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Comparison of Health Service Use Among Veterans With Methamphetamine Versus Alcohol Use Disorders
Abstract
Methamphetamine use disorders (MUD) are associated with severe health effects and psychiatric comorbidities, but little is known about the health care utilization of patients with MUD. The goal of this study was to describe health service use among veterans with MUD relative to a group of veterans with an alcohol use disorder (AUD).
Using Veterans Affairs (VA) administrative data, we identified 718 patients who were diagnosed with MUD and had confirmatory drug testing. Data were compared with those of 744 patients who had diagnoses of an AUD also with confirmatory testing. We examined diagnoses and medical utilization for 5 years after their index date.
Patients with MUD and laboratory-confirmed recent use were younger and more likely to be diagnosed with a mood disorder, posttraumatic stress disorder, and a psychotic-spectrum disorder (all P values < 0.05). After statistical controls, patients with MUD were more likely to have an inpatient hospitalization (80% vs 70%, odds ratio [OR] = 1.8; 95% confidence interval [CI] = 1.4-2.3), discharge from an inpatient admission against medical advice (23.4% vs 8.3%, OR = 2.6, 95% CI = 1.9-3.7), receive care at 3 or more VA medical centers (13.1% vs 5.4%, OR = 2.3, 95% CI = 1.5-3.5), have a behavioral flag in the medical record (5.6% vs 1.1%, OR = 4.6, 95% CI = 2.1-10.6), and have more total missed appointments in the 5-year study period (M = 33.1 vs M = 23.5, P < 0.001).
Among veterans with substance use disorders, those with MUD and laboratory-confirmed recent use have additional behavioral, health care utilization, and psychiatric characteristics that need to be considered in developing programs of care.
... Multiple barriers may prevent these individuals from receiving medical care, as evidenced by higher rates of missed appointments, decreased compliance, and factors that interfere with effective substance use disorder treatment (Marquez et al., 2009;Lai et al., 2020). Additionally, high frequency of co-occurring addiction and mental health problems may lead to a higher risk of treatment non-adherence and missed appointments (Morasco et al., 2014). Children of methamphetamine users are exposed to a myriad of risk factors, including maltreatment, exposure to violence, and criminal behaviors. ...
Methamphetamine use has become a rampant public health issue that not only causes devastating consequences to the user but also poses a burden to surrounding communities. A spectrum of ophthalmic sequelae is associated with methamphetamine use and includes episcleritis, scleritis, corneal ulceration, panophthalmitis, endophthalmitis, retinal vasculitis, and retinopathy. In many instances, prompt recognition of the condition and associated infectious process and early initiation of antimicrobial therapy are crucial steps to preventing vision loss. In this review, we summarize the reported ocular complications that may result from methamphetamine use in addition to several postulated mechanisms regarding the ocular toxicity of methamphetamine. The increasing prevalence of methamphetamine use as a public health threat highlights the need for continued investigation of this ophthalmologic issue.
Introduction: Methamphetamine is a highly stimulating psychoactive drug that causes life-threatening addictions and affects millions of people around the world. Its effects on the brain are complex and include disturbances in the neurotransmitter systems and neurotoxicity. There are several known treatment methods, but their effectiveness is moderate. It must be emphasised that no drugs have been approved for treatment. For this reason, there is an urgent need to develop new, effective, and safe treatments for methamphetamine. One of the potential treatments is mindfulness meditation. In recent years, this technique has been researched extensively in the context of many neurological and psychiatric disorders. Methods: This review explores the use of mindfulness in the treatment of methamphetamine addiction. Searches were conducted in the PubMed/Medline, Research Gate, and Cochrane databases. Results: Seven studies were identified that used mindfulness-based interventions in the treatment of methamphetamine addiction. The results show that mindfulness is an effective form of reducing hunger, risk of relapses, stress indicators, depression, and aggression, alone or in combination with transcranial direct current stimulation (tDCS). Mindfulness also improved the cognitive function in addicts. The included studies used only behavioural measures. The potential mechanisms of mindfulness in addiction were explained, and it was proposed that it can induce neuroplasticity, alleviating the symptoms of addiction. Conclusions: Evidence from the studies suggest that mindfulness may be an effective treatment option for methamphetamine addiction, used alone or in combination with tDCS. However, further high-quality research is required to establish the role of this treatment option in this field. The use of neuroimaging and neurophysiological measures is fundamental to understand the mechanisms of mindfulness.
Background
Since the late 1990s, methamphetamine use has become a considerable public health concern. Despite high suicide rates among methamphetamine users, studies exploring medical utilization and psychiatric and physical comorbidities before suicide are scant. We aim to examine the pattern of medical utilization and distribution of comorbidities shortly before suicide in methamphetamine users who died of suicide and compared these data with those of living methamphetamine users.
Methods
From Taiwan’s National Health Insurance Research Database, we identified the cohort with methamphetamine use disorder (n = 23,248) between January 1, 2001, and December 31, 2005. We identified 5972 deceased patients (of whom 745 died of suicide) by linking each patient with the national mortality database during the study period. By conducting a nested case–control study with risk-set sampling, from the methamphetamine cohort, we selected four age- and sex-matched controls for each patient who died of suicide (cases). We applied conditional logistic regression to investigate differences in medical utilization and physical and psychiatric comorbidities between cases and controls.
Results
Cases had higher medical utilization within 3 months before suicide, particularly in the departments of psychiatry, internal medicine, emergency, and family practice. Cases had higher risks of physical comorbidities, including pneumonia and renal disease, and psychiatric comorbidities, including depressive disorder, sleep disorder, drug-induced mental disorder, schizophrenia, and bipolar disorder.
Conclusions
The findings of increased medical utilization and the higher risks of physical and psychiatric comorbidities in cases are crucial for developing specific interventions to prevent suicide in this patient population.
Background:
The fourth wave of the opioid crisis is characterized by increased use and co-use of methamphetamine. How opioid and methamphetamine co-use is associated with health care use, housing instability, social service use, and criminal justice involvement has not been studied and could inform future interventions and partnerships.
Objectives:
To estimate service involvement across sectors among people who reported past year opioid and methamphetamine co-use, methamphetamine use, opioid use, or neither opioid nor methamphetamine use.
Research design:
We examined 2015-2018 data from the National Survey on Drug Use and Health. We used multivariable negative binomial and logistic regression models and predictive margins, adjusted for sociodemographic and clinical characteristics.
Subjects:
Nonelderly US adults aged 18 or older.
Measures:
Hospital days, emergency department visits, housing instability, social service use, and criminal justice involvement in the past year.
Results:
In adjusted analyses, adults who reported opioid and methamphetamine co-use had 99% more overnight hospital days, 46% more emergency department visits, 2.1 times more housing instability, 1.4 times more social service use, and 3.3 times more criminal justice involvement compared with people with opioid use only. People who used any methamphetamine, with opioids or alone, were significantly more likely be involved with services in 2 or more sectors compared with those who used opioids only (opioids only: 11.6%; methamphetamine only: 19.8%; opioids and methamphetamine: 27.6%).
Conclusions:
Multisector service involvement is highest among those who use both opioids and methamphetamine, suggesting that partnerships between health care, housing, social service, and criminal justice agencies are needed to develop, test, and implement interventions to reduce methamphetamine-related morbidity.
Background:
The use of amphetamines is a global public health concern. We summarise global data on use of amphetamines and mental health outcomes.
Methods:
A systematic review and meta-analysis (CRD 42017081893). We searched Medline, EMBASE, PsycInfo for methamphetamine or amphetamine combined with psychosis, violence, suicidality, depression or anxiety. Included studies were human empirical cross-sectional surveys, case-control studies, cohort studies and randomised controlled trials that assessed the association between methamphetamine and one of the mental health outcomes. Random effects meta-analysis was used to pool results for any use of amphetamines and amphetamine use disorders.
Findings:
149 studies were eligible and 59 were included in meta-analyses. There was significant heterogeneity in effects. Evidence came mostly from cross-sectional studies. Any use of amphetamines was associated with higher odds of psychosis (odds ratio [OR] = 2.0, 95%CI 1.3-3.3), violence (OR = 2.2, 95%CI 1.2-4.1; adjusted OR [AOR] = 1.4, 95%CI 0.8-2.4), suicidality OR = 4.4, 95%CI 2.4-8.2; AOR = 1.7, 95%CI 1.0-2.9) and depression (OR = 1.6, 95%CI 1.1-2.2; AOR = 1.3, 95%CI 1.2-1.4). Having an amphetamine use disorder was associated with higher odds of psychosis (OR = 3.0, 95%CI 1.9-4.8; AOR = 2.4, 95%CI 1.6-3.5), violence (OR = 6.2, 95%CI 3.1-12.3), and suicidality (OR = 2.3, 95%CI 1.8-2.9; AOR = 1.5, 95%CI 1.3-1.8).
Interpretation:
Methamphetamine use is an important risk factor for poor mental health. High quality population-level studies are needed to more accurately quantify this risk. Clinical responses to methamphetamine use need to address mental health harms.
Background: Psychotic disorder due to methamphetamine has a high prevalence with an unknown nature and history. Patients with such disorders are faced with the risk of recurrence of abuse and other psychiatric disorders. Methamphetamine-induced psychotic disorders may continue by independent of methamphetamine abuse, such as primary psychotic disorders (such as schizophrenia). Objectives: This study was performed to evaluate the mental health and frequency of methamphetamine-induced psychosis in patients referred to Iran psychiatric hospital (a university hospital in Tehran, Iran). Patients and Methods: The research was done on patients with methamphetamine-induced psychosis after 2 to 5 years using of methamphetamine (150 person in the Iran Psychiatric Hospital) .The diagnostic interview was done based on a semi-structured interview (SCID). The data was analyzed by Binary Logistic Regression Model. Results: From 150 patients that were followed, 6 of them (4.0%) died during the phone interview-follow up. The mean age of alive patients was 34.9 ± 8.7 years and 12 of them were women (8.0%). At the follow-up interview, 38 patients reclassified as the cases of schizophrenia (25.3%), 17 as the cases of major depressive disorder (11.3%), 7 as the cases of bipolar disorder type I (4.7), two as the cases of schizoaffective disorder (1.3%), and two of them as the cases of delusional disorder (1.3%). A total of 84 cases (56.0%) were diagnosed as recovered cases or as methamphetamine-induced psychotic disorders. Prediction of diagnosis change showed the diagnosis of methamphetamine use disorder (adjustedOR= 3.978, 95% CI: 1.265 - 12.512), previous psychiatric admission (adjustedOR= 6.749; 95% CI: 1.639 - 27.779), and short duration of psychotic episode (adjusted OR = 0.171; 95% CI: 0.056 - 0.520. Conclusions: The results of our study show that methamphetamine-induced psychotic disorders are associated, in many cases, with the mood disorders. It seems that comorbid mood disorders, age of first use, history of previous psychiatric hospitalization, the risk of methamphetamine use disorders, and psychotic episodes are associated longer with the diagnosis towards primary psychotic disorders. © 2018, International Journal of High Risk Behaviors and Addiction.
Aim and background:
We estimated health service utilisation attributable to methamphetamine use, its national impact and examined other predictors of health service utilisation among dependent methamphetamine users.
Method:
Past year rates of health service utilisation (number of attendances for general hospitals, psychiatric hospitals, emergency departments, general practitioners, psychiatrists, counsellors or psychologists, and dentists) were estimated for three levels of methamphetamine use (no use, < weekly, ≥ weekly) using panel data from a longitudinal cohort of 484 dependent methamphetamine users from Sydney and Brisbane, Australia. Marginal rates for methamphetamine use were multiplied by 2013 prevalence estimates from the National Drug Strategy Household Survey. Covariates included other substance use, demographics, mental disorders and drug treatment.
Findings:
Health service use was high. More frequent methamphetamine use was associated with more frequent presentations to emergency departments (incidence rate ratios 1.3-2.1) and psychiatric hospitals (incidence rate ratios 5.3-8.3) and fewer presentations to general practitioners, dentists and counsellors. We estimate methamphetamine use accounted for between 28 400 and 80 900 additional psychiatric hospital admissions and 29 700 and 151 800 additional emergency department presentations in 2013. More frequent presentations to these services were also associated with alcohol and opioid use, comorbid mental health disorders, unemployment, unstable housing, attending drug treatment, low income and lower education.
Conclusions:
Frequent methamphetamine use has a significant impact on emergency medical and psychiatric services. Better provision of non-acute health care services to address the multiple health and social needs of dependent methamphetamine users may reduce the burden on these acute care services. [McKetin R, Degenhardt L, Shanahan M, Baker AL, Lee NK, Lubman DI. Health service utilisation attributable to methamphetamine use in Australia: patterns, predictors and national impact. Drug Alcohol Rev 2017;00:000-000].
The Side Effects of Drugs Annuals form a series of volumes in which the adverse effects and adverse reactions of drugs are surveyed. The series supplements the contents of Meyler's Side Effects of Drugs: the International Encyclopedia of Adverse Drug Reactions and Interactions. This is a review of the July 2013 to December 2014 publications on central nervous system stimulants and drugs that suppress appetite. This chapter covers amphetamines (including lisdexamfetamine, methamphetamine and 3,4-methylenedioxymetamphetamine), methylphenidate, modafinil and armodafinil, methylxanthines (caffeine), monotherapies and combinational therapies that suppress appetite (lorcaserin, naltrexone/bupropion, phentermine, and phentermine/topiramate) as well as medications used in Alzheimer's disease and cognitive decline (rivastigmine, donepezil and galantamine).
Improvement collaboratives consisting of various components are used throughout health care to improve quality, but no study has identified which components work best. This study tested the effectiveness of different components in addiction treatment services, hypothesizing that a combination of all components would be most effective.
An unblinded cluster-randomized trial assigned clinics to one of four groups: interest circle calls (group teleconferences), clinic-level coaching, learning sessions (large face-to-face meetings) and a combination of all three. Interest circle calls functioned as a minimal intervention comparison group.
Out-patient addiction treatment clinics in the United States.
Two hundred and one clinics in five states.
Clinic data managers submitted data on three primary outcomes: waiting-time (mean days between first contact and first treatment), retention (percentage of patients retained from first to fourth treatment session) and annual number of new patients. State and group costs were collected for a cost-effectiveness analysis.
Waiting-time declined significantly for three groups: coaching (an average of 4.6 days/clinic, P = 0.001), learning sessions (3.5 days/clinic, P = 0.012) and the combination (4.7 days/clinic, P = 0.001). The coaching and combination groups increased significantly the number of new patients (19.5%, P = 0.028; 8.9%, P = 0.029; respectively). Interest circle calls showed no significant effect on outcomes. None of the groups improved retention significantly. The estimated cost per clinic was $2878 for coaching versus $7930 for the combination. Coaching and the combination of collaborative components were about equally effective in achieving study aims, but coaching was substantially more cost-effective.
When trying to improve the effectiveness of addiction treatment services, clinic-level coaching appears to help improve waiting-time and number of new patients while other components of improvement collaboratives (interest circles calls and learning sessions) do not seem to add further value.
Background
In response to the rising rate of treatment admissions related to illicit use of amphetamines (eg, methamphetamine), we examined the prevalence of amphetamine use among treatment-seeking, opioid-dependent adults, explored whether amphetamine users were as likely as nonamphetamine users to enroll in opioid-dependence treatment trials, and determined whether amphetamine users manifested greater levels of medical and psychiatric comorbidity than nonusers.
Methods
The sample included 1257 opioid-dependent adults screened for participation in three-multisite studies of the National Drug Abuse Treatment Clinical Trials Network (CTN001-003), which studied the effectiveness of buprenorphine for opioid detoxification under varying treatment conditions. Patients were recruited from 23 addiction treatment programs across the US. Medical and psychiatric comorbidity were examined by past-month amphetamine use (current vs former) and route of administration. Five mutually exclusive groups were examined, ie, nonusers, current amphetamine injectors, current amphetamine noninjectors, former amphetamine injectors, and former amphetamine noninjectors.
Results
Of the sample (n = 1257), 22.3% had a history of regular amphetamine use. Of the 280 amphetamine users, 30.3% reported injection as their primary route. Amphetamine users were more likely than nonusers to be white and use more substances. Amphetamine users were as likely as nonusers to enroll in treatment trials. Bivariate analyses indicated elevated rates of psychiatric problems (depression, anxiety, hallucinations, cognitive impairment, violence, suicidal thoughts/attempts) and medical illnesses (dermatological, hepatic, cardiovascular, respiratory, neurological, seizure, allergy conditions) among amphetamine users. After adjusting for demographic variables and lifetime use of other substances: current amphetamine users and former injectors showed an increased likelihood of having medical illnesses and hospitalizations; current injectors had elevated odds of suicidal thoughts or attempts; current noninjectors exhibited elevated odds of anxiety, cognitive impairment, and violent behaviors; and former noninjectors had increased odds of depression.
Conclusion
Treatment-seeking, amphetamine-using, opioid-dependent adults manifest greater levels of medical and psychiatric morbidity than treatment-seeking, opioid-dependent adults who have not used amphetamines, indicating a greater need for intensive clinical management.
Methamphetamine (MAP) abuse continues to increase worldwide, based on morbidity, mortality, drug treatment, and epidemiologic studies and surveys. MAP abuse has become a significant health care, environmental, and law enforcement problem. Acute intoxication often results in agitation, violence, and death. Chronic use may lead to infection, heart failure, malnutrition, and permanent psychiatric illness. MAP users frequently use the emergency department (ED) for their medical care. Over a 6-month period we studied the demographics, type, and frequency of medical and traumatic problems in 461 MAP patients presenting to our ED, which serves an area noted for high levels of MAP production and consumption. Comparison was made to the general ED population to assess use patterns. MAP patients were most commonly Caucasian males who lacked health insurance. Compared to other ED patients during this time, MAP patients used ambulance transport more and were more likely to be admitted to the hospital. There was a significant association between trauma and MAP use in this patient population. Our data suggest MAP users utilize prehospital and hospital resources at levels higher than the average ED population. Based on current trends, we can expect more ED visits by MAP users in the future.
Methamphetamine use has clearly reached epidemic proportions in large parts of the western and midwestern US. Because of the regional specificity of methamphetamine use, there is speculation that it may be a temporary problem and not a long-term public health problem. Unfortunately there are a number of factors that suggest that significant methamphetamine problems may persist or even expand. For this reason, it is important that federal law enforcement, prevention, research and treatment agencies prepare strategies to address the likelihood of this persisting problem. This article reviews the issues concerning the future of the methamphetamine problem in the US and provides some recommendations for setting priorities to address the problem.
Patients who leave hospital against medical advice (AMA) may be at risk of adverse health outcomes and readmission. In this study we examined rates of readmission and predictors of readmission among patients leaving hospital AMA.
We prospectively studied 97 consecutive patients who left the general medicine service of an urban teaching hospital AMA. Each patient was matched according to age, sex and primary diagnosis with a control patient who was discharged routinely. Readmission rates were examined using Kaplan-Meier analysis. Regression models were used to test the hypothesis that readmissions among patients discharged AMA followed a biphasic curve.
Patients who left AMA were much more likely than the control patients to be readmitted within 15 days (21% v. 3%, p < 0.001). Readmissions occurred at an accelerated pace during the first 15 days, followed by a 75-day period during which readmissions occurred at a rate comparable to that among the control patients. Among the patients who left AMA, being male and having a history of alcohol abuse were significant predictors of readmission within 15 days; however, these characteristics were common among the patients who left AMA. In the Cox proportional hazard models, leaving AMA was the only significant predictor of readmission (adjusted hazard ratio 2.5, 95% confidence interval 1.4-4.4).
The significantly increased risk of readmission among general medicine patients who leave hospital AMA is concentrated in the first 2 weeks after discharge. However, it is difficult to identify which patients will likely be readmitted.
The Methamphetamine Treatment Project (MTP) offers the opportunity to examine co-occurring psychiatric conditions in a sample of 1016 methamphetamine users participating in a multisite outpatient treatment study between 1999-2001. Participants reported high levels of psychiatric symptoms, particularly depression and attempted suicide, but also anxiety and psychotic symptoms. They also reported high levels of problems controlling anger and violent behavior, with a correspondingly high frequency of assault and weapons charges. Findings continue to support the value of integrated treatment for co-occurring conditions, especially the importance of training counseling staff to handle psychotic symptoms when needed.
The Network for the Improvement of Addiction Treatment (NIATx) teaches participating treatment centers to use process improvement strategies. A cross-site evaluation monitored impacts on days between first contact and first treatment and percent of patients who started treatment and completed two, three and four units of care (i.e., one outpatient session, 1 day of intensive outpatient care, and 1 week of residential treatment). The analysis included 13 agencies that began participation in August 2003, submitted 10-15 months of data, and attempted improvements in outpatient (n=7), intensive outpatient (n=4) or residential treatment services (n=4) (two agencies provided data for two levels of care). Days to treatment declined 37% (from 19.6 to 12.4 days) across levels of care; the change was significant overall and for outpatient and intensive outpatient services. Significant overall improvement in retention in care was observed for the second unit of care (72-85%; 18% increase) and the third unit of care (62-73%; 17% increase); when level of care was assessed, a significant gain was found only for intensive outpatient services. Small incremental changes in treatment processes can lead to significant reductions in days to treatment and consistent gains in retention.
To compare the patient characteristics, clinical conditions, and short-term recidivism rates of emergency department (ED) patients who leave against medical advice (AMA) with those who leave without being seen (LWBS) or complete their ED care.
All eligible patients who visited the ED between July 1, 2004, and June 30, 2005 (N = 31,252) were classified into one of four groups: 1) AMA (n = 857), 2) LWBS (n = 2,767), 3) admitted (n = 8,894), or 4) discharged (n = 18,734). The patient characteristics, primary diagnosis, and 30-day rates of emergent hospitalizations, nonemergent hospitalizations, and ED discharge visits were compared between patients who left AMA and each of the other study groups. A Cox proportional hazards model was used to examine the influence of study group status on the risk of emergent hospitalization, adjusted for patient characteristics.
Patients who left AMA were significantly more likely to be uninsured or covered by Medicaid compared with those admitted or discharged (p < 0.001). The AMA visit rates were highest for nausea and vomiting (9.7%), abdominal pain (7.9%), and nonspecific chest pain (7.6%). During the 30-day follow-up period, patients who left AMA had significantly higher emergent hospitalization and ED discharge visit rates compared with each of the other study groups (p < 0.001). Insurance status, male gender, and higher acuity level were also associated with a significantly higher emergent hospitalization rate.
Patients who leave AMA may do so prematurely, as evidenced by higher emergent hospitalization rates compared with those who LWBS or complete their care.
Objectives: Implementation of the International Statistical Classification of Disease and Related Health Problems, 10th Revision (ICD-10) coding system presents challenges for using administrative data. Recognizing this, we conducted a multistep process to develop ICD-10 coding algorithms to define Charlson and Elixhauser comorbidities in administrative data and assess the performance of the resulting algorithms. Methods: ICD-10 coding algorithms were developed by "translation" of the ICD-9-CM codes constituting Deyo's (for Charlson comorbidities) and Elixhauser's coding algorithms and by physicians' assessment of the face-validity of selected ICD- 10, codes. The process of carefully developing ICD-10 algorithms also produced modified and enhanced ICD-9-CM coding algorithms for the Charlson and Elixhauser comorbidities. We then used data on in-patients aged 18 years and older in ICD-9-CM and ICD-10 administrative hospital discharge data from a Canadian health region to assess the comorbidity frequencies and mortality prediction achieved by the original ICD-9-CM algorithms, the enhanced ICD-9-CM algorithms, and the new ICD-10 coding algorithms. Results: Among 56,585 patients in the ICD-9-CM data and 58,805 patients in the ICD-10 data, frequencies of the 17 Charlson comorbidities and the 30 Elixhauser comorbidities remained generally similar across algorithms. The new ICD-10 and enhanced ICD9-CM coding algorithms either matched or outperformed the original Deyo and Elixhauser ICD-9-CM coding algorithms in predicting in-hospital mortality. The C-statistic was 0.842 for Deyo's ICD9-CM coding algorithm, 0.860 for the ICD-10 coding algorithm, and 0.859 for the enhanced ICD-9-CM coding algorithm, 0.868 for the original Elixhauser ICD-9-CM coding algorithm, 0.870 for the ICD-10 coding algorithm and 0.878 for the enhanced ICD-9-CM coding algorithm. Conclusions: These newly developed ICD-10 and ICD-9-CM comorbidity coding algorithms produce similar estimates of comorbidity prevalence in administrative data, and may outperform existing ICD-9-CM coding algorithms.
A survey of 8,034 primary care patients in a health maintenance organization examined the relationship between alcohol consumption and health care costs and service use. Costs were estimated from service use data for 1 year before and 2 years after study enrollment. No strong, consistent relationships were identified between multiple indicators of drinking patterns and either health care costs or service use. Compared with total costs among very light drinkers, former drinkers were higher, lifetime abstainers were similar, and persons in the higher drinking levels tended to have lower but not significantly different costs. Drinking patterns did not appear to be an important predictor of short-term health care costs or service use in this setting. Further study of former drinkers is warranted to examine the role of alcohol-related illnesses in the decision to quit drinking.
The primary aim of the present study was to assess the prevalence of psychiatric comorbidity in a large sample of methamphetamine (MA)-dependent subjects using a validated structured clinical interview, without limitation to sexual orientation or participation in a treatment program. The secondary aim was to assess whether the prevalence of psychiatric comorbidities varied by gender. Structured clinical interviews (SCIDs) were administered to 189 MA-dependent subjects and lifetime prevalence of DSM-IV diagnoses was assessed. Across the sample, 28.6% had primary psychotic disorders, 23.8% of which were substance-induced; 13.2% had MA-induced delusional disorders and 11.1% had MA-induced hallucinations. A substantial number of lifetime mood disorders were identified that were not substance-induced (32.3%), whereas 14.8% had mood disorders induced by substances, and 10.6% had mood disorders induced by amphetamines. Of all participants, 26.5% had anxiety disorders and 3.7% had a substance-induced anxiety disorder, all of which were induced by MA. Male subjects reported a higher percentage of MA-induced delusions compared to female abusers. Given the impact of MA psychosis and other drug-induced symptoms on hospitals and mental health services, the description and characterization of comorbid psychiatric symptoms associated with MA use is of paramount importance.
The clinical effects of methamphetamines (MA) may complicate medical management, potentially increasing resource utilization and hospital costs out of proportion to the patient's severity of injury. We hypothesize that minimally injured (MI) patients testing positive for MA consume more resources than patients testing negative for MA.
Adult trauma patients were identified from 4 years of registry data, which was linked to cost data from our center's financial department. Patients were classified as MI (Injury Severity Score <9) or severely injured (Injury Severity Score >9). Primary outcome was total direct costs for the inpatient hospital stay. Secondary outcomes included direct costs by cost center, contribution margin, and hospital length of stay.
Sixty-five percent (n = 6,193) of the 10,663 adult patients during the study period were admitted with MI. Nine percent (n = 557) of those tested were positive for MA. Total direct costs were higher in MI MA patients compared to nonusers ($2,998 vs. $2,667, p < 0.001), and users consumed more resources in all 10 cost centers. The same multivariate model showed marginally increased costs with MI alcohol users, but not with MI cocaine users or severely injured MA users.
MI MA patients consume more resources than patients testing negative for MA. Although MA use complicates the initial evaluation of patients, resource consumption was increased for all cost centers representing the entirety of a patients hospital stay, suggesting that the influence of MA is not limited to the initial diagnostic workup. Centers with high proportions of MA users may realize significant losses if compensation contracts are inadequate.
The objective of this study was to develop a prospectively applicable method for classifying comorbid conditions which might alter the risk of mortality for use in longitudinal studies. A weighted index that takes into account the number and the seriousness of comorbid disease was developed in a cohort of 559 medical patients. The 1-yr mortality rates for the different scores were: "0", 12% (181); "1-2", 26% (225); "3-4", 52% (71); and "greater than or equal to 5", 85% (82). The index was tested for its ability to predict risk of death from comorbid disease in the second cohort of 685 patients during a 10-yr follow-up. The percent of patients who died of comorbid disease for the different scores were: "0", 8% (588); "1", 25% (54); "2", 48% (25); "greater than or equal to 3", 59% (18). With each increased level of the comorbidity index, there were stepwise increases in the cumulative mortality attributable to comorbid disease (log rank chi 2 = 165; p less than 0.0001). In this longer follow-up, age was also a predictor of mortality (p less than 0.001). The new index performed similarly to a previous system devised by Kaplan and Feinstein. The method of classifying comorbidity provides a simple, readily applicable and valid method of estimating risk of death from comorbid disease for use in longitudinal studies. Further work in larger populations is still required to refine the approach because the number of patients with any given condition in this study was relatively small.
To investigate the hypothesis that increasing alcohol consumption is accompanied by increasing use of acute, but decreasing use of preventative, medical services among the general population.
Health and life-style survey of 41,000 randomly-sampled adults in SE England who self-completed a validated questionnaire covering socio-demographics, alcohol and tobacco usage and use of acute (A&E department and general practitioner) and preventative (dental, optician, mammography and cervical cytology) services: the response rate was 60%.
Comparative use of acute and preventative health care services by patients with varying consumption of alcoholic beverages. This was estimated by the odds ratio for service use, after correcting for the following confounding variables; age, social class, ethnic group, employment status, whether lives with children or with other adults, whether is a career, limiting long-term illness, depression status, smoking habit and use of private health insurance.
There was increased use of accident and emergency services by the harmful and intermediate drinking groups compared with the safe drinking group. Male abstainers attended their A&E departments more frequently than 'safe limit' drinkers. With respect to preventative services, both male and female abstainers and harmful drinkers used dental services less than safe limit drinkers. For females, mammography and cervical cytology services were less frequently used by abstainers and by harmful drinkers.
This study supports the generally held view that heavy alcohol consumers are disproportionate users of acute medical services but they are relative under-users of preventative medical care services. Alcohol abstainers are also over-users of acute services, but under-users of preventative services. These latter observations are relevant to the claims that moderate alcohol consumers have lower apparent morbidity and mortality rates compared to abstainers.
The purpose of this study was to examine the relationships between problem drinking, health services utilization, and the cost of medical care in a community-based setting. In addition to descriptive analyses, these relationships were estimated with multivariate regression models. Data were collected in 1996 and 1997 through a standardized self-administered questionnaire designed to obtain important information on demographics, health status, morbidity, health care utilization, drug and alcohol use, and related lifestyle behaviors. The survey instrument also included the 10-item Michigan Alcoholism Screening Test (MAST-10), which was used to identify problematic alcohol users (PAUs). The empirical findings indicated that PAUs had a significantly higher number of outpatient visits, more emergency room episodes, and more admissions to a hospital than a combined group of nondrinkers and nonproblematic alcohol users (NPAUs). Analyses of total health care cost showed that the estimated differential in total cost for PAUs during the past year, including the interaction effect with problematic drug use, was $367. The total cost (full effect) for PAUs was composed of a main effect ($984) and an interaction effect (-$617). These findings have implications for substance abuse interventions and health care policy.
The comorbidity variables that constitute the Charlson index are widely used in health care research using administrative data. However, little is known about the validity of administrative data in these comorbidities. The agreement between administrative hospital discharge data and chart data for the recording of information on comorbidity was evaluated. The predictive ability of comorbidity information in the two data sets for predicting in-hospital mortality was also compared.
One thousand two hundred administrative hospital discharge records were randomly selected in the region of Calgary, Alberta, Canada in 1996 and used a published coding algorithm to define the 17 comorbidities that constitute the Charlson index. Corresponding patient charts for the selected records were reviewed as the "criterion standard" against which validity of the administrative data were judged.
Compared with the chart data, administrative data had a lower prevalence in 10 comorbidities, a higher prevalence in 3 and a similar prevalence in 4. The kappa values ranged from a high of 0.87 to a low of 0.34; agreement was therefore near perfect for one variable, substantial for six, moderate for nine, and only fair for one variable. For the Charlson index score ranging from 0 to 5 to 6 or higher, agreement was moderate to substantial (kappa = 0.56, weighted kappa = 0.71). When 16 Charlson comorbidities from administrative data were used to predict in-hospital mortality, 10 comorbidities and the index scores defined using administrative data yielded odds ratios that were similar to those derived from chart data. The remaining six comorbidities yielded odds ratios that were quite different from those derived from chart data.
Administrative data generally agree with patient chart data for recording of comorbidities although comorbidities tend to be under-reported in administrative data. The ability to predict in-hospital mortality is less reliable for some of the individual comorbidities than it is for the summarized Charlson index scores in administrative data.
Previous research has identified risk factors for early attrition from substance abuse treatment, but has not assessed reasons for dropout from the client's perspective. Interview and self-report assessment data were collected from 24 clients who prematurely terminated outpatient treatment to evaluate their subjective reasons for dropping out and the association of these reasons with demographic and clinical variables. Items from scales indicating problems with client motivation or conflicts with program staff were the most commonly endorsed. The severity of participant's symptoms and logistical problems interfering with appointments were less commonly reported as reasons for dropping out. Demographic, substance abuse, and motivational stage indicators were infrequently associated with subjective reasons for dropout. In contrast, indicators of maladaptive personality functioning were strongly associated with many reasons for dropping out, especially concerns about privacy and boundary issues within the program. Results from this preliminary evaluation will guide the development of an instrument and intervention focused on dropout risk factors and treatment reengagement.
Implementation of the International Statistical Classification of Disease and Related Health Problems, 10th Revision (ICD-10) coding system presents challenges for using administrative data. Recognizing this, we conducted a multistep process to develop ICD-10 coding algorithms to define Charlson and Elixhauser comorbidities in administrative data and assess the performance of the resulting algorithms.
ICD-10 coding algorithms were developed by "translation" of the ICD-9-CM codes constituting Deyo's (for Charlson comorbidities) and Elixhauser's coding algorithms and by physicians' assessment of the face-validity of selected ICD-10 codes. The process of carefully developing ICD-10 algorithms also produced modified and enhanced ICD-9-CM coding algorithms for the Charlson and Elixhauser comorbidities. We then used data on in-patients aged 18 years and older in ICD-9-CM and ICD-10 administrative hospital discharge data from a Canadian health region to assess the comorbidity frequencies and mortality prediction achieved by the original ICD-9-CM algorithms, the enhanced ICD-9-CM algorithms, and the new ICD-10 coding algorithms.
Among 56,585 patients in the ICD-9-CM data and 58,805 patients in the ICD-10 data, frequencies of the 17 Charlson comorbidities and the 30 Elixhauser comorbidities remained generally similar across algorithms. The new ICD-10 and enhanced ICD-9-CM coding algorithms either matched or outperformed the original Deyo and Elixhauser ICD-9-CM coding algorithms in predicting in-hospital mortality. The C-statistic was 0.842 for Deyo's ICD-9-CM coding algorithm, 0.860 for the ICD-10 coding algorithm, and 0.859 for the enhanced ICD-9-CM coding algorithm, 0.868 for the original Elixhauser ICD-9-CM coding algorithm, 0.870 for the ICD-10 coding algorithm and 0.878 for the enhanced ICD-9-CM coding algorithm.
These newly developed ICD-10 and ICD-9-CM comorbidity coding algorithms produce similar estimates of comorbidity prevalence in administrative data, and may outperform existing ICD-9-CM coding algorithms.
This report describes trends in treatment admissions for methamphetamine/amphetamine (MA) abuse from 1992 to 2002 in California and assesses predictors of treatment retention and completion. Results show such admissions increasing fivefold and representing a growing proportion of overall treatment admissions. Patients admitted for MA abuse were increasingly diverse in race/ethnicity, older in age, and more frequently under legal supervision status over time. There was a decrease in injection drug use. Several user characteristics played consistent roles as risk factors for noncompletion and shorter treatment retention for both residential and outpatient admissions: having lower than a high school education, being younger at treatment admission, having a disability, having greater severity of MA use, and using injection drugs. Consistently, those with legal supervision status at admission had higher completion rates and longer retention than those reporting no legal status. Overall, findings suggested that clients with greater socioeconomic disadvantage and more severe problems may require greater efforts (e.g., services) to be retained in treatment.
To present national data on the prevalence, correlates, and comorbidity of nonmedical prescription drug use and drug use disorders for sedatives, tranquilizers, opioids, and amphetamines.
Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a face-to-face nationally representative survey of 43,093 adults conducted during 2001 and 2002.
Lifetime prevalences of nonmedical use of sedatives, tranquilizers, opioids, and amphetamines were 4.1%, 3.4%, 4.7%, and 4.7%, respectively. Corresponding rates of abuse and/or dependence on these substances were 1.1%, 1.0%, 1.4%, and 2.0%. The odds of nonmedical prescription drug use and drug use disorders were generally greater among men, Native Americans, young and middle-aged, those who were widowed/ separated/divorced or never married, and those residing in the West. Abuse/dependence liability was greatest for amphetamines, and nonmedical prescription drug use disorders were highly comorbid with other Axis I and II disorders. The majority of individuals with non-medical prescription drug use disorders never received treatment.
Nonmedical prescription drug use and disorders are pervasive in the U.S. population and highly comorbid with other psychiatric disorders. Native Americans had significantly greater rates of nonmedical prescription drug use and drug use disorders, highlighting the need for culturally-sensitive prevention and intervention programs. Unprecedented comorbidity between nonmedical prescription drug use disorders and between nonmedical prescription drug use disorders and illicit drug use disorders suggests that the typical individual abusing or dependent on these drugs obtained them illegally, rather than through a physician. Amphetamines had the greatest abuse/dependence liability, and recent increases in the potency of illegally manufactured amphetamines may portend an epidemic in the youngest NESARC cohort.
To examine the prevalence of psychotic symptoms among regular methamphetamine users.
Cross-sectional survey.
Participants were recruited from Sydney, Australia, through advertisements in free-press magazines, flyers and through word-of-mouth.
Methamphetamine users (n = 309) who were aged 16 years or over and took the drug at least monthly during the past year.
A structured face-to-face interview was used to assess drug use, demographics and symptoms of psychosis in the past year. Measures of psychosis included: (a) a psychosis screening instrument derived from the Composite International Diagnostic Interview; and (b) the Brief Psychiatric Rating Scale subscales of suspiciousness, unusual thought content, and hallucinations. Dependence on methamphetamine was measured using the Severity of Dependence Scale.
Thirteen per cent of participants screened positive for psychosis, and 23% had experienced a clinically significant symptom of suspiciousness, unusual thought content or hallucinations in the past year. Dependent methamphetamine users were three times more likely to have experienced psychotic symptoms than their non-dependent counterparts, even after adjusting for history of schizophrenia and other psychotic disorders.
The prevalence of psychosis among the current sample of methamphetamine users was 11 times higher than among the general population in Australia. Dependent methamphetamine users are a particularly high-risk group for psychosis.
A discharge against medical advice (AMA) after an asthma hospitalization is a frustrating problem for health care providers, yet little is known about this occurrence.
To determine the baseline characteristics, reasons for leaving, and clinical outcomes of patients with asthma who leave AMA.
A retrospective study from 1999 to 2004 of all asthma discharges from 3 large hospitals in Detroit compared those who left AMA with those who left with medical approval.
There were 180 patients who left AMA and 3457 patients who had a standard discharge. Patients with asthma who left AMA were more likely to be younger, male, have Medicaid or lack insurance, require intensive care unit admission, and have a lower socioeconomic status than patients with asthma discharged with approval (P < .05 for all comparisons). There was no difference in race, day of the week admitted, or month admitted. Among records that documented a reason for leaving AMA, the most common was dissatisfaction with care, although a variety of motives were found. Finally, patients who left AMA were more likely to have an asthma relapse within 30 days. This included both emergency department revisits (21.7% vs 5.4%; P < .001) and readmission to the hospital (8.5% vs 3.2%; P < .001).
Patients with asthma who leave AMA have demographic and hospital admission characteristics that differ from those who leave with approval. The reasons why patients with asthma leave AMA are varied. Within 30 days, patients with asthma who leave AMA have much higher readmission and emergency department return rates.
Patients with asthma who leave AMA are at increased risk of relapse.
Approximately 1% of patients leave hospitals against medical advice, but the clinical significance of premature hospital discharge is unknown, particularly after admission for acute myocardial infarction (AMI).
We used California hospital discharge data (1998-2000) to compare readmissions and mortality among patients admitted for AMI who were discharged against medical advice with those who weren't. Effects were adjusted for age, race, income, comorbidity, insurance, and hospital characteristics. We also examined whether the effects of premature hospital discharge were partly explained by lower rates of coronary revascularization.
There were 1079 patients (1.1% of the sample) with AMI on admission who left against medical advice. Compared with those who didn't leave against medical advice, these patients were younger, more often male, low income, black, insured through Medicaid or uninsured, and had less physical comorbidity, but greater mental health comorbidity. Their mean length of stay was shorter (4 vs 8 days) than those who stayed. They were transferred less often. They received fewer cardiac procedures, including coronary revascularization. In multivariate analyses, they had 60% higher risk for death or re-admission for AMI or unstable angina up to 2 years postdischarge than patients with standard discharge (hazard ratio 1.59; 95% confidence interval, 1.43-1.77). Adjustment for revascularization attenuated, but did not eliminate, this risk (hazard ratio 1.39; 95% confidence interval, 1.25-1.55).
Discharge against medical advice after AMI is associated with appreciable morbidity and mortality. These results should be used to manage AMI patients contemplating such discharge.
The major physical and psychological health effects of methamphetamine use, and the factors associated with such harms.
Comprehensive review.
Physical harms reviewed included toxicity and mortality, cardiovascular/cerebrovascular pathology, dependence and blood-borne virus transmission. Psychological harms include methamphetamine psychosis, depression, suicide, anxiety and violent behaviours.
While high-profile health consequences, such as psychosis, are given prominence in the public debate, the negative sequelae extend far beyond this. This is a drug class that causes serious heart disease, has serious dependence liability and high rates of suicidal behaviours.
The current public image of methamphetamine does not portray adequately the extensive, and in many cases insidious, harms caused.
Major physical and psychological harms of methamphetamine use.
- Darke
Prevalence, correlates, and comorbidity of nonmedical prescription drug use and drug use disorders in the United States: results of the National Epidemiologic Survey on Alcohol and Related Conditions.
- Huang
Validity of information on comorbidity derived from ICD-9-CM administrative data.
- Quan
Will the MA problem go away J Addict D
- Rawson