Update on Alcohol, Other Drugs, and Health

www.aodhealth.orgwww.aodhealth.org 11

Update on Update on Alcohol, Other Alcohol, Other

Drugs, and HealthDrugs, and Health

January-March 2008January-March 2008


Studies on Studies on Interventions and Interventions and

AssessmentsAssessments


Topiramate Reduces Topiramate Reduces Drinking in Adults With Drinking in Adults With

Alcohol DependenceAlcohol Dependence

Johnson BA, et al. Johnson BA, et al. JAMA.JAMA. 2007;298(14):1641–1651. 2007;298(14):1641–1651.

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


Objectives/MethodsObjectives/Methods Researchers aimed to determine topiramate’s Researchers aimed to determine topiramate’s

efficacy for reducing drinking.efficacy for reducing drinking.

They randomized 371 patients with alcohol They randomized 371 patients with alcohol dependence from 17 U.S. sites to receive dependence from 17 U.S. sites to receive topiramate (up to 300 mg per day) or placebo topiramate (up to 300 mg per day) or placebo for 14 weeks. for 14 weeks.

Only subjects without comorbid conditions Only subjects without comorbid conditions who wanted to quit or reduce drinking were who wanted to quit or reduce drinking were eligible. eligible.

All subjects received weekly, manual-guided All subjects received weekly, manual-guided adherence enhancement counseling.adherence enhancement counseling.


ResultsResults In analyses that considered all dropouts as In analyses that considered all dropouts as

having relapsed to baseline measures, having relapsed to baseline measures, topiramate recipients had… topiramate recipients had…

greater reductions in the percentage of greater reductions in the percentage of drinking days (from a mean of 82% to 44% drinking days (from a mean of 82% to 44% compared with 82% to 52% for placebo compared with 82% to 52% for placebo recipients),recipients),

greater reductions in liver enzymes, andgreater reductions in liver enzymes, and

greater increases in abstinent days (from a greater increases in abstinent days (from a mean of 10% to 38% compared with 9% to mean of 10% to 38% compared with 9% to 29% for placebo recipients). 29% for placebo recipients).


Results (cont.)Results (cont.) In analyses that considered dropouts as missing In analyses that considered dropouts as missing

rather than as relapses…rather than as relapses…

the differences between the topiramate and the differences between the topiramate and placebo groups were even greater.placebo groups were even greater.

With both analytic approaches, topiramate With both analytic approaches, topiramate recipients achieved…recipients achieved…

≥≥28 days of both continuous abstinence and 28 days of both continuous abstinence and continuous nonheavy drinking faster than continuous nonheavy drinking faster than placebo recipients did.placebo recipients did.


CommentsComments Topiramate is a promising treatment for alcohol Topiramate is a promising treatment for alcohol

dependence. dependence.

Both analytic approaches suggest that broadening Both analytic approaches suggest that broadening the use of topiramate to treat alcohol dependence the use of topiramate to treat alcohol dependence among adults who want to reduce their drinking is among adults who want to reduce their drinking is warranted. warranted.

Because this randomized controlled trial had strict Because this randomized controlled trial had strict eligibility criteria to ensure that safety and efficacy eligibility criteria to ensure that safety and efficacy could be measured…could be measured…

the generalizability of these findings to patients the generalizability of these findings to patients with comorbid illnesses may be limited.with comorbid illnesses may be limited.


Van Den Berg C, et al. Van Den Berg C, et al. Addiction.Addiction. 2007;102(9):1454–1462. 2007;102(9):1454–1462.Summary by Peter D. FriedmannSummary by Peter D. Friedmann

Methadone MaintenanceMethadone MaintenancePlus Syringe Exchange Plus Syringe Exchange Reduces HIV and HCV Reduces HIV and HCV

IncidenceIncidence


Objectives/MethodsObjectives/Methods

Participation in syringe exchange programs Participation in syringe exchange programs plus receipt of methadone maintenance may plus receipt of methadone maintenance may reduce the likelihood of HIV and HCV. reduce the likelihood of HIV and HCV.

Researchers in Amsterdam assessed the effects Researchers in Amsterdam assessed the effects of the combination of these strategies among of the combination of these strategies among 714 injection drug users (IDUs) at risk for HIV or 714 injection drug users (IDUs) at risk for HIV or HCV. HCV.


ResultsResults Over 20 years of follow-up, neither methadone Over 20 years of follow-up, neither methadone

maintenance alone nor needle exchange alone maintenance alone nor needle exchange alone was significantly associated with HIV or HCV was significantly associated with HIV or HCV seroincidence.seroincidence.

Daily methadone maintenance of ≥60 mg plus Daily methadone maintenance of ≥60 mg plus no drug injection or injection only with no drug injection or injection only with exchanged needles (all in the past 6 months) exchanged needles (all in the past 6 months) significantly reduced both HIV and HCV significantly reduced both HIV and HCV seroincidence.seroincidence.

Adjusted incidence rate ratios 0.43 and 0.36, Adjusted incidence rate ratios 0.43 and 0.36, respectively, when compared with no methadone respectively, when compared with no methadone maintenance and drug injection without maintenance and drug injection without exchanging needles exchanging needles


CommentsComments This study provides evidence that a long-term, This study provides evidence that a long-term,

comprehensive public strategy to reduce comprehensive public strategy to reduce bloodborne infections among IDUs must…bloodborne infections among IDUs must…

include both syringe exchange and opioid include both syringe exchange and opioid agonist therapy at effective dose levels.agonist therapy at effective dose levels.

Although most relevant to policy in countries with Although most relevant to policy in countries with recent outbreaks of HIV and HCV among IDUs…recent outbreaks of HIV and HCV among IDUs…

these findings are also applicable to these findings are also applicable to communities in the U.S. that lack adequate communities in the U.S. that lack adequate access to opioid treatment programs and/or access to opioid treatment programs and/or syringe exchange. syringe exchange.


O’Malley SS, O’Malley SS, J Clin Psychopharm.J Clin Psychopharm. 2007;27(5):507–512. 2007;27(5):507–512.Summary by Richard Saitz, MD, MPHSummary by Richard Saitz, MD, MPH

Extended-Release Naltrexone Extended-Release Naltrexone Works Particularly Well for Works Particularly Well for

Abstinent PatientsAbstinent Patients



In the trial that showed the efficacy of In the trial that showed the efficacy of naltrexone plus psychosocial therapy, naltrexone plus psychosocial therapy, subjects with ≥7 days of abstinence subjects with ≥7 days of abstinence benefited the most. benefited the most.

Achieving 7 days of abstinence before Achieving 7 days of abstinence before treatment is difficult. treatment is difficult.

So, researchers assessed naltrexone’s So, researchers assessed naltrexone’s efficacy, in that same clinical trial, among efficacy, in that same clinical trial, among the subgroup of 82 subjects with ≥4 days of the subgroup of 82 subjects with ≥4 days of abstinence. abstinence.


ResultsResults380 mg 380 mg

naltrexone naltrexone (n=28)(n=28)

PlaceboPlacebo

(n=28)(n=28)

Increases in the time to first Increases in the time to first drink (median days)drink (median days)

4141 1212

Increases in continuous Increases in continuous abstinence over 6 monthsabstinence over 6 months

32%32% 11%11%

Increases in the time to first Increases in the time to first heavy drinking (median heavy drinking (median days)days)

>180>180 2020

Decreases in days/month Decreases in days/month with any drinking (median with any drinking (median days)days)

0.70.7 7.27.2

Decreases in days/month Decreases in days/month with heavy drinking (median with heavy drinking (median days)days)

0.20.2 2.92.9Smaller benefits, which were not always statistically Smaller benefits, which were not always statistically significant, were found among the 28 subjects treated with significant, were found among the 28 subjects treated with 190 mg of naltrexone.190 mg of naltrexone.


CommentsComments Requiring abstinence before starting treatment Requiring abstinence before starting treatment

for alcohol dependence can be a barrier to care.for alcohol dependence can be a barrier to care.

In this industry-sponsored secondary analysis of In this industry-sponsored secondary analysis of a small subgroup, those with 4 days of a small subgroup, those with 4 days of abstinence before entering treatment abstinence before entering treatment responded well to extended-release naltrexone. responded well to extended-release naltrexone.

Unfortunately, this and other medications with Unfortunately, this and other medications with proven efficacy are underutilized in the proven efficacy are underutilized in the treatment of alcohol dependence.treatment of alcohol dependence.


Prevalence of Adolescent Prevalence of Adolescent Substance Use Identified Substance Use Identified by Screening in Primary by Screening in Primary

CareCare

Knight JR, et al. Knight JR, et al. Arch Pediatr Adolesc Med.Arch Pediatr Adolesc Med. 2007;161(11):1035–1041.2007;161(11):1035–1041.

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


Objectives/MethodsObjectives/Methods In adolescents, the prevalence of substance In adolescents, the prevalence of substance

use problems and disorders identified with an use problems and disorders identified with an accepted screening instrument is not known. accepted screening instrument is not known.

Researchers used the validated CRAFFT to Researchers used the validated CRAFFT to screen 2133 12- to 18-year olds (representing screen 2133 12- to 18-year olds (representing a 93% participation rate) from various New a 93% participation rate) from various New England primary care practices. England primary care practices.

A positive screen was defined as ≥2 positive A positive screen was defined as ≥2 positive responses, highly correlated with having a responses, highly correlated with having a substance-related diagnosis and needing substance-related diagnosis and needing treatment.treatment.


Results Results Overall, 44% of the adolescents reported any Overall, 44% of the adolescents reported any

lifetime substance use.lifetime substance use.

15% screened positive on the CRAFFT with the 15% screened positive on the CRAFFT with the highest prevalence in school-based clinics (30%) and highest prevalence in school-based clinics (30%) and rural family practices (24%). rural family practices (24%).

The prevalence of positive screens was lower at well-The prevalence of positive screens was lower at well-child visits (11%) than at sick visits (23%).child visits (11%) than at sick visits (23%).

Statistical modeling estimated that 22% of the Statistical modeling estimated that 22% of the adolescents had nonproblematic use, 11% had adolescents had nonproblematic use, 11% had problematic use, 7% had abuse, and 3% had problematic use, 7% had abuse, and 3% had dependence.dependence.


CommentsComments

The prevalence of substance use problems The prevalence of substance use problems among adolescents, as determined with a among adolescents, as determined with a validated tool in primary care settings, is validated tool in primary care settings, is high. high.

Therefore, identifying and implementing Therefore, identifying and implementing efficacious approaches to address these efficacious approaches to address these problems is essential. problems is essential.


Melatonin, Melatonin, Benzodiazepines, and Benzodiazepines, and Sleep Quality Among Sleep Quality Among Patients Receiving Patients Receiving

MethadoneMethadone

Peles E, et al. Peles E, et al. Addiction.Addiction. 2007; 2007;102(12):1947–1953.102(12):1947–1953. Summary by Peter D. Friedmann, MD, MPHSummary by Peter D. Friedmann, MD, MPH


Objectives/MethodsObjectives/Methods Both benzodiazepine abuse and sleep disorders are Both benzodiazepine abuse and sleep disorders are

common worldwide among patients receiving common worldwide among patients receiving methadone. methadone.

This double-blind trial evaluated melatonin’s This double-blind trial evaluated melatonin’s effectiveness in reducing sleep problems among…effectiveness in reducing sleep problems among…

80 patients who were receiving methadone 80 patients who were receiving methadone maintenance and abusing benzodiazepines. maintenance and abusing benzodiazepines.

Patients were recruited into a benzodiazepine Patients were recruited into a benzodiazepine withdrawal program where they each received…withdrawal program where they each received…

melatonin (5 mg per day) for 6 weeks, melatonin (5 mg per day) for 6 weeks, nothing for 1 week (washout week), and nothing for 1 week (washout week), and placebo for 6 weeks.placebo for 6 weeks.


ResultsResults Overall, subjects reported higher subjective Overall, subjects reported higher subjective

sleep quality, regardless of treatment arm, at 6 sleep quality, regardless of treatment arm, at 6 weeks. weeks.

About one-third of subjects had stopped using About one-third of subjects had stopped using benzodiazepines (identified by urine screen) by benzodiazepines (identified by urine screen) by 6 weeks. 6 weeks.

Sleep quality among these subjects was not Sleep quality among these subjects was not affected by melatonin but was…affected by melatonin but was…

significantly better than sleep quality among significantly better than sleep quality among subjects who continued benzodiazepines.subjects who continued benzodiazepines.


Results (cont.)Results (cont.) Of subjects who continued using benzodiazepines Of subjects who continued using benzodiazepines

at 6 weeks, sleep quality significantly improved at 6 weeks, sleep quality significantly improved with melatonin versus placebo.with melatonin versus placebo.

Over approximately 21 months, 63 patients Over approximately 21 months, 63 patients stopped using benzodiazepines, although all but stopped using benzodiazepines, although all but 4 relapsed. 4 relapsed.

Time to benzodiazepine relapse was significantly Time to benzodiazepine relapse was significantly longer among subjects who received melatonin in longer among subjects who received melatonin in the first 6 weeks.the first 6 weeks.

125 versus 42 days 125 versus 42 days


CommentsComments Most improvement in sleep quality was attributable Most improvement in sleep quality was attributable

to stopping benzodiazepines,…to stopping benzodiazepines,…

a finding physicians may choose to highlight a finding physicians may choose to highlight when discussing benzodiazepine use with their when discussing benzodiazepine use with their sleep-disturbed patients who receive methadone.sleep-disturbed patients who receive methadone.

Melatonin did not improve benzodiazepine Melatonin did not improve benzodiazepine discontinuation overall.discontinuation overall.

But, melatonin improved sleep quality in patients But, melatonin improved sleep quality in patients who could not stop benzodiazepines and who could not stop benzodiazepines and lengthened the time to relapse in those who did lengthened the time to relapse in those who did stop. stop.


Comments (cont.)Comments (cont.)

If replicated, these findings will support If replicated, these findings will support the use of melatonin..the use of melatonin..

for sleep problems among patients who for sleep problems among patients who receive methadone maintenance and receive methadone maintenance and use anxiolytics and use anxiolytics and

as a possible adjunct to decrease as a possible adjunct to decrease relapse to benzodiazepines.relapse to benzodiazepines.


O’Toole TP, et al. O’Toole TP, et al. Med CareMed Care 2007;45(11):1110–1115. 2007;45(11):1110–1115.Summary by Marc N. Gourevitch, MD, MPHSummary by Marc N. Gourevitch, MD, MPH

Inpatient Medical Care Plus Inpatient Medical Care Plus Substance Abuse Treatment Substance Abuse Treatment

Improves Health Services UtilizationImproves Health Services Utilization



Researchers evaluated the impact of a…Researchers evaluated the impact of a… special 12-bed unit in an inpatient day special 12-bed unit in an inpatient day

hospital (DH) that addressed patients’ hospital (DH) that addressed patients’ medical and substance use treatment medical and substance use treatment needs. needs.

Patients were assigned to DH (n=63) or Patients were assigned to DH (n=63) or usual care (n=327) based on the availability usual care (n=327) based on the availability of beds. of beds.


ResultsResults 49% of patients assigned to DH completed the 49% of patients assigned to DH completed the

2-week program. 2-week program.

In the 6 months after discharge, DH completers In the 6 months after discharge, DH completers (vs. usual care patients) were...(vs. usual care patients) were...

less likely to have ≥3 emergency department less likely to have ≥3 emergency department visits (adjusted odds ratio [AOR], 0.3) and visits (adjusted odds ratio [AOR], 0.3) and

more likely to have ≥1 ambulatory care visit more likely to have ≥1 ambulatory care visit (AOR, 4.1).(AOR, 4.1).

Patients assigned to but who did not complete Patients assigned to but who did not complete the DH program had no post-discharge the DH program had no post-discharge improvements in health service utilization. improvements in health service utilization.


CommentsComments Completing an integrated program of Completing an integrated program of

substance use care and inpatient medical substance use care and inpatient medical treatment was associated with post-treatment was associated with post-discharge improvements in health services discharge improvements in health services utilization. utilization.

Study limitations included nonrandom Study limitations included nonrandom assignment of subjects and restriction of assignment of subjects and restriction of utilization data to nearby health facilities. utilization data to nearby health facilities.

Other models that bridge inpatient care for Other models that bridge inpatient care for substance use-related conditions with substance use-related conditions with effective outpatient treatment should be effective outpatient treatment should be developed and evaluated. developed and evaluated.


Tidey JW, et al.Tidey JW, et al. Alcohol Clin Exp Res.Alcohol Clin Exp Res. 2008;32(1):1–9. 2008;32(1):1–9.Summary by Kevin L. Kraemer, MD, MScSummary by Kevin L. Kraemer, MD, MSc

Do Patient Characteristics Do Patient Characteristics Moderate Naltrexone’s Moderate Naltrexone’s

Effects on Drinking?Effects on Drinking?



Researchers identified moderators of Researchers identified moderators of naltrexone’s effects on drinking.naltrexone’s effects on drinking.

They randomized 180 heavy drinkers* who They randomized 180 heavy drinkers* who were not seeking alcohol treatment to were not seeking alcohol treatment to receive 3 weeks of daily naltrexone (50 mg) receive 3 weeks of daily naltrexone (50 mg) or placebo. or placebo.

Subjects kept a real-time electronic diary Subjects kept a real-time electronic diary about their drinking at specific times during about their drinking at specific times during the day.the day.

*Drank on ≥4 days per week and heavily (>6 drinks for men, >4 for women) on ≥2 days per *Drank on ≥4 days per week and heavily (>6 drinks for men, >4 for women) on ≥2 days per week over the prior monthweek over the prior month


ResultsResults

63% of subjects had alcohol dependence.63% of subjects had alcohol dependence.

Overall, naltrexone was associated with a Overall, naltrexone was associated with a significantly lower mean percentage of significantly lower mean percentage of drinking days.drinking days.

57% versus 65% for the placebo group57% versus 65% for the placebo group

Naltrexone was not associated with other Naltrexone was not associated with other drinking outcomes or subjective outcomes drinking outcomes or subjective outcomes (e.g., drinking urge, stimulation, sedation). (e.g., drinking urge, stimulation, sedation).


Results (cont.)Results (cont.) In analyses that assessed possible moderators, In analyses that assessed possible moderators,

naltrexone was associated with the following: naltrexone was associated with the following:

reduced stimulation from drinking among womenreduced stimulation from drinking among women

lower urge to drink among subjects with earlier age lower urge to drink among subjects with earlier age of alcoholism onsetof alcoholism onset

longer time between drinks among subjects with a longer time between drinks among subjects with a family history of alcohol problemsfamily history of alcohol problems

lower mean % of heavy drinking days among lower mean % of heavy drinking days among subjects with the D4 dopamine receptor subjects with the D4 dopamine receptor polymorphism DRD4-Lpolymorphism DRD4-L


CommentsComments The effect of naltrexone on drinking in this study The effect of naltrexone on drinking in this study

was small and limited to mean percentage of was small and limited to mean percentage of drinking days. drinking days.

The study identified several moderators of The study identified several moderators of naltrexone’s effects on drinking and several naltrexone’s effects on drinking and several subjective measures.subjective measures.

But, each moderator interacted with naltrexone But, each moderator interacted with naltrexone on only one, often intermediary, outcome. on only one, often intermediary, outcome.

Real-time electronic-diary data collection and the Real-time electronic-diary data collection and the nontreatment-seeking population are strengths of nontreatment-seeking population are strengths of this study.this study.

Further work is needed to identify which patients Further work is needed to identify which patients will have the best response to naltrexone.will have the best response to naltrexone.


Studies of Studies of Health OutcomesHealth Outcomes


Davis WR, et al. Davis WR, et al. Drug Alcohol DependDrug Alcohol Depend. 2008;92(1–3):267–. 2008;92(1–3):267–276.276.

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

Prescription Opioid Use Prescription Opioid Use

and Diversionand Diversion



Researchers aimed to determine the Researchers aimed to determine the patterns of prescription opioid use, misuse, patterns of prescription opioid use, misuse, and sales (diversion) among drug users.and sales (diversion) among drug users.

They conducted interviews with 586 drug They conducted interviews with 586 drug users in New York City.users in New York City.


ResultsResults 72% of subjects used methadone and 65% sold it.72% of subjects used methadone and 65% sold it.

Methadone was used and sold by more individuals Methadone was used and sold by more individuals than was OxyContin, Vicodin, or Percocet.than was OxyContin, Vicodin, or Percocet.

58% of prescription drug users obtained opioids 58% of prescription drug users obtained opioids for pain, withdrawal, or euphoria from doctors.for pain, withdrawal, or euphoria from doctors.

42% obtained them from dealers. 42% obtained them from dealers.


Results (cont.)Results (cont.) Of subjects who reported using Oxycontin they Of subjects who reported using Oxycontin they

obtained from physicians…obtained from physicians…

83% reported having used the drug mainly for 83% reported having used the drug mainly for pain, pain,

50% used it mainly to prevent opioid 50% used it mainly to prevent opioid withdrawal symptoms, andwithdrawal symptoms, and

38% used it mainly for euphoria. 38% used it mainly for euphoria.

Prescription drug users were less likely to obtain Prescription drug users were less likely to obtain prescription opioids for euphoria than for pain. prescription opioids for euphoria than for pain.

When they obtained prescription opioids for When they obtained prescription opioids for euphoria, they usually did so from dealers. euphoria, they usually did so from dealers.


CommentsComments This study helps to illuminate an emergent, and fairly This study helps to illuminate an emergent, and fairly

American, drug abuse pattern—abuse and dependence American, drug abuse pattern—abuse and dependence on prescription opioids. on prescription opioids.

Many individuals used these medications to avoid Many individuals used these medications to avoid opioid withdrawal or to treat pain, an informative opioid withdrawal or to treat pain, an informative finding. finding.

Patients were less likely to use physician-obtained Patients were less likely to use physician-obtained medications for euphoria than for other indications, medications for euphoria than for other indications, most likely reflecting a high level of opioid tolerance. most likely reflecting a high level of opioid tolerance.

Many patients were interacting with physicians, Many patients were interacting with physicians, suggesting that physicians should show caution when suggesting that physicians should show caution when prescribing opioids and should consider offering office-prescribing opioids and should consider offering office-based treatment or specialty treatment referral when based treatment or specialty treatment referral when indicated. indicated.


Hicks PL, et al. Hicks PL, et al. AIDS CareAIDS Care. 2007;19(9):1134–1140.. 2007;19(9):1134–1140.Summary by David A. Fiellin, MDSummary by David A. Fiellin, MD

Impact of Substance Use Impact of Substance Use

on Adherence to on Adherence to

HIV Medications HIV Medications



High levels of adherence to highly active High levels of adherence to highly active antiretroviral therapy (HAART) are associated antiretroviral therapy (HAART) are associated with improved outcomes for patients with with improved outcomes for patients with HIV. HIV.

Researchers assessed whether illicit Researchers assessed whether illicit substance use and receiving substance use substance use and receiving substance use treatment influence adherence to HAART. treatment influence adherence to HAART.

They interviewed 659 patients with HIV.They interviewed 659 patients with HIV.


ResultsResults

42% had used illicit drugs in the past 6 42% had used illicit drugs in the past 6 months (current use).months (current use).

30% had used illicit drugs but not in the 30% had used illicit drugs but not in the past 6 months (former use).past 6 months (former use).

28% had never used illicit drugs.28% had never used illicit drugs.


ResultsResultsAdherence was… Adherence was…

significantly less common among subjects with significantly less common among subjects with current use (60%) than among subjects with current use (60%) than among subjects with former (68%) or no (77%) use;former (68%) or no (77%) use;

similar between subjects with former use plus similar between subjects with former use plus recent treatment and subjects with no use;recent treatment and subjects with no use;

lower in subjects with former use but no recent lower in subjects with former use but no recent treatment than in subjects with no use (adjusted treatment than in subjects with no use (adjusted odds ratio, 0.6; odds ratio, 0.6; PP=0.05); =0.05);

lower in subjects with current use than in subjects lower in subjects with current use than in subjects with no use, regardless of receipt of substance with no use, regardless of receipt of substance use treatment.use treatment.


CommentsComments This study demonstrates the potential adverse impact This study demonstrates the potential adverse impact

of illicit drug use on adherence to HIV medications. of illicit drug use on adherence to HIV medications.

It also indicates the importance of ongoing substance It also indicates the importance of ongoing substance use treatment for people with past substance use. use treatment for people with past substance use.

The study is limited because it did not evaluate The study is limited because it did not evaluate biologic outcomes or the impact of alcohol separately biologic outcomes or the impact of alcohol separately from the impact of illicit substance use in multivariate from the impact of illicit substance use in multivariate analyses. analyses.

But, these findings support the importance of But, these findings support the importance of engaging patients with HIV and substance use engaging patients with HIV and substance use (current or former) in substance use treatment.(current or former) in substance use treatment.


Combining Healthy Combining Healthy Behaviors, Including Behaviors, Including Moderate Drinking, Moderate Drinking,

Reduces MI in WomenReduces MI in Women

Akesson A, et al. Akesson A, et al. Arch Intern Med.Arch Intern Med. 2007;167(19):2122– 2007;167(19):2122–2127. 2127.

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


Objectives/MethodsObjectives/Methods Certain behaviors can reduce myocardial infarction Certain behaviors can reduce myocardial infarction

(MI) risk in women. But, the magnitude of the risk (MI) risk in women. But, the magnitude of the risk reduction from a combination of these behaviors is reduction from a combination of these behaviors is unknown. unknown.

Swedish researchers studied 24,444 postmenopausal Swedish researchers studied 24,444 postmenopausal women without cancer, cardiovascular disease, or women without cancer, cardiovascular disease, or diabetes at baseline to determine the benefit of…diabetes at baseline to determine the benefit of…

eating a healthy diet plus eating a healthy diet plus drinking about ≥0.5 alcoholic drinks per day,drinking about ≥0.5 alcoholic drinks per day, not smoking,not smoking, having a waist-hip ratio <0.85, and having a waist-hip ratio <0.85, and being physically active.being physically active.


Results Results

During 6.2 years of follow-up, 308 cases of During 6.2 years of follow-up, 308 cases of primary MI occurred. primary MI occurred.

In adjusted analyses, each of the assessed In adjusted analyses, each of the assessed healthy behaviors was inversely and healthy behaviors was inversely and independently associated with the risk of MI.independently associated with the risk of MI.

The results for physical activity were not The results for physical activity were not significant.significant.


Results (cont.)Results (cont.) The risk of MI was significantly lower among The risk of MI was significantly lower among

women with a healthy diet plus the following:women with a healthy diet plus the following:

alcohol consumption (relative risk, RR, 0.5)alcohol consumption (relative risk, RR, 0.5) alcohol consumption and not smoking (RR, 0.2)alcohol consumption and not smoking (RR, 0.2) alcohol consumption, not smoking, and physical alcohol consumption, not smoking, and physical

activity (RR, 0.1)activity (RR, 0.1) alcohol consumption, not smoking, physical activity, alcohol consumption, not smoking, physical activity,

and a waist-to-hip ratio <0.85 (RR, 0.08)and a waist-to-hip ratio <0.85 (RR, 0.08)

Most MIs were attributable to the lack of these Most MIs were attributable to the lack of these healthy behaviors. healthy behaviors.


CommentsComments In a recent study by Mukamal et al, men with In a recent study by Mukamal et al, men with

healthy lifestyles who drank had a greater healthy lifestyles who drank had a greater reduction in MI risk than did men with healthy reduction in MI risk than did men with healthy lifestyles who did not drink. lifestyles who did not drink.

The present study shows a similar finding The present study shows a similar finding among women: it supports the notion that…among women: it supports the notion that…

combining a Mediterranean-type diet and combining a Mediterranean-type diet and other healthy lifestyle factors, including low other healthy lifestyle factors, including low alcohol intake, may substantially reduce the alcohol intake, may substantially reduce the risk of myocardial infarction in women.risk of myocardial infarction in women.


Suris JC, et al. Suris JC, et al. Arch Pediatr Adolesc MedArch Pediatr Adolesc Med. . 2007;161(11):1042–1047.2007;161(11):1042–1047.

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

Characteristics of Characteristics of Adolescent Cannabis Users Adolescent Cannabis Users Who Don’t Smoke TobaccoWho Don’t Smoke Tobacco


Objectives/MethodsObjectives/Methods Cannabis is associated with tobacco use and has Cannabis is associated with tobacco use and has

been described as a “gateway” drug. been described as a “gateway” drug.

Whether adolescents who use cannabis only differ Whether adolescents who use cannabis only differ from those who use cannabis from those who use cannabis andand tobacco is tobacco is unclear. unclear.

Researchers assessed social and academic Researchers assessed social and academic performance among…performance among…

a nationally representative sample of 5263 a nationally representative sample of 5263 Swiss adolescents Swiss adolescents

who used cannabis only, cannabis and tobacco, who used cannabis only, cannabis and tobacco, or neither. or neither.


ResultsResults

Cannabis Only Users vs. Cannabis Only Users vs. Cannabis Plus Tobacco Cannabis Plus Tobacco

UsersUsers

Adjusted ORsAdjusted ORs

Practice sportsPractice sports 2.42.4

Be on an academic trackBe on an academic track 2.62.6

Get good gradesGet good grades 1.61.6

Use cannabis ≥10 times in the Use cannabis ≥10 times in the last monthlast month

0.30.3

Get drunkGet drunk 0.60.6


Results (cont.)Results (cont.)Cannabis Only Users Cannabis Only Users vs. Never Users of vs. Never Users of

Cannabis or TobaccoCannabis or Tobacco

Adjusted ORsAdjusted ORs

Practice sportsPractice sports 1.41.4

Be on an academic trackBe on an academic track 1.41.4

Report good peer relationshipsReport good peer relationships 1.61.6

Be truantBe truant 2.32.3

Get drunk in the last monthGet drunk in the last month 4.54.5

Use other illegal drugs in the last Use other illegal drugs in the last monthmonth

2.32.3

Report a good relationship with Report a good relationship with parentsparents

0.60.6


CommentsComments Unexpectedly, this cross-sectional study found that Unexpectedly, this cross-sectional study found that

adolescents who smoked cannabis, versus those who adolescents who smoked cannabis, versus those who never smoked cannabis or tobacco, were…never smoked cannabis or tobacco, were… more likely to be engaged in sports, in an academic more likely to be engaged in sports, in an academic

track, and to report good peer relationships.track, and to report good peer relationships.

At the same time, cannabis only users were more likely At the same time, cannabis only users were more likely to be truant, to get drunk, and to use other drugs.to be truant, to get drunk, and to use other drugs.

Prospective longitudinal analyses are needed to Prospective longitudinal analyses are needed to determine…determine…

whether cannabis use is a cause or effect of these whether cannabis use is a cause or effect of these outcomes and outcomes and

how the interaction between tobacco and cannabis how the interaction between tobacco and cannabis smoking influences adolescent development.smoking influences adolescent development.


Racial Differences in Racial Differences in Treatment Received and in Treatment Received and in

Treatment CompletedTreatment Completed

Bluthenthal RN, et al. Bluthenthal RN, et al. Alcohol Clin Exp ResAlcohol Clin Exp Res. . 2007;31(11):1920–1926.2007;31(11):1920–1926.

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


Objectives/MethodsObjectives/Methods Researchers assessed whether racial/ethnic Researchers assessed whether racial/ethnic

differences in type of treatment received differences in type of treatment received could…could…

explain differences in treatment completion explain differences in treatment completion rates.rates.

They analyzed the discharge data of…They analyzed the discharge data of…

10,591 patients (4141 African Americans, 10,591 patients (4141 African Americans, 3120 Hispanics, and 3330 whites) 3120 Hispanics, and 3330 whites)

treated in the publicly funded programs of a treated in the publicly funded programs of a large, urban county in California. large, urban county in California.


ResultsResults

Rate of Rate of Completing Completing Outpatient Outpatient TreatmentTreatment

Rate of Rate of Completing Completing Residential Residential TreatmentTreatment

African AmericansAfrican Americans 18%18% 31%31%

HispanicsHispanics 30%30% 43%43%

WhitesWhites 27%27% 46%46%

In analyses adjusted for potential confounders, In analyses adjusted for potential confounders, African Americans and Hispanics were more likely African Americans and Hispanics were more likely than whites to enter outpatient (versus residential) than whites to enter outpatient (versus residential) treatment.treatment.

ORs, 1.9 and 2.1, respectivelyORs, 1.9 and 2.1, respectively


Results (cont.)Results (cont.)

Further analyses indicated that…Further analyses indicated that…

if minority patients in outpatient care had the if minority patients in outpatient care had the same odds of receiving residential treatment same odds of receiving residential treatment as did white patients with otherwise similar as did white patients with otherwise similar characteristics…characteristics…

the disparity in completion rates would the disparity in completion rates would improve for African Americans and resolve improve for African Americans and resolve for Hispanics.for Hispanics.


CommentsComments This study showed that completion rates for alcohol This study showed that completion rates for alcohol

treatment were low among all racial/ethnic groups treatment were low among all racial/ethnic groups but lowest among African Americans. but lowest among African Americans.

Even if African Americans had an equal chance as Even if African Americans had an equal chance as whites of entering residential treatment, they would whites of entering residential treatment, they would still be less likely to complete treatment. still be less likely to complete treatment.

This study is unable to determine whether racial and This study is unable to determine whether racial and ethnic minorities should be steered to residential ethnic minorities should be steered to residential alcohol treatment. alcohol treatment.

It does underscore the need to improve retention It does underscore the need to improve retention and completion rates of patients with alcohol and completion rates of patients with alcohol dependence, especially African Americans, enrolled dependence, especially African Americans, enrolled in publicly funded alcohol treatment programs.in publicly funded alcohol treatment programs.


Shai I, et al. Shai I, et al. Diabetes Care.Diabetes Care. 2007;30(12):3011–3016. 2007;30(12):3011–3016.Summary by R. Curtis Ellison, MDSummary by R. Curtis Ellison, MD

Moderate Drinking May Moderate Drinking May Improve Fasting Glucose Improve Fasting Glucose in People with Diabetesin People with Diabetes


Objectives/MethodsObjectives/Methods Researchers aimed to clarify the association Researchers aimed to clarify the association

between moderate drinking and glycemic control.between moderate drinking and glycemic control.

They conducted a randomized trial of 109 They conducted a randomized trial of 109 subjects with type 2 diabetes who had not subjects with type 2 diabetes who had not consumed >1 drink in the past week. consumed >1 drink in the past week.

Subjects, aged 41 to 74 years, were given either Subjects, aged 41 to 74 years, were given either about 1 glass of wine or nonalcoholic beer about 1 glass of wine or nonalcoholic beer (control) daily with dinner. (control) daily with dinner.

Each subject received dietary counseling, was Each subject received dietary counseling, was instructed to consume a specific amount of instructed to consume a specific amount of calories, completed food diaries and calories, completed food diaries and questionnaires, and underwent blood testing. questionnaires, and underwent blood testing.


ResultsResults 91 patients completed the 3-month trial. 91 patients completed the 3-month trial. Fasting blood glucose decreased in the alcohol Fasting blood glucose decreased in the alcohol

group (from 140 to 118 mg/dl) but not in the group (from 140 to 118 mg/dl) but not in the control group.control group.

In the alcohol group, decreases were greatest In the alcohol group, decreases were greatest among patients with higher levels of hemoglobin among patients with higher levels of hemoglobin A1c at baseline. A1c at baseline.

Postprandial glucose levels did not significantly Postprandial glucose levels did not significantly differ between the groups. differ between the groups.

No notable adverse effects were reported.No notable adverse effects were reported.


CommentsComments Patients with diabetes who had abstained for Patients with diabetes who had abstained for

a week but started consuming a glass of wine a week but started consuming a glass of wine per day had a rather marked improvement in per day had a rather marked improvement in their fasting blood glucose levels. their fasting blood glucose levels.

Those with more severe disease showed the Those with more severe disease showed the largest effect from alcohol, a finding largest effect from alcohol, a finding supported from many observational studies. supported from many observational studies.

Since subjects were followed for only 3 Since subjects were followed for only 3 months, long-term effects cannot be months, long-term effects cannot be estimated from this study. estimated from this study.

Update on Alcohol, Other Drugs, and Health

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