Www.aodhealth.org1 Update on Alcohol, Other Drugs, and Health September-October 2007.

www.aodhealth.orgwww.aodhealth.org 11

Update on Update on Alcohol, Other Alcohol, Other

Drugs, and HealthDrugs, and Health

September-October 2007September-October 2007


Studies on Studies on Health OutcomesHealth Outcomes


Alcohol Use Disorders: Alcohol Use Disorders: Chronic or Not?Chronic or Not?

Hasin DS, et al. Hasin DS, et al. Arch Gen Psychiatry.Arch Gen Psychiatry. 2007;64(7):830–842. 2007;64(7):830–842.Summary by Richard Saitz, MD, MPHSummary by Richard Saitz, MD, MPH


Objectives/MethodsObjectives/Methods

To examine the usual course of alcohol To examine the usual course of alcohol use disorders (abuse or dependence),…use disorders (abuse or dependence),…

researchers analyzed data from researchers analyzed data from interviews of a representative sample interviews of a representative sample of 43,093 U.S. adults.of 43,093 U.S. adults.


Results Results About 5% of adults had past-year abuse; 4% About 5% of adults had past-year abuse; 4%

had past-year dependence. had past-year dependence.

18% had lifetime abuse; 13% had lifetime 18% had lifetime abuse; 13% had lifetime dependence.dependence.

Of those with lifetime dependence, only 24% Of those with lifetime dependence, only 24% reported ever having received alcohol reported ever having received alcohol treatment…treatment…

even though treatment was defined broadly and even though treatment was defined broadly and included participation in 12-step programs, care in included participation in 12-step programs, care in an emergency department, and assistance by an emergency department, and assistance by clergy or other professionals. clergy or other professionals.


Results (cont.)Results (cont.)

The mean age of onset of an alcohol use The mean age of onset of an alcohol use disorder was 22 years.disorder was 22 years.

Most patients with lifetime abuse or Most patients with lifetime abuse or dependence had only 1 episode (72%). dependence had only 1 episode (72%).

Those with >1 episode had a mean of 5 Those with >1 episode had a mean of 5 episodes. episodes.

The mean duration of the longest episode The mean duration of the longest episode was about 3 years for abuse and 4 years was about 3 years for abuse and 4 years for dependence.for dependence.


CommentsComments This nationally representative survey tells us This nationally representative survey tells us

that alcohol use disorders begin in young that alcohol use disorders begin in young adulthood and usually go untreated. adulthood and usually go untreated.

They are characterized by recurrence for They are characterized by recurrence for relatively few patients (though patients with relatively few patients (though patients with recurring episodes are the ones that recurring episodes are the ones that physicians are most likely to encounter and physicians are most likely to encounter and remember). remember).

More commonly, alcohol use disorders More commonly, alcohol use disorders consist of 1 symptomatic episode, even when consist of 1 symptomatic episode, even when not treated, lasting up to several years.not treated, lasting up to several years.


Risk Factors for Risk Factors for Nonfatal Drug OverdoseNonfatal Drug Overdose

Coffin PO et alCoffin PO et al. . Acad Emerg MedAcad Emerg Med. 2007;14(7):616–623. . 2007;14(7):616–623. Summary by Alexander Y. Walley, MDSummary by Alexander Y. Walley, MD



Fatal overdose is the leading cause of death Fatal overdose is the leading cause of death among drug users, and nonfatal overdose among drug users, and nonfatal overdose causes medical complications. causes medical complications.

To identify risk factors for nonfatal overdose, To identify risk factors for nonfatal overdose, researchers surveyed…researchers surveyed…

772 street-recruited drug users in New York 772 street-recruited drug users in New York City City

who had been injecting drugs for at least 1 who had been injecting drugs for at least 1 year and injected heroin in the last 2 months.year and injected heroin in the last 2 months.


ResultsResults

All results are significant and from analyses adjusted for potential confounders.All results are significant and from analyses adjusted for potential confounders.

Risk FactorRisk Factor Odds of Nonfatal Odds of Nonfatal Overdose in the Last 6 Overdose in the Last 6

MonthsMonths

Overdose >6 months before study Overdose >6 months before study entryentry

Odds ratio (OR) 28.6Odds ratio (OR) 28.6

Younger ageYounger age E.g., OR 7.2 for those 18–24 E.g., OR 7.2 for those 18–24 versus those 45 and olderversus those 45 and older

Cocaine use in the last 6 monthsCocaine use in the last 6 months OR 2.1 OR 2.1

Serious withdrawal in the last 2 Serious withdrawal in the last 2 monthsmonths

OR 2.7OR 2.7

Alcohol use in the last 6 monthsAlcohol use in the last 6 months OR 1.9OR 1.9

One of 6 subjects had a nonfatal overdose in the One of 6 subjects had a nonfatal overdose in the 6 months before study entry.6 months before study entry.


CommentsComments

This cross-sectional study confirms findings This cross-sectional study confirms findings from previous studies reporting that…from previous studies reporting that…

nonfatal overdoses often recur in drug nonfatal overdoses often recur in drug users and users and

are positively associated with alcohol use, are positively associated with alcohol use, cocaine use, and periods of abstinence. cocaine use, and periods of abstinence.

Clinicians should target both drug users with Clinicians should target both drug users with previous overdoses and polysubstance users previous overdoses and polysubstance users for overdose prevention efforts.for overdose prevention efforts.


The Effects of Alcohol Use The Effects of Alcohol Use on Blood Pressure: on Blood Pressure:

Does Gender Matter?Does Gender Matter?

McFarlane SI et alMcFarlane SI et al. . J HypertensJ Hypertens. 2007;25(5):965–970.. 2007;25(5):965–970.Summary by R. Curtis Ellison, MD Summary by R. Curtis Ellison, MD



Researchers assessed whether the effects of Researchers assessed whether the effects of alcohol use on blood pressure differ by alcohol use on blood pressure differ by gender. gender.

They examined data from 2650 subjects who They examined data from 2650 subjects who had…had…

participated in a national health and nutrition participated in a national health and nutrition study and study and

reported consuming about ≥1 drinks per day reported consuming about ≥1 drinks per day in the past year.in the past year.


Results Results 21% of subjects had hypertension. 21% of subjects had hypertension.

Systolic blood pressure was significantly higher in men Systolic blood pressure was significantly higher in men who drank ≥3 drinks per day than in men who drank 1 who drank ≥3 drinks per day than in men who drank 1 drink per day. drink per day.

E.g., about 125 mm Hg with 1 drink, 128 mm Hg E.g., about 125 mm Hg with 1 drink, 128 mm Hg with 3 drinks, and 131 mm Hg with ≥4 drinks with 3 drinks, and 131 mm Hg with ≥4 drinks

Results were similar for diastolic blood pressure.Results were similar for diastolic blood pressure.

Alcohol use did not significantly affect blood pressure Alcohol use did not significantly affect blood pressure in women. in women.


CommentsCommentsThe results of this study should be interpreted The results of this study should be interpreted

with with caution: caution:

The analyses were limited to subjects who The analyses were limited to subjects who consumed about ≥1 drink per day, a group consumed about ≥1 drink per day, a group representing a small proportion of U.S. adults. representing a small proportion of U.S. adults.

Further, no information on people who drank Further, no information on people who drank less or who abstained was provided. less or who abstained was provided.

Thus, the author’s statement that "alcohol Thus, the author’s statement that "alcohol intake of up to 2 drinks per day has no effect intake of up to 2 drinks per day has no effect on blood pressure" cannot be supported. on blood pressure" cannot be supported.


Comments (cont.)Comments (cont.)

Similarly, while blood pressure did not differ Similarly, while blood pressure did not differ among women who drank 1 drink per day among women who drank 1 drink per day and those who drank more, a significant and those who drank more, a significant difference might have been observed at a difference might have been observed at a lower threshold: lower threshold:

It is possible that women who consumed It is possible that women who consumed <1 drink per day had higher blood <1 drink per day had higher blood pressure than those who abstained, but pressure than those who abstained, but this was not tested.this was not tested.


What Predicts Harmful What Predicts Harmful Alcohol Use After Liver Alcohol Use After Liver

Transplantation?Transplantation?

De Gottardi A et al. De Gottardi A et al. Arch Intern MedArch Intern Med. . 2007;167(11):1183–1188.2007;167(11):1183–1188.

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



Patients should not drink alcohol after liver Patients should not drink alcohol after liver transplantation (LT) for alcoholic liver disease. transplantation (LT) for alcoholic liver disease.

To identify risk factors for alcohol use after LT, To identify risk factors for alcohol use after LT, researchers analyzed pre- and post-LT data researchers analyzed pre- and post-LT data from…from…

387 patients (76% male, average age 51 387 patients (76% male, average age 51 years) years)

who underwent the procedure in Switzerland who underwent the procedure in Switzerland or France. or France.


ResultsResults During an average follow-up of 61 months after During an average follow-up of 61 months after

LT, 12% had harmful alcohol use (about >3.5 LT, 12% had harmful alcohol use (about >3.5 drinks per day plus alcohol-related physical or drinks per day plus alcohol-related physical or mental consequences).mental consequences).

In adjusted analyses, the following were In adjusted analyses, the following were significantly associated with harmful alcohol use significantly associated with harmful alcohol use after LT: after LT:

>3 on the High-Risk Alcoholism Relapse >3 on the High-Risk Alcoholism Relapse scale, used to assess pre-transplantation scale, used to assess pre-transplantation alcohol use (OR, 10.7)alcohol use (OR, 10.7)

psychiatric comorbidity (OR, 7.8)psychiatric comorbidity (OR, 7.8)

pre-transplantation abstinence from alcohol pre-transplantation abstinence from alcohol for for ≤≤6 months (OR, 3.3)6 months (OR, 3.3)


Results (cont.)Results (cont.)

Harmful alcohol use after transplantation Harmful alcohol use after transplantation occurred in…occurred in…

5% of patients with none of the above 5% of patients with none of the above factors, factors,

18% with 1 factor, 18% with 1 factor, 64% with 2 factors, and 64% with 2 factors, and 100% with all 3 factors. 100% with all 3 factors.


CommentsComments This study found that pre-transplantation alcohol This study found that pre-transplantation alcohol

use, inpatient alcohol treatment, and psychiatric use, inpatient alcohol treatment, and psychiatric factors are associated with relapse to harmful factors are associated with relapse to harmful alcohol use after liver transplantation for alcoholic alcohol use after liver transplantation for alcoholic liver disease. liver disease.

The outcome measure for this study required not The outcome measure for this study required not only a fairly high daily intake of alcohol but also only a fairly high daily intake of alcohol but also alcohol-related physical or mental harm. alcohol-related physical or mental harm.

Thus, it is not clear how many patients in the Thus, it is not clear how many patients in the “nonrelapse” group were drinking at unhealthy “nonrelapse” group were drinking at unhealthy levels, despite recommendations to abstain after levels, despite recommendations to abstain after transplantation.transplantation.


Braithwaite RS et al. Braithwaite RS et al. AIDS CareAIDS Care. 2007;19(4):459–466.. 2007;19(4):459–466.Summary by Jeffrey H. Samet, MD, MA, MPHSummary by Jeffrey H. Samet, MD, MA, MPH

Estimating the Impact of Estimating the Impact of Alcohol Use on Survival Alcohol Use on Survival Among Veterans With Among Veterans With

HIV HIV


Objectives/MethodsObjectives/Methods The adverse impact of alcohol use on The adverse impact of alcohol use on

adherence to antiretroviral therapy (ART) has adherence to antiretroviral therapy (ART) has been repeatedly demonstrated. been repeatedly demonstrated.

Alcohol’s effects on survival among individuals Alcohol’s effects on survival among individuals with HIV, however, is not clear. with HIV, however, is not clear.

Investigators estimated these effects by using Investigators estimated these effects by using a computer simulation model of HIV that…a computer simulation model of HIV that…

incorporated data on drinking and ART adherence incorporated data on drinking and ART adherence from an observational study of 2702 male from an observational study of 2702 male veterans. veterans.


ResultsResults Any drinking (versus no drinking) diminished Any drinking (versus no drinking) diminished

survival (median time until death).survival (median time until death).

As frequency of drinking increased, survival As frequency of drinking increased, survival decreased.decreased.

E.g., drinking 1–4 drinks one or more times per E.g., drinking 1–4 drinks one or more times per week reduced survival by >1 year; drinking 1–4 week reduced survival by >1 year; drinking 1–4 drinks daily reduced survival by 3 yearsdrinks daily reduced survival by 3 years

Heavier drinking had the greatest impact on Heavier drinking had the greatest impact on survival.survival.

E.g., drinking ≥5 drinks one or more times per E.g., drinking ≥5 drinks one or more times per week reduced median survival by >2 years; week reduced median survival by >2 years; drinking ≥5 drinks daily reduced survival by 6 drinking ≥5 drinks daily reduced survival by 6 yearsyears


CommentsComments An association between mortality and heavier An association between mortality and heavier

alcohol use among people taking ART is alcohol use among people taking ART is credible and supported in this model. credible and supported in this model.

But, the finding of diminished survival with But, the finding of diminished survival with consuming lesser amounts is unexpected. consuming lesser amounts is unexpected.

As these findings are derived from a As these findings are derived from a simulation model based on data from one simulation model based on data from one observational cohort of veterans taking ART… observational cohort of veterans taking ART…

generalization beyond the examined cohort generalization beyond the examined cohort requires caution. requires caution.


Collins RL et al. Collins RL et al. Addiction.Addiction. 2007;102(5):786–794. 2007;102(5):786–794.Summary by Peter D. Friedmann, MD, MPHSummary by Peter D. Friedmann, MD, MPH

Divorce: Grounds for Divorce: Grounds for Substance Use ScreeningSubstance Use Screening


Objectives/MethodsObjectives/Methods Half of first marriages in the U.S. end in Half of first marriages in the U.S. end in

divorce. divorce.

Researchers estimated the extent to which Researchers estimated the extent to which substance use during marriage contributes to substance use during marriage contributes to divorce rates among young adults.divorce rates among young adults.

They studied…They studied…

454 individuals in California and Oregon who 454 individuals in California and Oregon who had married by age 23 and had married by age 23 and

completed periodic surveys as part of a completed periodic surveys as part of a longitudinal study.longitudinal study.


ResultsResults 22% had divorced by age 29.22% had divorced by age 29.

In unadjusted analyses, the following predicted In unadjusted analyses, the following predicted divorce by age 29: divorce by age 29:

greater frequencies of past-year alcohol greater frequencies of past-year alcohol intoxication (OR, 1.3) and marijuana use (OR, intoxication (OR, 1.3) and marijuana use (OR, 1.2)1.2)

any past-year hard drug use (OR, 1.8; any past-year hard drug use (OR, 1.8; borderline significance)borderline significance)

In analyses adjusted for potential confounders, In analyses adjusted for potential confounders, only frequency of alcohol intoxication was only frequency of alcohol intoxication was significantly associated with divorce (OR, 1.2). significantly associated with divorce (OR, 1.2).


CommentsComments Greater frequency of alcohol intoxication at age Greater frequency of alcohol intoxication at age

23 predicted marital dissolution by age 29. 23 predicted marital dissolution by age 29.

Frequent substance use has many adverse effects Frequent substance use has many adverse effects on marital relationships, including partner on marital relationships, including partner violence, legal problems, job loss, and sexual violence, legal problems, job loss, and sexual dysfunction. dysfunction.

A social or family history of divorce or marital A social or family history of divorce or marital problems should cue all clinicians to ask carefully problems should cue all clinicians to ask carefully about substance use disorders (although about substance use disorders (although universal screening is preferable). universal screening is preferable).

Also, clinicians should consider discussing the risk Also, clinicians should consider discussing the risk of marital discord and divorce when talking about of marital discord and divorce when talking about heavy drinking with young married people.heavy drinking with young married people.


Drinking May Lower Drinking May Lower Postprandial GlycemiaPostprandial Glycemia

Brand-Miller JC et al. Brand-Miller JC et al. Am J Clin NutrAm J Clin Nutr. 2007;85(6):1545. 2007;85(6):1545––1551.1551.

Summary by R. Curtis Ellison, MDSummary by R. Curtis Ellison, MD


Objectives/MethodsObjectives/Methods Researchers in Australia assessed the association Researchers in Australia assessed the association

between postprandial glycemia and drinking beer, between postprandial glycemia and drinking beer, white wine, or gin under 3 conditions: white wine, or gin under 3 conditions:

without a meal, without a meal, with a carbohydrate meal, and with a carbohydrate meal, and 1 hour before a carbohydrate meal. 1 hour before a carbohydrate meal.

Subjects included 38 healthy college students (10 in Subjects included 38 healthy college students (10 in the first condition, 10 in the second, and 18 in the the first condition, 10 in the second, and 18 in the third).third).

They had fingertip blood samples taken at baseline They had fingertip blood samples taken at baseline and at regular intervals over 2–3 hours. and at regular intervals over 2–3 hours.


ResultsResults Mean glucose scores (summarized glucose Mean glucose scores (summarized glucose

response over a 2response over a 2––3 hour period) were 3 hour period) were significantly lower for…significantly lower for…

isoenergetic portions of beer (58), wine (7), and isoenergetic portions of beer (58), wine (7), and gin (10) than for bread (100, an arbitrary gin (10) than for bread (100, an arbitrary reference score); reference score);

meals with 2 typical glasses of wine (63) or gin meals with 2 typical glasses of wine (63) or gin (80), but not beer, than meals with water (100);(80), but not beer, than meals with water (100);

meals preceded by 1 hour with about 2 drinks of meals preceded by 1 hour with about 2 drinks of beer (67), wine (75), or gin (78) than meals beer (67), wine (75), or gin (78) than meals preceded with water (100).preceded with water (100).


CommentsComments This study in healthy subjects demonstrated that This study in healthy subjects demonstrated that

drinking drinking ≈≈2 drinks of beer, wine, or gin with, or 2 drinks of beer, wine, or gin with, or within an hour before, a high-carbohydrate meal…within an hour before, a high-carbohydrate meal…

limited the rise in glucose that occurs after limited the rise in glucose that occurs after carbohydrate ingestion.carbohydrate ingestion.

Since higher glucose levels are associated with Since higher glucose levels are associated with higher risk of diabetes and coronary heart disease, higher risk of diabetes and coronary heart disease, the demonstrated decrease in postprandial the demonstrated decrease in postprandial glycemia may be…glycemia may be…

another mechanism by which moderate alcohol another mechanism by which moderate alcohol consumption lowers the risk of chronic diseases.consumption lowers the risk of chronic diseases.


Assessments and Assessments and InterventionsInterventions


Does Methadone Does Methadone Treatment Change Alcohol Treatment Change Alcohol

Consumption? Consumption?

Srivastava A et al. Srivastava A et al. J Subst Abuse Treat.J Subst Abuse Treat. 2007; 2007;doi: 10.1016/j.jsat.2007.04.001.doi: 10.1016/j.jsat.2007.04.001.Summary by Julia H. Arnsten, MD, MPHSummary by Julia H. Arnsten, MD, MPH



Patients receiving methadone treatment have Patients receiving methadone treatment have a high prevalence of unhealthy alcohol use. a high prevalence of unhealthy alcohol use.

The impact of such treatment on alcohol The impact of such treatment on alcohol consumption, however, is not clearly consumption, however, is not clearly understood. understood.

Therefore, researchers conducted a Therefore, researchers conducted a systematic review and summarized the systematic review and summarized the findings of 15 relevant studies. findings of 15 relevant studies.


ResultsResults

9 studies found no change in alcohol 9 studies found no change in alcohol consumption after initiation of or during consumption after initiation of or during methadone treatment. methadone treatment.

3 studies found an increase in consumption; 3 studies found an increase in consumption; another 3 reported a decrease.another 3 reported a decrease.

The studies that found no change or a decrease The studies that found no change or a decrease in alcohol consumption included 3 randomized in alcohol consumption included 3 randomized controlled trials and 7 prospective cohorts. controlled trials and 7 prospective cohorts.

These were stronger methodologically than the These were stronger methodologically than the studies that found an increase in alcohol studies that found an increase in alcohol consumption, which were all retrospective and subject consumption, which were all retrospective and subject to recall bias.to recall bias.


CommentsComments Alcohol consumption does not appear to change Alcohol consumption does not appear to change

after initiation of methadone treatment. after initiation of methadone treatment.

Regardless, to help prevent additional morbidity, Regardless, to help prevent additional morbidity, clinicians should conduct screening and offer clinicians should conduct screening and offer appropriate treatment for unhealthy alcohol use appropriate treatment for unhealthy alcohol use for all patients receiving methadone. for all patients receiving methadone.

To ensure this occurs, methadone treatment To ensure this occurs, methadone treatment programs should develop cost-effective programs should develop cost-effective mechanisms for alcohol screening and mechanisms for alcohol screening and intervention. intervention.


Tossonian HK et al. Tossonian HK et al. J Acquir Immune Defic SyndrJ Acquir Immune Defic Syndr. . 2007;45(3):324–327. 2007;45(3):324–327.

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

Antiretroviral Antiretroviral Medication Affects Dose Medication Affects Dose

of Methadoneof Methadone


Objectives/MethodsObjectives/Methods Pharmacokinetic interactions between Pharmacokinetic interactions between

antiretrovirals and methadone can potentially antiretrovirals and methadone can potentially affect levels of either medication and lead to affect levels of either medication and lead to over- and/or underdosing. over- and/or underdosing.

These researchers evaluated the average These researchers evaluated the average change in methadone dose that occurred with change in methadone dose that occurred with co-administration of nevirapine, efavirenz, co-administration of nevirapine, efavirenz, ritonavir-boosted lopinavir, or atazanavir.ritonavir-boosted lopinavir, or atazanavir.

Subjects included 120 patients in a directly Subjects included 120 patients in a directly observed therapy program. observed therapy program.

All patients also had Hepatitis C.All patients also had Hepatitis C.


ResultsResults

The HIV virus was suppressed to fewer than 400 The HIV virus was suppressed to fewer than 400 copies/mL in 67%–76% of patients, with no copies/mL in 67%–76% of patients, with no difference based on antiretroviral regimen difference based on antiretroviral regimen ((PP=0.89).=0.89).

Antiretroviral DrugAntiretroviral Drug Median Change in Methadone Median Change in Methadone Dose in the 3 months After HAART Dose in the 3 months After HAART

InitiationInitiation

NevirapineNevirapine 20 mg/d (20 mg/d (PP< 0.001), with 32 (86%) of < 0.001), with 32 (86%) of 37 patients requiring daily dose 37 patients requiring daily dose increasesincreases

EfavirenzEfavirenz 7.5 mg/d (7.5 mg/d (PP=0.004), with 11 (61%) of =0.004), with 11 (61%) of 18 patients requiring daily increases18 patients requiring daily increases

Ritonavir-boosted Ritonavir-boosted lopinavir or atazanavirlopinavir or atazanavir

0 for both (0 for both (PP=0.56 and 0.95, =0.56 and 0.95, respectively)respectively)


CommentsComments Clinicians providing either methadone or Clinicians providing either methadone or

antiretrovirals to patients should be mindful of the antiretrovirals to patients should be mindful of the potential interactions between these medications. potential interactions between these medications.

Interactions can alter methadone levels, which can Interactions can alter methadone levels, which can lead to sedation (from increased levels) or lead to sedation (from increased levels) or withdrawal (from decreased levels). withdrawal (from decreased levels).

Depending on the specific case, the dose of Depending on the specific case, the dose of methadone will need to be increased, decreased, or methadone will need to be increased, decreased, or maintained. maintained.

Notably, there were significant variations in Notably, there were significant variations in methadone dose requirements between individual methadone dose requirements between individual patients. patients.

These data support close clinical observation of and These data support close clinical observation of and medication adjustment in patients receiving medication adjustment in patients receiving methadone and HAART. methadone and HAART.


Do Mortality Rates Differ Do Mortality Rates Differ by Type of by Type of

Pharmacotherapy for Pharmacotherapy for Opioid Dependence?Opioid Dependence?

Gibson AE et al. Gibson AE et al. Drug Alcohol Rev.Drug Alcohol Rev. 2007;26(4):405–410. 2007;26(4):405–410. Summary by Marc N. Gourevitch, MD, MPHSummary by Marc N. Gourevitch, MD, MPH



The risk of death from overdose associated The risk of death from overdose associated with induction, maintenance, or with induction, maintenance, or discontinuation of an opioid discontinuation of an opioid pharmacotherapy may depend on the pharmacotherapy may depend on the opioid’s mechanism of action. opioid’s mechanism of action.

Australian researchers analyzed coroner’s Australian researchers analyzed coroner’s reports and various prescription data reports and various prescription data sources to estimate mortality rates possibly sources to estimate mortality rates possibly associated with these pharmacotherapies. associated with these pharmacotherapies.


ResultsResults From 2000 to 2003, 1 buprenorphine-, 32 oral From 2000 to 2003, 1 buprenorphine-, 32 oral

naltrexone-, and 282 methadone-related deaths naltrexone-, and 282 methadone-related deaths occurred.occurred.

The overall mortality rate associated with methadone The overall mortality rate associated with methadone was significantly lower than the rate associated with was significantly lower than the rate associated with oral naltrexone (2.7 vs. 10.1 per 1000 treatment oral naltrexone (2.7 vs. 10.1 per 1000 treatment episodes). episodes).

The mortality rate associated with methadone The mortality rate associated with methadone treatment was 3.0 per 100 person years during the first treatment was 3.0 per 100 person years during the first week of treatment versus 0.34 per 100 person years week of treatment versus 0.34 per 100 person years during the remainder of treatment. during the remainder of treatment.

The mortality rate associated with oral naltrexone The mortality rate associated with oral naltrexone treatment was 1 per 100 person years during treatment treatment was 1 per 100 person years during treatment versus 22.1 per 100 person years in the 2 weeks after versus 22.1 per 100 person years in the 2 weeks after treatment was discontinued. treatment was discontinued.


CommentsComments

While the methods used permit only crude While the methods used permit only crude estimates and specific causes of death were not estimates and specific causes of death were not addressed…addressed… these findings heighten concerns about the possible these findings heighten concerns about the possible

increased risk of opioid overdose shortly after oral increased risk of opioid overdose shortly after oral naltrexone treatment is discontinued. naltrexone treatment is discontinued.

More rigorous studies are needed to…More rigorous studies are needed to… refine the estimates presented here, refine the estimates presented here, define risks and benefits of other (e.g., depot) define risks and benefits of other (e.g., depot)

naltrexone preparations in treating opioid naltrexone preparations in treating opioid dependence, and dependence, and

develop treatment protocols to further enhance the develop treatment protocols to further enhance the safety profiles of specific opioid pharmacotherapies. safety profiles of specific opioid pharmacotherapies.


A Simplified Method to A Simplified Method to Assess Alcohol Use Assess Alcohol Use

DisordersDisorders

Vinson DC et al.Vinson DC et al. Alcohol Clin Exp ResAlcohol Clin Exp Res. 2007;31(8):1392–. 2007;31(8):1392–1398.1398.

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



One of the challenges with alcohol screening in One of the challenges with alcohol screening in primary care settings is the lack of a brief primary care settings is the lack of a brief assessment to determine whether abuse or assessment to determine whether abuse or dependence is present in screen-positive dependence is present in screen-positive patients. patients.

Researchers developed a simple assessment Researchers developed a simple assessment with data from the cases (1522 injured patients) with data from the cases (1522 injured patients) of a case-control study. of a case-control study.

They validated the assessment with data from…They validated the assessment with data from… the controls (1124 noninjured patients) from the same the controls (1124 noninjured patients) from the same

study, study, a primary care sample (n=623), and a primary care sample (n=623), and a nationally representative sample of U.S. adults a nationally representative sample of U.S. adults

(n=26,946).(n=26,946).


ResultsResults

GroupGroup SensitivitySensitivity SpecificitySpecificity

Subjects in the Subjects in the developmental developmental samplesample

96%96% 85%85%

Subjects in the 3 Subjects in the 3 validation samplesvalidation samples

72% to 94%72% to 94% 80% to 95%80% to 95%

Screen-positive Screen-positive subjects in the 3 subjects in the 3 validation samplesvalidation samples

77% to 95%77% to 95% 62% to 86%62% to 86%

Sensitivity and Specificity of 2 Criteria—Sensitivity and Specificity of 2 Criteria—Recurrent drinking in physically hazardous situations Recurrent drinking in physically hazardous situations

and Drinking more or for longer than intended—and Drinking more or for longer than intended—for Detecting Alcohol Use Disorders for Detecting Alcohol Use Disorders


CommentsComments Clinicians must be able to quickly and accurately Clinicians must be able to quickly and accurately

assess the presence of an alcohol use disorder if assess the presence of an alcohol use disorder if alcohol screening and intervention strategies are to alcohol screening and intervention strategies are to be effective. be effective.

Although the 2 criteria had reasonable sensitivity Although the 2 criteria had reasonable sensitivity and specificity for alcohol use disorders in this and specificity for alcohol use disorders in this retrospective study, it is not clear…retrospective study, it is not clear…

how the relevant questions should be worded for use how the relevant questions should be worded for use in primary care settings or in primary care settings or

how they would perform outside the context of a large how they would perform outside the context of a large diagnostic questionnaire. diagnostic questionnaire.

As the researchers mention, the items should be As the researchers mention, the items should be tested prospectively in practice settings.tested prospectively in practice settings.


Who Receives and Who Receives and Remains in Office-Based Remains in Office-Based

Buprenorphine Buprenorphine Treatment?Treatment?

Magura S et al. Magura S et al. J Addict DisJ Addict Dis. 2007;26(2):13–23.. 2007;26(2):13–23.

Summary by Julia H. Arnsten, MD, MPHSummary by Julia H. Arnsten, MD, MPH


Objectives/MethodsObjectives/Methods Buprenorphine treatment for opioid Buprenorphine treatment for opioid

dependence has been provided in office-based dependence has been provided in office-based settings in the United States for several years settings in the United States for several years now. now.

Data on patients receiving buprenorphine in Data on patients receiving buprenorphine in these settings, however, are lacking. these settings, however, are lacking.

Therefore, researchers analyzed data from a Therefore, researchers analyzed data from a medical record review of…medical record review of…

86 patients receiving office-based buprenorphine 86 patients receiving office-based buprenorphine treatment from 6 physicians in New York City.treatment from 6 physicians in New York City.


ResultsResults One-half of patients were misusing a prescription opioid One-half of patients were misusing a prescription opioid

at intake, 35% were using heroin, and 9% were using at intake, 35% were using heroin, and 9% were using both. both. The remaining subjects were either transferring from The remaining subjects were either transferring from

other treatment, had cravings, or had fear of relapse. other treatment, had cravings, or had fear of relapse.

Almost 50% reported misusing non-opioid drugs (e.g., Almost 50% reported misusing non-opioid drugs (e.g., cocaine, marijuana) at intake.cocaine, marijuana) at intake.

63% of patients received prescriptions for at least 1 63% of patients received prescriptions for at least 1 psychiatric medication during buprenorphine treatment.psychiatric medication during buprenorphine treatment.

The median time in treatment was 8 months (range <1 The median time in treatment was 8 months (range <1 to 30 months).to 30 months).


Results (cont.)Results (cont.) According to the last entry in the medical record...According to the last entry in the medical record...

24% were misusing any substance, 24% were misusing any substance, 8% were misusing opioids, and 8% were misusing opioids, and 58% were still receiving buprenorphine (52% from the 58% were still receiving buprenorphine (52% from the

index physician). index physician).

Factors associated with retention in buprenorphine Factors associated with retention in buprenorphine treatment with the index physician included…treatment with the index physician included…

full-time employment or other forms of support, full-time employment or other forms of support, stable housing, and stable housing, and prescription opioid (versus heroin) misuse at intakeprescription opioid (versus heroin) misuse at intake but not psychiatric disorders or substance misuse during but not psychiatric disorders or substance misuse during

treatment.treatment.


CommentsComments This is one of a growing number of descriptive This is one of a growing number of descriptive

studies of unselected patients receiving office-studies of unselected patients receiving office-based buprenorphine treatment. based buprenorphine treatment.

It demonstrates that successful buprenorphine It demonstrates that successful buprenorphine treatment can be achieved in office-based treatment can be achieved in office-based settings. settings.

To ensure successful treatment in these patients To ensure successful treatment in these patients who often have psychiatric comorbidity, strong who often have psychiatric comorbidity, strong referral networks and access to consultation for referral networks and access to consultation for complex cases are desirable. complex cases are desirable.


Health Plans’ Health Plans’ Requirements for Mental Requirements for Mental

Health and Substance Health and Substance Use ScreeningUse Screening

Horgan CM et al. Horgan CM et al. J Gen Intern MedJ Gen Intern Med. 2007; . 2007; 22(7):930–936.22(7):930–936.

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


Objectives/MethodsObjectives/Methods Most health plans cover some treatment for mental Most health plans cover some treatment for mental

health and substance use disorders, but a minority health and substance use disorders, but a minority of people who need these services receive them. of people who need these services receive them.

Limited requirements for screening and Limited requirements for screening and identification of these disorders partially explain this identification of these disorders partially explain this treatment gap. treatment gap.

To estimate the extent of health plans’ To estimate the extent of health plans’ requirements for mental health and substance use requirements for mental health and substance use screening in primary care, researchers analyzed screening in primary care, researchers analyzed data from…data from…

a nationally representative survey of health plans a nationally representative survey of health plans in 1999 (n=434 health plans, 92% response rate) in 1999 (n=434 health plans, 92% response rate) and 2003 (n=368, 83% response rate).and 2003 (n=368, 83% response rate).


ResultsResults The proportion of health plans with a screening The proportion of health plans with a screening

requirement for mental health or substance use requirement for mental health or substance use disorders…disorders…

did not significantly change from 1999 (32%) did not significantly change from 1999 (32%) to 2003 (34%).to 2003 (34%).

Among plans with a screening requirement, Among plans with a screening requirement, there was a significant increase in the there was a significant increase in the proportion that required…proportion that required… alcohol screening (from 33% in 1999 to 78% alcohol screening (from 33% in 1999 to 78%

in 2003) and in 2003) and drug screening (from 8% to 78%).drug screening (from 8% to 78%).


CommentsComments Health plan mandates and reimbursement for Health plan mandates and reimbursement for

substance use screening would encourage primary substance use screening would encourage primary care physicians to take a greater role in identifying, care physicians to take a greater role in identifying, managing, and referring patients with substance use managing, and referring patients with substance use disorders. disorders.

The finding that only one-third of health insurance The finding that only one-third of health insurance products in 1999 and 2003 required screening for products in 1999 and 2003 required screening for mental health or substance use disorders highlights mental health or substance use disorders highlights missed opportunities to improve detection and missed opportunities to improve detection and intervention. intervention.

Although tracking adherence to such a requirement Although tracking adherence to such a requirement might be challenging to insurers, the recent addition might be challenging to insurers, the recent addition of procedure codes for substance use screening and of procedure codes for substance use screening and brief intervention promises to provide a mechanism brief intervention promises to provide a mechanism for reimbursement and monitoring in the future.for reimbursement and monitoring in the future.


HAART and Drug HAART and Drug Treatment May Improve Treatment May Improve Survival in People With Survival in People With

HIV HIV Who Inject DrugsWho Inject Drugs

Muga R et al.Muga R et al. CID. CID. 2007;45(3):370–376. 2007;45(3):370–376. Summary by David A. Fiellin, MDSummary by David A. Fiellin, MD


Objectives/MethodsObjectives/Methods It is not clear whether HIV infection and HAART influence the It is not clear whether HIV infection and HAART influence the

length of survival among people with injection drug use length of survival among people with injection drug use (IDU) who receive drug treatment.(IDU) who receive drug treatment.

This observational study from Spain examined survival This observational study from Spain examined survival

among…among…

1181 people with IDU (59% with HIV) 1181 people with IDU (59% with HIV) who had been admitted to a substance abuse treatment who had been admitted to a substance abuse treatment

program before or after 1997 (the era of established program before or after 1997 (the era of established methadone programs and HAART). methadone programs and HAART).

One-third of subjects with HIV had received HAART.One-third of subjects with HIV had received HAART.


ResultsResults

Survival was shortest in people with IDU Survival was shortest in people with IDU and HIV admitted to drug treatment before and HIV admitted to drug treatment before 1997.1997.

However, survival has improved However, survival has improved substantially since 1997, when HAART was substantially since 1997, when HAART was introduced. introduced.

Survival since 1997 in people with IDU and Survival since 1997 in people with IDU and HIV was similar to that in people with IDU HIV was similar to that in people with IDU but not HIV. but not HIV.


CommentsComments This study supports the benefit of both HAART and This study supports the benefit of both HAART and

drug treatment on survival in people with IDU and drug treatment on survival in people with IDU and HIV. HIV.

The longer survival in patients who did not receive The longer survival in patients who did not receive HAART may be partially attributable to access to HAART may be partially attributable to access to drug treatment, prophylaxis for opportunistic drug treatment, prophylaxis for opportunistic infections, and ongoing clinical care. infections, and ongoing clinical care.

The increase in survival, even in patients with HIV The increase in survival, even in patients with HIV who did not receive HAART, is encouraging. who did not receive HAART, is encouraging.

Yet, it reminds us of the challenge in providing Yet, it reminds us of the challenge in providing state-of-the-art care to patients with substance use state-of-the-art care to patients with substance use disorders and HIV. disorders and HIV.

Www.aodhealth.org1 Update on Alcohol, Other Drugs, and Health September-October 2007.

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Transcript of Www.aodhealth.org1 Update on Alcohol, Other Drugs, and Health September-October 2007.