Genetic contributors to variation in alcohol consumption vary by race/ethnicity in a large multi-ethnic genome-wide association study.

Alcohol consumption is a complex trait determined by both genetic and environmental factors, and is correlated with the risk of alcohol use disorders. Although a small number of genetic loci have been reported to be associated with variation in alcohol consumption, genetic factors are estimated to explain about half of the variance in alcohol consumption, suggesting that additional loci remain to be discovered. We conducted a genome-wide association study (GWAS) of alcohol consumption in the large Genetic Epidemiology Research in Adult Health and Aging (GERA) cohort, in four race/ethnicity groups: non-Hispanic whites, Hispanic/Latinos, East Asians and African Americans. We examined two statistically independent phenotypes reflecting subjects' alcohol consumption during the past year, based on self-reported information: any alcohol intake (drinker/non-drinker status) and the regular quantity of drinks consumed per week (drinks/week) among drinkers. We assessed these two alcohol consumption phenotypes in each race/ethnicity group, and in a combined trans-ethnic meta-analysis comprising a total of 86 627 individuals. We observed the strongest association between the previously reported single nucleotide polymorphism (SNP) rs671 in ALDH2 and alcohol drinker status (odd ratio (OR)=0.40, P=2.28 × 10-72) in East Asians, and also an effect on drinks/week (beta=-0.17, P=5.42 × 10-4) in the same group. We also observed a genome-wide significant association in non-Hispanic whites between the previously reported SNP rs1229984 in ADH1B and both alcohol consumption phenotypes (OR=0.79, P=2.47 × 10-20 for drinker status and beta=-0.19, P=1.91 × 10-35 for drinks/week), which replicated in Hispanic/Latinos (OR=0.72, P=4.35 × 10-7 and beta=-0.21, P=2.58 × 10-6, respectively). Although prior studies reported effects of ADH1B and ALDH2 on lifetime measures, such as risk of alcohol dependence, our study adds further evidence of the effect of the same genes on a cross-sectional measure of average drinking. Our trans-ethnic meta-analysis confirmed recent findings implicating the KLB and GCKR loci in alcohol consumption, with strongest associations observed for rs7686419 (beta=-0.04, P=3.41 × 10-10 for drinks/week and OR=0.96, P=4.08 × 10-5 for drinker status), and rs4665985 (beta=0.04, P=2.26 × 10-8 for drinks/week and OR=1.04, P=5 × 10-4 for drinker status), respectively. Finally, we also obtained confirmatory results extending previous findings implicating AUTS2, SGOL1 and SERPINC1 genes in alcohol consumption traits in non-Hispanic whites.

Use of exclusion criteria in selecting research subjects and its effect on the generalizability of alcohol treatment outcome studies.

OBJECTIVE: Researchers have not systematically examined how exclusion criteria used in selection of research subjects affect the generalizability of treatment outcome research. This study evaluated the use of exclusion criteria in alcohol treatment outcome research and its effects on the comparability of research subjects with real-world individuals seeking alcohol treatment. METHOD: Eight of the most common exclusion criteria described in the alcohol treatment research literature were operationalized and applied to large, representative clinical patient samples from the public and private sectors to determine whether the hypothetical research samples differed substantially from real-world samples. Five hundred ninety-three consecutive individuals seeking alcohol treatment at one of eight treatment programs participated. A trained research technician gathered information from participants on demographic variables and on alcohol, drug, and psychiatric problems as measured by the Addiction Severity Index. RESULTS: Large proportions of potential research subjects were excluded under most of the criteria tested. The overall pattern of results showed that African Americans, low-income individuals, and individuals who had more severe alcohol, drug, and psychiatric problems were disproportionately excluded under most criteria. CONCLUSIONS: Exclusion criteria can result in alcohol treatment outcome research samples that are more heavily composed of white, economically stable, and higher-functioning individuals than are real-world samples of substance abuse patients seen in clinical practice, potentially compromising the generalizability of results. For both scientific and ethical reasons, in addition to studies that use exclusion criteria, outcome research that uses no or minimal exclusion criteria should be conducted so that alcohol treatment outcome research can be better generalized to vulnerable populations.

The Community Epidemiology Laboratory: studying alcohol problems in community and agency-based populations.

This paper describes the Community Epidemiology Laboratory (CEL) of the Alcohol Research Group, a project focusing on the epidemiology of alcohol problems and community responses to those problems. Since 1980, a series of probability surveys have been conducted in the general population and in a wide range of health and social service agencies in a northern California county. The agency-based samples have included all agencies or representative samples of each system (alcohol treatment, drug treatment, mental health treatment, emergency rooms, primary health care, criminal justice and welfare) with probability samples of clients interviewed at intake. These studies have addressed questions regarding (1) the burden and epidemiologic description of alcohol problems in a community; (2) the relationship of alcohol to other health and social problems; (3) the influence of social policy on the constitution of services and care of individuals; and (4) health services issues of access and pathways to treatment. The project is designed for comparable analysis of studies with special focus on women and ethnic minorities. This paper provides an overview of the CEL, including its major research questions, overall design, sampling principles, methodological issues and measures. It highlights the main findings and discusses the limitations and advantages of such methodologies for further understanding alcohol problems in a community.

The association between DSM-III-R alcohol dependence, psychological distress and drug use.

This paper examines the association between DSM-III-R alcohol dependence, psychological distress and the frequency of drug use in a sample of 219 men and 162 women consecutively admitted to nine alcohol treatment programs in a Northern California county. Results show that psychological distress is higher among men who are more severely dependent on alcohol and among those who have lower education; women who are less alcohol dependent and women who are younger have higher scores in psychological distress than other women. With regard to drug use, about 65% of the men and 64% of the women report using a drug other than alcohol at least once a week during the 12 months prior to admission into treatment. Among both men and women, the drugs most frequently used are crack/cocaine, marijuana and methamphetamine. Among men, regression analysis shows that drug use is associated with being younger. Among women results show that the predictors of drug use are being younger, being unemployed, having a higher income, being a heavier drinker and having fewer symptoms of alcohol dependence. These results show a complex pattern of association across alcohol dependence, drug use and psychological distress. Knowledge of this pattern is necessary for tailoring effective clinical interventions to clients with different kinds of comorbidity.

Drinking problems and self-reported criminal behavior, arrests and convictions: 1990 US alcohol and 1989 county surveys.

Use of general population surveys in addition to institutional samples is critical to disentangling the relationship between criminal behavior and alcohol problems or use of illicit drugs. Local area studies can be useful but generalizability of their results is seldom studied. Data from recent US national (n = 2058) and county (n = 3069) general population surveys are used to examine the role of alcohol problem and drug use history in predicting self-reported criminal behavior, arrest and conviction within a logistic regression framework. In the national and county surveys controlling for age, gender, income, marital status, employment, education, race and drug use, lifetime drinking problems significantly predicted current criminal behavior (odds ratios 1.3 and 1.5, respectively) with slightly stronger relationships noted in equivalent models predicting arrest (odds ratios 1.7 and 1.8) and conviction (odds ratios 1.7 and 1.6). Relationships between alcohol, drugs and criminal behavior/justice variables are discussed. Parallels between US and county results suggest that findings from intensive, articulated analyses of community-level population and institutional surveys may be cautiously generalized beyond their geographic locus.

Assessing bias in community-based prevalence estimates: towards an unduplicated count of problem drinkers and drug users.

General population survey estimates of the overall prevalence of problem drinking and drug use in a community are biased by the exclusion of non-household populations. Estimates based on compiling prevalences in community institutions may also be biased due to over-counting of users of more than one institution. This paper examines prevalence estimates derived from probability samples of problem drinkers in the general population and within alcohol treatment, drug treatment, mental health, criminal justice and welfare agencies in a single US county. Data sets are merged and weighted to reflect a community sample of institutions, and a 17% subset of cases is identified within the institutional samples that are not living in housing units typically included in general population sampling frames. The difference in prevalences of problem drinking in the household and non-household populations is found to be large: 11% and 48%, respectively. Even greater differences are found between estimates of unprescribed weekly drug use (6% and 47%, respectively) and combined problem drinking and weekly drug use (2% and 27%, respectively). This suggests that confining samples to the household population can systematically under-represent the prevalence of problem drinking and drug use. A second source of bias in prevalence is characteristic of studies using records from multiple institutions. When duplication of service use in the five agency samples is considered, it becomes apparent that prevalence may be biased upward due to over-counting of multiple service users.

Patterns in the institutional encounters of problem drinkers in a community human services network.

It is useful to view the social handling of alcohol problems in US communities from the perspective of a whole network of human service systems that share in the burden of identifying and responding to problem drinkers. This analysis examines the management of alcohol problems in different community service systems by mapping patterns in the institutional encounters of problem drinkers across alcohol treatment, drug treatment, mental health treatment, social welfare and criminal justice systems in a single US community. Findings highlight the prominence of large bureaucratic systems for social welfare and criminal justice as sources of referrals for smaller service systems offering treatment for alcohol problems. However, large proportions of problem-drinking service recipients in the community remain exclusive clients of the welfare and criminal justice systems, making no contact with therapeutically orientated service settings. Compared with problem drinkers who obtain treatment services, problem drinkers on the case-loads of criminal justice and welfare agencies tend to be younger, of higher socio-economic status, are more likely to be male, and tend to drink less heavily and to experience fewer symptoms of alcohol dependence. Given the distinctive characteristics of problem drinkers found exclusively in criminal justice and welfare settings, it may be advisable for communities to introduce early intervention programs in these systems that target services to this particular subgroup of problem drinkers.

Factors affecting the initiation of substance abuse treatment in managed care.

AIMS: A long-standing concern of clinicians in addiction treatment is that a large number of individuals who are admitted to treatment do not return to actually begin the program. We identified characteristics that predict treatment initiation. DESIGN: In-person structured interviews were conducted with consecutive admissions to a large outpatient program (N = 1204), and the health plan's automated registration data were used to determine treatment attendance. We compared those who returned to begin treatment with those who did not. SETTING: The study was conducted at the Chemical Dependency program of a large group model health maintenance organization (HMO). PARTICIPANTS: Study subjects were individuals age 18 or over admitted to the program. MEASUREMENT: Study variables included DSM-IV alcohol and drug dependence and abuse, Addiction Severity Index problem severity, motivation and treatment entry measures. FINDINGS: Those who were drug-dependent were less likely to begin treatment than those dependent only on alcohol. Measures of motivation, such as work-place pressures and the patient's perception of the importance of alcohol treatment, predicted starting treatment for individuals who were alcohol-dependent only or alcohol- and drug-dependent. Among patients who were dependent only on alcohol, women were more likely than men to start treatment, and for those who were drug-dependent, being employed and having higher drug severity scores predicted starting treatment. CONCLUSIONS: Screening at intake may identify those at risk of not returning after admission to start treatment. Clinicians may consider making additional efforts during the intake process to engage individuals who are unemployed and have drug (as opposed to alcohol) disorders and less motivation.

Methods for evaluating policy changes in alcohol services.

Policy research assesses how outside forces affect alcohol treatment services. In this primer, we examine a range of effective methods that can be brought to bear by researchers and address the issues involved in conceptualizing and conducting studies of policy formation, implementation and policy implications. Because there is no single superior methodology for studying policy change, researchers have relied on five broad methodologies for studying policy context, formation, change and implications. We provide specific examples of each approach, addressing the following issues: data sources and samples; the problems, challenges, strengths, and limitations of the approach; and whether (and how) the method has been used in the alcohol field. The five methods are archival studies; key informant studies; ethnographic and observational studies; surveys; and meta-analyses. The strongest research designs in alcohol services research often combine methods and sources to get different vantage points on questions about policy change.

'When you were drinking' vs. 'in the past 12 months': the impact of using different time frames in clinical and general populations.

AIM: Different time frames have been used to ask about drinking in clinical and general populations. Surveys of clinical populations have asked about the quantity and frequency of drinking within the context of "when you were drinking". In general population surveys, the customary practice has been to ask about a period of time such as "the last 12 months". This paper compares answers to questions about drinking using both time frames. DESIGN: Bivariate chi-squares and multi-variate logistic regression analyses were used to compare consumption estimates across the two time frames for different demographic and drinking categories of respondents. SETTING AND PARTICIPANTS: In-person interviews were conducted with general population (N = 3069) and representative treatment samples (N = 381) in a northern California county. MEASUREMENTS: Respondents were asked about their drinking within the context of "the last 12 months" and only "when you were drinking". FINDINGS: There were no meaningful differences in aggregate measures of drinking based on the time frame of assessment in either sample. Drinking five or more drinks weekly was a significant predictor of consistent reporting of frequency of drinking among the clinical sample, and of reporting inconsistent frequency of drinking 12 or more drinks among the general population. Being female or being age 46 or over also was predictive of a "consistent" response in the general population for drinking 12 or more drinks; while being 46 or older, married, and white was predictive of consistent responses for drinking to intoxication in that population. CONCLUSIONS: Survey respondents do not average their drinking across a 12-month time frame that includes periods of abstinence; rather, they appear to answer only for the periods they were drinking.

The role of alcohol-related problematic events in treatment entry.

This is an analysis of alcohol-related problematic events experienced by alcohol treatment clients in the year before treatment and the reporting of these events as major reasons for treatment entry. A probability sample of new intakes (N = 316) of the 8 contracted alcohol programs of a California county was interviewed. Data were collected on demographics, drinking patterns and a series of ten problematic events. Events (N = 982) are the unit of analysis. The analysis examines the events reported as major reasons for entering treatment. Logistic regression is used to investigate the socio-demographic and drinking variables associated with that reporting. Drinking driving, relapses and serious drinking episodes were reported as being major reasons for entering treatment a significant proportion of the times they occurred. Public drunkenness and non-traffic accidents had significant proportions of individuals reporting them as not being major reasons for treatment when they occurred. Age, gender, ethnicity, marital status, employment and frequency of drunkenness were predictors of some types of events being major reasons, but there was no pattern across all events. The variables associated with experiencing an event were not the same as those which predicted the event would be reported a major reason for treatment.

Factors associated with coercion in entering treatment for alcohol problems.

Although the importance of coercion in entry to treatment for alcohol problems is recognized, few studies have focused on different types and levels of coercion among heterogeneous groups of clients entering treatment agencies. This paper describes demographic and problem characteristics associated with various sources and levels of coercion. More than 40% (n = 377) of individuals entering a representative sample of a county's HMO, public, and private indemnity-based non-DUI alcohol treatment services (n = 927) indicated they received an ultimatum to enter treatment from at least one person. The most common source of an ultimatum to enter treatment was from family members (n = 222), followed by the legal system (n = 78), and healthcare professionals (n = 55). Respondents experiencing pressure to enter treatment reported that ultimatums from more than one source were common. Individuals entering treatment who were most likely to report being coerced were white, young adults (age 18-39), and married or living with a partner. When controlling for demographic characteristics and problem severity, family problem severity and legal problem severity predicted having received an ultimatum to enter treatment. Alcohol and drug problem severity were not related to receiving a treatment ultimatum.

The relationship of pre-treatment Alcoholics Anonymous affiliation with problem severity, social resources and treatment history.

Little research has examined the relationship of substance abuse patients' prior Alcoholics Anonymous (AA) affiliation to important treatment-related variables. This study of 927 individuals seeking treatment in public, health maintenance organization (HMO) and private-for-profit medical programs, found that 82.8% of patients presented at treatment with a history of AA affiliation. Degree of prior AA affiliation was significantly associated with more extensive prior utilization of formal and informal helping resources, current seeking of treatment in the public sector, having low income, being divorced/separated and having more severe alcohol, employment/support and psychiatric problems. Implications for service delivery and future research are discussed.

Alcohol consumption patterns and health care costs in an HMO.

We examined the relationship between patterns of alcohol consumption and health care costs among adult members of the Kaiser Permanente Medical Care Program (KPMCP) in Northern California. A telephone survey of a random sample of the KPMCP membership aged 18 and over was conducted between June 1994 and February 1996 (n=10,175). The survey included questions on sociodemographic characteristics, general and mental health status, patterns of past and current alcohol consumption; inpatient and outpatient costs were obtained from Kaiser Permanentes cost management information system. Results showed that current non-drinkers with a history of heavy drinking had higher health costs than other non-drinkers and current drinkers. The per person per year costs for non-drinkers with a heavy drinking history were $2421 versus $1706 for other non-drinkers and $1358 for current drinkers in 1995 US dollars. A history of heavy drinking has a significant effect on costs after controlling for sociodemographic characteristics, health status and health practices. Current drinkers have the lowest costs, suggesting that they may be more likely than non-drinkers to delay seeking care until they are sick and require expensive medical care.

Expanding the frame of health services research in the drug abuse field.

OBJECTIVE: This article examines the distribution of heavy drug users across health and social service agencies in a community, and ways in which organizational and social policy factors influence pathways to services. DATA SOURCES/STUDY SETTING: Data are from the Community Epidemiology Laboratory, a project that includes comparable surveys of a wide variety of client, service provider, and general population groups in a single northern California county. STUDY DESIGN: The design is a cross-sectional analysis of patterns of service use and referral by heavy drug users distributed across a variety of service settings and in the general population. DATA COLLECTION: In-person, structured interviews by trained interviewers were conducted using comparable instruments, measures, sampling strategies, and fieldwork procedures. PRINCIPAL FINDINGS: The specialty drug treatment system serves only a small proportion of heavy drug users in the community. Large proportions of drug users are found in criminal justice, primary health, and welfare agencies. Patterns of service encounter and referral suggest that drug treatment clients typically have been in jail or on welfare prior to attending treatment, and are far less likely to have been referred to or from treatment by health providers. CONCLUSIONS: Health services research on drug abuse should expand its frame of reference to include services outside the specialty treatment sector. Drug treatment facilities are somewhat remote from other agencies in community service networks and are organizationally dependent on criminal justice and welfare systems. Further research should investigate both the costs and benefits of screening and providing services at earlier points of institutional involvement with drug abusers and the implications of interorganizational dependencies among criminal justice, welfare, and drug agencies for providers and clients.

The outcome and cost of alcohol and drug treatment in an HMO: day hospital versus traditional outpatient regimens.

OBJECTIVE: To compare outcome and cost-effectiveness of the two primary addiction treatment options, day hospitals (DH) and traditional outpatient programs (OP) in a managed care organization, in a population large enough to examine patient subgroups. DATA SOURCES: Interviews with new admissions to a large HMO's chemical dependency program in Sacramento, California between April 1994 and April 1996, with follow-up interviews eight months later. Computerized utilization and cost data were collected from 1993 to 1997. STUDY DESIGN: Design was a randomized control trial of adult patients entering the HMO's alcohol and drug treatment program (N = 668). To examine the generalizability of findings as well as self-selection factors, we also studied patients presenting during the same period who were unable or unwilling to be randomized (N = 405). Baseline interviews characterized type of substance use, addiction severity, psychiatric status, and motivation. Follow-up interviews were conducted at eight months following intake. Breathanalysis and urinalysis were conducted. Program costs were calculated. DATA COLLECTION: Interview data were merged with computerized utilization and cost data. PRINCIPAL FINDINGS: Among randomized subjects, both study arms showed significant improvement in all drug and alcohol measures. There were no differences overall in outcomes between DH and OP, but DH subjects with midlevel psychiatric severity had significantly better outcomes, particularly in regard to alcohol abstinence (OR = 2.4; 95% CI = 1.2, 4.9). The average treatment costs were $1,640 and $895 for DH and OP programs, respectively. In the midlevel psychiatric severity group, the cost of obtaining an additional person abstinent from alcohol in the DH cohort was approximately $5,464. Among the 405 self-selected subjects, DH was related to abstinence (OR = 2.1; 95% CI = 1.3, 3.5). CONCLUSIONS: Although significant benefits of the DH program were not found in the randomized study, DH treatment was associated with better outcomes in the self-selected group. However, for subjects with mid-level psychiatric severity in both the randomized and self-selected samples, the DH program produced higher rates of abstention and was more cost-effective. Self-selection in studies that randomize patients to services requiring very different levels of commitment may be important in interpreting findings for clinical practice.

The merging of alcohol and drug treatment: a policy review.

Alcohol and drug treatment have separate histories in the United States. The large public treatment systems were established as separate institutions in the early 1970s and have developed separate research traditions and treatment programs. However, as a response to current treatment financing policy and epidemiologic descriptions of combined alcohol and other drug use in the population, the two treatment systems are merging at the state and local levels. This large structural change is taking place without the development and evaluation of treatment methods for combined problems and without discussion of overall health service or policy implications. This paper describes the changes occurring, examines the literature for its contributions in providing direction, and presents treatment method and policy issues which need to be part of the overall discourse.

New directions in alcohol and drug treatment under managed care.

OBJECTIVE: To examine the potential effects of the introduction and expansion of managed care on the financing and organization of public and private alcohol and drug abuse treatment systems by reviewing studies on managed care and substance abuse. STUDY DESIGN: Spending on treatment for alcohol and drug abuse, the organization of treatment, treatment workforce composition, provision of services, and their implications for access and treatment outcome were examined by review of the treatment literature. RESULTS: Managed care has had major effects on the organization of service delivery, the workforce, and the provision of services. Most of the changes have occurred without the benefit of clinical or policy research. Although managed care has the potential ability to address longstanding problems associated with alcohol and drug treatment, it also presents additional barriers to access and improving treatment outcome. CONCLUSIONS: The review suggests that organizational approaches, particularly the settings in which treatment is placed, will differ in their impact on ties between treatment agencies and the medical community, and ties with other health and social service agencies. Also of importance is a new emphasis on accountability of treatment through the mechanisms of outcomes monitoring and performance indicators. It remains to be seen whether these innovations will be meaningfully linked with outcomes research. It is incumbent on researchers and clinicians to explore these issues.

Addiction severity index data from general membership and treatment samples of HMO members. One case of norming the ASI.

The Addiction Severity Index (ASI) is a widely used interview among substance-dependent populations in treatment. Its value as a treatment planning and evaluation tool has been diminished by the lack of comparative data from nonclinical samples. The present study included four scales from the ASI collected on samples of adult subscribers to a large health maintenance organization (HMO) in northern California, as well as an adult clinical sample from the same geographic region with the same HMO insurance, thereby offering informative contrasts. Interviews (N = 9,398) of non-alcohol-dependent or abuse adults from a random sample of members of a large HMO were analyzed. We collected complete ASI data on the alcohol, drug, medical, and psychiatric composite scales and partial data on the employment scale. A sample of 327 adult members of the same HMO from one of the counties included in the survey, who were admitted to treatment for alcohol and/or drug addiction, was administered the same ASI items at treatment admission. Analyses compare problem severities in the two samples by age and gender. The general membership reported some problems in most of the ASI problem areas, although at levels of severity that were typically far below those seen in the clinical sample. General membership and clinical samples were somewhat similar in medical status and in employment. As expected, alcohol, drug, and psychiatric status were much more severe in the clinical sample. The data from the HMO general membership sample provide one potential comparison group against which to judge the severity of problems presented by drug- and alcohol-dependent patients at treatment admission and at posttreatment follow-up. The authors discuss the implications for treatment planning and the evaluation of treatment outcome.

The epidemiology of combined alcohol and drug use within treatment agencies: a comparison by gender.

As clinical and research attention focuses on the phenomenon of combined alcohol- and drug-related problems and alcohol and drug systems merge, important questions remain regarding the role of gender across treatment systems. This study examines epidemiologic characteristics in a comprehensive sample of female and male clients in one county's separately administered alcohol treatment (N = 381) and drug treatment (N = 304) systems. Large differences were found between women in alcohol and drug treatment agencies on measures of alcohol and drug patterns and problems. Women in alcohol treatment reported more combined use of problem attribution than women in drug treatment. The same patterns were found for men in comparisons across the two systems. A multivariate model predicting membership in drug versus alcohol treatment discriminated better between women than between men. An unexpected finding was that for all measures of alcohol and drug use and problems, gender differences within treatment systems were smaller than differences comparing women and comparing men between the two treatment systems. The findings point to the heterogeneous nature of both women and men in alcohol and drug programs, and call for further examination of these differences in planning treatment strategies in combined alcohol and drug programs.