that the environment young people find themselves in matters for social inequalities in alcohol-related harm.

The Prescription of Anticraving Medication and its Economic Consequences.

IMPORTANCE: According to recent studies, only a small proportion of alcoholics in the system for addiction treatment receive expedited treatment [Rehm et al.: Sucht 2014;60:93-105] and that those who are untreated are at risk of harmful and dependent alcohol consumption. This is associated with significantly negative effects on morbidity, mortality, and quality of life [Kraus et al.: Sucht 2010;56:337-347]. As a result, not only individuals and their environment suffer but there is also a health economic impact. OBJECTIVE: How often do patients with a primary or secondary diagnosis of alcohol dependence who have been discharged from inpatient treatment receive anticraving medication in the follow-up period of 6 months? DESIGN, SETTING, AND PARTICIPANTS: Based on data from a statutory health insurance in Germany, 12,958 patients were investigated regarding alcohol dependence, rates for readmission to hospital, and prescription of anticraving drugs. In addition, outpatient and inpatient treatment costs were calculated. Main Outcomes and Measures: There will be an examination of how often anticraving medications are prescribed and what the economic consequences are. RESULTS: Two hundred and eighty-eight (2.22%) patients received anticraving medication, 98 (0.76%) in the first 6 months after inpatient treatment. Fifty-nine of the 288 patients were monitored with a pre- and postcomparison over a 90-day period. Inpatient treatment fell from 0.83 times (±1.10) during the 3 months afterward to 0.79 (±1.01). On average, the duration of an inpatient stay before anticraving treatment (n = 29) was 17.34 days (±14.37), with an average cost of EUR 4,142.70 (±2,721.28). Among the anticraving treatment group, this fell to 14.03 days (±9.96) with an average cost of EUR 3,685.43 (±2,307.67). Overall, the average outpatient and inpatient treatment costs dropped from EUR 1,533.88 before treatment to EUR 1,462.76 after treatment. If this is extrapolated to the whole group, it leads to between EUR 921,500 and EUR 6.6 million saving for a health insurance company. CONCLUSION: Anticraving medications are hardly ever prescribed. Their routine use could reduce hospital readmission rates and save on health-care costs.

The contribution of alcohol use disorder to decompensated cirrhosis among people with hepatitis C: An international study.

BACKGROUND & AIMS: The advent of direct-acting antivirals (DAAs) has led to ambitious targets for hepatitis C virus (HCV) elimination. However, in the context of alcohol use disorder the ability of DAAs to achieve these targets may be compromised. The aim of this study was to evaluate the contribution of alcohol use disorder to HCV-related decompensated cirrhosis in three settings. METHODS: HCV notifications from British Columbia, Canada; New South Wales, Australia, and Scotland (1995-2011/2012/2013, respectively) were linked to hospital admissions (2001-2012/2013/2014, respectively). Alcohol use disorder was defined as non-liver-related hospitalisation due to alcohol use. Age-standardised decompensated cirrhosis incidence rates were plotted, associated factors were assessed using Cox regression, and alcohol use disorder-associated population attributable fractions (PAFs) were computed. RESULTS: Among 58,487, 84,529, and 31,924 people with HCV in British Columbia, New South Wales, and Scotland, 2,689 (4.6%), 3,169 (3.7%), and 1,375 (4.3%) had a decompensated cirrhosis diagnosis, and 28%, 32%, and 50% of those with decompensated cirrhosis had an alcohol use disorder, respectively. Age-standardised decompensated cirrhosis incidence rates were considerably higher in people with alcohol use disorder in New South Wales and Scotland. Decompensated cirrhosis was independently associated with alcohol use disorder in British Columbia (aHR 1.92; 95% CI 1.76-2.10), New South Wales (aHR 3.68; 95% CI 3.38-4.00) and Scotland (aHR 3.88; 95% CI 3.42-4.40). The PAFs of decompensated cirrhosis-related to alcohol use disorder were 13%, 25%, and 40% in British Columbia, New South Wales and Scotland, respectively. CONCLUSIONS: Alcohol use disorder was a major contributor to HCV liver disease burden in all settings, more distinctly in Scotland. The extent to which alcohol use would compromise the individual and population-level benefits of DAA therapy needs to be closely monitored. Countries, where appropriate, must develop strategies combining promotion of DAA treatment uptake with management of alcohol use disorders, if World Health Organization 2030 HCV mortality reduction targets are going to be achieved. LAY SUMMARY: The burden of liver disease has been rising among people with hepatitis C globally. The recent introduction of highly effective medicines against hepatitis C (called direct-acting antivirals or DAAs) has brought renewed optimism to the sector. DAA scale-up could eliminate hepatitis C as a public health threat in the coming decades. However, our findings show heavy alcohol use is a major risk factor for liver disease among people with hepatitis C. If continued, heavy alcohol use could compromise the benefits of new antiviral treatments at the individual- and population-level. To tackle hepatitis C as a public health threat, where needed, DAA therapy should be combined with management of heavy alcohol use.

Alcohol and Opioid Use, Co-Use, and Chronic Pain in the Context of the Opioid Epidemic: A Critical Review.

The dramatic increase in opioid misuse, opioid use disorder (OUD), and opioid-related overdose deaths in the United States has led to public outcry, policy statements, and funding initiatives. Meanwhile, alcohol misuse and alcohol use disorder (AUD) are a highly prevalent public health problem associated with considerable individual and societal costs. This study provides a critical review of alcohol and opioid misuse, including issues of prevalence, morbidity, and societal costs. We also review research on interactions between alcohol and opioid use, the influence of opioids and alcohol on AUD and OUD treatment outcomes, respectively, the role of pain in the co-use of alcohol and opioids, and treatment of comorbid OUD and AUD. Heavy drinking, opioid misuse, and chronic pain individually represent significant public health problems. Few studies have examined co-use of alcohol and opioids, but available data suggest that co-use is common and likely contributes to opioid overdose-related morbidity and mortality. Co-use of opioids and alcohol is related to worse outcomes in treatment for either substance. Finally, chronic pain frequently co-occurs with use (and co-use) of alcohol and opioids. Opioid use and alcohol use are also likely to complicate the treatment of chronic pain. Research on the interactions between alcohol and opioids, as well as treatment of the comorbid disorders is lacking. Currently, most alcohol research excludes patients with OUD and there is lack of measurement in both AUD and OUD research in relation to pain-related functioning. Research in those with chronic pain often assesses opioid use, but rarely assesses alcohol use or AUD. New research to examine the nexus of alcohol, opioids, and pain, as well as their treatment, is critically needed.

Public Beliefs About Obesity Relative to Other Major Health Risks: Representative Cross-Sectional Surveys in the USA, the UK, and Germany.

Background: Overweight and obesity are among the leading risk factors for death worldwide. Scientists believe that the increase in obesity is primarily due to environmental changes and thus favor obesity prevention measures targeting the environment. However, it is less clear what lay people perceive as causes of obesity, and which measures they deem acceptable and promising in fighting it. Purpose: This article compares lay beliefs about obesity with beliefs about other major health risks sharing certain similarities with obesity (alcohol and tobacco dependence, depression) in three countries with high obesity rates. Methods: Computer-assisted face-to-face interviews with representative samples in the UK (N = 1,216) and Germany (N = 973) and an online survey in the USA (N = 982) tapping beliefs about locus of responsibility, liability for treatment costs, and effectiveness of policy measures. Results: In each country, respondents attributed responsibility for obesity primarily to the individual; the same pattern emerged for alcohol and tobacco dependence, but not for depression (ps < .01). The higher the attribution of personal responsibility, the more strongly respondents endorsed individual liability for treatment costs (ps < .01). Respondents judged information and fiscal policies as most and least effective, respectively, in obesity prevention. Conclusions: Respondents' views about obesity are similar to those about addictions; however, they regard fiscal and regulatory policies as less effective for obesity than for addictions. Raising awareness about environmental drivers of obesity and framing policy measures by reference to the fight against tobacco and alcohol could increase public support of obesity-targeted policies.

Symptom-Triggered Detoxification Using the Alcohol-Withdrawal-Scale Reduces Risks and Healthcare Costs.

AIMS: As there are only a few existing experimental studies on symptom-triggered therapy for patients with alcohol withdrawal, we investigated the effectiveness of symptom-triggered detoxification regarding the use and dosage of benzodiazepine and withdrawal complications in a naturalistic clinical setting of a specialized treatment center for alcohol use disorder. METHODS: In total, 301 charts of patients who entered residential treatment for alcohol withdrawal were included in the retrospective analysis. Charts of 176 patients treated with the Alcohol Withdrawal-Scale (AWS) were compared to the charts of 125 patients treated with treatment as usual (TAU) before the implementation of AWS. Sociodemographical and clinical variables, previous detoxifications and complications, duration of treatment, use and dose of benzodiazepine and other withdrawal medication, complications and premature discontinuation of treatment were abstracted from the patients' medical records. RESULTS: The two groups did not differ in any demographical or clinical variables measured upon treatment admission. The total percentage of patients being treated with benzodiazepines during detoxification decreased from 78.4 to 38.6% after the implementation of the AWS. The implementation of the AWS significantly reduced the duration of the acute detoxification from 136 to 66 h, and the use, duration and dose of benzodiazepine by nearly two-thirds while complications and treatment discontinuation remained unvaryingly. Healthcare costs for detoxification were reduced by half per patient. CONCLUSIONS: The findings indicate that symptom-triggered treatment for alcohol withdrawal is safe and effective in a naturalistic clinical setting and significantly reduces healthcare costs and the risk for overmedicating patients.

Development of a resource allocation formula for substance misuse treatment services.

Background: Funding for substance misuse services comprises one-third of Public Health spend in England. The current allocation formula contains adjustments for actual activity, performance and need, proxied by the Standardized Mortality Ratio for under-75s (SMR < 75). Additional measures, such as deprivation, may better identify differential service need. Methods: We developed an age-standardized and an age-stratified model (over-18s, under-18s), with the outcome of expected/actual cost at postal sector/Local Authority level. A third, person-based model incorporated predictors of costs at the individual level. Each model incorporated both needs and supply variables, with the relative effects of their inclusion assessed. Results: Mean estimated annual cost (2013/14) per English Local Authority area was £5 032 802 (sd: 3 951 158). Costs for drug misuse treatment represented the majority (83%) of costs. Models achieved adjusted R-squared values of 0.522 (age-standardized), 0.533 (age-stratified over-18s), 0.232 (age-stratified under-18s) and 0.470 (person-based). Conclusion: Improvements can be made to the existing resource allocation formulae to better reflect population need. The person-based model permits inclusion of a range of needs variables, in addition to strong predictors of cost based on the receipt of treatment in the previous year. Adoption of this revised person-based formula for substance misuse would shift resources towards more deprived areas.

Visualizing value for money in public health interventions.

Background: The Socio-Technical Allocation of Resources (STAR) has been developed for value for money analysis of health services through stakeholder workshops. This article reports on its application for prioritization of interventions within public health programmes. Methods: The STAR tool was used by identifying costs and service activity for interventions within commissioned public health programmes, with benefits estimated from the literature on economic evaluations in terms of costs per Quality-Adjusted Life Years (QALYs); consensus on how these QALY values applied to local services was obtained with local commissioners. Results: Local cost-effectiveness estimates could be made for some interventions. Methodological issues arose from gaps in the evidence base for other interventions, inability to closely match some performance monitoring data with interventions, and disparate time horizons of published QALY data. Practical adjustment for these issues included using population prevalences and utility states where intervention specific evidence was lacking, and subdivision of large contracts into specific intervention costs using staffing ratios. The STAR approach proved useful in informing commissioning decisions and understanding the relative value of local public health interventions. Conclusions: Further work is needed to improve robustness of the process and develop a visualization tool for use by public health departments.

A systematic review of economic evaluations of local authority commissioned preventative public health interventions in overweight and obesity, physical inactivity, alcohol and illicit drugs use and smoking cessation in the United Kingdom.

Background: Since 2013, local authorities in England have been responsible for commissioning preventative public health interventions. The aim of this systematic review was to support commissioning by collating published data on economic evaluations and modelling of local authority commissioned public health preventative interventions in the UK. Methods: Following the PRISMA protocol, we searched for economic evaluations of preventative intervention studies in four different areas: overweight and obesity, physical inactivity, alcohol and illicit drugs use and smoking cessation. The systematic review identified studies between January 1994 and February 2015, using five databases. We synthesized the studies to identify the key methods and examined results of the economic evaluations. Results: The majority of the evaluations related to cost-effectiveness, rather than cost-benefit analyses or cost-utility analyses. These analyses found preventative interventions to be cost effective, though the context of the interventions differed between the studies. Conclusions: Preventative public health interventions in general are cost-effective. There is a need for further studies to support justification of continued and/or increased funding for public health interventions. There is much variation between the types of economically evaluated preventative interventions in our review. Broader studies incorporating different contexts may help support funding for local authority-sponsored public health initiatives.

Alcohol, tobacco and health care costs: a population-wide cohort study (n = 606 947 patients) of current drinkers based on medical and administrative health records from Catalonia.

Background: Most cost of illness studies are based on models where information on exposure is combined with risk information from meta-analyses, and the resulting attributable fractions are applied to the number of cases. Methods: This study presents data on alcohol and tobacco use for 2011 and 2012 obtained from a routine medical practice in Catalonia of 606 947 patients, 18 years of age and older, as compared with health care costs for 2013 (all costs from the public health care system: primary health care visits, hospital admissions, laboratory and medical tests, outpatient visits to specialists, emergency department visits and pharmacy expenses). Quasi-Poisson regressions were used to assess the association between alcohol consumption and smoking status and health care costs (adjusted for age and socio-economic status). Results: Resulting health care costs per person per year amounted to 1290 Euros in 2013, and were 20.1% higher for men than for women. Sex, alcohol consumption, tobacco use and socio-economic status were all associated with health care costs. In particular, alcohol consumption had a positive dose-response association with health care costs. Similarly, both smokers and former smokers had higher health care costs than did people who never smoked. Conclusions: Alcohol and tobacco use had modest and large impacts respectively on health care costs, confirming the results of previous ecological modelling analyses. Reductions of alcohol consumption and smoking through public policies and via early identification and brief interventions would likely be associated with reductions in health care costs.

Cost-Effectiveness Analysis of Genotype-Guided Treatment Allocation in Patients with Alcohol Use Disorders Using Naltrexone or Acamprosate, Using a Modeling Approach.

Alcohol use disorders (AUD) are a major contributor to the global burden of disease, and have huge societal impact. Some studies show that AUD patients carrying the G-allele of the OPRM1 variant c.118A>G respond better to naltrexone, resulting in reduced relapse rates compared to carriers of the AA genotype. Genotype-guided treatment allocation of these patients carrying a G-allele to naltrexone could potentially improve the treatment outcome. However, cost-effectiveness of this strategy should be investigated before considering clinical implementation. We, therefore, evaluated costs and Quality-Adjusted Life-Years (QALYs), using a modelling approach, from an European perspective, of genotype-guided treatment allocation (G-allele carriers receiving naltrexone; AA homozygotes acamprosate or naltrexone) compared to standard care (random treatment allocation to acamprosate or naltrexone), by using a Markov model. Genotype-guided treatment allocation resulted in incremental costs of EUR 66 (95% CI -28 to 149) and incremental effects of 0.005 QALYs (95% CI 0.000-0.011) per patient (incremental cost-effectiveness ratio of EUR 13,350 per QALY). Sensitivity analyses showed that the risk ratio to relapse after treatment allocation had the largest impact on the cost-effectiveness. Depending on the willingness to pay for a gain of one QALY, probabilities that the intervention is cost-effective varies between 6 and 79%. In conclusion, pharmacogenetic treatment allocation of AUD patients to naltrexone, based on OPRM1 genotype, can be a cost-effective strategy, and could have potential individual and societal benefits. However, more evidence on the impact of genotype-guided treatment allocation on relapse is needed to substantiate these conclusions, as there is contradictory evidence about the effectiveness of OPRM1 genotyping.