The Veterans Health Administration has implemented annual screening for heavy drinking during primary care encounters using the 3-item Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) questionnaire and made specialized services available to patients with alcohol use disorders (AUDs). We sought to identify the factors that influence whether a patient who has an elevated AUDIT-C score receives appropriate care in the context of an integrated mental health services program. We focused on higher AUDIT-C scores, as these are seen in individuals who are most likely to have a moderate-to-severe AUD and more severe alcohol-related consequences. Utilizing electronic health record data, we conducted a four-year retrospective study of veterans at high-risk for an AUD, based upon an AUDIT-C score >=8 recorded during a primary care encounter at a Veterans Affairs Medical Center and its community-based outpatient clinics. In multivariate analysis, the predictors of treatment referral were younger age, being non-white, higher AUDIT-C score, and main campus location. Among patients referred for treatment, younger age and being white were associated with an increased likelihood of completing a pre-treatment assessment. Efforts to increase the consistency of treatment referrals, according to established clinical guidelines, could enhance the effectiveness of AUDIT-C screening during primary care visits. Subgroups of patients who may benefit from such efforts include individuals with high-risk but sub-maximal AUDIT-C scores, older patients, and patients who are seen at community-based outpatient clinics.

Objectives: Authors tried to delineate the main trends in dual disorder assessment and treatment, and compared them with current state-of-the-art research. Materials and Methods: European studies and reports about dual disorder, when available, were commented upon and summarized. The main sources consisted of the EMCDDA body of data about psychiatric comorbidity of substance abuse in European countries, based on national reports and single studies; and publications in the official journal of the European Opiate Addiction Treatment Association. Results and Conclusions: Data were hard to compare, and were incomplete as regards the type of substance and the diagnostic criteria for psychiatric diagnosis. The state-dependent (intoxication) dual disorder is probably overrated, whereas some diagnoses may be initially disguised by on-going effective treatment, and then reemerge clearly after treatment discontinuation. The chronology of illness does not offer a reasonable criterion for the classification of dual disorder. The anticraving intervention is often the priority, and is likely to produce, as one favorable effect, the retention of dual disorder patients. The dosage of opiate agonists appears to be crucial in improving the outcome of dual disorder heroin addicts, while low dosages could play the role of offering an effective form of initial involvement in higher threshold treatment, instead of drugless harm reduction. A unique, 1-spot treatment organization should be preferred.

Objectives:The objectives of this study are (1) to compare the satisfaction between patients who have received treatment as usual face-to-face (TAU group) and patients who have received optional videoconferencing-based treatment for alcohol use disorders (TAU+I group); and (2) to elaborate on the TAU+I group’s satisfaction with the treatment in general and the technical equipment.Methods:The design consisted of mixed methods: a survey and a qualitative study. Data consisted of self-reported data from questionnaires filled out by both groups and semistructured interviews with the TAU+I group. Data from the questionnaires were analyzed statistically using Stata. The semistructured interviews were analyzed using a general inductive approach.Results:The survey indicated that the TAU+I group and TAU group were equally satisfied with the elements in the treatment. The interview indicated that the TAU+I group seemed to have a high satisfaction with most elements in the treatment. Patients who used videoconferencing were satisfied with establishing the videoconferencing connection and with the picture quality but less satisfied with the sound quality.Conclusions:Overall, the patients were satisfied with the treatment. We saw a nonsignificant tendency that the TAU+I group were more satisfied with the treatment in general, compared with the TAU group. It is a possibility that patients in this group felt more satisfied with the treatment as they had the opportunity to choose videoconferencing. Offering videoconferencing-based treatment may be a positive feature in the treatment and lead to improved outcomes of the treatment courses. The technical equipment and routine using it should be improved in future studies or during implementation.

Objective: Opiate misuse epidemic and its associated morbidity and mortality have seen an alarming rise in the last decade. In recent years, the transition from prescription opiate misuse to heroin has also been noted. The aim of this review is to understand factors affecting the opiate epidemic and current deficits in the system to enhance management and improve outcomes for this population. Materials and Methods: Case presentation and literature review was conducted. Results: We present a case series that illustrates how medical and psychiatric disorders play a major role in the tragic transition many patients make from prescription analgesics to illicit heroin. Literature review suggests a strong relationship between decrease in the opiate prescription by physicians and the increase in heroin epidemic. Conclusions: Although preventive measures (ie, educating physicians and changing prescribing patterns) as well as enhancing treatments are being increased, more focus is needed to address management of addiction itself and its comorbidities (ie, psychiatric and medical disorders that increase risk of substance use).

University of Miami Miller School of Medicine Miami, FL The author declares no conflicts of interest.

Objectives To obtain the initial safety, tolerability, and treatment effect size of combination baclofen and bupropion slow release (SR) for smoking cessation. Methods A prospective single-arm open-label 7-week trial involving 20 smokers treated with baclofen and bupropion SR, along with brief counseling for smoking cessation. Primary outcome measures included adverse events, tolerability, and smoking cessation. Results No serious adverse effects were reported. The most commonly reported adverse effects were fatigue (40%), disturbance in attention (40%), dry mouth (35%), and insomnia (35%). Combination therapy was well tolerated with 1 (5%) dropout not attributed to medication, and 3 (15%) participants requiring dose reduction for adverse effects. Eleven of 20 participants (55%, SE 11%, 95% confidence interval 32 to 77) achieved continuous abstinence over the final 4 weeks. Conclusions Combination of baclofen and bupropion SR seems safe and well tolerated with preliminary efficacy for smoking cessation comparing favorably with current first-line smoking cessation aids. The combination of baclofen and bupropion SR may provide an additional treatment option to varenicline or bupropion SR monotherapy. (Health Canada Clinical Trial Registration Control number: 105226).

As part of a series of trials of office-based opioid treatment (OBOT) in different US settings, we explore the circumstances favoring OBOT in different community settings and patient characteristics that seem to predict different patient outcomes in OBOT. In the New Mexico trial, we found that 11 of the 14 patients (followed for 12 mo) made a good adjustment to OBOT with outcomes equal or superior to their clinic care. We focus here on the cases of 3 women who were stable in methadone maintenance treatment and transferred to OBOT, but did not do well and had to be returned to clinic care. We examine the course of their treatment for factors related to treatment noncompletion, the course of their OBOT progress, and discuss the reasons it was necessary to return them to clinic care. Case study method was used to examine the course of the treatment noncompleters for factors related to treatment noncompletion and the course of their OBOT progress. The data collected were the eligibility screening form, methadone maintenance treatment program clinic counselor referral, social work case notes, clinical case conference notes, methadone dosage, take-home schedules, and toxicology results. The problems that arose in the care of this small group represent a sampling of the issues facing many potential candidates for methadone maintenance treatment in a primary care/pharmacy OBOT model. Common themes were varied interpretation of the study criteria, suboptimal methadone dosage, stigma and ambivalence toward methadone, sensitivity to treatment change (provider leaving study and pharmacy closing), co-occurring disorders, and illicit drug use. Our experience indicates that patients who do not adapt well to OBOT will most likely display early signs that they need to return to the more familiar structure of their methadone maintenance treatment program and will readily agree to return to clinic care.

Objectives This article examines agreement between physicians and psychiatric inpatients on the presence of comorbid substance abuse. In addition, inpatients with comorbid substance abuse were compared on demographic and diagnostic-related symptoms with those with a single, non–substance-related disorder. Methods At admission and discharge, 539 patients completed self-report measures of substance use and diagnostic symptoms. Their attending physicians and nurses completed rating scales in the same time frame. In addition, physician discharge diagnoses were examined. Results For 69% of patients there was agreement between patients and physicians for the absence (30.4%) or presence (38.6%) of substance abuse. For 31%, there was disagreement; 10% were those in whom physicians diagnosed substance abuse but patients denied it, and 21% endorsed substance abuse which their physicians did not diagnose. Also, those who were not substance users tended to receive more severe clinician ratings but self-reported fewer symptoms. They also were more likely to be older, have longer lengths of stay, and to have been admitted involuntarily. Conclusions A considerable number of psychiatric inpatients are underdiagnosed for comorbid substance abuse. Multimodal means of assessment would probably enhance the inclusion of such diagnoses. Also, differences in symptoms may suggest differences in treatment regimens.