There has been a substantial rise in the number of publications and training opportunities on the care and treatment of emergency department (ED) patients with opioid use disorder over the past several years. The American College of Emergency Physicians recently published recommendations for providing buprenorphine to patients with opioid use disorder, but barriers to implementing this clinical practice remain. We describe the models for implementing ED-initiated buprenorphine at 4 diverse urban, academic medical centers across the country as part of a federally funded effort termed "Project ED Health." These 4 sites successfully implemented unique ED-initiated buprenorphine programs as part of a comparison of implementation facilitation to traditional educational dissemination on the uptake of ED-initiated buprenorphine. Each site describes the elements central to the ED process, including screening, treatment initiation, referral, and follow-up, while harnessing organizational characteristics, including ED culture. Finally, we discuss common facilitators to program success, including information technology and electronic medical record integration, hospital-level support, strong connections with outpatient partners, and quality improvement processes. Copyright (C) 2022 by the American College of Emergency Physicians.

Background: Social connections can lead to contagion of healthy behaviors. Successful treatment of patients with opioid use disorder may lay in rebuilding social networks. Strong social networks of support can reinforce the benefits of medication treatments that are the current standard of care and the most effective tool physicians have to fight the opioid epidemic. Methods: The research team conducted a systematic review of electronic research databases, specialist journals and grey literature up to August 2020 to identify randomized controlled trials of social network support in patient populations receiving medication for opioid use disorder (MOUD). The research team placed the studies into a framework of dynamic social networks, examining the role of networks before MOUD treatment is initiated, during the treatment, and in the long-term following the treatment. The research team analyzed the results across three sources of social network support: partner relationships, family, and peer networks. Results: Of 5193 articles screened, eight studies were identified as meeting inclusion criteria. Five studies indicated that social network support had a statistically significant effect on improved MOUD treatment outcomes. We find the strongest support for the positive impact of family social network support. Conclusions: Social networks significantly shape effectiveness of opioid use disorder treatments. While negative social ties reinforce addiction, positive social support networks can amplify the benefits of medication treatments. Targeted interventions to improve treatment outcomes can be designed and added to MOUD treatment with their effects evaluated in improving patients' odds of recovery from opioid use disorder and reversing the rising trend in opioid deaths.

BackgroundPatients with opioid use disorder (OUD) frequently present to the emergency department (ED) after overdose, or seeking treatment for general medical conditions, their addiction, withdrawal symptoms, or complications of injection drug use, such as soft tissue infections. ED-initiated buprenorphine has been shown to be effective in increasing patient engagement in treatment compared with brief intervention with a facilitated referral or referral alone. However, adoption into practice has lagged behind need. To address this implementation challenge, we are evaluating the impact of implementation facilitation (IF) on the adoption of ED-initiated buprenorphine for OUD into practice.MethodsThis protocol describes a study that is being conducted through the National Institute on Drug Abuse's Center for the Clinical Trials Network. A hybrid type III effectiveness-implementation study design is used to evaluate the effectiveness of a standard educational dissemination strategy versus IF on implementation (primary) and effectiveness (secondary) outcomes in four urban, academic EDs. Sites start with a standard 60-min Grand Rounds educational intervention describing the prevalence of ED patients with OUD, the evidence for opioid agonist treatment and for innovative interventions with ED-initiated buprenorphine; followed by a 1-year baseline evaluation period. Using a modified stepped wedge design, sites are randomly assigned to the IF intervention which is guided by the Promoting Action on Research Implementation in Health Services (PARiHS) framework to assess evidence, context, and facilitation-related factors impacting the adoption of ED-initiated buprenorphine. During the 6months of IF through the 1-year IF evaluation period, external facilitators work with local stakeholders to tailor and refine a bundle of activities to meet the site's needs. The primary analyses compare the baseline evaluation period to the IF evaluation period (n=120 patients with untreated OUD enrolled during each period) on (1) rates of provision of ED-initiated buprenorphine by ED providers with referral for ongoing medication (implementation outcome) and (2) rates of patient engagement in addiction treatment on the 30th day after the ED visit (effectiveness outcome). Finally, we will perform a cost-effectiveness analysis (CEA) to determine if the effectiveness benefits are worth the additional costs.DiscussionResults will generate novel information regarding the impact of IF as a strategy to promote ED-initiated buprenorphine.Trial registrationClinicalTrials.gov NCT03023930 first posted 1/10/2017, https://clinicaltrials.gov/ct2/show/NCT03023930?term=0069&rank=1

The purpose of this project was to assess the feasibility and acceptability of a hatha yoga program designed to target chronic pain in people receiving opioid agonist therapy for opioid use disorder. We conducted a pilot randomized trial in which people with chronic pain who were receiving either methadone maintenance therapy (n = 20) or buprenorphine (n = 20) were randomly assigned to weekly hatha yoga or health education (HE) classes for 3 months. We demonstrated feasibility in many domains, including recruitment of participants (58% female, mean age 43), retention for follow-up assessments, and ability of teachers to provide interventions with high fidelity to the manuals. Fifty percent of participants in yoga (95% CI: 0.28–0.72) and 65% of participants in HE (95% CI: 0.44–0.87) attended at least 6 of 12 possible classes (p = 0.62). Sixty-one percent in the yoga group reported practicing yoga at home, with a mean number of times practicing per week of 2.67 (SD = 2.37). Participant mood improved pre-class to post-class, with greater decreases in anxiety and pain for those in the yoga group (p < 0.05). In conclusion, yoga can be delivered on-site at opioid agonist treatment programs with home practice taken up by the majority of participants. Future research may explore ways of increasing the yoga “dosage” received. This may involve testing strategies for increasing either class attendance or the amount of home practice or both.

Emergency physicians are uniquely positioned to deliver interventions after management of non-fatal opioid overdose, but little is known about how to most effectively engage patients to improve morbidity and mortality in this vulnerable, high risk population. We sought to develop, refine and pilot a tailored, multi-step intervention for out-of-treatment ED patients after acute opioid overdose that will be acceptable to patients, increase engagement in treatment for opioid use disorder, and improve knowledge of overdose prevention strategies. Using a sequential exploratory mixed-methods design, perceived treatment needs and attitudes of out-of-treatment emergency department patients after acute opioid overdose were collected by conducting real-time qualitative interviews with a focus on identifying: (1) facilitators and barriers to accessing treatment for substance use disorders (SUDs) and (2) acceptability of overdose prevention education and naloxone distribution. A purposive sample of 24 adult opioid overdose survivors receiving ED care was identified through screening or staff referral. Included patients were not suicidal, not currently in treatment for a substance use disorder (SUD), and provided consent. Participants were asked about age, race, lifetime number of opioid overdoses, and assessed for opioid dependence using the DSM-IV (MINI-SCID). Interviews were audio-recorded, transcribed verbatim and independently coded using thematic analysis. An interview guide with the domains of overdose knowledge, drug use and treatment history, and perceived needs was used. A codebook was generated using open and axial coding and constant comparison, and data were collected and analyzed iteratively. We identified common patterns across the dataset and grouped them into themes. An audit trail was maintained. Participant incentive was provided. A multi-component intervention for ED patients after acute opioid overdose was created to increase engagement in treatment for OUD and the adoption of overdose prevention and harm reduction strategies. Interview data has been incorporated into our manualized motivational interview based psychosocial intervention, which includes components of overdose prevention education, naloxone distribution, harm reduction, and an offer for the ED initiation of buprenorphine and linkage to treatment. Iterative pilot testing of our multi-component intervention is currently underway. Participants were an average of 31 years old (range: 22-56), 83% white, 12% black, opioid dependent (83% MINI-SCID+), 67% male, with a median of 2 lifetime opioid overdoses (interquartile range from 2-3; range: 1-11). All reported heroin use preceding most recent overdose. Emergent themes include (1) limited knowledge of overdose prevention strategies, moderate knowledge of overdose response strategies and excellent knowledge of overdose recognition; (2) SUD minimization despite multiple overdoses; (3) ambivalence about SUD treatment effectiveness, with a stated need for social support (eg, housing, mental health); (4) a strong desire to stop opioid use, without concrete strategy as SUD treatment referrals were often refused. Understanding opioid overdose survivors’ knowledge and perceived needs can provide opportunities to improve ED care and referrals for this vulnerable population at high risk for fatal overdose.

Importance:Previous studies have found racial and ethnic inequities in the receipt of academic awards, such as promotions and National Institutes of Health research funding, among academic medical center faculty. Few data exist about similar racial/ethnic disparities at the level of undergraduate medical education.Objective:To examine the association between medical student race/ethnicity and induction into the Alpha Omega Alpha (AΩA) honor society.Design, Setting, and Participants:This study analyzed data from the Electronic Residency Application Service, the official service used by US medical students to apply to residency programs. A total of 4655 US medical students from 123 allopathic US medical schools who applied to 12 distinct residency programs associated with one academic health center in the 2014 to 2015 academic year were studied.Main Outcomes and Measures:Membership in the AΩA society among black, white, Hispanic, and Asian medical students.Results:A total of 4655 unique applications were analyzed in the study (median age, 26 years; 2133 women [45.8%]). Overall, self-reported race/ethnicity in our sample was 2605 (56.0%) white (691 [71.5%] of AΩA applicants were white), 276 (5.9%) black (7 [0.7%] AΩA), 186 (4.0%) Hispanic (27 [2.8%] AΩA), and 1170 (25.1%) Asian (168 [17.4%] AΩA). After controlling for US Medical Licensing Examination Step 1 scores, research productivity, community service, leadership activity, and Gold Humanism membership, the study found that black (adjusted odds ratio [aOR], 0.16; 95% CI, 0.07-0.37) and Asian (aOR, 0.52; 95% CI, 0.42-0.65) medical students remained less likely to be AΩA members than white medical students. No statistically significant difference was found in AΩA membership between white and Hispanic medical students (aOR, 0.79; 99% CI, 0.45-1.37) in the adjusted model.Conclusions and Relevance:Black and Asian medical students were less likely than their white counterparts to be members of AΩA, which may reflect bias in selection. In turn, AΩA membership selection may affect future opportunities for minority medical students.

BACKGROUND:Quantitative urine buprenorphine testing is used to monitor patients receiving buprenorphine for the treatment of opioid use disorder (OUD), however the interpretation of urine buprenorphine testing is complex. Currently, interpretation of quantitative buprenorphine testing is guided by data from drug assay development studies and forensic labs rather than clinical treatment cohorts. METHODS:In this retrospective study, we describe the patterns of urine buprenorphine and norbuprenorphine levels in patients prescribed sublingual buprenorphine for OUD in an office-based addiction treatment clinic. Urine buprenorphine and norbuprenorphine levels were analyzed in patients who reported having adulterated their urine, patients clinically suspected of adulterating their urine, and patients without concern for urine adulteration. Finally, we tested the accuracy of urine buprenorphine, norbuprenorphine, and norbuprenorphine: buprenorphine ratio (Norbup:Bup) to identify adulterated urine samples. RESULTS:Patients without suspicion for urine adulteration rarely provided specimens with buprenorphine >=1000ng/ml (4.4%), while the proportion provided by those who endorsed or were suspected of urine adulteration was higher (42.9%, 40.6%, respectively). Compared to patients without reported urine adulteration, specimens from patients who reported or were suspected of urine adulteration had significantly higher buprenorphine (p=0.0001) and lower norbuprenorphine (<0.0001) levels, and significantly lower Norbup:Bup ratios (p=0.04). Buprenorphine >=700ng/ml offered the best accuracy for discriminating between adulterated and non-adulterated specimens. CONCLUSION:This study describes the patterns of urine buprenorphine and norbuprenorphine levels from patients with OUD receiving buprenorphine treatment in an office-based addiction treatment clinic. Parameters for identifying urine adulterated by submerging buprenorphine medication in the urine specimen are discussed.

BACKGROUND:Despite increasing reliance on prescription drug monitoring programs (PDMPs) as a response to the opioid epidemic, the relationship between aberrant drug-related behaviors captured by the PDMP and opioid use disorder is incompletely understood. How PDMP data should guide emergency department (ED) assessment has not been studied.OBJECTIVES:The objective was to evaluate a relationship between PDMP opioid prescription records and self-reported nonmedical opioid use of prescription opioids in a cohort of opioid-dependent ED patients enrolled in a treatment trial.METHODS:PDMP opioid prescription records during 1 year prior to study enrollment on 329 adults meeting Diagnostic and Statistical Manual IV criteria for opioid dependence entering a randomized clinical trial in a large, urban ED were cross-tabulated with data on 30-day nonmedical prescription opioid use self-report. The association among these two types of data was assessed by the Goodman and Kruskal's gamma; a logistic regression was used to explore characteristics of participants who had PDMP record of opioid prescriptions.RESULTS:During 1 year prior to study enrollment, 118 of 329 (36%) patients had at least one opioid prescription (range = 1-51) in our states' PDMP. Patients who reported ≥15 of 30 days of nonmedical prescription opioid use were more likely to have at least four PDMP opioid prescriptions (20/38; 53%) than patients reporting 1 to 14 days (14/38, 37%) or zero days of nonmedical prescription opioid use (4/38, 11%; p = 0.002). Female sex and having health insurance were significantly more represented in the PDMP (p < 0.05 for both).CONCLUSION:PDMPs may be helpful in identifying patients with certain aberrant drug-related behavior, but are unable to detect many patients with opioid use disorder. The majority of ED patients with opioid use disorder were not captured by the PDMP, highlighting the importance of using additional methods such as screening and clinical history to identify opioid use disorders in ED patients and the limitations of PDMPs to detect opioid use disorders.

Emergency department (ED)-initiated buprenorphine/naloxone with continuation in primary care was found to increase engagement in addiction treatment and reduce illicit opioid use at 30 days compared to referral only or a brief intervention with referral.To evaluate the long-term outcomes at 2, 6 and 12 months following ED interventions.Evaluation of treatment engagement, drug use, and HIV risk among a cohort of patients from a randomized trial who completed at least one long-term follow-up assessment.A total of 290/329 patients (88% of the randomized sample) were included. The followed cohort did not differ significantly from the randomized sample.ED-initiated buprenorphine with 10-week continuation in primary care, referral, or brief intervention were provided in the ED at study entry.Self-reported engagement in formal addiction treatment, days of illicit opioid use, and HIV risk (2, 6, 12 months); urine toxicology (2, 6 months).A greater number of patients in the buprenorphine group were engaged in addiction treatment at 2 months [68/92 (74%), 95% CI 65-83] compared with referral [42/79 (53%), 95% CI 42-64] and brief intervention [39/83 (47%), 95% CI 37-58; p < 0.001]. The differences were not significant at 6 months [51/92 (55%), 95% CI 45-65; 46/70 (66%) 95% CI 54-76; 43/76 (57%) 95% CI 45-67; p = 0.37] or 12 months [42/86 (49%) 95% CI 39-59; 37/73 (51%) 95% CI 39-62; 49/78 (63%) 95% CI 52-73; p = 0.16]. At 2 months, the buprenorphine group reported fewer days of illicit opioid use [1.1 (95% CI 0.6-1.6)] versus referral [1.8 (95% CI 1.2-2.3)] and brief intervention [2.0 (95% CI 1.5-2.6), p = 0.04]. No significant differences in illicit opioid use were observed at 6 or 12 months. There were no significant differences in HIV risk or rates of opioid-negative urine results at any time.ED-initiated buprenorphine was associated with increased engagement in addiction treatment and reduced illicit opioid use during the 2-month interval when buprenorphine was continued in primary care. Outcomes at 6 and 12 months were comparable across all groups.

BACKGROUND AND AIMS:In a recent randomized trial, patients with opioid dependence receiving brief intervention, emergency department (ED)-initiated buprenorphine and ongoing follow-up in primary care with buprenorphine (buprenorphine) were twice as likely to be engaged in addiction treatment compared with referral to community-based treatment (referral) or brief intervention and referral (brief intervention). Our aim was to evaluate the relative cost-effectiveness of these three methods of intervening on opioid dependence in the ED.DESIGN:Measured health-care use was converted to dollar values. We considered a health-care system perspective and constructed cost-effectiveness acceptability curves that indicate the probability each treatment is cost-effective under different thresholds of willingness-to-pay for outcomes studied.SETTING:An urban ED in the United States.PARTICIPANTS:Opioid-dependent patients aged 18 years or older.MEASUREMENTS:Self-reported 30-day assessment data were used to construct cost-effectiveness acceptability curves for patient engagement in formal addiction treatment at 30 days and the number of days illicit opioid-free in the past week.FINDINGS:Considering only health-care system costs, cost-effectiveness acceptability curves indicate that at all positive willingness-to-pay values, ED-initiated buprenorphine treatment was more cost-effective than brief intervention or referral. For example, at a willingness-to-pay threshold of $1000 for 30-day treatment engagement, we are 79% certain ED-initiated buprenorphine is most cost-effective compared with other studied treatments. Similar results were found for days illicit opioid-free in the past week. Results were robust to secondary analyses that included patients with missing cost data, included crime and patient time costs in the numerator, and to changes in unit price estimates.CONCLUSION:In the United States, emergency department-initiated buprenorphine intervention for patients with opioid dependence provides high value compared with referral to community-based treatment or combined brief intervention and referral.

Background: Effective counseling and pharmacotherapy for unhealthy alcohol use are rarely provided in HIV treatment settings to patients. Our goal was to describe factors influencing implementation of a stepped care model to address unhealthy alcohol use in HIV clinics from the perspectives of social workers, psychologists and addiction psychiatrists.Methods: We conducted two focus groups with Social Workers (n = 4), Psychologists (n = 2), and Addiction Psychiatrists (n = 4) involved in an ongoing randomized controlled trial evaluating the effectiveness of integrated stepped care for unhealthy alcohol use in HIV-infected patients at five Veterans Health Administration (VA) HIV clinics. Data collection and analyses were guided by the Consolidated Framework for Implementation Research (CFIR) domains, with a focus on the three domains which we considered to be most relevant: intervention characteristics (i.e. motivational interviewing, pharmacotherapy), the inner setting (i.e. HIV clinics), and characteristics of individuals (i.e. the providers). A multidisciplinary team used directed content analysis to identify major themes.Results: From the providers' perspective, the major implementation themes that emerged by CFIR domain included: (1) Intervention characteristics: providers valued tools and processes for facilitating patient motivation for treatment of unhealthy alcohol use given their perceived lack of motivation, but expressed a desire for greater flexibility; (2) Inner setting: treating unhealthy alcohol use in HIV clinics was perceived by providers to be consistent with VA priorities; and (3) Characteristics of individuals: there was high self-efficacy to conduct the intervention, an expressed need for more consistent utilization to maintain skills, and consideration of alternative models for delivering the components of the intervention.Conclusions: Use of the CFIR framework reveals that implementation of integrated stepped care for unhealthy alcohol use in HIV clinics is facilitated by tools to help providers enhance patient motivation or address unhealthy alcohol use among patients perceived to be unmotivated. Implementation may be facilitated by its consistency with organizational values and existing models of care and attention to optimizing provider self-efficacy and roles (i.e. approaches to treatment integration).

BACKGROUND: Chronic hepatitis C (HCV) infection is an important public health issue in New Zealand, and an increasing cause of advanced liver disease.METHOD: This study examined the 2015 data on hepatitis C serology in patients on opiate substitution at four Alcohol and Drug Services, as well as rates of referral and responses to treatment for HCV.RESULTS: Among 579 patients tested, 439 (76 %) were positive for HCV antibody. For a subgroup of patients, those who reported their first use of injecting since 2010, the prevalence of HCV antibody was 48%. Among 405 patients with PCR/viral load test on file, 206 had a positive result when most recently tested. In all, 191 patients were referred for treatment, and of the 91 treated, 68 achieved viral clearance. Overall, it was found that 131 (32%) patients with a PCR/viral load test on file had cleared the HCV without treatment, as indicated by at least one negative PCR.CONCLUSIONS: HCV remains highly prevalent in injecting drug users attending these clinics, with no important reduction in infection rates from past studies. There appears to be considerable rates of spontaneous viral clearance. Nevertheless, it remains important, from individual and public health perspectives, to refer patients for treatment, which is becoming increasingly effective and safe.

The goal of the current study was to use tree-based methods to identify moderators of acamprosate effect on abstinence from heavy drinking in COMBINE, the largest study of pharmacotherapy for alcoholism in the United States to date. We used three different tree-based methods for identification of subgroups with enhanced treatment response on acamprosate based on over 100 predictors measured at baseline in COMBINE. No heavy drinking during the last two months of treatment was the considered outcome. All three methods identified consecutive days of abstinence prior to treatment as the most important moderator of treatment effect. Acamprosate was beneficial for participants with shorter abstinence (1 week or less) especially when body mass index was low or normal. In this group, 46% of participants receiving active acamprosate abstained from heavy drinking compared to 23% of those receiving placebo acamprosate. Prior treatment, age, drinking goal and cognitive inefficiency were identified as moderators of acamprosate effects by one of the three methods. In conclusion, acamprosate may be beneficial for participants with shorter abstinence who are not overweight or obese. One hypothesis for this finding is that this subgroup may have greater glutamatergic hyperactivity, a target of acamprosate, and may achieve better drug plasma levels based on their lower BMI. In contrast, those with extended pretreatment abstinence who have an otherwise good prognosis did not benefit from acamprosate. Further validation of the results in independent data sets is necessary.

To determine whether treatment outcomes differed for prescription opioid and heroin use disorder patients, we conducted a secondary analysis of a 24-week (N = 140) randomized trial of physician management (PM) or PM plus cognitive behavioral therapy (CBT) in primary care buprenorphine/naloxone treatment. Self-reported opioid use and urine toxicology analyses were obtained weekly. We examined baseline demographic differences between primary prescription opioid use patients (n = 49) and primary heroin use patients (n = 91) and evaluated whether treatment response differed by assigned condition. Compared to primary heroin use patients, primary prescription opioid use patients had marginally fewer years of opioid use, were less likely to have had a previous drug treatment or detoxification, and were less likely to report injection drug use. Although opioid abstinence only, and treatment retention did not differ by opioid use group, opioid category moderated the effect of CBT on urine samples negative for all drugs. Primary prescription opioid use patients assigned to PM-CBT had more than twice the mean number of weeks of abstinence for all drugs (7.6) than those assigned to PM only (3.6; p = .02), while primary heroin use patients did not differ by treatment. Findings suggest that examination of other factors that may predict response to behavioral interventions is warranted.

Opioid Use Disorder (OUD) affects 16 million people worldwide and stems from the repeated use of opioids. Although standard care for OUD is based on harm reduction policy and relies on Opioid Maintenance Treatment, opioid detoxification still has some advantages over OMT. However, little is known about the medical community's views on this specific topic of the current advantages of detoxification.The objective of this study is to collect the views of GPs on detoxification and identify the facilitators, barriers and strategies associated with detoxification.We conducted a qualitative study using semi-structured in-person interviews with fifteen French GPs. After a triple-blind thematic analysis, main themes and sub-themes were selected after consensual agreement. We conducted an in-depth analysis of the discourse favouring an interdisciplinary approach.The main themes are: GPs' views on detoxification, facilitators, barriers and strategies associated with detoxification. Detoxification is seen through OMT tapering or inpatient detoxification. Facilitators of detoxification include a steady environment, sufficient motivation and trust. Barriers to detoxification include abuse of OMT, polydrug use, long periods of drug use and pregnancy. Alleged obstacles include lack of availability/knowledge and difficulty having access to specialised care. Strategies facilitating detoxification include a coordinated healthcare circuit involving multiple providers in a dedicated healthcare facility and the practice of physical activity.Detoxification is perceived through OMT tapering or inpatient detoxification. The conditions of practice influence the implementation of detoxification. This study shows that detoxification is possible in primary care in dedicated outpatient practices coordinated by GPs.

BACKGROUND:The goal of the current study was to use tree-based methods (Zhang and Singer, 2010, Recursive Partitioning and Applications, 2nd ed. Springer, New York) to identify predictors of abstinence from heavy drinking in COMBINE (Anton et al. JAMA 2006; 295:2003), the largest study of pharmacotherapy for alcoholism in the United States to date, and to validate these results in PREDICT (Mann et al. Addict Biol 2012; 18:937), a parallel study conducted in Germany.METHODS:We compared a classification tree constructed according to purely statistical criteria to a tree constructed according to a combination of statistical criteria and clinical considerations for prediction of no heavy drinking during treatment in COMBINE. We considered over 100 baseline predictors. The tree approach was compared to logistic regression. The trees and a deterministic forest identified the most important predictors of no heavy drinking for direct testing in PREDICT.RESULTS:The tree built using both clinical and statistical considerations consisted of 4 splits based on consecutive days of abstinence (CDA) prior to randomization, age, family history of alcoholism, and confidence to resist drinking in response to withdrawal and urges. The tree based on statistical considerations with 4 splits also split on CDA and age but also on gamma-glutamyl transferase level and drinking goal. Deterministic forest identified CDA, age, and drinking goal as the most important predictors. Backward elimination logistic regression among the top 18 predictors identified in the deterministic forest analyses identified only age and CDA as significant main effects. Longer CDA and goal of complete abstinence were associated with better outcomes in both data sets.CONCLUSIONS:The most reliable predictors of abstinence from heavy drinking were CDA and drinking goal. Trees provide binary decision rules and straightforward graphical representations for identification of subgroups based on response and may be easier to implement in clinical settings.

Worldwide, alcohol use accounts for approximately 2.5 million deaths annually1 and in the United States is estimated to account for economic costs exceeding $200 billion per year.2 According to the 2011 National Survey on Drug Use Health, 52% of Americans aged 12 years or older reported alcohol use, nearly 25% reported binge drinking (≥5 drinks on 1 occasion), and 6% reported heavy drinking (binge drinking on ≥5 occasions) over the past 30 days.3 The harmful effects of alcohol on health involve nearly every organ system as well as psychiatric and social comorbidity. While less prevalent, illicit drug use is also associated with health problems (such as human immunodeficiency virus infection and overdose) and substantial health care expenditures. The 2011 National Survey on Drug Use Health estimates that approximately 9% of Americans aged 12 years or older—an estimated 22.5 million individuals—used illicit drugs during the past 30 days in the United States.3 Because individuals who use alcohol and other drugs may have substantial health problems, they interact frequently with primary care, emergency departments, and other health care settings. Although some have questioned the “disease model” of addiction, asserting that substance use is a chosen behavior andnotadisease,4 there isnodoubt thatalcoholandotherdrug use disorders are prototypical chronic diseases and should be approached as such by the health care system.5 Substanceusedisorders, likediabetes, cardiovascular disease, and other chronic diseases, are characterized by a prolongedduration, intermittent acute and chronic exacerbations, and substantial morbidity and mortality. These disorders also are influenced by genetic and environmental factors, are related tospecificpathophysiologicphenomenon,and have major psychosocial components. Like other chronic diseases, substance use disorders are also treatable. Evidence for the effectiveness of treatment for improving outcomes among hazardous and harmful drinkers and among those with alcohol or drug dependence has increased considerably in the past 50 years. Screening, brief intervention, and referral to treatment (SBIRT) has been advocated for both alcoholand drug-using medical patients.6 Systematic reviews strongly support pharmacologicmanagement of alcohol withdrawal7 and also support the use of brief interventions inprimary care tomodestly decreasedrinking.8 Similarly, evidenceexists supporting theeffectivenessofpharmacotherapy suchasnaltrexone toprevent relapse in alcoholdependent individuals, althoughtheeffect size isalsomodest.9 Pharmacological approaches to opioid dependence such as buprenorphine10 have demonstrated efficacy, and buprenorphine is available in primary care. The availability of effective treatments for substance use disorders is a prerequisite for a systematic approach to treatmentandfollow-upknownaschroniccaremanagement (CCM). Chronic caremanagement is designed to improve the quality of health care and reduce health care costs for patients with chronic diseases such as diabetes,11 cardiovascular disease,12 and comorbidmedical andpsychiatric disease.13 Chronic care management also appears to be effective in increasing smoking abstinence.14 However, CCMhas not been studiedwidely in individuals with alcohol or drug dependence. Thus, the study in this issue of JAMA by Saitz and colleagues15 evaluatingCCMvsusualprimarycare for the treatment of patientswithdependence on alcohol andother drugs (opioids or stimulants) is an important addition to the literature. The authors randomly assigned 563 individuals to the 2 treatment strategies andassessed theprimaryoutcomes—selfreported abstinence fromheavydrinking, opioids, and stimulants—at baseline and 3, 6, and 12 months along with a series of secondary outcomes including other substance use measures, hospitalization, emergency department use, and substance use–related biomarkers. In comparisonwith usual primary care,CCMhadnosignificant effect onanyof theprimary outcomes. At 12months, 44% of patients assigned to CCM reported past-30-day abstinence from heavy drinking, opioids, andstimulants comparedwith42%ofpatients in theusualprimary care group. Similarly, there were virtually no differences in the other substance use–related measures and biomarkers, quality-of-life scores, or hospital and emergency department utilization. The only exception was that CCMtreated alcohol-dependent patientswere slightly less likely to experience alcohol problems, but this difference is probably clinically unimportant. Even though the patients in the CCM group were more likely to receive addiction treatment and medications, there was no improvement in outcomes vs primary care. For clinicians who believe that CCM should have a role in substancedependence treatment, these results are likely tobe disappointing.Methodologically, thiswasanexceedinglywelldesigned study in a “real-world” group of substancedependent patients using a comprehensive CCM model that was compared with usual primary care. The outcomes were well chosen and included both substance use–specific and broader measures. The 12-month follow-up rate (98% had Related article page 1156 Opinion

OBJECTIVE:To determine the impact of cognitive behavioral therapy on outcomes in primary care, office-based buprenorphine/naloxone treatment of opioid dependence.METHODS:We conducted a 24-week randomized clinical trial in 141 opioid-dependent patients in a primary care clinic. Patients were randomized to physician management or physician management plus cognitive behavioral therapy. Physician management was brief, manual guided, and medically focused; cognitive behavioral therapy was manual guided and provided for the first 12 weeks of treatment. The primary outcome measures were self-reported frequency of illicit opioid use and the maximum number of consecutive weeks of abstinence from illicit opioids, as documented by urine toxicology and self-report.RESULTS:The 2 treatments had similar effectiveness with respect to reduction in the mean self-reported frequency of opioid use, from 5.3 days per week (95% confidence interval, 5.1-5.5) at baseline to 0.4 (95% confidence interval, 0.1-0.6) for the second half of maintenance (P<.001 for the comparisons of induction and maintenance with baseline), with no differences between the 2 groups (P=.96) or between the treatments over time (P=.44). For the maximum consecutive weeks of opioid abstinence there was a significant main effect of time (P<.001), but the interaction (P=.11) and main effect of group (P=.84) were not significant. No differences were observed on the basis of treatment assignment with respect to cocaine use or study completion.CONCLUSIONS:Among patients receiving buprenorphine/naloxone in primary care for opioid dependence, the effectiveness of physician management did not differ significantly from that of physician management plus cognitive behavioral therapy.