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.

Integrating primary medical care with addiction treatment: a randomized controlled trial.

CONTEXT: The prevalence of medical disorders is high among substance abuse patients, yet medical services are seldom provided in coordination with substance abuse treatment. OBJECTIVE: To examine differences in treatment outcomes and costs between integrated and independent models of medical and substance abuse care as well as the effect of integrated care in a subgroup of patients with substance abuse-related medical conditions (SAMCs). DESIGN: Randomized controlled trial conducted between April 1997 and December 1998. SETTING AND PATIENTS: Adult men and women (n = 592) who were admitted to a large health maintenance organization chemical dependency program in Sacramento, Calif. INTERVENTIONS: Patients were randomly assigned to receive treatment through an integrated model, in which primary health care was included within the addiction treatment program (n = 285), or an independent treatment-as-usual model, in which primary care and substance abuse treatment were provided separately (n = 307). Both programs were group based and lasted 8 weeks, with 10 months of aftercare available. MAIN OUTCOME MEASURES: Abstinence outcomes, treatment utilization, and costs 6 months after randomization. RESULTS: Both groups showed improvement on all drug and alcohol measures. Overall, there were no differences in total abstinence rates between the integrated care and independent care groups (68% vs 63%, P =.18). For patients without SAMCs, there were also no differences in abstinence rates (integrated care, 66% vs independent care, 73%; P =.23) and there was a slight but nonsignificant trend of higher costs for the integrated care group ($367.96 vs $324.09, P =.19). However, patients with SAMCs (n = 341) were more likely to be abstinent in the integrated care group than the independent care group (69% vs 55%, P =.006; odds ratio [OR], 1.90; 95% confidence interval [CI], 1.22-2.97). This was true for both those with medical (OR, 3.38; 95% CI, 1.68-6.80) and psychiatric (OR, 2.10; 95% CI, 1.04-4.25) SAMCs. Patients with SAMCs had a slight but nonsignificant trend of higher costs in the integrated care group ($470.81 vs $427.95, P =.14). The incremental cost-effectiveness ratio per additional abstinent patient with an SAMC in the integrated care group was $1581. CONCLUSIONS: Individuals with SAMCs benefit from integrated medical and substance abuse treatment, and such an approach can be cost-effective. These findings are relevant given the high prevalence and cost of medical conditions among substance abuse patients, new developments in medications for addiction, and recent legislation on parity of substance abuse with other medical benefits.

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.

The provision of services for alcohol problems: a community perspective for understanding access.

Alcohol use is related to numerous health and social problems. The article describes the prevalence of alcohol problems and dependence across a county and its institutions. While high rates of problem drinking were found across health, mental health, criminal justice, welfare, drug, and alcohol programs, the proportion was highest for primary health clinics, the criminal justice system, and welfare agencies. This also was the case when the county's most serious alcohol problem cases--individuals who were alcohol dependent--were examined. Thus it may be useful to develop screening procedures, mainstream treatment interventions in non-alcohol specialty agencies, and include non-specialty agencies in services research on access.

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.

Association of outpatient alcohol and drug treatment with health care utilization and cost: revisiting the offset hypothesis.

OBJECTIVE: This study examines the hypothesis that treatment reduces medical utilization and costs of patients with substance use problems. METHOD: Adult patients (N = 1.011; 67% men) entering the outpatient chemical dependency recovery program at Sacramento Kaiser Permanente over a 2-year period were recruited into the study. Medical utilization and costs were examined for 18 months prior and 18 months after intake. To account for overall changes in utilization and cost, an age, gender and length-of-enrollment matched nonpatient control group (N = 4,925) was selected from health-plan members living in the same service area. Multivariate analyses controlling for age and gender were conducted using generalized estimating equation methods, allowing for correlation between repeated measures and nonnormal distributions of the outcome variable. RESULTS: The treatment cohort was less likely to be hospitalized (odds ratio [OR] = 0.59; p < .01) and there was a trend for having spent fewer days (rate ratio [RR] = 0.77; p < .10) in the hospital in the posttreatment period compared to pretreatment period. These patients were also less likely to visit the emergency room (ER) (OR = 0.64; p < .01) and had fewer ER visits (RR = 0.81; p < .01) following treatment. Inpatient, ER and total medical costs declined by 35%, 39% and 26%, respectively (p < .01). Reductions in cost were greater for the treatment cohort when compared with the matched sample (p < .05). Among women, there were significant reductions (p < .05) in inpatient, ER and total costs for the study cohort when compared with the matched sample; among men, the reductions in inpatient and ER cost (but not total cost) were significantly larger (p < .05) for the study cohort when compared with the matched sample. For the treatment cohort, the change in medical cost was not significantly different by gender. Changes in cost were significantly different across the various age groups (p < .05) for the study cohort and the matched sample. Among those in the group aged 40-49 years, the decline in cost for study cohort was significantly larger (p < .05) than for the matched sample. CONCLUSIONS: For patients with substance use disorders entering treatment, there was a substantial decline in inappropriate utilization and cost (hospital and ER) in the posttreatment period. The disaggregated pattern of posttreatment decline in utilization and cost is suggestive of long-term reductions that warrant a longer follow-up.

Improving alcoholism treatment across the spectrum of services.

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. The chair was Michael E. Hilton. The presentations were (1) The effects of brief advice and motivational enhancement on alcohol use and related variables in primary care, by Stephen A. Maisto, Joseph Conigliaro, Melissa McNiel, Kevin Kraemer, Mary E. Kelley, and Rosemarie Conigliaro; (2) Enhanced linkage of alcohol dependent persons to primary medical care: A randomized controlled trial of a multidisciplinary health evaluation in a detoxification unit, by Jeffrey H. Samet, Mary Jo Larson, Jacqueline Savetsky, Michael Winter, Lisa M. Sullivan, and Richard Saitz; (3) Cost-effectiveness of day hospital versus traditional alcohol and drug outpatient treatment in a health maintenance organization: Randomized and self-selected samples, by Constance Weisner, Jennifer Mertens, Sujaya Parthasarathy, Charles Moore, Enid Hunkeler, Teh-Wei Hu, and Joe Selby; and (4) Case monitoring for alcoholics: One year clinical and health cost effects, by Robert L. Stout, William Zywiak, Amy Rubin, William Zwick, Mary Jo Larson, and Don Shepard.

Predictors of substance abuse treatment retention among women and men in an HMO.

BACKGROUND: Although prior research has examined predictors of treatment retention in public alcohol and drug treatment programs, little is known about factors that influence treatment retention in an insured outpatient population. Because there is growing evidence that the factors which influence treatment retention may differ by gender, we identify sex-specific predictors. METHODS: We recruited all eligible intakes to a health maintenance organization's outpatient alcohol and drug treatment program during a 2-year period and obtained a sample of 317 women and 599 men. The programs, day hospital and traditional outpatient modalities, were abstinence based. We separated our sample by sex and used least squares and logistic regression to identify independent predictors of length of stay and program completion, respectively. RESULTS: One general pattern of predictors of increased retention was shared by women and men in this alcohol and drug treatment program--fewer and less severe drug problems. However, most predictors were sex-specific. Among women, retention was predicted by having higher incomes, belonging to ethnic categories other than African American, being unemployed, being married, and having lower levels of psychiatric severity. Among men, predictors of higher retention included being older, receiving employer suggestions to enter treatment, and having abstinence goals. CONCLUSIONS: These findings highlight the importance of examining aspects of the course of treatment separately by sex. They also suggest treatment factors that may enhance retention among insured populations, including employer referrals, psychiatric services, and drug-related services.

Hospitalization for suicide attempt and completed suicide: epidemiological features in a managed care population.

BACKGROUND: Understanding factors that contribute to high suicide risk holds important implications for prevention. We aimed to examine the sociodemographic and medical predictors of attempted suicide (severe enough to require hospitalization) and of completed suicide in a large population-based sample from a health maintenance organization (HMO) in northern California, USA. METHOD: We designed a cohort study, including 87,257 women and 70,570 men aged 15 through 89 years old at baseline (in 1977-1985) with follow-up for hospitalizations and mortality through the end of 1993. RESULTS: After a median of 10 years, 169 first hospitalizations for attempted suicide (111 among women, 58 among men) and 319 completed suicides (101 among women, 218 among men) were identified. There was a greater incidence of hospitalization for suicide attempt in women than in men and, conversely, a greater incidence of completed suicide in men than in women. The predominant methods of attempted and completed suicides were ingestion of psychotropic agents and use of firearms, respectively. In gender-specific multivariate analysis of hospitalization for suicide attempt, statistically significant associations were seen for age 15-24 years (women), 65-89 years (men), white race (women), 12th grade or less education (both genders), technical/business school education (men), never being married (men), history of emotional problems (both genders), history of family problems (women), history of job problems (men) and presence of one or more comorbidities (men). The independent predictors of completed suicide were: age 15-24 years (both genders), Asian race (women), Caucasian race (both genders), never being married (both genders), being separated/divorced (women), prior inpatient hospitalization for suicide attempt (both genders) and history of emotional problems (both genders). CONCLUSION: These findings could help health professionals be more effective in the prevention of suicide morbidity and mortality.

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.

Women and alcohol problems: a critical analysis of the literature and unanswered questions.

The evaluation of alcohol treatment services for women that emerged from the deliberations of the expert panel and RSA roundtable clearly documents the importance of interdisciplinary research. This research considers the particular social and physical context of women's lives and uses measurement tools and outcome measures appropriate for women. Development of gender-tested measurements, gender-relevant treatment services, and gender-appropriate outcome evaluations is necessary to ensure that women receive the services they need. The inclusion of women from geographically and ethnically diverse subject populations, as well as from subgroups who have traditionally been excluded from health research, is critical in the development of scientifically sound, research-based knowledge of the treatment of women with alcohol problems. The papers that follow include critical reviews of the literature by members of the expert panel, and these reviews were enriched by the roundtable discussion at RSA. Schmidt and McCarty evaluate the research on women supported on welfare. The unique challenges for pregnant women on Medicaid are discussed by Hankin, McCaul, and Heussner. The research on alcohol treatment specific to older women is critiqued by Blow, and the barriers and need for alcohol service for women in rural populations are discussed by Booth and McLaughlin. The relationships between substance abuse and violence are assessed by Miller, Wilsnack, and Cunradi. Finally, Sinha and O'Malley discuss critical gaps in understanding the impact on treatment outcomes of co-occurring disorders such as depression, anxiety, and eating disorders.

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.

Alcohol drinking patterns and medical care use in an HMO setting.

The objective of this study was to examine the association of medical care use (outpatient visits and hospitalization) with alcohol drinking patterns in a large health maintenance organization (HMO). Data were gathered from a random sample of 10,292 adult respondents through a telephone survey conducted between June 1994 and February 1996. Findings indicate that current nondrinkers with no past history of drinking had higher rates of outpatient visits and hospitalizations than current drinkers. Among current drinkers, medical care use declined slightly as drinking levels increased. Among nondrinkers, those with a drinking history exhibited significantly higher use of outpatient visits and hospital care than nondrinkers with no drinking history and current drinkers. Controlling for demographic and socioeconomic factors, health status, and common medical conditions in multivariate analyses suggests that nondrinkers with a drinking history use more services because they are sicker than other nondrinkers or current drinkers.

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.

Drinking patterns and problems of the "stably insured": a study of the membership of a health maintenance organization.

OBJECTIVE: This article describes drinking patterns and examines the prevalence of heavy drinking and alcohol problems, and their association with other behavioral and social problems within the membership of a health maintenance organization, a setting in which increasing numbers of Americans receive services. METHOD: The sample is representative of the stably insured membership of the Northern California Region of Kaiser Permanente Medical Care Program; i.e., those who have been insured continuously under that plan for 30 months or longer. A telephone survey of the adult membership (N = 10,292) was conducted between June 1994 and February 1996. RESULTS: As in other studies, health and mental health status and smoking were related to drinking levels, with symptoms higher for those in the heaviest drinking group. However, in contrast to studies of those using medical services, demographic characteristics (e.g., young age) were not associated with heavy drinking in this population. When controlling for drug use and drinking, however, women and those reporting any mental health symptom were more likely to report alcohol problems. CONCLUSIONS: Findings suggest that in private managed care populations, particular behavioral indicators may be more important than demographic characteristics in screening for problem drinkers. The identification of individuals who report a mental health symptom, who drink a large number of drinks occasionally or who report any drug use may be important in a health maintenance approach to prevention and case finding.

Demographic characteristics, life context, and patterns of substance use among alcohol-dependent treatment clients in a health maintenance organization.

BACKGROUND: Although individuals dependent only on alcohol and those dependent on both alcohol and drugs typically are not studied together in clinical trials, they are treated together in most treatment programs. In this study we compared epidemiological characteristics of the alcohol-only and alcohol-and-drug dependents in a treatment sample to assess differential treatment needs. METHOD: Patients admitted to treatment at a health maintenance organization's chemical dependency program were sampled and interviewed by using a structured questionnaire. The sample included 491 alcohol-only and 217 alcohol-and-drug dependents. Demographic characteristics, lifetime and current substance use, Addiction Severity Index composite scores, and DSM-IV criteria for alcohol and drug dependence were assessed at admission. RESULTS: The odds of alcohol-and-drug dependence were higher among males, African Americans (when compared with whites), those who were younger, and those with less than college education. The risk was also higher among those who initiated heavy drinking or drug use before the age of 18. Increased psychiatric and family/social problems also were associated with combined dependence. CONCLUSIONS: Even in this relatively homogeneous socioeconomic status population, demographic characteristics were important predictors of type of dependence. Treatment programs which provide services that address prevention and psychosocial problems should pay attention to age of initiation as well as psychiatric and social problems.

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.