From the Editor
When she was admitted for liver cirrhosis – the last hospitalization in her too-short life – no one visited. In her community, the stigma was great. As she grew more and more ill, I asked if she wanted me to call her family to be at the bedside. She simply smiled and said that they were all busy.
Over the years, I have seen many patients like this woman; we all have. Alcohol misuse is common. What’s the best evidence for screening and treatment? Dr. Paul S. Haber (of the University of Sydney) tries to answer that question with a sparkling review, published in The New England Journal of Medicine. His paper is clearly written and draws from more than sixty references. “Alcohol use disorder is a relapsing and remitting medical and psychological disorder that influences physical health, mental health, and social functioning, and continuing care is recommended.” We consider the review and several key take-aways.

In the second selection, David T. Zhu (of Virginia Commonwealth University) and his co-authors analyze the ownership of opioid treatment programs in the United States, with a particular focus on private equity. The research letter, published in JAMA Psychiatry, drew on government data. “This study found that 29.1% of US opioid treatment programs were owned by private equity firms, exceeding private equity penetration in other sectors of health care (range, 2%-11%).”
And in the third selection, columnist Marcus Gee of The Globe and Mail writes about mental illness and patient rights. He discusses a woman in his neighbourhood who has delusions and refuses shelter in the cold weather, convinced that she will soon be offered keys to a new home. “Surely she deserves better. Surely we can do better.”
DG
Selection 1: “Identification and Treatment of Alcohol Use Disorder”
Paul S. Haber
The New England Journal of Medicine, 15 January 2025

Alcohol use disorder is a chronic relapsing and remitting syndrome in which excessive drinking of alcohol persists despite causing health and social problems. The disorder is a leading contributor to illness and death but is frequently not diagnosed or treated in clinical settings, and as a result, the burden of disease remains high. In the United States, an estimated 29 million persons are affected by the disorder, leading to approximately 178,000 deaths in 2021, a health burden that is approximately double that associated with the use of opioids. Unhealthy alcohol use by a patient is suggested by history, biologic markers, and coexisting conditions such as liver disease.
So begins a review by Dr. Haber.
Pathogenesis
“The enduring myth that alcohol use disorder results from a moral failure continues to influence public and professional views of the condition. However, an estimated 50% of the risk of alcohol use disorder is thought to be inherited. Furthermore, mental health disorders are associated with a doubled risk of alcohol use disorders. Adverse early life experiences and trauma in adult life (e.g., sexual assault or trauma during military service) have been reported to increase risk. Ready availability of alcohol at low cost and widespread outlets are considered additional important risk factors.”
Definition and History
“The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), defines alcohol use disorder as the presence of at least 2 of 11 symptoms. These symptoms relate to drinking behavior and its consequences and not directly to the amount consumed. Moderate drinking is defined by the Department of Health and Human Services as up to one drink per day for women and two for men, with each standard drink containing 14 g of alcohol. Alcohol use disorders are commonly overlooked in clinical practice. When appropriate, a quantitative alcohol history should be recorded by health care personnel because the risk of medical complications such as cancer and liver injury are related to the average daily consumption of alcohol.”
Screening
“Systematic use of screening instruments reportedly increases detection of alcohol use disorder. The WHO has endorsed the Alcohol Use Disorders Identification Test (AUDIT), which is sensitive and has been implemented in various settings. There is a version for use in an interview and another for patient self-reporting; both versions score 10 questions on a scale of 0 to 4, with higher scores indicating greater use or problems from use. Scores of 8 or greater are considered to be indicative of hazardous alcohol use. Short versions (AUDIT-C and AUDIT-3) have been devised to rapidly screen for quantity of use but not for its consequences. The four-question CAGE (Cut Down Drinking, Annoyed by Criticism, Guilty Feelings, and Eye-Opener) screening is a brief instrument in which two or more affirmative answers suggest the presence of an alcohol use disorder; however, CAGE is insensitive for detection of mild problems with alcohol use.”
Treatment – Psychosocial
“Brief intervention refers to structured and time-limited advice regarding alcohol, typically one to three sessions, 5 to 20 minutes each, and is effective in a range of clinical contexts. It allows the provider to give personalized feedback regarding the patient’s alcohol use and its effects as well as advice on safe levels of consumption and encourages change with the use of a motivational interviewing approach. Brief intervention is designed to be delivered by professionals who are not specialists in addiction treatment and may also be effectively delivered by means of telephone or online approaches.”
The author notes other psychosocial interventions:
- Peer-support. Alcoholics Anonymous (AA) is still “the most widely used and effective intervention.” Evidence: “In one study, 23% of persons attended AA for more than 6 months, and of these, 72% were abstinent from alcohol at 16 years of follow-up.”
- CBT. Evidence: “15 to 26% of participants having better outcomes than controls.”
- Others. The review also notes evidence for “motivational enhancement therapy, 12-step facilitation, and newer, so-called third-wave psychotherapies, including acceptance and commitment therapy, mindfulness, and dialectical behavior therapy.”
Treatment – Medications
“Naltrexone is a long-acting orally active opioid receptor antagonist that reduces craving and consumption of alcohol, with its effectiveness established in trials and confirmed in a meta-analysis. Once-daily dose administration makes naltrexone a convenient first-line agent. Another agent, acamprosate, modulates glutamatergic neurotransmission, and its effectiveness has also been reported by meta-analysis. It has a favorable safety profile and is safe for use in patients with liver disease, but it requires administration in three daily doses. These drugs are only modestly effective, with a relative risk of heavy drinking reduced to 0.81 for naltrexone and the relative risk of any drinking reduced to 0.88 for acamprosate. Disulfiram may be the most effective of the current pharmacotherapies in accomplishing abstinence in a motivated patient in whom administration is supervised. Liver tests should be monitored early in treatment, and disulfiram is contraindicated in advanced liver disease owing to a risk of life-threatening hepatotoxic effects. If alcohol is consumed, disulfiram precipitates an adverse reaction comprising flushing, nausea, tachycardia, and hypotension…”
The review also makes mention of other medications that not approved, including topiramate which is “at least as effective as naltrexone in a comparative trial” and advises “slow dose adjustment” to minimize side effects. “As well, gabapentin has been shown to be effective and to have a satisfactory safety profile, but it is associated with a substantial risk of abuse.”

A few thoughts:
1. This is an excellent review in a major journal.
2. Five take-aways:
- Take a good history. “A quantitative alcohol history should be recorded for all patients, because alcohol use contributes to many physical and mental disorders.”
- Screening tools can be useful. Yes, even short ones (like the AUDIT-3).
- Brief interventions help. And they “can be delivered effectively by most health care professionals.”
- Remember AA. It’s widely available – but there are psychosocial interventions, too.
- Meds work. “Pharmacologic treatment is effective and underused.”
3. The woman I mentioned at the beginning of this Reading had an illness, alcohol use disorder. She also had an unsupportive family who viewed her problem as being a moral failure. The comment on genetic risk is worth repeating: “an estimated 50% of the risk of alcohol use disorder is thought to be inherited.”
The full NEJM review can be found here:
https://www.nejm.org/doi/full/10.1056/NEJMra2306511
Selection 2: “Private Equity Ownership of US Opioid Treatment Programs”
David T. Zhu, Zirui Song, Sneha Kannan, et al.
JAMA Psychiatry, 11 December 2024

Opioid overdose deaths exceed 80 000 annually in the US, but only 1 in 4 adults with opioid use disorder (OUD) receives evidence-based medications like methadone and buprenorphine. Amid this epidemic, private equity (PE) firms have acquired numerous opioid treatment programs (OTPs), sometimes referred to as methadone clinics. While PE ownership has been linked to adverse clinical events and increased prices in other health care settings, its role in addiction treatment is less understood.
So begins a research letter by Zhu et al.
Here’s what they did:
- They looked at private equity ownership, using a dataset from the Substance Abuse and Mental Health Services Administration and checking against Pitchbook (a database with acquisition information).
- They linked the type of ownership with sociodemographic data and zip codes.
Here’s what they found:
- They identified 1 932 opioid treatment programs across 50 states.
- PE owned. 29.1% were private equity owned.
- Parent companies. PE-owned opioid treatment programs belonged to one of 11 parent companies, each owned by one to two firms. The three largest parent companies accounted for 54.6% of all PE-owned opioid treatment programs nationwide. (!)
- Geography. “States in the Midwest and South exhibited higher PE penetration. In 14 states, PE firms owned over 50% of OTPs, with 100% PE ownership in 3 states (Montana, Nebraska, and South Dakota).”
- Demographics. “Zip codes with PE-owned OTPs had higher shares of non-Hispanic White residents, lower shares of non-Hispanic Black and Hispanic residents, and lower median household incomes compared with zip codes with non–PE-owned OTPs.”

A few thoughts:
1. This is a unique and important look at opioid treatment in the United States, published in an excellent journal.
2. The key finding: about a third of opioid treatment programs are owned by private equity firms.
3. What is the impact on care? On outcomes? The research letter doesn’t consider such questions.
4. Of course, we can speculate that the for-profit motives of private equity may run contrary to evidence-based care. This is an American research letter published in an American journal. Are there lessons for other countries – indeed, a warning?
The full JAMA Psych research letter can be found here:
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2827734
Selection 3: “If the woman on the sidewalk refuses help, do we just let her freeze?”
Marcus Gee
The Globe and Mail, 28 December 2024

I had a beautiful Christmas, full of laughter and light. But through it all, I kept wondering about the woman on the sidewalk.
She is camped out on a busy street just a few blocks from my house in west-end Toronto. She sits on one of those folding camp chairs with her back to a small tree. Her feet rest on a second chair. Layers of blankets and sleeping bags cover her from head to foot.
She has been there – or spots nearby – for months. Day after day, night after night, in all weathers, she sits silent and unmoving in the same place. She wears a big hood and a vest that covers her neck and mouth, so only her eyes are visible – wary, watching.
So begins an essay by Gee.
The woman is clearly delusional. “She tells them she is not homeless. She and her family own many buildings in the neighbourhood, but evil people – demons, in fact – have moved in and displaced her. If someone would just give her the keys, she would have a place to live again… In the meantime, she insists she will not move into a shelter, even though space was available this week. Those are for homeless people. She won’t even go to a warming centre. She prefers to wait for her keys.”
He notes that she has significant rights. “That is the position we seem to have arrived at as a society. If you don’t (or can’t) express a desire for help, we won’t help you. We will simply leave you there – under a bridge, in a tent in a park, even on the pavement with nothing over your head but the sky. Your autonomy trumps your safety.”
“A woman who has a son who lives with schizophrenia wrote on my neighbourhood chat group that she may have a condition called anosognosia: an inability to recognize that you are, in fact, ill. That belief often leads people to go off their meds and refuse help. No amount of reasoning will persuade them they need treatment, even if they are in rags on the street.”
Gee wonders about the larger significance. “If we call ourselves a caring society, don’t we have a duty to intervene in some way on her behalf? At least two provinces, Alberta and British Columbia, are expanding involuntary treatment for those with addiction and mental-health problems.”
“Though it would be awful to see her carted off somewhere against her will, it seems wrong to the point of cruelty to let her sit there week after week in the cold, trapped in the prison of her mind.”
A few thoughts:
1. This is a thoughtful and well-written essay.
2. Should this person have a right to be mentally ill?
3. Increasingly, some advocate for the rebalancing of patient rights, allowing for more coercive care. Regardless of where you stand on these issues, perhaps we can all agree that there is something wrong when a person without treatment sleeps on camp chairs outside during a Canadian winter.
The full Globe essay can be found here:
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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