Determining ethyl glucuronide cutoffs when detecting self-reported alcohol use in addiction treatment patients.

BACKGROUND: Ethyl glucuronide (EtG) is an alcohol biomarker with potential utility as a clinical research and alcohol treatment outcome. Debate exists regarding the appropriate cutoff level for determining alcohol use, particularly with the EtG immunoassay. This study determined the EtG immunoassay cutoff levels that most closely correspond to self-reported drinking in alcohol-dependent outpatients. METHODS: Eighty adults with alcohol dependence and mental illness, taking part in an alcohol treatment study, provided urine samples 3 times per week for up to 16 weeks (1,589 samples). Self-reported drinking during 120 hours prior to each sample collection was assessed. Receiver operating characteristic analyses were conducted to assess the ability of the EtG immunoassay to detect self-reported alcohol use across 24- to 120-hour time periods. Sensitivity and specificity of EtG immunoassay cutoff levels was compared in 100 ng/ml increments (100 to 500 ng/ml) across 24 to 120 hours. RESULTS: Over half (57%) of the 1,589 samples indicated recent alcohol consumption. The EtG immunoassay closely corresponded to self-reported drinking from 24 (area under the curve [AUC] = 0.90, 95% confidence interval [CI]: 0.88, 0.92) to 120 hours (AUC = 0.88, 95% CI: 0.87, 0.90). When cutoff levels were compared across 24 to 120 hours, 100 ng/ml had the highest sensitivity (0.93 to 0.78) and lowest specificity (0.67 to 0.85). Relative to 100 ng/ml, the 200 ng/ml cutoff demonstrated a reduction in sensitivity (0.89 to 0.67), but improved specificity (0.78 to 0.94). The 300, 400, and 500 ng/ml cutoffs demonstrated the lowest sensitivity (0.86 to 0.33) and highest specificity (0.86 to 0.97) over 24 to 120 hours. CONCLUSIONS: For detecting alcohol use for >24 hours, the 200 ng/ml cutoff level is recommended for use as a research and clinical outcome.

High levels of agreement between clinic-based ethyl glucuronide (EtG) immunoassays and laboratory-based mass spectrometry.

BACKGROUND: Immunoassay urine drug screening cups that detect use for two or more days are commonly used in addiction treatment settings. Until recently, there has been no comparable immunoassay test for alcohol use in these settings. OBJECTIVES: The aim of this study was to assess the agreement of a commercially available ethyl glucuronide immunoassay (EtG-I) test conducted at an outpatient addiction clinic and lab-based EtG mass spectrometry (EtG-MS) conducted at a drug testing laboratory at three cut-off levels. High agreement between these two measures would support the usefulness of EtG-I as a clinical tool for monitoring alcohol use. METHODS: Forty adults with co-occurring alcohol dependence and serious mental illnesses submitted 1068 urine samples over a 16-week alcohol treatment study. All samples were tested using EtG-I on a benchtop analyzer and 149 were randomly selected for EtG-MS analysis at a local laboratory. Agreement was defined as the number of samples where EtG-I and EtG-MS were both above or below a specific cut-off level. Agreement was calculated at low cut-off levels (100 and 250 ng/ml), as well as at a higher cut-off level (500 ng/ml) recommended by most by commercial drug testing laboratories. RESULTS: Agreement between EtG-I and EtG-MS was high across all cut-off levels (90.6% at 100 ng/ml, and 96.6% at 250 and 500 ng/ml). CONCLUSIONS: EtG immunoassays conducted at low cut-off levels in point-of-care testing settings have high agreement with lab-based EtG-MS. EtG-I can be considered a useful clinical monitoring tool for alcohol use in community-based addiction treatment settings.

Acceptability of contingency management among clinicians and clients within a co-occurring mental health and substance use treatment program.

BACKGROUND: Emerging evidence supports the effectiveness of contingency management (CM) for addictions treatment among individuals with co-occurring serious mental illness (SMI). Addiction treatment for people with SMI generally occurs within community mental health centers (CMHCs) and it is not known whether CM is acceptable within this context. Client views regarding CM are also unknown. OBJECTIVES: This study is the first to describe CM acceptability among CMHC clinicians, and the first to explore client views. Clinician-level predictors of CM acceptability are also examined. METHODS: This study examined views about CM among 80 clinicians and 29 clients within a CMHC within the context of a concurrent CM study. RESULTS: Three-quarters of clinicians reported they would use CM if funding were available. Clinicians and clients affirmed that incentives enhance abstinence motivation. Clinician CM acceptability was related to greater years of experience, and identifying as an addictions or co-occurring disorders counselor, more than a mental health clinician. CONCLUSIONS: The findings provide preliminary evidence that CMHC clinicians, serving clients with addictions and complicating SMI, and client participants in CM, view CM as motivating and a positive tool to facilitate recovery. SCIENTIFIC SIGNIFICANCE: As an evidence-based intervention, CM warrants further efforts toward funding and dissemination in CMHCs.

Validation of the co-occurring disorder quadrant model.

The co-occurring disorders quadrant model has been used as a framework for characterizing the heterogeneity in persons with low- and high-severity substance use and psychiatric disorders. This study investigated the validity and stability of the quadrant model in 155 adults who presented to one county hospital with psychiatric, substance use, or medical complaints. Quadrant placement was defined using data that is routinely gathered in clinical care or available in administrative data sets (i.e., substance dependence diagnosis, Global Assessment of Functioning scores). Fifty-four percent (n = 84) of study participants were categorized into quadrant IV (high-severity psychiatric/substance use), followed by quadrant I (low-severity psychiatric/substance use) (n = 32, 21%), quadrant II (high-severity psychiatric & low-severity substance use) (n = 25, 16%), and quadrant III (low-severity psychiatric & high-severity substance use) (n = 14, 9%). Quadrant placement was correlated with psychiatric and/or substance use diagnoses, psychiatric symptom severity, drug/alcohol toxicology and psychiatric and substance use health utilization, supporting the concurrent validity of the model. Initial quadrant placement was correlated with validity measures administered at three-month follow-up supporting predictive validity of the model. Initial and follow-up quadrant placement was significantly correlated suggesting stability of the quadrant model. Data support the validity of the quadrant model for application in clinical and administrative purposes.

Use of a Mental Health Center Collaborative Care Team to Improve Diabetes Care and Outcomes for Patients With Psychosis.

OBJECTIVE: This study aimed to evaluate the feasibility, acceptability, and preliminary effectiveness (compared with usual care) of a collaborative care model to treat community mental health center (CMHC) patients with psychosis and poorly controlled diabetes. METHODS: Stakeholder input was used to adapt a primary care-based collaborative care intervention for CMHC settings. Thirty-five adult CMHC clients with type II diabetes and hemoglobin A1c (HbA1c) >8% or blood pressure >140/90 were randomized to receive either collaborative care or usual care. Change in HbA1c was evaluated between baseline and three months. Paired t tests were used for within-group comparisons. RESULTS: After three months, intervention participants had a statistically significant mean decrease in HbA1c of 1.1% (p=.049). There was no significant change in HbA1c in the usual-care group. CONCLUSIONS: This pilot demonstrates the feasibility and acceptability of implementing collaborative care in CMHC settings and its preliminary effectiveness in improving glycemic control in a high-risk population.

Randomized controlled trial of contingency management for stimulant use in community mental health patients with serious mental illness.

OBJECTIVE: The primary objective of this study was to determine whether contingency management was associated with increased abstinence from stimulant drug use in stimulant-dependent patients with serious mental illness treated in a community mental health center. Secondary objectives were to determine whether contingency management was associated with reductions in use of other substances, psychiatric symptoms, HIV risk behavior, and inpatient service utilization. METHOD: A randomized controlled design was used to compare outcomes of 176 outpatients with serious mental illness and stimulant dependence. Participants were randomly assigned to receive 3 months of contingency management for stimulant abstinence plus treatment as usual or treatment as usual with reinforcement for study participation only. Urine drug tests and self report, clinician-report, and service utilization outcomes were assessed during the 3-month treatment period and the 3-month follow-up period. RESULTS: Although participants in the contingency management condition were significantly less likely to complete the treatment period than those assigned to the control condition (42% compared with 65%), they were 2.4 times (95% CI=1.9­3.0)more likely to submit a stimulant-negative urine test during treatment. Compared with participants in the control condition,they had significantly lower levels of alcohol use, injection drug use, and psychiatric symptoms and were one-fifth as likely as those assigned to the control condition to be admitted for psychiatric hospitalization during treatment. They also reported significantly fewer days of stimulant drug use during the 3-month follow-up. CONCLUSIONS: When added to treatment as usual, contingency management is associated with large reductions in stimulant,injection drug, and alcohol use.Reductions in psychiatric symptoms and hospitalizations are important secondary benefits.