Substance Abuse Treatment Admissions Research Articles

Unemployment rate, opioids misuse and other substance abuse: quasi-experimental evidence from treatment admissions data

BackgroundThe relationship between economic conditions and substance abuse is unclear, with few studies reporting drug-specific substance abuse. The present study examined the association between economic conditions and drug-specific substance abuse admissions.MethodsState annual administrative data were drawn from the 1993–2016 Treatment Episode Data Set. The outcome variable was state-level aggregate number of treatment admissions for six categories of primary substance abuse (alcohol, marijuana/hashish, opiates, cocaine, stimulants, and other drugs). Additionally, we used a broader outcome for the number of treatment admissions, including primary, secondary, and tertiary diagnoses. We used a quasi-experimental approach -difference-in-difference model- to estimate the association between changes in economic conditions and substance abuse treatment admissions, adjusting for state characteristics. In addition, we performed two additional analyses to investigate (1) whether economic conditions have an asymmetric effect on the number of substance use admissions during economic downturns and upturns, and (2) the moderation effects of economic recessions (2001, 2008–09) on the relationship between economic conditions and substance use treatment.ResultsThe baseline model showed that unemployment rate was significantly associated with substance abuse treatment admissions. A unit increase in state unemployment rate was associated with a 9% increase in treatment admissions for opiates (β = 0.087, p < .001). Similar results were found for other substance abuse treatment admissions (cocaine (β = 0.081, p < .001), alcohol (β = 0.050, p < .001), marijuana (β = 0.036, p < .01), and other drugs (β = 0.095, p < .001). Unemployment rate was negatively associated with treatment admissions for stimulants (β = − 0.081, p < .001). The relationship between unemployment rate and opioids treatment admissions was not statistically significant in models that adjusted for state fixed effects and allowed for a state- unique time trend. We found that the association between state unemployment rates and annual substance abuse admissions has the same direction during economic downturns and upturns. During the economic recession, the negative association between unemployment rate and treatment admissions for stimulants was weakened.ConclusionThese findings suggest that economic hardship may have increased substance abuse. Treatment for substance use of certain drugs and alcohol should remain a priority even during economic downturns.

Burden of Substance Abuse-Related Admissions to the Medical ICU

Admissions to the ICU related to alcohol, prescription drugs, and illicit drugs are shown to be widespread and costly. In 1993, a study revealed 28%of ICU admissions at Johns Hopkins Hospital were related to substance abuse and accrued 39%of costs. Since then, health-care expenditures have increased, and substance abuse treatment admissions have risen. We conducted a study to provide updated data on ICU utilization and costs related to licit and illicit abuse at a large county hospital in Indianapolis, Indiana. All admissions to the medical ICU at Eskenazi Hospital from March to October 2017 were reviewed. Demographics, reason for admission, relation to substance abuse and specific substance, ICU and hospital length of stay, Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, mortality, insurance status, and hospital charges were collected based on chart review. A total of 611 admissions generated $74,587,280.35 in charges. A total of 25.7%of admissions related to substance abuse accounted for 23.1%of total charges. Illicit drugs were 13%of total admissions, generating 11%of charges. Alcohol-related admissions were 9.5%of total admissions, generating 7.6%of charges. Prescription drugs were 2.9%of admissions, generating 4.2%of charges. Of the substance abuse admissions, patients were generally men and 40 to 64 years of age, with longer ICU stay, higher APACHE II scores, and higher mortality. Substance abuse admissions make up almost a one-quarter of resources used by our ICU. Patients tend to be younger and sicker with a higher risk of death. Identifying and accurately describing the landscape of this current health crisis will help us take appropriate action in the future.

Mandatory Access Prescription Drug Monitoring Programs and Prescription Drug Abuse

Despite the significant cost of prescription (Rx) drug abuse and calls from policymakers for effective interventions, there is limited research on the effects of policies intended to limit such abuse. This study estimates the effects of prescription drug monitoring (PDMP) programs, which constitute a key policy targeting access to non-medical use of Rx drugs. Based on objective indicators of abuse as measured by substance abuse treatment admissions and mortality related to Rx drugs, estimates do not suggest any substantial effects of instituting an operational PDMP. We find, however, that mandatory-access provisions, which raised PDMP utilization rates by actually requiring providers to query the PDMP prior to prescribing a controlled drug, are significantly associated with a reduction in Rx drug abuse. The effects are driven primarily by a reduction in opioid abuse, generally strongest among young adults (ages 18 to 24), and underscore important dynamics in the policy response. Robustness checks are consistent with a causal interpretation of these effects. We also assess potential spillovers of mandatory PDMPs on the use of other illicit drugs and find a complementary reduction in admissions related to cocaine and marijuana abuse.

Predictors of Topiramate Tolerability in Heavy Cannabis-Using Adolescents and Young Adults: A Secondary Analysis of a Randomized, Double-Blind, Placebo-Controlled Trial.

Cannabis is the most commonly abused illicit drug and accounts for the greatest number of adolescent substance abuse treatment admissions. Despite urgent need for effective interventions, the best available psychosocial treatment options yield only modest effects. Topiramate showed promise as an adjunctive pharmacotherapy to a psychosocial intervention for cannabis misuse among adolescents and young adults in a recent clinical trial, but it was not well tolerated. This study investigated associations between clinical characteristics and side effects and dropout among adolescents and young adults randomized to topiramate. This study involved secondary data analysis of a randomized placebo-controlled trial of topiramate for treating cannabis misuse (ages, 15-24 years; 50% female). We explored the interaction effects of baseline characteristics and medication condition (topiramate vs placebo) on treatment dropout. We also explored the relationship between side effects and dropout. Higher cannabis problems were significantly associated with reduced hazard of dropout in the topiramate group (P = 0.048) and were nonsignificantly associated with increased hazard of dropout in the placebo group (P = 0.062). Results also showed that memory difficulties were an overwhelming predictor of dropout in the topiramate condition; 42% of participants who dropped out experienced memory difficulties, whereas none of those who remained in the study experienced these effects. By identifying who may most benefit from and tolerate this medication, treatment for substance use disorders can become more individualized and positive outcomes may be enhanced.

Trends in substance use admissions among older adults

BackgroundSubstance abuse is a growing, but mostly silent, epidemic among older adults. We sought to analyze the trends in admissions for substance abuse treatment among older adults (aged 55 and older).MethodsTreatment Episode Data Set - Admissions (TEDS-A) for period between 2000 and 2012 was used. The trends in admission for primary substances, demographic attributes, characteristics of substance abused and type of admission were analyzed.ResultsWhile total number of substance abuse treatment admissions between 2000 and 2012 changed slightly, proportion attributable to older adults increased from 3.4% to 7.0%. Substantial changes in the demographic, substance use pattern, and treatment characteristics for the older adult admissions were noted. Majority of the admissions were for alcohol as the primary substance. However there was a decreasing trend in this proportion (77% to 64%). The proportion of admissions for following primary substances showed increase: cocaine/crack, marijuana/hashish, heroin, non-prescription methadone, and other opiates and synthetics. Also, admissions for older adults increased between 2000 and 2012 for African Americans (21% to 28%), females (20% to 24%), high school graduates (63% to 75%), homeless (15% to 19%), unemployed (77% to 84%), and those with psychiatric problems (17% to 32%).The proportion of admissions with prior history of substance abuse treatment increased from 39% to 46% and there was an increase in the admissions where more than one problem substance was reported. Ambulatory setting continued to be the most frequent treatment setting, and individual (including self-referral) was the most common referral source. The use of medication assisted therapy remained low over the years (7% - 9%).ConclusionsThe changing demographic and substance use pattern of older adults implies that a wide array of psychological, social, and physiological needs will arise. Integrated, multidisciplinary and tailored policies for prevention and treatment are necessary to address the growing epidemic of substance abuse in older adults.

Trends of Youth Marijuana Treatment Admissions: Increasing Admissions Contrasted with Decreasing Drug Involvement

ABSTRACTBackground: Recent changes in marijuana policies and their potential negative effects on youth development are a public health concern. Identifying the most appropriate treatment approaches for problematic marijuana use is important. Objectives: The aim of this study was to track marijuana use among young people by examining national changes from 1995 to 2012 in the demographics, referral sources, and the substance use patterns related to youth admissions to substance abuse treatment programs. Methods: We examined first-time substance abuse treatment admissions among youth, utilizing the Treatment Episode Data Set - Admissions (TEDS-A) of the Substance Abuse Mental Health Services Administration (N = 12,025,787). Chi-squared analysis was used to examine differences between admission years and binomial logistic regression was used to examine trends over the 18 years. Results: We found increasing numbers of youth in dependent living situations (e.g. with parents) admitted to substance use disorder treatment for marijuana. We also found a dramatic drop in the degree of drug involvement for those admissions over nearly two decades of data. Conclusions/Importance: While availability and changing perceptions of marijuana might have caused an increase in admissions to substance abuse treatment, our findings indicate that the severity of drug use involved in those admissions has decreased. This study highlights the importance of identifying youth in actual need of treatment services and not overlooking tools such as screening, brief intervention, and motivational interviewing as effective for varying levels of marijuana use by youth.

Racial and Ethnic Differences in Referral Source for Substance Abuse Treatment Admissions for Youths

ABSTRACTThis study examined racial and ethnic differences in admissions to substance abuse treatment and in the referral source in admissions to treatment. The 2012 Treatment Episode Data Set (N = 117,862) was used and included African-American, Hispanic, non-Hispanic White, and other racial/ethnic youths, ages 12 to 17. Age at admission to treatment, racial and ethnic differences in primary substance used, and co-occurrence of a psychiatric problem were found to be statistically significant. Health care providers were 3 times more likely to refer youths with psychiatric problems and the school system was 2 times more likely to refer Hispanic youths to treatment. Implications are discussed.

Trend Analysis of Substance Abuse Treatment Admissions in New Orleans From 2000–2012: A Population-Based Comparison Pre- and Post-Hurricane Katrina

ABSTRACTBackground: Substance abuse treatment following a natural disaster is often met with challenges. If treatment is available, facilities may be unequipped to service an influx of patients or provide specialized care for unique populations. Objectives: This paper seeks to evaluate trends in substance abuse treatment over time and assess changes pre- and post-Hurricane Katrina. Methods: Substance abuse treatment admission data (N = 42,678) from New Orleans, Louisiana, for years 2000 through 2012 were obtained from the Treatment Episode Data Set. Admissions were examined to evaluate demographic, socioeconomic, psychiatric, and criminality trends in substance abuse treatment and assess changes following Hurricane Katrina. Results: Treatment admissions have decreased from 2000 to 2012. About one in five admissions had a psychiatric illness in addition to a substance abuse problem. A staggering 76% of admissions with a psychiatric illness were referred by the criminal justice system post-Katrina as compared to pre-Katrina. Rates of alcohol and marijuana admissions have remained stable from 2000 to 2012. Cocaine/crack admissions have declined and admissions who abused heroin have increased over time. Conclusions: Treatment admissions stabilized following Hurricane Katrina; however, since 2009, they have begun to decline. Targeted exploration of factors affecting admission to treatment in New Orleans with populations such as the homeless, those with a psychiatric illness in addition to a substance abuse problem, and those referred by the criminal justice system is essential. The results of this study assist in identifying variations in substance abuse treatment characteristics for those admitted to treatment in New Orleans.

A brief report on Hispanic youth marijuana use: Trends in substance abuse treatment admissions in the United States

ABSTRACTIncreases in Hispanic youth admissions to substance abuse treatment programs for marijuana use are a growing public health concern. In this study, we investigated trends in Hispanic youth from 1995 to 2012 utilizing the Treatment Episode Data Set—Admissions of the Substance Abuse Mental Health Services Administration. Hispanic youth marijuana admissions are associated with youth 15–17 years old, in high school, and living in a dependent situation. Notably, female admissions increased at greater rates than males. Results also point to decreasing tolerance of minor marijuana use by schools and community agencies. Findings highlight the need for targeted, culturally specific, and cost-effective treatment and prevention efforts.

Topiramate and motivational enhancement therapy for cannabis use among youth: a randomized placebo-controlled pilot study.

Cannabis misuse accounts for nearly all of the substance abuse treatment admissions among youth in the United States. Most youth do not experience sustained benefit from existing psychosocial treatments; however, medication development research for treating adolescent cannabis misuse is almost nonexistent. We conducted a double-blind, placebo-controlled, pilot study to test the potential efficacy of topiramate plus motivational enhancement therapy (MET) for treating cannabis use among adolescents. Sixty-six heavy cannabis users, ages 15 to 24 years, were randomized to one of two 6-week treatment conditions: topiramate plus MET or placebo plus MET. Topiramate was titrated over 4 weeks then stabilized at 200 mg/day for 2 weeks. MET was delivered biweekly for a total of three sessions. Only 48 percent of youths randomized to topiramate completed the 6-week trial (n = 19), compared with 77 percent of youths in the placebo condition (n = 20). Adverse medication side effects were the most common reason for withdrawal among participants in the topiramate group. Latent growth models showed that topiramate was superior to placebo for reducing the number of grams smoked per use day, but it did not improve abstinence rates. The same pattern of results was found when values for missing outcomes were imputed. We show that topiramate combined with MET demonstrated efficacy for reducing how much cannabis adolescents smoked when they used but did not affect abstinence rates. The magnitude of this effect was modest, however, and topiramate was poorly tolerated by youths, which calls into question the clinical importance of these findings.

How Increasing Medical Access to Opioids Contributes to the Opioid Epidemic: Evidence from Medicare Part D

Drug overdoses involving opioid analgesics have increased dramatically since 1999, representing one of the United States’ top public health crises. Opioids have legitimate medical functions, but improving access may increase abuse rates even among those not prescribed the drugs given that opioids are frequently diverted to nonmedical use. We have little evidence about the causal relationship between increased medical access to opioids and spillovers resulting in abuse. We use the introduction of the Medicare Prescription Drug Benefit Program (Part D) as a large and differential shock to the geographic supply of opioids. We compare growth in opioid supply and abuse rates in states with large 65+ population shares to states with smaller elderly population shares with a focus on abuse among the Medicare-ineligible population. Part D increased opioid utilization for the 65+ population, and we show that this increase in utilization led to significant growth in the overall supply of opioids in high elderly share states relative to low elderly share states. This relative expansion in opioid supply resulted in an escalation in opioid-related substance abuse treatment admissions and opioid-related mortality among the Medicare-ineligible population, implying meaningful spillovers to individuals who did not experience any change in prescription drug benefits. The evidence suggests that increased opioid supply is associated with economically-important levels of diversion for nonmedical purposes. Our estimates imply that a 10% increase in medical opioid distribution leads to a 7.4% increase in opioid-related deaths and a 14.1% increase in substance abuse treatment admission rates for the Medicare-ineligible population.

Syringe Service Programs for Persons Who Inject Drugs in Urban, Suburban, and Rural Areas - United States, 2013.

Reducing human immunodeficiency virus (HIV) infection rates in persons who inject drugs (PWID) has been one of the major successes in HIV prevention in the United States. Estimated HIV incidence among PWID declined by approximately 80% during 1990-2006 (1). More recent data indicate that further reductions in HIV incidence are occurring in multiple areas (2). Research results for the effectiveness of risk reduction programs in preventing hepatitis C virus (HCV) infection among PWID (3) have not been as consistent as they have been for HIV; however, a marked decline in the incidence of HCV infection occurred during 1992-2005 in selected U.S. locations when targeted risk reduction efforts for the prevention of HIV were implemented (4). Because syringe service programs (SSPs)* have been one effective component of these risk reduction efforts for PWID (5), and because at least half of PWID are estimated to live outside major urban areas (6), a study was undertaken to characterize the current status of SSPs in the United States and determine whether urban, suburban, and rural SSPs differed. Data from a recent survey of SSPs(†) were analyzed to describe program characteristics (e.g., size, clients, and services), which were then compared by urban, suburban, and rural location. Substantially fewer SSPs were located in rural and suburban than in urban areas, and harm reduction services(§) were less available to PWID outside urban settings. Because increases in substance abuse treatment admissions for drug injection have been observed concurrently with increases in reported cases of acute HCV infection in rural and suburban areas (7), state and local jurisdictions could consider extending effective prevention programs, including SSPs, to populations of PWID in rural and suburban areas.

Codeine misuse and dependence in South Africa--learning from substance abuse treatment admissions.

Misuse of prescription and over-the-counter codeine-containing products is a global public health issue. To investigate the extent of treatment demand related to the misuse of codeine or codeine dependence in South Africa (SA) and the profile of patients seeking treatment, so as to understand the nature and extent of the problem. Data were collected from centres participating in the South African Community Epidemiology Network on Drug Use in 2014. A total of 17 260 admissions were recorded. There were 435 recorded treatment admissions for codeine misuse or dependence as a primary or secondary substance of abuse (2.5% of all admissions). Of treatment admissions, 137 (0.8%) involved codeine as the primary substance of abuse; 74.9% of patients were males, with an even spread across population groups. Ages ranged from 11 to 70 years, with the highest proportion aged 20 - 29 years; &gt;40% were referred by self, family and/or friends, and 26.7% by health professionals; and 36.8% had received treatment previously. The majority reported misuse of tablets/capsules, with 17.6% reporting misuse of syrups. Oral use comprised 96.6% and daily use 63.1%. Data from treatment admissions related to codeine misuse and dependence are informative, but provide an incomplete picture of the nature and extent of codeine-related problems in SA. Other data sources must be considered before further regulatory/policy changes regarding codeine are implemented.

The impact of prison deinstitutionalization on community treatment services

BackgroundWith one in every 108 Americans behind bars, the deinstitutionalization of prisons is a pressing issue for all those facing the daunting challenges of successfully reintegrating ex-offenders into both their communities and the larger society. Given the strong evidence that treatment services, such as mental/behavioral health, alcohol/substance abuse, and primary healthcare may reduce recidivism, the large number of prisoner releases highlights the need for adequate treatment services in the community. It is within this context that the current study aims to examine the effects of prison deinstitutionalization on community based intervention modalities.MethodsThis study set out to address a set of fundamental research questions in the current climate of reversing the 40-year upward trend in prison population. This thread of inquiry is based on a hydraulic model of institutionalization of transinstitutionalization. This hydraulic framework posits that there are many overlaps between public safety and mental health needs, and that psychiatric institutionalization and penal institutionalization are functionally dependent. Longitudinal data with annual standardized measures such as rates and percentages for this change modeling were obtained from a number of national data programs for all 50 states. Our analytical focus concentrated on the second half of the decade of the 2000s.ResultsChange in the state imprisonment rate was negatively correlated with change in the rate of substance abuse treatment admissions (r = -0.24; p < .05) and the change in the rate of inpatient admissions in state psychiatric hospitals (r = 0.10; p > .05) as predicted. However, only the bivariate association between imprisonment and substance abuse treatment admissions attained the conventional threshold of statistical significance. Holding constant the direct and indirect effects of changes in the rates of violent crime and illicit drug use, change in prison population was negatively associated with changes in the rate of substance abuse (unstandardized coefficient = -0.891; p < 0.05) and mental health admissions (unstandardized coefficient = -0.509; p > 0.05) in the community.ConclusionBy using a path analysis of the hydraulic model, we argue that social systems, similar to water moving in closed tubes, aspire to equilibrate. In other words, a decrease in prison population will not go without a corresponding increase in community mental health and substance abuse services. Social voids like those created by deinstitutionalization must be filled; and with states deinstitutionalizing offenders the toll is on their corresponding communities to address the needs of those offenders who are reentering after being incarcerated. In devising a policy and practice strategy to address the projected increase in the reentry population, leadership within communities for social and supportive services to ex-prisoners, specifically treatment services should be of primary concern.

Recent trends in treatment admissions for marijuana use during pregnancy.

The objective of this study was to investigate recent trends in substance abuse treatment admissions for marijuana use during pregnancy in the United States. Data were obtained from the Treatment Episodes Data Set from 1992 to 2012 and analyzed for trends over time using χ, Cochran-Armitage, and Moran's I tests. The proportion of treatment admissions for women who were pregnant remained stable at 4%; however, admissions of pregnant women reporting any marijuana use increased substantially from 29% to 43% (P < 0.01). The West North Central census division (20%) experienced the greatest increase followed by the Middle Atlantic (18%) and Pacific (14%) divisions. The demographic characteristics of pregnant marijuana admissions changed over time, with white non-Hispanic women, criminal justice referrals, and those with a psychiatric comorbidity becoming more common whereas polysubstance users decreased (P < 0.01). Even though more women using marijuana are seeking and receiving substance abuse treatment during pregnancy, targeting certain risk groups while improving screening and treatment referral systems by health care providers, such as prenatal caregivers, should be emphasized.

Harms of prescription opioid use in the United States

BackgroundConsumption levels of prescription opioids (POs) have increased substantially worldwide, particularly the United States. An emerging perspective implicates increasing consumption levels of POs as the primary system level driving factor behind the observed PO-related harms. As such, the present study aimed to assess the correlations between consumption levels of POs and PO-related harms, including non-medical prescription opioid use (NMPOU), PO-related morbidity and PO-related mortality.FindingsPearson’s product-moment correlations were computed using published data from the United States (2001 – 2010). Consumption levels of POs were extracted from the technical reports published by the International Narcotics Control Board, while data for NMPOU was utilized from the National Survey on Drug Use and Health. Additionally, data for PO-related morbidity (substance abuse treatment admissions per 10,000 people) and PO-related mortality (PO overdose deaths per 100,000 people) were obtained from published studies. Consumption levels of POs were significantly correlated with prevalence of NMPOU in the past month (r =0.741, 95% CI =0.208–0.935), past year (r =0.638, 95% CI =0.014–0.904) and lifetime (r =0.753, 95% CI =0.235-0.938), as well as average number of days per person per year of NMPOU among the general population (r =0.900, 95% CI =0.625-0.976) and NMPOU users (r =0.720, 95% CI =0.165–0.929). Similar results were also obtained for PO-related morbidity and PO-related mortality measures.ConclusionThese findings suggest that reducing consumption levels of POs at the population level may be an effective strategy to limit PO-related harms.

Recent trends in treatment admissions for prescription opioid abuse during pregnancy

Prescription opioid abuse is a significant and costly public health problem among pregnant women in the United States. We investigated recent trends in substance abuse treatment admissions for prescription opioids during pregnancy using the Treatment Episodes Data Set. From 1992 to 2012 the overall proportion of pregnant admissions remained stable at 4%; however, admissions of pregnant women reporting prescription opioid abuse increased substantially from 2% to 28% especially in the south. Demographic characteristics of pregnant opioid admissions changed from 1992 to 2012 with younger, unmarried White non-Hispanic women, criminal justice referrals, and those with a psychiatric co-morbidity becoming more common (p<0.01). About a third received medication assisted therapy despite this being the standard of care for opioid abuse in pregnancy. While substance abuse treatment centers have increased treatment volume to address the increase in prescription opioid dependence among pregnant women, targeting certain risk groups and increasing utilization of medication assisted therapy should be emphasized.

Medicaid Expansion Initiative in Massachusetts: Enrollment Among Substance-Abusing Homeless Adults

We assessed whether homeless adults entering substance abuse treatment in Massachusetts were less likely than others to enroll in Medicaid after implementation of the MassHealth Medicaid expansion program in 1997. We used interrupted time-series analysis in data on substance abuse treatment admissions from the Treatment 0Episode Data Set (1992-2009) to evaluate Medicaid coverage rates in Massachusetts and to identify whether trends differed between homeless and housed participants. We also compared Massachusetts data with data from 17 other states and the District of Columbia combined. The percentage of both homeless and housed people entering treatment with Medicaid increased approximately 21% after expansion (P = .01), with an average increase of 5.4% per year over 12 years (P = .01). The increase in coverage was specific to Massachusetts, providing evidence that the MassHealth policy was the cause of this increase. Findings provide evidence in favor of state participation in the Medicaid expansion in January 2014 under the Affordable Care Act and suggest that hard-to-reach vulnerable groups such as substance-abusing homeless adults are as likely as other population groups to benefit from this policy.

Commentary on Acionet al. (2013): Alcohol and drug use among children from deployed military families in the United States-an important and growing health disparity

The need for mental health services, and substance use treatment in particular, among deployed military personnel is well known and can hardly be debated 1-4. However, the need of the children in families with deployed parents is relatively poorly understood and remains a critically important and largely unaddressed public health issue in the United States 5-7. This is why the manuscript by Acion and colleagues 6 is both timely and important, as it examines the increased risk of alcohol and drug use among children from deployed families. The findings, while descriptive in nature, clearly demonstrate higher levels of current alcohol use, heavy alcohol use, current marijuana use, current illegal drug use and current prescription drug misuse among children in deployed families versus children in other families. This issue is particularly troubling given that the United States has had a substantial increase in deployed military personnel in recent years and a corresponding increase in the number of children who have had their parents deployed. An emerging literature outlines a range of psychosocial issues among children in military-connected families 5, 8. The issue of increased substance use among the children in military families appears to be troubling, in particular because substance use may exacerbate many of the other issues these children and youth are facing 5. It has been well documented that alcohol and substance misuse is a pervasive problem among military personnel and veterans that extends to their families 3, 4, 8, 9. Recent findings indicate that half the substance abuse treatment admissions among veterans aged 21–39 years involve alcohol as the primary substance of abuse 10. Additionally, research concerning army soldiers examined shortly after returning from deployment show that 27% met criteria for alcohol abuse 1. As such, it is not surprising that alcohol misuse is a critically important problem not only for those serving in the military, but also for their family members. However, data on substance use among family members, particularly the children, are lacking 5-7. While most attention has been given to the deployed family member, less attention has been given to the children of the deployed family members. These children may be vulnerable to a host of issues that also include mobility and disruption of care and social networks 5. Several new strategies have been proposed 11, and recent initiatives have been launched to understand more clearly and address the broader issues of family functioning in this population 12, 13. For example, in 2010 the National Institute of Drug Abuse and the Department of Veteran Affairs launched a program to support research on substance abuse among US military personnel, veterans and their families 1. However, it is not yet clear how these initiatives will address the growing needs of at-risk children in military families specifically and what the outcomes may be pertaining to prevention and intervention initiatives, including screening and treatment services. The paper by Acion and colleagues 6 suggest that schools and health-care providers conduct screening for early substance use and facilitate access to services among youth at heightened risk for substance use. Similarly, the American Academy of Pediatrics recommends that pediatricians screen and evaluate youth routinely for substance use and provide office interventions and referrals for patients who are using alcohol or other substances 14. While this policy does not address military-connected families specifically, if the policy were implemented fully, with particular attention to youth whose parents are deployed, substance use issues in this population could be addressed more promptly and thoroughly, and then evaluated in future research. Additionally, the National Institute of Alcohol Abuse and Alcoholism has disseminated the recently developed Alcohol Screening and Brief Intervention for Youth: A Practitioner's Guide [15], which will greatly streamline interaction with youth and provide guidance to practitioners on this important topic. In addition to these new tools and initiatives, it will be important to establish future research priorities regarding substance use among the children in military-connected families 5. It is particularly important to identify strategies to reduce and delay alcohol use in this population and seek to prevent the consequences of early alcohol and substance use 16, 17. Additionally, providing reassurance to the impacted communities will also be important by implementing additional protection to these youth to offset the hardship their families have faced. To conclude, military-connected youth have substantially higher levels of substance use than other youth for a number of reasons and, as such, it should be considered an important health disparity. This issue, as do other disparities, merits commensurate increased attention and provision of resources to these affected children and youth. Unfortunately, lack of action to address this issue more deliberately raises important questions about our capacity, commitment and willingness to provide the support services that many of these children need and deserve. None.

Opioid Prescribing: Can the Art Become More Science?

There is controversy regarding the effectiveness and safety of long-term opioid therapy for the treatment of chronic pain. Since the 1980s, a four-fold increase in opioid prescribing has been correlated with a four-fold increase in unintentional opioid overdose deaths and a six-fold increase in substance abuse treatment admissions for prescription opioid addiction. 1 Unrealistic expectations by patients, patients’ families and providers regarding the benefits of opioids, and lack of understanding of the potential risks and harms complicate opioid prescribing. While not all patients with chronic pain improve on chronic opioid therapy, 2 some do. For those patients who do not respond, uncontrolled dose escalation often ensues, all in a desperate yet futile attempt to obtain pain relief. In this issue of JGIM, Becker and colleagues address important issues for the safe and effective use of opioids in treating chronic pain in primary care. 3 They suggest key areas of research aimed at reducing inappropriate prescribing. They begin by characterizing “appropriate ongoing opioid prescribing” and then identify quality improvement priorities, including: 1) developing brief, patient-administered screening checklists that incorporate items related to safety, efficacy and misuse; 2) developing treatment pathways to manage safety-related issues, low efficacy and problems related to misuse; and 3) promoting patient-centered, multimodal treatment plans. I agree with their characterization that appropriate prescribing should include measures of efficacy, safety and harm; however the devil is in the details. Measures of efficacy, safety and harm are subjective impressions of the patient and the provider, even when assessed using validated “objective” multidimensional scales such as the Brief Pain Inventory. 4 How much improvement in pain, functionand quality of life is enough to say the opioid treatment is efficacious for any given patient? Does a pain score that improves from 9 to 7 on a 10point scale warrant continued opioid therapy? Is walking an additional block to the store once per week enough functional