www.aodhealth.org1 update on alcohol, other drugs, and health july–august 2008

www.aodhealth.orgwww.aodhealth.org 11

Update on Update on Alcohol, Other Alcohol, Other

Drugs, and HealthDrugs, and Health

July–August 2008July–August 2008


Studies on Studies on Interventions and Interventions and

AssessmentsAssessments


Brief Alcohol Counseling in Brief Alcohol Counseling in the Emergency the Emergency

Department: The Details Department: The Details May MatterMay Matter

D’Onofrio G, et al. D’Onofrio G, et al. Ann Emerg Med.Ann Emerg Med. 2008;51(6):742–750. 2008;51(6):742–750.

Summary by Richard Saitz MD, MPHSummary by Richard Saitz MD, MPH


Objectives/MethodsObjectives/Methods Researchers sought to determine the efficacy of Researchers sought to determine the efficacy of

brief alcohol counseling in emergency brief alcohol counseling in emergency departments (EDs).departments (EDs).

They randomized 494 patients identified as They randomized 494 patients identified as consuming risky amounts of alcohol (12–14 consuming risky amounts of alcohol (12–14 drinks per week at baseline) or as having injury drinks per week at baseline) or as having injury and alcohol use to either…and alcohol use to either… participate in a brief negotiated interview with ED participate in a brief negotiated interview with ED

practitioners, orpractitioners, or receive scripted discharge instructions about receive scripted discharge instructions about

health behaviors, including alcohol use.health behaviors, including alcohol use.

Likely alcohol or drug dependent individuals Likely alcohol or drug dependent individuals were excluded.were excluded.


ResultsResults

At 12 months, with 92% follow-up, drinking At 12 months, with 92% follow-up, drinking decreased but did not differ significantly by group.decreased but did not differ significantly by group.

There were no differences between groups in…There were no differences between groups in…

consumption of riskyconsumption of risky amountsamounts number of drinks per number of drinks per weekweek driving after drinkingdriving after drinking injury while drinkinginjury while drinking

missed workmissed work contact with thecontact with the legal systemlegal system alcohol treatmentalcohol treatment readiness to readiness to changechange


CommentsComments Although brief counseling for alcohol misuse has Although brief counseling for alcohol misuse has

decreased consumption in primary care decreased consumption in primary care settings, in this study, brief counseling in the ED settings, in this study, brief counseling in the ED had no more efficacy than simple instructions. had no more efficacy than simple instructions.

Possible explanations for the negative findings Possible explanations for the negative findings have been postulated:have been postulated: the relatively mildly affected populationthe relatively mildly affected population lack of skill in the counseling clinicianlack of skill in the counseling clinician intervention effects in the control group from intervention effects in the control group from

simple discharge instructionssimple discharge instructions

Excessive drinking should be identified and Excessive drinking should be identified and addressed in the ED; however, how best to do it addressed in the ED; however, how best to do it remains unclear and should be addressed in remains unclear and should be addressed in future studies.future studies.


Bischof G, et al. Bischof G, et al. Drug Alcohol Depend.Drug Alcohol Depend. 2008;93(3):244–251. 2008;93(3):244–251.Summary by Summary by Kevin L. Kraemer, MD, MScKevin L. Kraemer, MD, MSc

Telephone-based Telephone-based Stepped Care for Stepped Care for

Unhealthy Alcohol UseUnhealthy Alcohol Use


Objectives/MethodsObjectives/Methods In a controlled trial, investigators sought to determine In a controlled trial, investigators sought to determine

whether telephone-based, stepped-care strategies whether telephone-based, stepped-care strategies improve delivery of alcohol interventions in primary improve delivery of alcohol interventions in primary care settings.care settings.

They randomized 408 primary care patients with at-They randomized 408 primary care patients with at-risk drinking, heavy drinking, alcohol abuse, or alcohol risk drinking, heavy drinking, alcohol abuse, or alcohol dependence to either…dependence to either… full care (computerized feedback plus four 30-minute full care (computerized feedback plus four 30-minute

telephone interventions),telephone interventions), stepped care (computerized feedback plus up to threestepped care (computerized feedback plus up to three 40-minute telephone interventions), or40-minute telephone interventions), or a control group (no alcohol intervention).a control group (no alcohol intervention).

Telephone interventions were based on motivational Telephone interventions were based on motivational interviewing and delivered by trained psychologists.interviewing and delivered by trained psychologists.


ResultsResults Compared with controls, participants in the intervention Compared with controls, participants in the intervention

groups (full care and stepped care combined) reported…groups (full care and stepped care combined) reported… a greater decrease in grams of alcohol per day from a greater decrease in grams of alcohol per day from

baseline to 12 months (-12.6 versus -6.3 in the overall baseline to 12 months (-12.6 versus -6.3 in the overall sample; -17.9 versus -3.7 in the alcohol abuse/at-risk sample; -17.9 versus -3.7 in the alcohol abuse/at-risk drinking subgroup); anddrinking subgroup); and

a lower proportion of binge drinking at 12 months (25% a lower proportion of binge drinking at 12 months (25% versus 41%) in the alcohol abuse/at-risk drinking versus 41%) in the alcohol abuse/at-risk drinking subgroup.subgroup.

Outcomes were similar in the full- and stepped care Outcomes were similar in the full- and stepped care groups despite the fact that the stepped care group groups despite the fact that the stepped care group received half the counseling time received by the full received half the counseling time received by the full care group.care group.

Outcomes did not differ between the control and Outcomes did not differ between the control and intervention groups for subjects with alcohol intervention groups for subjects with alcohol dependence or heavy drinking.dependence or heavy drinking.


CommentsComments These findings suggest that computerized These findings suggest that computerized

feedback combined with telephone-based feedback combined with telephone-based interventions may decrease alcohol use in primary interventions may decrease alcohol use in primary care patients.care patients.

““As-needed” telephone interventions appear to be As-needed” telephone interventions appear to be as effective as “fixed” doses for patients with as effective as “fixed” doses for patients with alcohol abuse/at-risk drinking, but neither was alcohol abuse/at-risk drinking, but neither was effective for alcohol dependence/heavy drinking. effective for alcohol dependence/heavy drinking.

How this intervention compares with face-to-face How this intervention compares with face-to-face briefer interventions, which can be effective for briefer interventions, which can be effective for nondependent at-risk drinking, is not known.nondependent at-risk drinking, is not known.


Gruber VA, et al. Gruber VA, et al. Drug Alcohol Depend.Drug Alcohol Depend. 2008;94(1– 2008;94(1–3):199–206.3):199–206.

Summary by Jeffrey H. Samet, MD, MA, MPHSummary by Jeffrey H. Samet, MD, MA, MPH

Methadone DetoxifMethadone Detoxif ication ication Remains No Match for Remains No Match for

Methadone Maintenance, Even Methadone Maintenance, Even with Minimal Counselingwith Minimal Counseling


Objectives/MethodsObjectives/Methods Although it is known that open-ended Although it is known that open-ended

methadone maintenance (MM) is more methadone maintenance (MM) is more effective than methadone detoxification (MD), effective than methadone detoxification (MD), no controlled studies have compared short-no controlled studies have compared short-term MM to MD.term MM to MD.

Analyzing a subsample (n=111) from a larger Analyzing a subsample (n=111) from a larger randomized controlled trial, researchers randomized controlled trial, researchers compared the effects of 21-day MD alone with compared the effects of 21-day MD alone with 6-month MM including either…6-month MM including either… minimal counseling (a single 15-minute session minimal counseling (a single 15-minute session

per month), or per month), or standard counseling standard counseling (2 sessions per month or (2 sessions per month or

more, if needed, and the opportunity to earn more, if needed, and the opportunity to earn take-home medications).take-home medications).


Objectives/Methods Objectives/Methods (cont’d)(cont’d)

Outcomes were substance use and Outcomes were substance use and depressive symptoms measured at depressive symptoms measured at baseline and monthly for 6 months.baseline and monthly for 6 months.

The majority of subjects were male, The majority of subjects were male, nonwhite, poor, and not interested in nonwhite, poor, and not interested in stopping heroin but rather in cutting stopping heroin but rather in cutting down on use.down on use.


ResultsResults

Compared with 6-week MD, 6-month MM Compared with 6-week MD, 6-month MM resulted in a greater decrease from baseline in resulted in a greater decrease from baseline in self-reported opiate use, opiate positive self-reported opiate use, opiate positive urines, and days of alcohol use.urines, and days of alcohol use.

No difference between groups was found for No difference between groups was found for cocaine use or depressive symptoms.cocaine use or depressive symptoms.

Results for MM with standard counseling did Results for MM with standard counseling did not differ from those for MM with minimal not differ from those for MM with minimal counseling.counseling.


CommentsComments

These findings show that the duration of time These findings show that the duration of time on methadone therapy is key to the benefits on methadone therapy is key to the benefits received with regard to opiate-related received with regard to opiate-related outcomes.outcomes.

As the treatment groups were small (As the treatment groups were small (MM with MM with minimal counseling, n=35; MM with standard minimal counseling, n=35; MM with standard counseling, n=37),counseling, n=37), few conclusions can be few conclusions can be drawn concerning the lack of differences drawn concerning the lack of differences noted between counseling intensity in the 6-noted between counseling intensity in the 6-month MM groups.month MM groups.


Naltrexone Implantation Naltrexone Implantation versus Methadone versus Methadone

Maintenance for Heroin Maintenance for Heroin Dependence: Impact on Dependence: Impact on

Drug-Related Drug-Related HospitalizationHospitalization

Ngo HT, et al. Ngo HT, et al. Arch Gen Psychiatry.Arch Gen Psychiatry. 2008;65(4):457–465. 2008;65(4):457–465.Summary by Marc N. Gourevitch, MD, MPHSummary by Marc N. Gourevitch, MD, MPH


Objectives/MethodsObjectives/Methods Long-lasting formulations of naltrexone are Long-lasting formulations of naltrexone are

increasingly used to treat opioid dependence.increasingly used to treat opioid dependence.

Their long-term safety and effectiveness Their long-term safety and effectiveness compared with methadone maintenance (MM) are compared with methadone maintenance (MM) are uncertain.uncertain.

In a retrospective longitudinal study, researchers In a retrospective longitudinal study, researchers compared drug-usecompared drug-use –related outcomes in heroin-–related outcomes in heroin-dependent persons before and after treatment dependent persons before and after treatment with either naltrexone implantation (NIT) (n=314) with either naltrexone implantation (NIT) (n=314) requiring reimplantation every 6 months, or MM requiring reimplantation every 6 months, or MM (n=522).(n=522).


Results Results

Patients treated with NIT had a substantial Patients treated with NIT had a substantial decrease in opioid overdose admissions decrease in opioid overdose admissions (odds ratio [OR], 0.23) at 3½-year follow-up.(odds ratio [OR], 0.23) at 3½-year follow-up.

The NIT group had a marked increase in The NIT group had a marked increase in nonopioid overdose admissions at 6 months nonopioid overdose admissions at 6 months (OR, 16.3) that did not persist after 3½ (OR, 16.3) that did not persist after 3½ years of follow-up.years of follow-up.

Other nonopioid-related admissions also Other nonopioid-related admissions also increased in the NIT group at 6 months and increased in the NIT group at 6 months and 3½ years (OR, 2.54 and 1.52, respectively).3½ years (OR, 2.54 and 1.52, respectively).


Results Results (cont’d)(cont’d)

Patients treated with MM had no change in Patients treated with MM had no change in opioid overdose admissions.opioid overdose admissions.

The MM group had an increase in The MM group had an increase in nonopioid overdose admissions at 6 nonopioid overdose admissions at 6 months (OR, 5.03) that did not persist months (OR, 5.03) that did not persist after 3½ years of follow-up.after 3½ years of follow-up.


CommentsComments Although implantable naltrexone reduced the Although implantable naltrexone reduced the

incidence of opioid overdose, a substantial increase incidence of opioid overdose, a substantial increase in adverse outcomes related to nonopioid drug use in adverse outcomes related to nonopioid drug use were observed.were observed.

The lack of a controlled, randomized study design did The lack of a controlled, randomized study design did not allow for meaningful comparisons between NIT not allow for meaningful comparisons between NIT and MM groups, nor was the study powered to look at and MM groups, nor was the study powered to look at mortality. mortality.

Prospective assessment of diverse outcomes is Prospective assessment of diverse outcomes is needed to better define the effectiveness of NIT.needed to better define the effectiveness of NIT.

Clinicians must be alert to increases in nonopioid Clinicians must be alert to increases in nonopioid drug use among heroin users initiating drug use among heroin users initiating pharmacotherapy for opioid dependence.pharmacotherapy for opioid dependence.


Understanding of Risks Understanding of Risks and Benefits of and Benefits of

Moderate Alcohol Intake Moderate Alcohol Intake is Lowis Low

Mukamal KJ, et al. Mukamal KJ, et al. Fam Med.Fam Med. 2008;40(3):188-195. 2008;40(3):188-195.Summary by Julia H. Arnsten, MD, MPHSummary by Julia H. Arnsten, MD, MPH


Objectives/MethodsObjectives/Methods Patient understanding of the relationship between Patient understanding of the relationship between

moderate alcohol use and health is not well known.moderate alcohol use and health is not well known.

To explore their knowledge of this association, To explore their knowledge of this association, researchers surveyed 878 outpatients at a single researchers surveyed 878 outpatients at a single urban medical center providing primary and urban medical center providing primary and tertiary care.tertiary care.

In a self-administered anonymous survey, In a self-administered anonymous survey, participants reported their…participants reported their…

medical history,medical history, usual alcohol consumption, andusual alcohol consumption, and preferences and opinions regarding moderate preferences and opinions regarding moderate

drinking.drinking.** *defined in this study as 1 drink every 1–2 days.*defined in this study as 1 drink every 1–2 days.


ResultsResults Approximately two-thirds of respondents Approximately two-thirds of respondents

reported current alcohol consumption:reported current alcohol consumption:

Most current drinkers believed that drinking is Most current drinkers believed that drinking is safe (62%) and healthy in moderation (61%), safe (62%) and healthy in moderation (61%), while most current abstainers disagreed with while most current abstainers disagreed with these statements (64% and 65%, respectively).these statements (64% and 65%, respectively).

FrequencyFrequency % (n=551) % (n=551)

less than weeklyless than weekly 5050

1–2 days per week1–2 days per week 2525

3–6 days per week3–6 days per week 1717

dailydaily 88



Prevention of health problems was endorsed by Prevention of health problems was endorsed by 36% of respondents as a motivation to drink 36% of respondents as a motivation to drink alcohol, compared with enjoyment (87%), alcohol, compared with enjoyment (87%), relaxation (79%), and socialization (76%).relaxation (79%), and socialization (76%).

Those who cited prevention of health problems Those who cited prevention of health problems tended to be older and consumed alcohol more tended to be older and consumed alcohol more frequently, but they consumed less per frequently, but they consumed less per drinking day and were more likely to have drinking day and were more likely to have coronary heart disease.coronary heart disease.

Forty-five percent of abstainers and 30% of Forty-five percent of abstainers and 30% of drinkers agreed to some extent with the drinkers agreed to some extent with the statement that moderate drinking can lead to statement that moderate drinking can lead to alcoholism.alcoholism.



Regarding the association between moderate Regarding the association between moderate drinking and specific health conditions,drinking and specific health conditions,

a minority of participants (1–32%) believed that a minority of participants (1–32%) believed that moderate drinking prevented any health moderate drinking prevented any health condition, even myocardial infarction (32% condition, even myocardial infarction (32% among drinkers and 27% among abstainers).among drinkers and 27% among abstainers).

slightly more than half of both abstainers and slightly more than half of both abstainers and drinkers believed that 1 drink every 1–2 days drinkers believed that 1 drink every 1–2 days could cause liver damage and birth defects.could cause liver damage and birth defects.

abstainers were twice as likely as drinkers to abstainers were twice as likely as drinkers to believe that 1 drink every 1–2 days causes believe that 1 drink every 1–2 days causes myocardial infarction, stroke, gallstones, and myocardial infarction, stroke, gallstones, and diabetes.diabetes.

only 10% of participants identified breast cancer only 10% of participants identified breast cancer as a possible risk of moderate drinking.as a possible risk of moderate drinking.


CommentsComments

Patient understanding of the potential risks Patient understanding of the potential risks and benefits of moderate alcohol intake and benefits of moderate alcohol intake appears to be low.appears to be low.

Clinicians have a particular opportunity to Clinicians have a particular opportunity to provide education and counseling with provide education and counseling with regard to alcohol use, misuse, and health.regard to alcohol use, misuse, and health.


Weaver MR, et al. Weaver MR, et al. J Acquir Immune Defic Syndr.J Acquir Immune Defic Syndr. 2008;47(4):449–458.2008;47(4):449–458.

Summary by David A. Fiellin, MDSummary by David A. Fiellin, MD

Substance Abuse Treatment Substance Abuse Treatment among Patients with HIV among Patients with HIV

and Mental Illnessand Mental Illness


Objectives/MethodsObjectives/Methods Untreated substance use and mental health Untreated substance use and mental health

conditions are associated with…conditions are associated with… increased risk of HIV transmission, andincreased risk of HIV transmission, and decreased adherence and poor response to highly decreased adherence and poor response to highly

active antiretroviral therapy (HAART).active antiretroviral therapy (HAART).

Researchers analyzed data from a cohort of 803 Researchers analyzed data from a cohort of 803 HIV infected individuals over a 3-month period to HIV infected individuals over a 3-month period to assess the receipt of substance abuse and mental assess the receipt of substance abuse and mental health treatment.health treatment.

All participants met diagnostic criteria for All participants met diagnostic criteria for substance use and mental health disorders.substance use and mental health disorders.


ResultsResults Forty-seven percent of subjects had drug Forty-seven percent of subjects had drug

and alcohol dependence, 33% had drug and alcohol dependence, 33% had drug dependence, 15% had alcohol dependence, dependence, 15% had alcohol dependence, and 5% had drug and/or alcohol abuse but and 5% had drug and/or alcohol abuse but not dependence.not dependence.

Only 33% had received concurrent Only 33% had received concurrent treatment for substance abuse and mental treatment for substance abuse and mental illness in the past 3 months; 26% had illness in the past 3 months; 26% had received only mental health services, 15% received only mental health services, 15% had received only substance abuse services, had received only substance abuse services, and 26% had received no services.and 26% had received no services.



Use of concurrent substance abuse and Use of concurrent substance abuse and mental health services was lower among mental health services was lower among nonwhites and Hispanics (p<0.05) but was nonwhites and Hispanics (p<0.05) but was positively associated with VA-CHAMPUS* positively associated with VA-CHAMPUS* insurance coverage (p<0.05).insurance coverage (p<0.05).

African American, Hispanic, and nonwhite African American, Hispanic, and nonwhite subjects were more likely to use self-help subjects were more likely to use self-help groups than white non-Hispanic subjects (p<0. groups than white non-Hispanic subjects (p<0. 001).001).

*Veterans Affairs’ Civilian Health and Medical Program of the Uniformed *Veterans Affairs’ Civilian Health and Medical Program of the Uniformed ServicesServices


CommentsComments

The low use and racial disparities seen in The low use and racial disparities seen in the receipt of substance-abuse treatment the receipt of substance-abuse treatment services among patients diagnosed with HIV services among patients diagnosed with HIV infection, substance abuse, and mental infection, substance abuse, and mental health disorders is concerning.health disorders is concerning.

Strategies to make substance-abuse Strategies to make substance-abuse treatment services more attractive, more treatment services more attractive, more available, and more effective are needed to available, and more effective are needed to address the issues highlighted in this study. address the issues highlighted in this study.


Metsch LR, et al.Metsch LR, et al. Drug Alcohol Depend.Drug Alcohol Depend. 2008;95(1–2):37–44. 2008;95(1–2):37–44.Summary by Julia H. Arnsten, MD, MPHSummary by Julia H. Arnsten, MD, MPH

Patient/Physician Discussion Patient/Physician Discussion of Alcohol Use Is Low among of Alcohol Use Is Low among HIV-infected Patients with HIV-infected Patients with

Problem DrinkingProblem Drinking


Objectives/MethodsObjectives/Methods

To develop effective interventions To develop effective interventions addressing alcohol use disorders in the HIV addressing alcohol use disorders in the HIV primary care setting, it is necessary to primary care setting, it is necessary to understand the frequency and extent of understand the frequency and extent of patient/provider discussions of alcohol use.patient/provider discussions of alcohol use.

Researchers conducted a cross-sectional Researchers conducted a cross-sectional study of 1225 HIV-positive patients study of 1225 HIV-positive patients attending 10 HIV primary care clinics in 3 attending 10 HIV primary care clinics in 3 US cities to determine the extent to which US cities to determine the extent to which alcohol was discussed with their primary alcohol was discussed with their primary care providers (PCPs).care providers (PCPs).


ResultsResults More than half (57.6%) of respondents More than half (57.6%) of respondents

reported using alcohol in the past 6 months. reported using alcohol in the past 6 months.

Based on CAGE* responses, 22% of Based on CAGE* responses, 22% of respondents had problem drinking, about 1/3 respondents had problem drinking, about 1/3 drank without problems, and the remainder drank without problems, and the remainder did not drink.did not drink.

FrequencyFrequency %%

<1 day per week<1 day per week 25.325.3

1-2 days per week1-2 days per week 18.018.0

3-6 days per week3-6 days per week 10.010.0

about every dayabout every day 4.34.3


Results Results (cont’d)(cont’d) Respondents discussed alcohol use most frequently with Respondents discussed alcohol use most frequently with

their PCPs (35.3%), followed by other professionals their PCPs (35.3%), followed by other professionals (18.4%) and support groups (17.8%). (18.4%) and support groups (17.8%).

Rates of alcohol discussion increased from nondrinkers Rates of alcohol discussion increased from nondrinkers (24%), to patients without problem drinking (39%), to (24%), to patients without problem drinking (39%), to patients with problem drinking (52%).patients with problem drinking (52%).

In multivariable analysis, those who drank alcohol (with In multivariable analysis, those who drank alcohol (with and without alcohol problems) were more likely to discuss and without alcohol problems) were more likely to discuss alcohol use with their PCPs than nondrinkers.alcohol use with their PCPs than nondrinkers.

Factors independently associated with discussing alcohol Factors independently associated with discussing alcohol use included male sex, age <40 years, non-Hispanic use included male sex, age <40 years, non-Hispanic ethnicity, better perception of engagement with the HIV ethnicity, better perception of engagement with the HIV provider, and worse self-reported general health status. provider, and worse self-reported general health status.


CommentsComments

Although patients with problem drinking Although patients with problem drinking were more likely to discuss alcohol use were more likely to discuss alcohol use with their PCPs than nondrinkers, only half with their PCPs than nondrinkers, only half of these patients reported such a of these patients reported such a discussion.discussion.

These findings reinforce the need to These findings reinforce the need to increase the focus on alcohol use in the increase the focus on alcohol use in the HIV primary care setting. Although PCPs HIV primary care setting. Although PCPs who treat HIV face many demands, they who treat HIV face many demands, they should be encouraged to screen for and should be encouraged to screen for and counsel patients about alcohol use.counsel patients about alcohol use.


Studies of Studies of Health OutcomesHealth Outcomes

www.aodhealth.orgwww.aodhealth.org 3838www.aodhealth.orgwww.aodhealth.org 3838

Hemoglobin A1C Levels Are Hemoglobin A1C Levels Are Lower among People with Lower among People with Diabetes Who Consume Diabetes Who Consume

AlcoholAlcohol

Ahmed AT, et al. Ahmed AT, et al. J Gen Intern Med.J Gen Intern Med. 2008;23(3):275–282. 2008;23(3):275–282.Summary by R. Curtis Ellison, MDSummary by R. Curtis Ellison, MD


Objectives/MethodsObjectives/Methods Few studies have measured the effects of alcohol Few studies have measured the effects of alcohol

consumption on glycemic control in patients with consumption on glycemic control in patients with diabetes.diabetes.

Investigators conducted a follow-up survey of Investigators conducted a follow-up survey of 38,564 adult patients with diabetes included in 38,564 adult patients with diabetes included in the Kaiser Permanente Northern California the Kaiser Permanente Northern California Diabetes Registry.Diabetes Registry.

The surveys, conducted between 1994 and 1997, The surveys, conducted between 1994 and 1997, assessed alcohol consumption based on a assessed alcohol consumption based on a modified AUDIT-Cmodified AUDIT-C** questionnaire. questionnaire.

Hemoglobin A1C was assessed within 1 year of Hemoglobin A1C was assessed within 1 year of the survey date.the survey date.

*Alcohol Use Disorders Identification Test—Consumption*Alcohol Use Disorders Identification Test—Consumption


Results Results Alcohol consumption was linearly and inversely Alcohol consumption was linearly and inversely

associated with A1C.associated with A1C.

A1C values adjusted for sociodemographic and A1C values adjusted for sociodemographic and clinical variables and disease: clinical variables and disease:

Alcohol consumptionAlcohol consumption A1C values A1C values (mean)(mean)

lifetime abstainers lifetime abstainers 8.888.88

former drinkersformer drinkers 8.798.79

<0.1 drink per day<0.1 drink per day 8.908.90

0.1–0.9 drink per day0.1–0.9 drink per day 8.718.71

1–1.9 drinks per day1–1.9 drinks per day 8.518.51

2–2.9 drinks per day2–2.9 drinks per day 8.398.39

≥≥3 drinks per day3 drinks per day 8.478.47


CommentsComments Results suggest that alcohol intake may be Results suggest that alcohol intake may be

associated with significantly lower A1C levels.associated with significantly lower A1C levels.

Earlier research has shown that a 1-point Earlier research has shown that a 1-point reduction in A1C is associated with…reduction in A1C is associated with…

a 21% reduction of the risk of diabetes complications, a 21% reduction of the risk of diabetes complications, andand

a 37% reduction in the risk of microvascular a 37% reduction in the risk of microvascular complications.complications.

Thus, the decrease in A1C levels associated with Thus, the decrease in A1C levels associated with alcohol use in this study, if not due to alcohol use in this study, if not due to uncontrolled confounding or cross-sectional uncontrolled confounding or cross-sectional design, could translate into clinically important design, could translate into clinically important reductions in diabetes complications for some reductions in diabetes complications for some people with the disease who drink moderately.people with the disease who drink moderately.


Dawson DA, et al. Dawson DA, et al. Drug Alcohol Depend.Drug Alcohol Depend. 2008;95(1– 2008;95(1–2):62–72.2):62–72.

Summary by Summary by Kevin L. Kraemer, MD, MScKevin L. Kraemer, MD, MSc

What Are the RisksWhat Are the Risks

of Risky Drinking? of Risky Drinking?


Objectives/MethodsObjectives/Methods To examine the adverse consequences of To examine the adverse consequences of

risky drinking,risky drinking,** researchers conducted researchers conducted interviews to assess baseline consumption interviews to assess baseline consumption and health and social status in 22,122 adult and health and social status in 22,122 adult national survey participants.national survey participants.

Criteria for inclusion were…Criteria for inclusion were… age ≥age ≥18 years, and18 years, and consumption of at least 1 drink in the year consumption of at least 1 drink in the year

preceding the baseline interview.preceding the baseline interview.

*In this paper, risky drinking was defined as 5+ drinks in a day for *In this paper, risky drinking was defined as 5+ drinks in a day for men and 4+ drinks in a day for women. men and 4+ drinks in a day for women.


Objectives/Methods Objectives/Methods (cont’d)(cont’d)

Risky drinking reported at baselineRisky drinking reported at baseline Subjects Subjects (%)(%)

NoneNone 6060

<1 time per month<1 time per month 1717

1–3 times per month1–3 times per month 99

1–2 times per week1–2 times per week 88

3–4 times per week3–4 times per week 33

daily/near dailydaily/near daily 33

The incidence of selected outcomes was measuredThe incidence of selected outcomes was measured at 3 years.at 3 years.


ResultsResults At 3-year follow-up, in adjusted analyses, At 3-year follow-up, in adjusted analyses,

participants who reported risky drinking 1 to 2 participants who reported risky drinking 1 to 2 times per week were more likely than those who times per week were more likely than those who reported no risky drinking to have… reported no risky drinking to have…

The risk for adverse consequences was generally The risk for adverse consequences was generally higher in subjects who reported risky drinking on a higher in subjects who reported risky drinking on a daily or near-daily basis. daily or near-daily basis.

incident alcohol abuse incident alcohol abuse (odds(odds ratio [OR], 3.3)ratio [OR], 3.3) alcohol dependence (OR, alcohol dependence (OR, 2.7)2.7) drug use (OR, 1.6)drug use (OR, 1.6) drug dependence (OR, 2.3)drug dependence (OR, 2.3) tobacco use (OR, 2.7)tobacco use (OR, 2.7)

nicotine dependence (OR, nicotine dependence (OR, 1.8)1.8) any liver disease (OR, 2.8)any liver disease (OR, 2.8) divorced or separated (OR, divorced or separated (OR, 1.3)1.3) lost their driver's licenses lost their driver's licenses (OR,(OR, 1.8)1.8)


CommentsComments This study demonstrates an increased risk This study demonstrates an increased risk

for a wide range of adverse consequences for a wide range of adverse consequences with increasing frequency of heavy with increasing frequency of heavy episodic drinking.episodic drinking.

The results support the need to identify The results support the need to identify individuals with risky drinking; to individuals with risky drinking; to intervene; and to monitor for alcohol, drug, intervene; and to monitor for alcohol, drug, tobacco, medical, and social problems. tobacco, medical, and social problems.

Interestingly, frequency of risky drinking Interestingly, frequency of risky drinking was not associated with mood and anxiety was not associated with mood and anxiety disorders in this study. disorders in this study.


Predicting Adverse Predicting Adverse Cardiovascular Effects of Cardiovascular Effects of

MethamphetamineMethamphetamine

Fleury G, et al. Fleury G, et al. Am J Addict.Am J Addict. 2008;17(2):103–110. 2008;17(2):103–110.Summary by David A. Fiellin, MDSummary by David A. Fiellin, MD


Objectives/MethodsObjectives/Methods Methamphetamine promotes the release of Methamphetamine promotes the release of

dopamine and norepinephrine, leading to an dopamine and norepinephrine, leading to an increase in heart rate and blood pressure. increase in heart rate and blood pressure. Cardiovascular complications may result, Cardiovascular complications may result, including arrhythmia, stroke, and acute coronary including arrhythmia, stroke, and acute coronary syndrome.syndrome.

The factors that predict cardiovascular response The factors that predict cardiovascular response to methamphetamine are not known.to methamphetamine are not known.

Under laboratory conditions, investigators Under laboratory conditions, investigators administered intravenous methamphetamine to administered intravenous methamphetamine to 67 methamphetamine-dependent individuals to 67 methamphetamine-dependent individuals to assess heart rate and blood pressure response.assess heart rate and blood pressure response.


Results Results Compared with baseline, heart rate increased by 18 bpm Compared with baseline, heart rate increased by 18 bpm

(p<0.001), and systolic blood pressure increased by(p<0.001), and systolic blood pressure increased by18 mm Hg (p<0.001) following methamphetamine 18 mm Hg (p<0.001) following methamphetamine administration (peak effect 10 minutes post-administration (peak effect 10 minutes post-administration).administration).

Factors associated with cardiovascular response Factors associated with cardiovascular response included…included…

Factors not associated with cardiovascular response Factors not associated with cardiovascular response included…included…

lifetime and past 30-day use of methamphetaminelifetime and past 30-day use of methamphetamine lifetime and past 30-day use of nicotinelifetime and past 30-day use of nicotine racerace

baseline heart rate and baseline heart rate and bloodblood pressure (men only)pressure (men only) female genderfemale gender alcohol use in the past 30 alcohol use in the past 30 daysdays

pre-study intravenous (compared pre-study intravenous (compared toto smoked)smoked) methamphetamine usemethamphetamine use cannabis use in the past 30 days,cannabis use in the past 30 days, which led to decreased peak which led to decreased peak changechange in heart ratein heart rate


CommentsComments The cardiovascular effects of methamphetamine The cardiovascular effects of methamphetamine

are substantial and put patients at risk for serious are substantial and put patients at risk for serious complications.complications.

This study helps to elucidate the factors that may This study helps to elucidate the factors that may be associated with more profound responses.be associated with more profound responses.

Clinicians should warn patients of the Clinicians should warn patients of the cardiovascular complications of methamphetamine cardiovascular complications of methamphetamine use and consider these factors when evaluating use and consider these factors when evaluating patients with recent methamphetamine ingestion.patients with recent methamphetamine ingestion.


Nielsen NR, et al. Nielsen NR, et al. Int J Cancer.Int J Cancer. 2008;122(5):1109–1113. 2008;122(5):1109–1113.Summary by R. Curtis Ellison, MDSummary by R. Curtis Ellison, MD

Alcohol, Postmenopausal Alcohol, Postmenopausal Hormones, and Risk of Hormones, and Risk of

Breast CancerBreast Cancer


Objectives/MethodsObjectives/Methods Both alcohol and postmenopausal hormone use Both alcohol and postmenopausal hormone use

increase the risk for breast cancer.increase the risk for breast cancer.

To determine whether alcohol interacts with To determine whether alcohol interacts with hormone use to further increase this risk, hormone use to further increase this risk, researchers followed 5035 postmenopausal researchers followed 5035 postmenopausal women participating in the Copenhagen City women participating in the Copenhagen City Heart Study. Heart Study.

Proportional hazard models were used for Proportional hazard models were used for analysis.analysis.

Participants reported alcohol intake and hormone Participants reported alcohol intake and hormone use at baseline (1981–1983) and were followed use at baseline (1981–1983) and were followed until 2002. Less than 0.1% were lost to follow up.until 2002. Less than 0.1% were lost to follow up.


ResultsResults Two hundred sixty-seven women developed breast cancer. Two hundred sixty-seven women developed breast cancer.

Compared with nondrinkers,Compared with nondrinkers,** women who consumed alcohol women who consumed alcohol had a small increase in breast cancer risk (hazard ratio [HR], had a small increase in breast cancer risk (hazard ratio [HR], 1.11 per drink/day; 95% CI, 0.99–1.25).1.11 per drink/day; 95% CI, 0.99–1.25).

Compared with women who did not use hormones, women Compared with women who did not use hormones, women who did had a significantly increased risk of breast cancer who did had a significantly increased risk of breast cancer (HR, 2.00 per drink/day).(HR, 2.00 per drink/day).

Women who consumed >2 drinks per day and used Women who consumed >2 drinks per day and used hormones had an increased risk for breast cancer (HR, 4.74) hormones had an increased risk for breast cancer (HR, 4.74) compared with nondrinkers who did not use hormones.compared with nondrinkers who did not use hormones.

Alcohol was not associated with breast cancer in women Alcohol was not associated with breast cancer in women who did not use hormones.who did not use hormones.

*defined as consuming <1 drink per week in this study*defined as consuming <1 drink per week in this study


CommentsComments This study supports previous findings that This study supports previous findings that

postmenopausal hormone use modifies the risk of postmenopausal hormone use modifies the risk of breast cancer associated with alcohol consumption. breast cancer associated with alcohol consumption.

Further, alcohol consumption in this study was not Further, alcohol consumption in this study was not associated with an increased risk of breast cancer associated with an increased risk of breast cancer among women who did not report hormone use. among women who did not report hormone use.

Despite a major limitation (hormone and alcohol Despite a major limitation (hormone and alcohol intake were measured only once during the 2-intake were measured only once during the 2-decade study), results of this study and others decade study), results of this study and others suggest that women who drink moderately may suggest that women who drink moderately may reduce, or even avoid, an increase in the risk of reduce, or even avoid, an increase in the risk of breast cancer if they…breast cancer if they…

do not take hormones,do not take hormones, do not have heavy drinking episodes, anddo not have heavy drinking episodes, and have an adequate intake of dietary folate.have an adequate intake of dietary folate.


Trends and Complications Trends and Complications among Hospitalized among Hospitalized

Pregnant Women with Pregnant Women with Stimulant AbuseStimulant Abuse

Cox S, et al. Cox S, et al. Obstet Gynecol.Obstet Gynecol. 2008;111(2):341–347. 2008;111(2):341–347.Summary by Alexander Y. Walley, MD, MScSummary by Alexander Y. Walley, MD, MSc


Objectives/MethodsObjectives/Methods Maternal and fetal complications associated Maternal and fetal complications associated

with stimulant abuse during pregnancy are with stimulant abuse during pregnancy are substantial and reported to be similar for substantial and reported to be similar for cocaine and amphetamines.cocaine and amphetamines.

Researchers from the Centers for Disease Researchers from the Centers for Disease Control and Prevention analyzed the Healthcare Control and Prevention analyzed the Healthcare Cost and Utilization Project National Inpatient Cost and Utilization Project National Inpatient Sample to assess linear trends in cocaine and Sample to assess linear trends in cocaine and amphetamine-related hospitalizations, and amphetamine-related hospitalizations, and complications during these hospitalizations, complications during these hospitalizations, among pregnant women.among pregnant women.

Assessments covered a 6-year period (1998–Assessments covered a 6-year period (1998–2004).2004).


ResultsResults The annual cocaine-related hospitalization rate The annual cocaine-related hospitalization rate

decreased from 0.74 per 100 deliveries to 0.41, decreased from 0.74 per 100 deliveries to 0.41, while the amphetamine-related rate increased while the amphetamine-related rate increased from 0.11 to 0.22.from 0.11 to 0.22.

Eighty-two percent of the amphetamine-related Eighty-two percent of the amphetamine-related hospitalizations were in Western states.hospitalizations were in Western states.

The proportion of women <24 years was higher in The proportion of women <24 years was higher in the amphetamine group than in the cocaine group.the amphetamine group than in the cocaine group.

Amphetamine-related hospitalizations were more Amphetamine-related hospitalizations were more common than cocaine-related hospitalizations common than cocaine-related hospitalizations among rural hospitals.among rural hospitals.



Psychiatric disorders, poor fetal growth, and Psychiatric disorders, poor fetal growth, and premature delivery were more common in the premature delivery were more common in the cocaine group versus the amphetamine group.cocaine group versus the amphetamine group.

Cardiovascular disorders, hypertension Cardiovascular disorders, hypertension complicating pregnancy, and placenta previa complicating pregnancy, and placenta previa were more common in the amphetamine were more common in the amphetamine group versus the cocaine group.group versus the cocaine group.

No significant differences between cocaine No significant differences between cocaine and amphetamine groups were detected for and amphetamine groups were detected for anemia, genitourinary infections, hepatitis, anemia, genitourinary infections, hepatitis, seizure disorder, injury, placental abruption, seizure disorder, injury, placental abruption, or premature labor.or premature labor.



The following were more common in the The following were more common in the amphet-amine group with compared with amphet-amine group with compared with pregnant women who did not have pregnant women who did not have substance abuse:substance abuse: psychiatric disorderspsychiatric disorders anemiaanemia genitourinary tract genitourinary tract infectionsinfections hepatitishepatitis epilepsyepilepsy cardiovascular disorderscardiovascular disorders injuryinjury infection of the amniotic infection of the amniotic cavitycavity

hypertension complicatinghypertension complicating pregnancypregnancy premature rupture of thepremature rupture of the membranesmembranes placenta previaplacenta previa placental abruptionplacental abruption intrauterine deathintrauterine death poor fetal growthpoor fetal growth


CommentsComments Most medical conditions are more common in Most medical conditions are more common in

those who use illicit stimulants than in those those who use illicit stimulants than in those who do not.who do not.

Cocaine-related hospitalizations are more Cocaine-related hospitalizations are more prevalent than amphetamine-related prevalent than amphetamine-related hospitalizations, but the gap has narrowed and hospitalizations, but the gap has narrowed and varies geographically.varies geographically.

Although many complications are similar, there Although many complications are similar, there is a higher incidence of psychiatric disorders, is a higher incidence of psychiatric disorders, poor fetal growth, and premature delivery with poor fetal growth, and premature delivery with cocaine abuse and more vascular-related cocaine abuse and more vascular-related complications with amphetamine abuse.complications with amphetamine abuse.


Becker WC, et al. Becker WC, et al. Drug Alcohol Depend.Drug Alcohol Depend. 2008; 94(1– 2008; 94(1–3):38–47. 3):38–47.

Wu LT, et al. Wu LT, et al. Drug Alcohol Depend.Drug Alcohol Depend. 2008;94(1–3):1–11. 2008;94(1–3):1–11. Simoni-Wastila L, et al. Simoni-Wastila L, et al. J Addict Med.J Addict Med. 2008;2(1):31–39. 2008;2(1):31–39.

Summary by Summary by Peter D. Friedmann, MD, MPHPeter D. Friedmann, MD, MPH

Prescription Drug Misuse Prescription Drug Misuse Is Prevalent and Is Prevalent and

Associated with Youth, Associated with Youth, Psychiatric Problems, Psychiatric Problems,

and Other Substance Useand Other Substance Use


Objectives/MethodsObjectives/Methods Nonmedical use of prescription drugs is a Nonmedical use of prescription drugs is a

growing problem among adolescents and growing problem among adolescents and young adults.young adults.

Three recent articles examine this problem Three recent articles examine this problem using cross-sectional data from the using cross-sectional data from the National Survey on Drug Use and Health National Survey on Drug Use and Health (NSDUH), a representative US sample (NSDUH), a representative US sample survey measuring the prevalence, patterns, survey measuring the prevalence, patterns, and consequences of alcohol, tobacco, and and consequences of alcohol, tobacco, and illegal drug use.illegal drug use.


ResultsResults Becker and colleagues analyzed data from Becker and colleagues analyzed data from

91,804 persons 91,804 persons ≥≥18 who participated in the 18 who participated in the survey between 2002–2004.survey between 2002–2004.

Past-year nonmedical use of prescription opioids Past-year nonmedical use of prescription opioids was found in 4.5% of subjects, 12.9% of whom was found in 4.5% of subjects, 12.9% of whom met criteria for abuse or dependence.met criteria for abuse or dependence.

Correlates of nonmedical use included younger Correlates of nonmedical use included younger age, depressive and anxiety symptoms, age, depressive and anxiety symptoms, cigarette smoking, alcohol misuse, Latino cigarette smoking, alcohol misuse, Latino ethnicity, unemployment, and low education ethnicity, unemployment, and low education attainment. attainment.



Wu and colleagues examined data from 18,678 Wu and colleagues examined data from 18,678 adoles-cents aged 12–17 who participated in the adoles-cents aged 12–17 who participated in the 2005 survey.2005 survey.

Ten percent reported lifetime nonmedical use of Ten percent reported lifetime nonmedical use of prescription opioids. Of these, 61% had used prescription opioids. Of these, 61% had used them before age 15, and 18% had used them them before age 15, and 18% had used them weekly or more in the previous year.weekly or more in the previous year.

Risk factors for lifetime use included age 16–17 Risk factors for lifetime use included age 16–17 (compared with age 12–13), younger age at first (compared with age 12–13), younger age at first drug use, fair or poor health, and 3 or more drug use, fair or poor health, and 3 or more emergency department visits in the past year.emergency department visits in the past year.

Mental-health service use was a significant Mental-health service use was a significant correlate for girls.correlate for girls.



In an analysis of the 2003 survey, Simoni-In an analysis of the 2003 survey, Simoni-Wastila and colleagues found a 9.3% Wastila and colleagues found a 9.3% prevalence of nonmedical prescription drug prevalence of nonmedical prescription drug use by adolescents.use by adolescents.

They similarly detected a relationship They similarly detected a relationship between past-year nonmedical use of between past-year nonmedical use of prescription drugs with age 16–17, prescription drugs with age 16–17, cigarette smoking, and alcohol use.cigarette smoking, and alcohol use.


CommentsComments Nonmedical use of prescription drugs, especially Nonmedical use of prescription drugs, especially

opioids, is highly prevalent among adolescents and opioids, is highly prevalent among adolescents and adults.adults.

Ideally, physicians ask all patients about nonmedical Ideally, physicians ask all patients about nonmedical use of prescription drugs as a routine part of the use of prescription drugs as a routine part of the medical history; however, this proves challenging in a medical history; however, this proves challenging in a busy clinic or office.busy clinic or office.

Although these studies cannot determine causal Although these studies cannot determine causal direction, they do provide clues that can guide direction, they do provide clues that can guide clinical prevention and case finding.clinical prevention and case finding.

Clinicians should be especially careful to screen for Clinicians should be especially careful to screen for prescription and other drug problems among persons prescription and other drug problems among persons in mid- to late adolescence or early adulthood; in in mid- to late adolescence or early adulthood; in those who smoke, drink, or use other substances; those who smoke, drink, or use other substances; and in those with depressive or anxiety symptoms.and in those with depressive or anxiety symptoms.


Perkonigg A, et al. Perkonigg A, et al. Addiction.Addiction. 2008;103(3):439-449. 2008;103(3):439-449.Summary by Summary by Peter D. Friedmann, MD, MPHPeter D. Friedmann, MD, MPH

Youth Cannabis Use Youth Cannabis Use Commonly Extends into Commonly Extends into

AdulthoodAdulthood


Objectives/MethodsObjectives/Methods Data from Western countries suggest that up to Data from Western countries suggest that up to

half of adolescents have used cannabis at least half of adolescents have used cannabis at least once, and up to 10% may develop cannabis abuse once, and up to 10% may develop cannabis abuse or dependence.or dependence.

To examine the natural history of cannabis use, To examine the natural history of cannabis use, German investigators analyzed 4- and 10-year German investigators analyzed 4- and 10-year follow-up data from 3021 youth (ages 14–24 follow-up data from 3021 youth (ages 14–24 years at baseline) enrolled in a prospective years at baseline) enrolled in a prospective population-based cohort study.population-based cohort study.

Cannabis use and dependence were measured Cannabis use and dependence were measured using the Composite International Diagnostic using the Composite International Diagnostic Interview-Substance Abuse Module (CIDI-SAM), Interview-Substance Abuse Module (CIDI-SAM), Munich version.Munich version.


ResultsResults At baseline, 7% had used cannabis once only. Eleven At baseline, 7% had used cannabis once only. Eleven

percent had used it 2 to 4 times, and 16% had used it percent had used it 2 to 4 times, and 16% had used it 5 times or more (repeated use). 5 times or more (repeated use).

Cannabis abuse or dependence was found in 12% of Cannabis abuse or dependence was found in 12% of sub-jects at baseline, in 15% at 4 years, and in 13.5% sub-jects at baseline, in 15% at 4 years, and in 13.5% at 10 years.at 10 years.

Of those who had repeated cannabis use at baseline, Of those who had repeated cannabis use at baseline, 56% still used it 4 years later, and 46% still used it 10 56% still used it 4 years later, and 46% still used it 10 years later.years later.

Predictors of repeated use at 10-year follow-up Predictors of repeated use at 10-year follow-up included…included…

repeated use at baselinerepeated use at baseline younger age of initial useyounger age of initial use male gendermale gender drug-using peersdrug-using peers distressing life eventsdistressing life events alcohol dependencealcohol dependence


CommentsComments Physicians and other adults commonly view Physicians and other adults commonly view

marijuana as harmless and worthy of marijuana as harmless and worthy of consideration as medical treatment by consideration as medical treatment by prescription.prescription.

This study suggests that a substantial This study suggests that a substantial proportion of young cannabis users develop proportion of young cannabis users develop recurrent cannabis use, abuse, or recurrent cannabis use, abuse, or dependence that persists into adulthood.dependence that persists into adulthood.

When viewed in light of the current epidemic When viewed in light of the current epidemic of prescription drug abuse among young of prescription drug abuse among young people, these data should give pause to people, these data should give pause to advocates of expanded access to marijuana advocates of expanded access to marijuana by prescription.by prescription.

www.aodhealth.org1 update on alcohol, other drugs, and health july–august 2008

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