Www.aodhealth.org1 Update on Alcohol, Other Drugs, and Health January–February 2015.

www.aodhealth.orgwww.aodhealth.org 11

Update on Update on Alcohol, Other Alcohol, Other

Drugs, and HealthDrugs, and Health

January–February 2015January–February 2015


Studies on Studies on Interventions & Interventions &

AssessmentsAssessments


The Majority of People with Unhealthy Alcohol Use Do

Not Have Dependence

Esser MB, et al. Prev Chronic Dis. 2014;11(E206):1–11.Summary by Hillary Kunins, MD, MPHSummary by Hillary Kunins, MD, MPH

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Objectives/MethodsObjectives/Methods

Numerous clinical studies have found that most patients with unhealthy alcohol use do not have DSM-IV dependence, but no recent population data exist.

Using the National Survey on Drug Use and Health (2009–2011), investigators examined evidence of “excessive drinking” (heavy episodic drinking,* any underage drinking, and drinking during pregnancy) and DSM-IV alcohol dependence among 138,000 adults.

* Defined as ≥5 drinks for men or ≥4 for women on at least 1 occasion in the last 30 days.

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ResultsResults

In the past month, 29% of participants had any excessive drinking, 27% had heavy episodic drinking, and 3.5% had alcohol dependence.

Highest rates of each were among men, people aged 18–24, and unemployed persons.

Dependence was highest among Native Americans/Alaskan Natives.


ResultsResults (cont (cont’’d)d)

The prevalence of alcohol dependence was 10% among people with any excessive drinking, 10.5% among people with heavy episodic drinking, and 1% among people with alcohol consumption reporting no heavy episodic drinking. Among people with heavy episodic drinking, alcohol dependence increased by frequency of episodes (4% among persons with 1–2 past-month episodes; 30% with ≥10 episodes).

Alcohol dependence was highest among those with less than a high school education or some college and with a family income of ≤$25,000. Heavy episodic drinking rates were higher among people with family incomes of ≥$75,000 compared with those with lower incomes.


CommentsComments

This study reminds us that the majority of US adults who consume alcohol, even if they do so excessively, do not meet criteria for alcohol dependence.

To address this public health problem, both population and clinical interventions need to focus on reducing excessive consumption overall.

Although the causality of the differential patterns in prevalence of alcohol dependence compared with unhealthy alcohol use cannot be determined from this cross-sectional study, it raises concern that the risk of alcohol dependence may not be distributed equally.


Interventions to Reduce Prenatal Alcohol Use Have

Mixed Results

van der Wulp NY, et al. J Med Internet Res. 2014;16(12):e274.

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


ObjectivesObjectives Researchers sought to test the effectiveness of an

internet-based, computer-tailored intervention to reduce prenatal alcohol use.

They randomized 60 midwifery practices to 1 of 3 arms: 1) computer-tailored feedback, delivered via webpage and

e-mail at baseline, 6 weeks, and 12 weeks; 2) face-to-face health counseling by the midwives (1 10-

minute session 2 weeks after baseline and 2 1-minute sessions, 8 and 14 weeks after baseline);

3) usual care. The study enrolled 349 pregnant women (mean age

= 33 years, mean gestational age = 7.9 weeks, mean pre-pregnancy drinks in a week = 5.8, mean pregnancy drinks in a week = 1.1).


ResultsResults At 24-week follow-up, 78% of the computer-tailored arm,

72% of the health counseling arm, and 55% of the usual care arm reported abstinence.

In an adjusted model, pregnant women in the computer-tailored arm were more likely to be abstinent at follow-up (odds ratio, 2.77) than those in usual care. The health counseling arm did not differ significantly from usual care.

At follow-up, among the 79 pregnant women who continued drinking, mean alcohol use was 0.35 drinks in a week in the computer-tailored arm, 0.77 drinks in a week in the health counseling arm, and 0.48 drinks in a week in the usual care arm.

Process evaluation indicated “suboptimal implementation of the health counseling intervention by the midwives.”


Comments Comments These findings suggest that computer-tailored feedback

may be an effective intervention to reduce self-reported prenatal alcohol use.

The authors believe this effect may be due, in part, to the computer helping maintain the pregnant women’s anonymity. However, it cannot be determined from this study if the computer-tailored intervention is superior to face-to-face brief counseling due to uncertainty about how well the counseling was delivered, and the questionable accuracy of self-reported drinking in these circumstances.

Further work is certainly needed, along with an estimation of the cost-effectiveness of the computer intervention.


Housing First Intervention Impacts Unhealthy Use of

Alcohol, Not Drugs

Kirst M, et al. Drug Alcohol Depend. 2015;146:24–29.Summary by Nicolas Bertholet, MD, MScSummary by Nicolas Bertholet, MD, MSc


Objectives/MethodsObjectives/Methods Housing First (HF) interventions provide homeless individuals

with housing and other support services and have shown efficacy in improving quality of life, but little is known about substance use outcomes among its recipients.

This Canadian study investigated the impact of an HF intervention on alcohol and other substance use outcomes among 575 individuals with mental illness and homelessness—with or without a co-occurring substance use disorder—who were randomized to an HF intervention or treatment as usual and were followed up at 2 years.

Participants were mostly male (68%) and 53% of them had a duration of homelessness of ≥3 years.


Results Results At baseline, 31% reported any unhealthy alcohol use

in the past 30 days and 39% reported any drug use.

At 2 years, those who received the HF intervention had greater reductions in the number of days of unhealthy alcohol use over the past month (incidence rate ratio, 0.46) and money spent on alcohol.

There were no differences between groups at 2 years for the number of drug problems over the past 30 days and money spent on drugs.


CommentsComments

This study found that the HF intervention positively affected alcohol use outcomes but not drug use among people with homelessness and mental illness, which is consistent with what other studies have shown.

It remains to be determined how best to impact drug use outcomes with HF interventions since these individuals may need additional support.


Buprenorphine Maintenance is More

Effective than Taper for Treating Prescription Opioid Use Disorder in

Primary Care Fiellin DA, et al. JAMA Intern Med. 2014;174:1947–

1954.Summary by Darius A. Rastegar, MDSummary by Darius A. Rastegar, MD


Objectives/MethodsObjectives/Methods Buprenorphine is an important treatment option for opioid use

disorder and can be prescribed as a gradual taper or maintenance treatment.

This trial recruited 113 subjects with DSM-IV prescription opioid dependence in a primary care practice. All participants underwent a 2-week buprenorphine induction, then randomly received either a stable dosage of buprenorphine for 4 weeks, followed by a gradual taper over 3 weeks (taper), or a stable dose for 14 weeks (maintenance).

All subjects received weekly drug counseling.

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Results Results Subjects assigned to taper had a lower mean

percentage of opioid-negative urine samples than those assigned to maintenance (35% versus 53%). The difference was observed primarily during the second half of the trial (33% versus 64%).

During the second half of the trial, subjects assigned to taper reported more mean days of opioid use in the past week than those in the maintenance group (1.3 versus 0.5).

Subjects assigned to taper achieved fewer mean maximum consecutive weeks of opioid abstinence than those assigned to maintenance (2.7 versus 5.2) and were less likely to complete the trial (11% versus 66%).



CommentsComments

This study confirms that FOR PRESCRIPTION OPIOID DEPENDENCE TREATED IN PRIMARY CARE, opioid agonist maintenance treatment is more effective than even a prolonged taper and reinforces that we should not place arbitrary time limits on treatment or pressure patients to taper their dose.

It also adds to the growing body of evidence demonstrating that this treatment can be provided in a primary care setting, but more primary care physicians need to do this in order to meet the tremendous need.


Nielsen S, et al. J Subst Abuse Treat. 2015;48:70–76.Summary by Jeanette M. Tetrault, MDSummary by Jeanette M. Tetrault, MD

Individuals with Prescription Opioid Use Disorder May

Respond Better to Buprenorphine Treatment

than Those with Heroin Use Disorder


Objectives/MethodsObjectives/Methods Prior studies have suggested that buprenorphine plus medical

management can be an effective treatment for individuals with prescription opioid use disorder, and that these patients may have more favorable outcomes with buprenorphine treatment than those with heroin use.

This secondary data analysis compared treatment outcomes among 179 individuals with either prescription opioid (PO), heroin (H), or combined prescription opioid and heroin (POH) use disorder, drawing on data from a 16-week randomized clinical trial studying four different behavioral treatments coupled with buprenorphine and standard medical management.

A subsequent 16-week buprenorphine-only phase followed. Follow-up was performed at weeks 40 and 52.

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Results Results At study entry, the PO-only patients were more likely to be

white, married, employed in the last 30 days, and to have shorter duration of opioid use than those in the other two groups.

The PO group provided more opioid-negative urine drug screens throughout treatment (PO: 70%, H: 38%, POH: 40%), and at the end of treatment (PO: 65%, H: 33%, POH: 31%).

Retention was lowest in the heroin group (PO: 80%, H: 57%, POH: 65%).

There were no significant differences in buprenorphine dose across the groups.



CommentsComments

The authors concluded that those patients with prescription opioid use disorder had more favorable buprenorphine treatment outcomes than individuals with heroin or combined prescription opioid and heroin use disorder.

However, differences in baseline characteristics between the three groups may explain some of the outcomes as the PO group had more social support at treatment outset.


Studies on Studies on Health OutcomesHealth Outcomes


135,971 Emergency Department Visits in the US for Opioid Overdose in 2010

Yokell MA, et al. JAMA Intern Med. 2014;174(12):2034–2037.

Summary by Summary by Alexander Y. Walley, MD, MScAlexander Y. Walley, MD, MSc

2626


Researchers analyzed the 2010 Nationwide Emergency Department Sample to characterize opioid overdose-related visits in the US.


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ResultsResults There were an estimated 135,971 visits in 2010. Of all visits, prescription opioids (including methadone)

were involved in 68%, heroin in 16%, multiple opioids in 2.7%, and unidentified opioids in 13%.

Benzodiazepine intoxication co-occurred in 22% of opioid overdoses.

Among the 45% of patients who were treated and released from the emergency department (ED), the mean charge was $3397; conversely, the mean charge for a hospitalized patient was $29,807 with a mean length of stay of 3.8 days.

1.4% of patients died before hospital discharge. Total charges for opioid overdose-related visits amounted

to $2.3 billion in 2010.



CommentsComments

This study of a nationally representative sample of ED visits provides volume, financial charges, and mortality estimates of the burden of opioid-related ED visits.

In addition to the overdoses reflected in ED visits, there are many fatal and non-fatal overdoses that occur elsewhere.


Mehlig K, et al. Alcohol. 2014;48:695–700.Summary by R. Curtis Ellison, MDSummary by R. Curtis Ellison, MD

Specific Genetic Factors Modify the Reduction in

Heart Disease Risk Associated with Alcohol

Consumption


Objectives/MethodsObjectives/Methods A number of genetic and environmental factors modify the

association between alcohol consumption and coronary heart disease (CHD).

Investigators carried out a population-based case-control study to determine whether there was an interaction between cholesteryl ester transfer protein (CETP TaqIB) genotypes and alcohol consumption for its effects on the risk of CHD.

The authors defined three categories of ethanol intake using tertiles of sex-specific average consumption (lowest = < 3.2 g ethanol in a day for women, < 6.5 g for men; intermediate = 3.2–6.3 g for women; 6.5–13.1 g for men).

The lowest tertile of alcohol consumption was chosen as the reference category.

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ResultsResults

Overall, participants with “intermediate” ethanol intake had lower risk of CHD than those with the lowest ethanol intake (odds ratio [OR], 0.65).

Participants who were CETP TaqIB B2 homozygotes had the greatest effect, for intermediate versus lowest ethanol intake (OR, 0.21). For B1B1 combined with B1B2b participants, the OR was 1.12 for abstainers and 0.80 for the intermediate category (versus the lowest).



CommentsComments Participants in this study included not only those

with new cases of CHD but people “who had an exacerbation of previously diagnosed coronary heart disease,” making it difficult to compare the results with those of other studies.

The controls were considerably younger than the cases and had different medical histories, so residual confounding remains possible.

The major concern with this paper is the small number of cases in many categories, limiting the general applicability of the results.


CommentsComments (cont (cont’’d)d)

Further, a number of previous large studies have had very conflicting results regarding the effects of CETP polymorphisms on the alcohol-CHD association.

While this paper adds information on one of many factors that affect the association between alcohol consumption and CHD, larger studies in different populations will be needed to determine the overall importance of this particular genetic polymorphism.


The Association of Alcohol Consumption with the Risk of Death from Colorectal

Cancer

Cai S, et al. Eur J Cancer Prev. 2014;23(6):532–539. Summary by Summary by R. Curtis Ellison, MDR. Curtis Ellison, MD

3535

Objectives/MethodsObjectives/Methods Data from prospective cohort studies on the association

between alcohol consumption and the occurrence of colorectal cancer (CRC) are conflicting, with some suggesting an increase in risk while others failing to show an effect.

Researchers analyzed data from 9 cohort studies (with a total of more than 2 million subjects) to evaluate how the level of alcohol intake relates to CRC mortality.

A total of almost 4000 deaths from CRC were recorded.


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ResultsResults

The consumption of an average of ≥ 50 g alcohol (about ≥ 4 standard drinks) in a day was associated with a modest increase in the risk of death from CRC (relative risk, 1.21).

“Light” (≤ 12.5 g in a day) and “moderate” average consumption (12.6–49.9 g in a day) did not increase the risk of CRC death. Odds ratios were 0.97 and 1.04, respectively.



CommentsComments Despite a very large sample size, the authors were

unable to evaluate differences in effect according to type of beverage consumed, the pattern of drinking, or the underlying folate levels of subjects, all of which probably modify the relation between alcohol consumption and CRC.

Overall, this meta-analysis supports a finding of increased risk of death from CRC associated with heavy drinking.

However, it shows rather convincingly that regular consumption of “light” to “moderate” amounts of alcohol does not increase the risk of death from this disease.


Studies on Studies on HIV and HCVHIV and HCV


Opioid Agonist Treatment Is Associated with a Lower Incidence of Hepatitis C Infection

Among People with Injection Drug Use

Tsui JI, et al. JAMA Intern Med. 2014;174:1974–1981. Summary by Summary by Darius A. Rastegar, MDDarius A. Rastegar, MD

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Objectives/MethodsObjectives/Methods Injection drug use (IDU) is the primary risk

factor for hepatitis C virus (HCV) infection. Researchers examined data from a cohort of

552 younger adults (< 30 years) with IDU who were not HCV infected at the time of enrollment. The outcome of interest was incident HCV infection.

Recruitment began in 2000 and the final assessment was in 2013, with a total of 680 person-years of observation.


4141

ResultsResults At the time of enrollment, participants’

median age was 23; 68% were men, 40% did not graduate from high school, and 69% were homeless or did not have stable housing in the last 3 months. The median duration of IDU was 3.6 years and 33% of participants had daily use; 60% reported that heroin was the drug they used most often. Most (82%) reported receiving no substance use treatment in the prior year and only 4% had received opioid agonist treatment (OAT).




There were a total of 171 incident HCV infections, with an estimated incidence rate of 25 per 100 person-years.

Participants who reported receiving OAT in the past year had a significantly lower incidence of HCV (rate ratio [RR], 0.31), while those who reported other forms of treatment did not. The RR for non-opioid agonist treatment was 0.63, and for opioid agonist detoxification it was 1.45.


CommentsComments This study shows that HCV is still a common

hazard for people with IDU and confirms prior observations that OAT reduces the risk of acquiring this deadly infection.

Unfortunately very few of the participants received methadone or buprenorphine maintenance treatment; we need to do more to improve access.


Awareness of Risk is Not Enough to Decrease Alcohol Use Among People with HIV

and Heavy Alcohol Consumption

Elliott JC, et al. Alcohol Clin Exp Res. 2014;38(12):3052–3059.

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


Objectives/MethodsObjectives/Methods Although alcohol use has known risks for

people with HIV, it is not clear whether those who drink are aware of these risks and change their alcohol use accordingly.

In this study, researchers interviewed 254 HIV-infected adults (78% men, 50% black, 45% Latino, 32% co-infected with hepatitis C (HCV), 77% prescribed antiretroviral medication) who had at least 1 instance of heavy episodic drinking (≥ 4 drinks on an occasion for men or ≥ 3 drinks for women) in the past 4 weeks.


Results Results

Participants had heavy alcohol use, with averages of > 5 drinks in a drinking day and at least weekly instances of heavy episodic drinking.

63% of the total sample and 67% of HIV/HCV co-infected patients were aware they had a medical problem made worse by alcohol use. However, awareness of risk was not associated with decreased alcohol use.



HIV/HCV co-infected patients were more likely than HIV mono-infected patients to report restriction of alcohol use to avoid a medical problem (72% versus 61%).

Reported alcohol use was lower—but still well above low-risk levels—among those who reported restriction of alcohol consumption to avoid a medical problem.


CommentsComments

Awareness of having a medical problem that is exacerbated by alcohol use was not associated with decreased consumption among people with HIV and heavy drinking, many of whom were co-infected with HCV.

These findings suggest that education about risk in this population should be followed with behavioral therapy and/or pharmacotherapy.


Prescription Opioid Use and Risk of HIV/HCV Transmission Among

Young Adults

Mateu-Gelabert P, et al. J Subst Abuse Treat. 2015;48(1):13–20.

Summary by Jeanette M. Tetrault, MDSummary by Jeanette M. Tetrault, MD



The prevalence of non-medical use of prescription opioids (PO) in the US has been growing exponentially, particularly among young adults.

This is, in part, due to the perception that PO use is safer than heroin use.

This qualitative study explored drug use and sexual risk experiences of young adults with PO use as they relate to risk of HIV and hepatitis C (HCV) transmission.

Forty-six young adults between the ages of 18-32 were recruited in New York City for individual in-depth semi-structured interviews focusing on key domains of the pre-specified research aims.


Results Results 70% of participants reported a pattern of escalating PO use

over time, eventually transitioning from PO use to heroin use; 63% reported changing their route of administration over time from oral or intranasal to injection drug use (IDU).

Individuals with IDU reported sporadic syringe-sharing, frequent sharing of non-syringe injection paraphernalia, and selective sharing with people who are assumed to be uninfected with HIV or HCV. Participants reported little knowledge of HCV injection-related risks and safer injection practices.

Participants reported engaging in unprotected sex with casual partners, exchanging sex for POs, and group sex, and that PO use increased the risk of sexual violence.


CommentsComments Although these data are obtained from a

single region, it sheds light on a growing concern regarding the disconnect between the perception of PO use as relatively innocuous and the reality of the risk behaviors with which it is often associated.

Further research should target prevention efforts within this population.


Psychosocial Factors Affect Risk Behaviors and HIV

Outcomes Among People with Injection Drug Use

Mizuno Y, et al. AIDS Behav. 2014 [Epub ahead of print]. doi: 10.1007/s10461-014-0890-0.

Summary by Jessica S. Merlin, MD, MBASummary by Jessica S. Merlin, MD, MBA


Objectives/MethodsObjectives/Methods Syndemics are interrelated social problems that

may be mutually reinforcing and combine to negatively influence health outcomes.

Using data from a randomized controlled trial of HIV transmission prevention among 1052 people with injection drug use (IDU) from 4 large US cities that addressed sexual and injection risk behaviors, the authors investigated syndemic psychosocial factors and their relationship to both risk behaviors and HIV outcomes.


Results Results

Participants reported psychosocial factors including polydrug use (59%), psychological distress (37%), homelessness (32%), incarceration (25%), and low social support (13%).

Most participants (80%) had a detectable viral load, and 21% reported no HIV care in the past 6 months. Among the 501 participants who were receiving antiretroviral therapy, 25% reported suboptimal adherence.



Psychosocial factors commonly co-occurred; this was especially true for low social support and psychological distress, homelessness and low social support, and homelessness and incarceration.

With one exception (adult abuse), all psychosocial

factors investigated were associated with unsafe sex and sharing needles and at least two suboptimal HIV outcomes. Homelessness was associated with all suboptimal HIV outcomes, and low social support was associated with all but one (adherence).


CommentsComments This study suggests that interventions

targeting people with HIV and IDU should consider the multiple factors that may influence an individual’s risk behavior or HIV outcomes.

The authors point out that these psychological factors often have a common root cause (e.g., poverty).

This study supports the importance of exploring interventions that address these root causes.

Www.aodhealth.org1 Update on Alcohol, Other Drugs, and Health January–February 2015.

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