Excessive alcohol use and use of other substances are among the major contributors to the burden of disease and injury. In addition, U.S. research shows that 52% of individuals 12 years and older use alcohol, 28% use tobacco, and 8% other substances, with the prevalence of alcohol or drug use disorders between 10% to 30%, depending on age and population group.
Use of multiple substances (especially with alcohol and tobacco) is also a concern. Accumulated evidence shows that alcohol and drug disorders are chronic medical conditions, and as with other chronic conditions, the onset and course of substance use disorders are influenced by genetic heritability as well as by behavior and personal choice.
Our researchers are conducting epidemiologic research on risk factors in adolescents and adults. They study the range of problems from risky use of alcohol and marijuana, prescription opioids and other drugs to dependence on these substances. They study tobacco, including the rising use of eCigarettes. They also study medical and mental health conditions of adults and adolescents with alcohol and/or drug (AOD) problems, and examine them as factors in treatment outcome and recovery over time. Researchers have conducted quantitative and qualitative studies on the most complex patients in the health system, finding that mental health conditions, chronic pain and adverse childhood experiences predict those who are high health care utilizers. Researchers also study the genetics of alcohol use disorders.
Addiction research has documented significant heterogeneity in longitudinal substance use trajectories, yet factors contributing to variable developmental trajectories are still largely unknown. Researchers study problem development and treatment effects longitudinally over many years, using both the health care databases and patient interviews. They conduct research on the life course, examining how substance use affects individuals during stages of development, and how stages of development affect substance use behaviors in the short and long run. This includes clinically meaningful concepts of turning points and their timing that may play an important role in long-term trajectories of alcohol and other drug outcomes. Adolescents with substance use problems have been followed over nine years, and adults for over 13 years. These findings are used to develop effective approaches for diagnosing, treating and preventing substance use and related problems, and the management of long-term recovery.
Prescription and other opioid dependence are increasing in prevalence and severity among chronic pain patients. Longitudinal research at the Division of Research examines patient and organizational characteristics associated with long-term use of opioids, as well as adverse events. Vulnerable populations, such as those with substance use disorders, depression and HIV, have been studied and found to be the groups most at risk for adverse effects and long-term use.
Chronic Care Models for Alcohol and Drug Disorders
As with other chronic conditions, alcohol and drug disorders are better managed with a continuing care approach with ongoing monitoring and extended services, than by an acute treatment approach. In addiction research, continuing care has focused on extending services based out of the specialty Chemical Dependency clinics. Researchers are studying innovative interventions to link patients in Chemical Dependency treatment with primary care in a medical home model. The approaches facilitate patients to take initiative in their health care, and involve use of Health IT, including incorporating the use of patient portals and better communication with physicians in interventions.
Integration with Health Care and Implementation Research
Alcohol and drug treatment has traditionally been treated in specialty clinics separate from other health care services, although approximately 10% of individuals receiving primary care services have an alcohol or drug problem, ranging from hazardous use to dependence. These patients also have many other medical and mental health conditions.
An SBIRT approach (Screening and Brief Intervention for those with low severity problems, and Referral to Treatment for those with high severity problems) to address excessive drinking, is a preventive health practice which is efficacious and recommended in national practice guidelines, but has not been widely implemented in general health care settings. Researchers have studied barriers to and facilitators of screening and developed large-scale approaches to implementing SBIRT in adult primary care. They have also studied different approaches to SBIRT in pediatrics for adolescents for alcohol and drug and mental health problems.
Researchers also study approaches to integrating alcohol and drug screening and treatment within depression patients in psychiatry, with HIV patients in primary care, and with patients with behavioral health problems in emergency departments, and people with chronic pain in primary care. In these interventions, researchers examine critical issues in health care, such as how to detect problems and intervene effectively and with cost efficiency in ways that are easily adaptable.
Specialty Chemical Dependency Treatment Interventions
Individuals whose alcohol and drug problems are sufficiently severe to require specialty treatment often have multiple other medical and mental health conditions. There remain many unanswered questions on how to treat these patients. Researchers have conducted multiple studies in adolescent and adult Chemical Dependency treatment. For example, they have found that day treatment programs are more effective than lesser intensity programs for individuals with co-occurring mental health problems, that bringing medical services into the specialty chemical dependency programs is cost-effective, that social networks and AA attendance are related to positive long-term outcomes, and for adolescents, co-location of chemical dependency and mental health programs is effective.
They study alcohol and drug outcomes, including low risk use and abstinence, as well as health and social functioning outcomes. Current research examines linkages with primary care and also assesses adjunctive psychosocial services to pair with buprenorphine for individuals with opiate dependence. Much of our intervention research examines health care utilization and cost outcomes as well. On the whole, these studies find that successful substance use treatment reduces emergency department and inpatient care.
There is evidence that having a family member with alcohol or drug problems affects family functioning and dynamics, which may lead to increased prevalence of medical and psychiatric conditions in the family members and increased medical utilization. Researchers have compared family members of adults with alcohol and/or drug disorders with family members of matched adults without alcohol or drug disorders. They have found that both spouses and children of persons with alcohol or drug disorders have more medical problems and higher health care costs than their counterparts in comparison families. They have also found that costs become similar to the comparison family when the person with the alcohol or drug disorder receives successful treatment.
Many policy changes have occurred regarding the treatment of alcohol and drug problems in health care in recent years. Both parity legislation and the Affordable Care Act have broadened access to health care and treatment of alcohol and drug treatment. The range of types of health coverage has broadened as well. Our researchers study the change in numbers of new patients with substance use disorders and those with and without HIV, smokers, and those with psychiatric diagnoses as a result of the new legislation and policy changes. They examine the impact on chemical dependency utilization of different benefit plans, including capitated and high deductible plans. They also study patient and system level factors associated with the HEDIS alcohol and drug, initiation and engagement of treatment measure performance.
Policy changes have also occurred which transition families from the State Children Health Insurance Program to Medicaid coverage, with their mental health coverage moved from the integrated health system to public Medicaid system. Researchers study the impact of the behavioral health carve-out on quality, continuity and access for adolescents with behavioral and substance use disorders.