Levels of engagement among office-based opioid treatment (OBOT) patients with concurrent methamphetamine use.

BACKGROUND AND OBJECTIVES: Recent increases in methamphetamine use among people seeking treatment for opioid use disorder (OUD) has created significant demand for effective approaches to support this clinical population. This study assessed the extent to which office-based opioid treatment (OBOT) patients, who were diagnosed with methamphetamine use disorder (MUD), engaged with providers. METHODS: A retrospective analysis was conducted of adult patients (n = 470) seeking treatment for OUD who attended at least one visit between March 2020 and March 2023 at a rural regional OBOT provider. Approximately one quarter (28.7%) of patients were diagnosed with MUD in addition to receiving an OUD diagnosis. Bivariate methods and multivariate negative binomial regression models were estimated to examine the associations between clinical measures and the numbers of office visits, peer visits, and telehealth visits. RESULTS: Regression results indicated patients who met criteria for MUD in addition to OUD attended a higher rate of peer visits (incidence rate ratio [IRR] = 2.63, p = .036) when compared to patients who did not meet criteria for MUD. In contrast, patients with MUD and OUD diagnoses displayed significantly lower (IRR = 0.68, p < .001) engagement rates through fewer office visits relative to those who did not meet MUD criteria. DISCUSSION AND CONCLUSIONS: Patients seeking treatment for OUD who meet criteria for MUD are more likely to engage through peer support specialists rather than office visits. SCIENTIFIC SIGNIFICANCE: This study demonstrates the ways patients who meet criteria for OUD and MUD engage with providers to receive treatment.

Detecting DSM-5 Opioid and Methamphetamine Use Disorders With the UNCOPE Screen.

BACKGROUND: The most recent wave of the opioid epidemic has contributed to record number of drug overdoses. Most fatal outcomes are associated with opioids and methamphetamine; two substances that tend to be used at high rates among criminal justice populations. Despite the steady rise in the number of overdoses in local detention centers, many correctional facilities do not conduct routine screens for opioid and methamphetamine use disorders. This study examines the utility of the UNCOPE, a 6-item brief screen, to detect probable Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) diagnoses for these 2 specific substance use disorders (SUDs). The study also examines key indicators of these specific SUDs. METHODS: Data were collected from comprehensive substance use assessments conducted with 717 adults who were recently admitted to 4 county jails. RESULTS: Findings indicate that 3 positive UNCOPE responses accurately detected 99.8% of opioid use disorder diagnoses and 98.7% of methamphetamine use disorder diagnoses. Receiver operating characteristic curve results generate an area under the curve at 0.99 for severe opioid use cases and 0.98 for severe methamphetamine use cases. Subsequent analyses indicate 2 of the 6 items on the UNCOPE function to accurately identify 100% of cases classified with opioid use disorder and 99.6% of cases classified with methamphetamine use disorder. CONCLUSIONS: Evidence suggests that UNCOPE is a practical and efficient approach to identifying opioid and methamphetamine use disorders. In addition, 2 items can serve as an ultra-brief method to detecting these conditions at the time of admission to detention centers.

Jail Characteristics and Availability of Opioid Treatment Services: Results from a Nationally Representative Survey.

The current wave of the opioid epidemic has contributed to a record number of drug-related overdoses and a significant proportion of people who experience opioid use disorder are admitted to local jails. These correctional facilities serve as the principal entry point to the criminal justice system as nearly every person who is taken into custody is admitted to a local detention center. Although jails are recognized as primary intervention points for people who may require treatment for opioid use disorder, services in these facilities remain deficient. The absence of jail-based treatment has become a pressing concern as the number of drug-related deaths in custody continues to rise and the risk of post-release overdose also remains high. The present study draws on the opioid-related module of the 2019 Bureau of Justice Statistics' Census of Jails to assess the relationships between the characteristics of 2588 local detention centers and the availability of treatment services. These specific approaches included screening for opioid use disorder, providing medication to manage withdrawal symptoms, administering medication for opioid use disorder (MOUD), providing overdose reversal medication at the time of release, and linking people with community-based care following release from the detention center. The results demonstrate facilities located in the Northeast, larger jails, those in urban areas, and detention centers with higher turnover rates are significantly more likely to provide a wider variety of opioid treatment services. These findings have important implications for the prioritization of policies and the allocation of resources to support the adoption of opioid treatment services in local jails.

Mental Health Conditions, Substance Use Disorders, and Jail Readmission in Four Rural Counties.

Most jails are in rural areas, and many adults who pass through these facilities experience behavioral health needs. Evidence suggests mental health conditions (MHCs) and substance use disorders (SUDs) may be linked to an increased risk for jail readmission, but most work documenting this relationship uses vague measures, outdated diagnostic information, has been conducted in large metropolitan jails, or has demonstrated significant variability between facilities. This multisite study examined the associations between specific MHCs, SUDs, and jail readmission among 675 adults from four rural jails. Descriptive statistics and multivariate analyses indicated rural jail populations are likely to present MHCs, especially major depression and PTSD, at higher rates than those found in national estimates. SUDs were also observed at rates higher than those typical of national surveys, and particular SUDs were significantly more prevalent in some facilities relative to others. MHCs were not associated with prior jail admission, but SUDs were linked to a greater probability of a previous jail stay. These results highlight the importance of increasing the availability of jail-based, substance-specific treatment programs that cater to individual facilities' most pressing needs to ultimately reduce jail readmission.

An Ultra-Brief 2-Item Depression Screening Tool for Correctional Populations.

Although a number of depression screening instruments exist for use primarily in community mental health and medical settings, few have been validated on correctional populations. This study sought to examine the clinical utility of six different 2-item pairs in identifying risk for DSM-5 major depressive episode among a sample of county jail inmates. Data for the current report were derived from routine clinical assessments of 283 inmates recently admitted to a county jail. All inmates were administered the depression screening items as part of a structured diagnostic assessment interview to identify mental health needs. Results revealed that the best performing 2-item screen involved the combination of "difficulty concentrating" and "lack of energy," which represented the best balance of sensitivity (85.5%) and specificity (76.6%). Screening for major depression using as few as two items can be a valid and efficient strategy in identifying risk for major depressive episode among jail inmates.

Behavioral health indicators and time-to-rearrest in an adult pre-arrest diversion program.

Several states have recently adopted legislation in support of pre-arrest diversion programs that give police the authority to refer adults with behavioral health needs to treatment providers instead of placing them under arrest and booking them into local jails. The Adult Civil Citation program has been operating since 2013 to divert adults accused for the first time of a misdemeanor offense to a community behavioral health provider with the primary goal of addressing underlying needs that are likely to be associated with future criminal justice contact. The current study analyzed data from a sample of 1,071 adults who participated in the program to assess the impact of behavioral health indicators on time-to-rearrest. Adults who presented greater behavioral health needs were more likely to come into subsequent contact with police, but these indications did not influence the amount of time that lapsed between program participation and rearrest events.

A prospective study of behavioral health indicators and repeat jail admissions among rural inmates.

BACKGROUND: Approximately three quarters of a million adults are detained in US jails, and rural detention centers are responsible for the largest recent increases in this population. It is estimated that two thirds of jail inmates meet criteria for a substance use disorder (SUD), nearly half present symptoms consistent with a mental health condition (MHC), and the vast majority of adults in jails have been arrested and booked into these facilities in the past. It is critical to examine the link between SUDs, MHCs, and readmissions to help inform better approaches. METHODS: This prospective study examined the associations between SUDs, MHCs, and jail readmissions in a random sample of 224 adults collected from a rural correctional facility in North Carolina. The Comprehensive Addiction and Psychological Evaluation-5 (CAAPE-5) was administered to participants within 24 to 96 h of admission to the jail. Information consistent with DSM-5 designations for SUDs and several MHCs was evaluated in conjunction with 12-month jail readmission data. RESULTS: Bivariate analyses demonstrated the disproportionality of SUDs and several MHCs (including depressive episode, posttraumatic stress, and antisocial personality) among adults who were readmitted to the jail. Binary multivariate logistic regression analyses showed SUDs nor MHCs to be associated with any jail readmissions, but multinomial regression results indicated SUDs were the most robust indicator of multiple 12-month jail readmissions. CONCLUSIONS: Local jails need to implement systems capable of conducting behavioral health assessments, with a special focus on SUDs as one of the strongest indicators of readmission. This information will allow jail administrators to better manage detainees while they are incarcerated, but it can also enhance the ability to connect adults with appropriate programming options to address the condition and reduce the likelihood of reentering the detention center.

Substance Use Risk Indicators and Offending Patterns Among Local Jail Inmates.

This study examined clinical indicators of adult jail inmates' substance use severity and offending patterns. Clinical assessment and booking data were gathered from a random sample of 283 adult inmates using the Comprehensive Addiction and Psychological Evaluation-5, which is consistent with diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Greater substance use risk was associated with increased likelihood of detention for property-related offenses, nonviolent offenses, and multiple jail admissions. Inmates with greater substance use risk were also significantly less likely to be detained for violent offenses. The assessment and coordination of care for jail inmates in local detention centers is paramount to reducing jail bookings, especially for nonviolent offenses.

Exposure to Violence and Substance Use Treatment Outcomes Among Female Patients.

BACKGROUND: Many female substance use patients have experienced violence in the past, with most estimates showing the majority of patients reporting violent experiences at some point. Prior experience with violence has been linked to increased severity of substance use, and this may contribute to more challenges in the path to recovery. OBJECTIVES: Existing research has confounded the timing at which violence has occurred with the type of violence to which patients have been exposed. The current study was conducted to specify the extent to which the timing of exposure and the type of violence were associated with substance use after discharge from treatment. METHODS: Data were collected from 3,439 female patients included in the Comprehensive Assessment and Treatment Outcome Research (CATOR) system. RESULTS: With regard to the type of exposure, findings indicated female patients who were exposed to multiple forms of violence (i.e. physical and sexual) displayed the greatest severity of substance use upon treatment initiation, as well as the greatest likelihood for use following discharge from treatment. In terms of the timing, female patients who experienced violence at various time points (i.e. before and after 18 years of age) displayed the greatest severity of substance use, but patients who experienced violence after 18 years of age had the highest probability of substance use following discharge from treatment. Conclusions/Importance: Clinicians should collect information related to these important details as treatment protocols are developed, and as patients are connected to aftercare services to minimize post-treatment substance use.

An Initial Assessment of Leon County Florida's Pre-Arrest Adult Civil Citation Program.

Momentum is building behind law enforcement-assisted diversion programs. Some of these programs have been designed specifically for drug-involved offenders, while others focus on adults who have no prior involvement in the criminal justice system. The Leon County Pre-Arrest Diversion program, which has been operating since March 2013, offers first-time arrestees the opportunity to participate in an alternative to arrest-as-usual. Successful completion of the program results in avoidance of a formal criminal arrest record. This paper provides an initial assessment of participants involved in the program during the first 3 years of operation. Results indicate male participants, those who submitted a positive drug test at program initiation, and those who presented significantly greater behavioral health needs were more likely to fail to complete the program and become rearrested. These findings are discussed with regard to practices among pre-arrest diversion programs.

The Role of Patient Payment Method in Premature Discharge from Methadone Maintenance Treatment.

BACKGROUND: Premature discharge is a pervasive problem in methadone maintenance treatment (MMT), and is associated with numerous adverse outcomes. Although a number of demographic variables have consistently been found to impact MMT retention, method of payment has received considerably less attention. A notable limitation of prior work is that most studies classify all patients who leave treatment early, irrespective of reason, as treatment dropouts and fail to account for specific reasons. OBJECTIVE: This study sought to determine whether method of payment for MMT services was associated with differential reasons for premature discharge. METHODS: The sample was comprised of 4158 patients prematurely discharged from 33 MMT facilities located throughout the U.S. from 2009 to 2012. Patients were classified into two groups based on their method of payment: self-pay and insurance (largely Medicaid). Patients were studied through retrospective electronic chart review. RESULTS: Binary logistic regression indicated that insurance patients who were prematurely discharged were significantly more likely to be discharged due to a program-initiated reason (administrative), while self-pay patients were more likely to be discharged due to a patient-initiated reason (against medical advice) after controlling for significant intake demographic and clinical covariates. CONCLUSIONS: Further research is needed to determine whether insurance patients may require different supports in place compared to self-pay patients in order to improve compliance with program guidelines (e.g. behavioral contracts providing a detailed description of rules both at admission and throughout treatment with an emphasis on the potential consequences of noncompliance), and whether self-pay patients may benefit from motivational incentives and interventions to remain engaged in treatment.

AiRCare: A naturalistic evaluation of the effectiveness of a protracted telephone-based recovery assistance program on continuing care outcomes.

BACKGROUND & OBJECTIVE: Substance use disorder treatments are increasingly being contextualized within a disease management framework. Within this context, there is an identified need to maintain patients in treatment for longer periods of time in order to help them learn how to manage their disease. One way to meet this need is through telephone-based interventions that engage patients, and include more active outreach attempts and involvement of the patient's family. This study sought to evaluate the effectiveness of three formats of an intensive 12-month post-discharge telephone-based case management approach (AiRCare) on adherence to continuing care plans and substance use outcomes. METHODS: Data were abstracted from electronic medical records for 379 patients (59.9% male) discharged from a residential treatment program located in the southwestern U.S. from 2013 to 2015. Patients were categorized into one of three groups and received telephone contacts based on their self-selection upon admission to residential treatment (i.e., patient only, family only, and both patient and family). Outcome variables included re-engagement and re-admission rates, quality of life, abstinence rates at 6 and 12 months, and compliance with continuing care plans. RESULTS & CONCLUSIONS: Favorable short- and long-term outcomes were found for the majority of patients, irrespective of case management group. There appeared to be some value in the addition of family contacts to patient contacts with respect to reducing risk for 12-month re-admission to residential care. These positive but preliminary indications of the effectiveness of AiRCare require replication in a well-powered, randomized controlled trial.

The entanglement between relapse and posttreatment criminal justice involvement.

BACKGROUND: Research has established a connection between substance use and criminal activity, but much less is known about the association between posttreatment relapse and related contact with the criminal justice system. OBJECTIVE: The current study was designed to elucidate this relationship by examining the long-term effects of relapse on arrest. The study also investigated the probability of relapse into substance use as it followed an arrest. METHOD: Data from 5,822 adults who participated in the Comprehensive Assessment and Treatment Outcome Research (CATOR) system were analyzed. This prospective longitudinal research design included 0-6, 6-12, 12-18, and 18-24 month follow-up data. RESULTS: A series of logistic regression analyses indicated that relapse was associated with posttreatment arrest within the observed follow-up period, but did not significantly influence the likelihood of arrest in future follow-up periods. In comparison, posttreatment arrest in the 6-12 month follow-up period had lasting effects for relapse to substance use in the 12-18 and 18-24 month periods. Arrest in the 0-6 month posttreatment period was also associated with increased risk for relapse in the 18-24 month period. CONCLUSIONS: Given the evidence that demonstrated within follow-up period associations between relapse and arrest, relapse prevention is critical to preventing contact with the criminal justice system. In addition, the lasting impact of an arrest must be mitigated to maintain posttreatment recovery from substance use for adults who come into contact with the criminal justice system.

Diagnostic Concordance between DSM-5 and ICD-10 Cannabis Use Disorders.

OBJECTIVES: With the recent federal mandate that all U.S. health care settings transition to ICD-10 billing codes, empirical evidence is necessary to determine if the DSM-5 designations map to their respective ICD-10 diagnostic categories/billing codes. The present study examined the concordance between DSM-5 and ICD-10 cannabis use disorder diagnoses. METHOD: Data were derived from routine clinical assessments of 6871 male and 801 female inmates recently admitted to a state prison system from 2000 to 2003. DSM-5 and ICD-10 diagnostic determinations were made from algorithms corresponding to the respective diagnostic formulations. RESULTS: Past 12-month prevalence rates of cannabis use disorders were comparable across classification systems. The vast majority of inmates with no DSM-5 diagnosis continued to have no diagnosis per the ICD-10, and a similar proportion with a DSM-5 severe diagnosis received an ICD-10 dependence diagnosis. Most of the variation in diagnostic classifications was accounted for by those with a DSM-5 moderate diagnosis in that approximately half of these cases received an ICD-10 dependence diagnosis while the remaining cases received a harmful use diagnosis. CONCLUSIONS: Although there appears to be a generally high level of agreement between diagnostic classification systems for those with no diagnosis or those evincing symptoms of a more severe condition, concordance between DSM-5 moderate and ICD-10 dependence diagnoses was poor. Additional research is warranted to determine the appropriateness and implications of the current DSM-5 coding guidelines regarding the assignment of an ICD-10 dependence code for those with a DSM-5 moderate diagnosis.

Pathways to rearrest among court mandated female substance use treatment patients.

BACKGROUND AND OBJECTIVES: Many women who experience substance dependence come into contact with the criminal justice system and are mandated by the court to enter treatment. Treatment is a viable option and can have many positive outcomes, but there remains significant room for improvement. This study was designed to identify key risk factors that can be addressed to improve substance use treatment outcomes for this population. METHODS: The study sample consisted of (n) 381 women who were court mandated to enter substance use treatment. Multivariate path analyses were conducted to assess the associations between correlates of substance use treatment outcomes, risk for relapse, and rearrest. RESULTS: Women who displayed certain demographic risk factors (i.e., less educated and unmarried) and had greater levels of substance use severity prior to entering treatment experienced elevated risk for relapse. Consequently, women who relapsed were nearly three times (OR = 2.50, 95% CI = 1.26-4.93) as likely to be rearrested within 12 months of discharge from treatment compared to those who did not relapse. DISCUSSION AND CONCLUSIONS: Certain risk factors contribute to relapse, which increases risk for rearrest. SCIENTIFIC SIGNIFICANCE: Services specifically tailored to women who were court mandated to enter treatment need to consider certain demographic risk factors, clinical substance use severity, and relapse prevention as key elements to minimize subsequent criminal offending.

Predictors of patient retention in methadone maintenance treatment.

This study sought to determine whether select pretreatment demographic and in-treatment clinical variables predict premature treatment discharge at 6 and 12 months among patients receiving methadone maintenance treatment (MMT). Data were abstracted from electronic medical records for 1,644 patients with an average age of 34.7 years (SD = 11.06) admitted to 26 MMT programs located throughout the United States from 2009 to 2011. Patients were studied through retrospective chart review for 12 months or until treatment discharge. Premature discharge at 6- and 12-month intervals were the dependent variables, analyzed in logistic regressions. Clinical predictor variables included average methadone dosage (mg/d) and urinalysis drug screen (UDS) findings for opioids and various nonopioid substances at intake and 6 months. Pretreatment demographic variables included gender, race/ethnicity, employment status, marital status, payment method, and age at admission. UDS findings positive (UDS+) for cocaine at intake and 6 months were found to be independent predictors of premature discharge at 12 months. UDS+ for opioids at 6 months was also an independent predictor of premature discharge at 12 months. Higher average daily methadone dosages were found to predict retention at both 6 and 12 months. Significant demographic predictors of premature discharge at 6 months included Hispanic ethnicity, unemployment, and marital status. At 12 months, male gender, younger age, and self-pay were found to predict premature discharge. Select demographic characteristics may be less important as predictors of outcome after patients have been in treatment beyond a minimum period of time, while others may become more important later on in treatment.

Breaking the addictive cycle of the system: improving US criminal justice practices to address substance use disorders.

PURPOSE: Recent political commentary in the USA has suggested that there is great potential for current criminal justice practices designed for drug-involved offenders to be significantly overhauled in the near future. It is imperative to plan for these changes by assessing how well current programs serve drug-involved criminal justice populations. The paper aims to discuss these issues. DESIGN/METHODOLOGY/APPROACH: This critical assessment begins with an overview of the most recent research on the prevalence and impact that substance use disorders have within the criminal justice system. Although the evidence demonstrates that relying on incarceration as a crime control method for drug-involved offenders has many shortcomings, there are innovative new programs being adopted across the country. Two of these promising programs are discussed, as well as the potential results that could be realized from integrating medication assisted treatment into appropriate criminal justice programs designed for drug-involved offenders. FINDINGS: Incarceration is a failed practice for attending to the underlying reasons why many drug-involved offenders become involved in criminal activities. There are encouraging new programs emerging in different parts of the USA, but the inclusion of supplemental treatment options could further promote positive outcomes. ORIGINALITY/VALUE: The impending expansion of criminal justice programs for drug-involved offenders must consider how innovative new programs can be fused with supplemental treatment options to achieve the best results.

How well do the DSM-5 alcohol use disorder designations map to the ICD-10 disorders?

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), and the International Statistical Classification of Diseases and Related Health Problems, 10th edition (ICD-10), both establish diagnostic criteria for alcohol use disorders. The dimensional severity perspective provided by the DSM-5 may overlap in important ways but also may diverge from the categorical harmful use versus dependence designations presented by the ICD-10. It is especially important to consider the convergence of these 2 diagnostic approaches as the DSM is widely used by clinicians, but the U.S. Centers for Medicare and Medicaid Services has recently required that providers bill for services using the ICD-10 designations. METHODS: Data from 6,871 male and 801 female admissions to a state prison system were used to compare the DSM-5 severity index for alcohol use disorder to the ICD-10 clinical and research formulations for harmful use and dependence. RESULTS: The DSM-5 and the ICD-10 were highly convergent for the most severe alcohol use disorders and also for those who did not receive a diagnosis. Most DSM-5 moderate alcohol use disorder cases were classified as dependence cases under both the clinical and research ICD criteria. In contrast, there was much more variation in the DSM mild cases. These were divided into categories of harmful use or misuse, depending on whether the clinical or research ICD criteria were applied. Results were similar among male and female inmates. CONCLUSIONS: The DSM-5 and ICD-10 exhibit a high level of agreement for cases that would not receive a diagnosis as well as the most severe cases. However, there are important distinctions to be made between the 2 approaches for mild and moderate DSM disorders in addition to harmful use/misuse cases in the ICD. The cases influenced by these discrepancies are most likely to be affected by recently implemented service provider billing practices.

A naturalistic comparison of the effectiveness of methadone and two sublingual formulations of buprenorphine on maintenance treatment outcomes: findings from a retrospective multisite study.

OBJECTIVE: This study sought to compare the effectiveness of the 3 most commonly prescribed maintenance medications in the United States indicated for the treatment of opioid dependence in reducing illicit drug use and retaining patients in treatment. METHOD: Data were abstracted from electronic medical records for 3,233 patients admitted to 34 maintenance treatment facilities located throughout the United States during the period of July 1, 2012, through July 1, 2013. Patients were grouped into 1 of 3 medication categories based on their selection at intake (methadone [n = 2,738; M dosage = 64.64 mg/d, SD = 25.58], Suboxone [n = 102; M dosage = 9.75 mg/d, SD = 4.04], or Subutex [n = 393; M dosage = 12.21 mg/d, SD = 5.31]) and were studied through retrospective chart review for 6 months or until treatment discharge. Two measures of patient retention in treatment and urinalysis drug screen (UDS) findings for both opioids and various nonopioid substances comprised the study outcomes. RESULTS: The average length of stay (LOS) in terms of days in treatment for the methadone group (M = 169.86, SE = 5.02) was significantly longer than both the Subutex (M = 69.34, SE = 23.43) and Suboxone (M = 119.35, SE = 20.82) groups. The Suboxone group evinced a significantly longer average LOS relative to the Subutex group. After adjustment for relevant covariates, patients maintained on methadone were 3.73 times (95% confidence interval [CI]= 2.82-4.92) and 2.48 times (95% CI = 1.57-3.92) more likely to be retained in treatment at 6 months than patients prescribed Subutex and Suboxone, respectively. The 6-month prevalence rates of positive UDS findings for both opioids and nonopioid substances were similar across medication groups. CONCLUSIONS: Comparable rates of illicit drug use at 6 months may be expected irrespective of maintenance medication, while increased retention may be expected for patients maintained on methadone relative to those maintained on Suboxone or Subutex.

Alcohol use disorder diagnoses in the criminal justice system: an analysis of the compatibility of current DSM-IV, proposed DSM-5.0, and DSM-5.1 diagnostic criteria in a correctional sample.

This study explored the compatibility between the current Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR) diagnostic criteria for alcohol abuse and dependence with the initial (DSM-5.0) and most recent (DSM-5.1) proposed diagnostic criteria. Data drawn from a structured clinical interview used in the assessment of 6,871 male and 801 female state prison inmates were analyzed according to the existing and proposed diagnostic formulations. The greatest congruence was observed in cases that received no diagnosis according to the DSM-IV-TR because these also received no diagnosis in the DSM-5.1. Most cases with a current dependence diagnosis received a severe designation according to the proposed criteria. However, those with an abuse diagnosis were divided across various DSM-5.1 severity levels. Some diagnostic criteria were nearly universally endorsed among those classified with the highest severity levels, which indicated that some criteria may serve as cardinal indicators of a severe alcohol use disorder (SAUD). Additional diagnostic criteria not yet suggested for inclusion in the DSM (i.e., preoccupation with alcohol use and alcohol use to relieve emotional distress) were also evaluated. Evidence demonstrated these two criteria served as functional indicators of alcohol use disorder (AUD). This assessment approach can be used to establish appropriate treatment objectives based on the severity of diagnosed AUDs. Meeting these treatment objectives, especially in a correctional population, may have important implications for future offending. Recommendations are made for prospective research in this area.