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

Alcohol, Other Drugs, and Health: Current Alcohol, Other Drugs, and Health: Current EvidenceEvidence

May-June 2007May-June 2007


Studies on Studies on Health OutcomesHealth Outcomes


Marijuana Smoking and Marijuana Smoking and Pulmonary Complications Pulmonary Complications

Tetrault JM, et al. Tetrault JM, et al. Arch Intern Med.Arch Intern Med. 2007;167(3):221– 2007;167(3):221–228.228.

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


Objectives/MethodsObjectives/Methods

The impact of marijuana smoking on The impact of marijuana smoking on pulmonary function and respiratory pulmonary function and respiratory complications is not clearly understood. complications is not clearly understood.

Researchers conducted a systematic review Researchers conducted a systematic review and summarized the findings of 34 studies.and summarized the findings of 34 studies.


ResultsResults Short-term marijuana smoking was associated with Short-term marijuana smoking was associated with

improved airway response in 10 of 11 challenge studies.* improved airway response in 10 of 11 challenge studies.* But, the results of 1 challenge study suggested a But, the results of 1 challenge study suggested a

reversal of this effect after 1.5 to 2 months of reversal of this effect after 1.5 to 2 months of marijuana smoking.marijuana smoking.

Longer-term** marijuana smoking was inconsistently Longer-term** marijuana smoking was inconsistently associated with airflow obstruction. associated with airflow obstruction. Results from pulmonary function tests (FEV1, FVC, Results from pulmonary function tests (FEV1, FVC,

FEV1/FVC, DLCO) were worse in marijuana smokers FEV1/FVC, DLCO) were worse in marijuana smokers than in controls in 8 of 14 studies.than in controls in 8 of 14 studies.

*Studies that experimentally administered marijuana and assessed its effects immediately or shortly after administration*Studies that experimentally administered marijuana and assessed its effects immediately or shortly after administration**Defined variably across studies**Defined variably across studies


Results (cont.)Results (cont.) Longer-term marijuana smoking was associated Longer-term marijuana smoking was associated

with an increased risk of…with an increased risk of… various respiratory complications (e.g., cough, various respiratory complications (e.g., cough,

sputum production, wheezing) in 14 of 14 sputum production, wheezing) in 14 of 14 studies. studies.

The overall quality of studies varied. The overall quality of studies varied. Many failed to control for tobacco smoking, and Many failed to control for tobacco smoking, and

none defined a standardized measure of none defined a standardized measure of marijuana dose. marijuana dose.


CommentsComments Although short-term marijuana exposure Although short-term marijuana exposure

may cause bronchodilation, longer-term may cause bronchodilation, longer-term exposure may obstruct airflow. exposure may obstruct airflow.

Physiologic data that can describe the Physiologic data that can describe the relationship between marijuana smoking relationship between marijuana smoking and airway hyperreactivity are currently and airway hyperreactivity are currently inconclusive. inconclusive.

Nonetheless, long-term marijuana smoking Nonetheless, long-term marijuana smoking appears to increase the risk of respiratory appears to increase the risk of respiratory symptoms and complications. symptoms and complications.


Patients on Methadone Patients on Methadone With Unhealthy Alcohol With Unhealthy Alcohol Use Have Poor Quality Use Have Poor Quality

of Lifeof Life

Senbanjo R, et al. Senbanjo R, et al. AddictionAddiction. 2007;102(2):257–263.. 2007;102(2):257–263.Summary by Julia H. Arnsten, MD, MPHSummary by Julia H. Arnsten, MD, MPH


Objectives/MethodsObjectives/Methods In this cross-sectional study of 192 In this cross-sectional study of 192

outpatients on methadone, English outpatients on methadone, English researchers assessed…researchers assessed… the association between unhealthy alcohol the association between unhealthy alcohol

use and health-related quality of life.use and health-related quality of life.

Unhealthy alcohol use was measured with the Unhealthy alcohol use was measured with the Alcohol Use Disorders Identification Test Alcohol Use Disorders Identification Test [AUDIT]. [AUDIT].

Health-related quality of life was measured with Health-related quality of life was measured with the SF-12. the SF-12.


Results Results 30% had current unhealthy alcohol use (30% had current unhealthy alcohol use (>>8 on 8 on

the AUDIT); 10% did not have current unhealthy the AUDIT); 10% did not have current unhealthy alcohol use but reported past alcohol problems.alcohol use but reported past alcohol problems.

The mean SF-12 score was 56 (indicating poor The mean SF-12 score was 56 (indicating poor health).health).

Patients with current unhealthy alcohol use or Patients with current unhealthy alcohol use or past alcohol problems (vs. those with neither) past alcohol problems (vs. those with neither) had…had… significantly worse health-related quality of life significantly worse health-related quality of life

(mean difference in SF-12 scores, 10.4 and (mean difference in SF-12 scores, 10.4 and 12.5, respectively).12.5, respectively).


CommentsComments

Because these findings are from a cross-Because these findings are from a cross-sectional survey, they should be confirmed sectional survey, they should be confirmed in other studies. in other studies.

However, addressing comorbid drinking However, addressing comorbid drinking problems should improve quality of life for problems should improve quality of life for patients receiving methadone treatment.patients receiving methadone treatment.


Persistent Pain Persistent Pain Increases Risk of Increases Risk of

RelapseRelapse

Larson MJ, et al. Larson MJ, et al. Addiction.Addiction. 2007;(Online Early Articles): 2007;(Online Early Articles): doi: 10.1111/j.1360-0443.2007.01759.x.doi: 10.1111/j.1360-0443.2007.01759.x.

Summary by Marc N. Gourevitch, MD, MPHSummary by Marc N. Gourevitch, MD, MPH


Objectives/MethodsObjectives/Methods Researchers assessed data on pain and Researchers assessed data on pain and

substance use in 397 adults who had been…substance use in 397 adults who had been… admitted to an urban, residential drug and admitted to an urban, residential drug and

alcohol detoxification unit and alcohol detoxification unit and interviewed periodically over 24 months as interviewed periodically over 24 months as

part of a larger randomized trial. part of a larger randomized trial.

Pain was measured with the SF-36 pain item. Pain was measured with the SF-36 pain item.

Analyses were adjusted for potential Analyses were adjusted for potential confounders.confounders.


ResultsResults 16% reported persistent pain (moderate-to-higher 16% reported persistent pain (moderate-to-higher

levels of pain at all available interviews) in the 24 levels of pain at all available interviews) in the 24 months after detoxification.months after detoxification.

Subjects reporting persistent pain were Subjects reporting persistent pain were significantly more likely than those with mild or no significantly more likely than those with mild or no pain to have (in the past 30 days at the 24-month pain to have (in the past 30 days at the 24-month follow-up)…follow-up)… used heroin/opioids not prescribed for pain used heroin/opioids not prescribed for pain

(odds ratio [OR], 5.4);(odds ratio [OR], 5.4); drunk drunk >>3 drinks on at least 1 day or been 3 drinks on at least 1 day or been

intoxicatedintoxicated (OR, 2.2). (OR, 2.2).


CommentsComments Persistent pain is common in people who have Persistent pain is common in people who have

undergone residential detoxification and increases undergone residential detoxification and increases relapse risk. relapse risk.

Clinicians must be careful to screen for pain Clinicians must be careful to screen for pain symptoms in patients with substance dependence. symptoms in patients with substance dependence.

When persistent pain is present, thoughtful When persistent pain is present, thoughtful management is required to…management is required to… minimize risks associated with undertreatment minimize risks associated with undertreatment while not fostering opioid analgesic abuse. while not fostering opioid analgesic abuse.


Alcohol Increases Alcohol Increases Breast Cancer Risk in Breast Cancer Risk in

Certain WomenCertain Women

Zhang SM, et al. Zhang SM, et al. Am J EpidemiolAm J Epidemiol. 2007;165(6):667–. 2007;165(6):667–676.676.

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


Objectives/MethodsObjectives/Methods Using data from the Women’s Health Study, researchers Using data from the Women’s Health Study, researchers

examined the association between…examined the association between… moderate drinking and breast cancermoderate drinking and breast cancer according to estrogen receptor and progesterone according to estrogen receptor and progesterone

receptor status. receptor status.

During an average of 10 years of follow-up, 1484 cases During an average of 10 years of follow-up, 1484 cases were documented among 38,454 women without cancer were documented among 38,454 women without cancer and cardiovascular disease at baseline. and cardiovascular disease at baseline.

Analyses were adjusted for potential confounders.Analyses were adjusted for potential confounders.


ResultsResults The risks of all breast cancers (invasive and in situ The risks of all breast cancers (invasive and in situ

tumors) and invasive breast cancer…tumors) and invasive breast cancer… were modestly higher in drinkers than were modestly higher in drinkers than

nondrinkers and nondrinkers and increased as drinking amounts increased.increased as drinking amounts increased.

Drinks per Drinks per DayDay

Relative Risk of Relative Risk of All Breast CancersAll Breast Cancers

PP for Trend for Trend

<0.5 <0.5 1.01.0 0.02 0.02

≈≈1 1 1.11.1

≈≈2.52.5 1.31.3


Results (cont.)Results (cont.) Increased risk was…Increased risk was…

limited to ER+ and PR+ tumors and limited to ER+ and PR+ tumors and strongest in women currently taking strongest in women currently taking

hormone replacement therapy. hormone replacement therapy.

Risks were similar across beverage type Risks were similar across beverage type and not affected by folate intake.and not affected by folate intake.


CommentsComments Like many previous reports, this analysis shows Like many previous reports, this analysis shows

that alcohol intake is associated with a slight that alcohol intake is associated with a slight overall increase in the risk of breast cancer. overall increase in the risk of breast cancer.

The important findings are that the increase was… The important findings are that the increase was… limited to ER+ and PR+ tumors and limited to ER+ and PR+ tumors and strongest in current users of postmenopausal strongest in current users of postmenopausal

hormonal therapy. hormonal therapy.

Unlike previous studies, this study did not show Unlike previous studies, this study did not show any protective effect of folate intake on breast any protective effect of folate intake on breast cancer risk.cancer risk.


Drinking Levels and Drinking Levels and Death: How Much Is Death: How Much Is

Safe?Safe?

Di Castelnuovo A, et al. Di Castelnuovo A, et al. Arch Intern MedArch Intern Med. . 2006;166(22):2437–2445.2006;166(22):2437–2445.

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


ObjectivesObjectives To help determine the safest level of alcohol To help determine the safest level of alcohol

intake, researchers conducted a…intake, researchers conducted a… meta-analysis of 34 prospective studies on meta-analysis of 34 prospective studies on

alcohol and all-cause mortality.alcohol and all-cause mortality.

29 of these studies reported adjustment for 29 of these studies reported adjustment for potential confounders and included…potential confounders and included… a total of 285,490 women and 622,692 mena total of 285,490 women and 622,692 men (13,448 and 73,493, respectively, died (13,448 and 73,493, respectively, died

during follow-up).during follow-up).


ResultsResults For men, drinking up to 3 standard drinks For men, drinking up to 3 standard drinks

(12–14 g of alcohol) per day decreased the (12–14 g of alcohol) per day decreased the risk of death. risk of death.

For women, drinking up to 1.5 drinks per For women, drinking up to 1.5 drinks per day decreased risk.day decreased risk.

For both men and women, risk was lowest For both men and women, risk was lowest at 0.5 drinks per day. at 0.5 drinks per day. Relative risks, 0.8 for both versus Relative risks, 0.8 for both versus

nondrinkersnondrinkers


CommentsComments This very large meta-analysis confirms the J-shaped This very large meta-analysis confirms the J-shaped

relationship between alcohol use and death. relationship between alcohol use and death.

The amount associated with the lowest risk in this The amount associated with the lowest risk in this study is lower than that reported for men in study is lower than that reported for men in previous research. previous research.

The upper limits associated with a protective effect The upper limits associated with a protective effect exceed U.S. recommendations for low-risk drinking.exceed U.S. recommendations for low-risk drinking.

Overall, the available research supports the Overall, the available research supports the beneficial effect of low levels of alcohol use on beneficial effect of low levels of alcohol use on mortality. mortality.


Cardiomyopathy Is Cardiomyopathy Is More Common in More Common in

Methamphetamine UsersMethamphetamine Users

Yeo K-K, et al. Yeo K-K, et al. Am J MedAm J Med. 2007;120(2):165–. 2007;120(2):165–171.171.

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


Objectives/MethodsObjectives/Methods In this case-control study, researchers examined the In this case-control study, researchers examined the

association between methamphetamine use and association between methamphetamine use and cardiomyopathy (CM).cardiomyopathy (CM).

Subjects included patients aged 45 years or younger Subjects included patients aged 45 years or younger discharged from a tertiary care medical center in discharged from a tertiary care medical center in Honolulu. Honolulu.

Through medical record review, researchers Through medical record review, researchers identified…identified… 107 cases (had a discharge diagnosis of CM or 107 cases (had a discharge diagnosis of CM or

congestive heart failure) and congestive heart failure) and 114 controls (ejection fraction 114 controls (ejection fraction >>55% and no wall 55% and no wall

motion abnormalities).motion abnormalities).


ResultsResults

42% of cases and 20% of controls had 42% of cases and 20% of controls had ever used methamphetamine.ever used methamphetamine.

Methamphetamine use was Methamphetamine use was significantly more common in cases significantly more common in cases than in controls. than in controls. OR in analyses adjusted for age, body OR in analyses adjusted for age, body

mass index, and renal failure, 3.7 mass index, and renal failure, 3.7


CommentsComments These data—plus a plausible These data—plus a plausible

pathophysiological mechanism of injury pathophysiological mechanism of injury related to excess catecholamines—related to excess catecholamines—support an evolving perspective:support an evolving perspective:

methamphetamine use is an important methamphetamine use is an important cause of cardiomyopathy in younger cause of cardiomyopathy in younger heart failure patients in regions where heart failure patients in regions where the drug is commonly abused.the drug is commonly abused.


HHow Much Can Older ow Much Can Older People Safely Drink?People Safely Drink?

Lang I, et al. Lang I, et al. J Am Geriatr SocJ Am Geriatr Soc. 2007;55(1):49–57.. 2007;55(1):49–57.

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


Objectives/MethodsObjectives/Methods Safer drinking recommendations for older people are Safer drinking recommendations for older people are

debated and vary from country to country. debated and vary from country to country.

Researchers addressed this debate by examining Researchers addressed this debate by examining data on alcohol use and functional and cognitive data on alcohol use and functional and cognitive disabilities from…disabilities from… U.S. and English longitudinal studies including a U.S. and English longitudinal studies including a

total of 13,333 people aged 65 years and older.total of 13,333 people aged 65 years and older.

Mortality-related outcomes were also assessed in the Mortality-related outcomes were also assessed in the U.S. subset. U.S. subset.

Analyses were adjusted for potential confounders.Analyses were adjusted for potential confounders.


ResultsResults

Outcomes at the Outcomes at the 4- to 5-year follow-up4- to 5-year follow-up

Baseline drinking of >1 to Baseline drinking of >1 to 2, vs. >0 to 1, drinks per 2, vs. >0 to 1, drinks per

dayday Difficulties with cognition* and Difficulties with cognition* and instrumental activities of daily instrumental activities of daily living**living**

Borderline-significant lower Borderline-significant lower risk risk

(ORs, 0.8 for both)(ORs, 0.8 for both)DeathDeath Similar risk (unadjusted)Similar risk (unadjusted)Combined death-disability Combined death-disability outcomesoutcomes

Similar risksSimilar risks

32% of English men, 12% of English women and U.S. 32% of English men, 12% of English women and U.S. men, and 3% of U.S. women drank >1 drink per day.men, and 3% of U.S. women drank >1 drink per day.

*Bottom quintile of cognitive function, based on scores on tests that assessed word recall, numeracy, and *Bottom quintile of cognitive function, based on scores on tests that assessed word recall, numeracy, and the ability to correctly specify the datethe ability to correctly specify the date**Difficulties with one or more of the following: preparing a hot meal, shopping for groceries, making **Difficulties with one or more of the following: preparing a hot meal, shopping for groceries, making telephone calls, taking medications, and managing moneytelephone calls, taking medications, and managing money


CommentsComments Older people who drank >1 to 2 drinks per day did not Older people who drank >1 to 2 drinks per day did not

develop greater functional or cognitive disabilities than develop greater functional or cognitive disabilities than those who drank the U.S. recommended level of those who drank the U.S. recommended level of <<1 1 drink per day. drink per day.

The researchers are to be commended for focusing on The researchers are to be commended for focusing on functional and cognitive outcomes. functional and cognitive outcomes.

But, drinking’s effect on mortality is unclear because But, drinking’s effect on mortality is unclear because adjusted analyses with mortality as the sole outcome adjusted analyses with mortality as the sole outcome were not reported. were not reported.

The safer drinking limit for older people will most likely The safer drinking limit for older people will most likely remain debated until more evidence is available. remain debated until more evidence is available.


Does Moderate Drinking Does Moderate Drinking Lower Risk of Heart Lower Risk of Heart

Failure?Failure?

Djoussé L, et al. Djoussé L, et al. Circulation.Circulation. 2007;115(1):34–39. 2007;115(1):34–39.Summary by R. Curtis Ellison, MDSummary by R. Curtis Ellison, MD


Objectives/MethodsObjectives/Methods To examine the link between moderate To examine the link between moderate

drinking and heart failure, researchers drinking and heart failure, researchers assessed data from…assessed data from… 21,601 male participants in the Physicians’ 21,601 male participants in the Physicians’

Health Study who were free of heart failure Health Study who were free of heart failure at that study’s baseline. at that study’s baseline.

Analyses were adjusted for potential Analyses were adjusted for potential confounders.confounders.


ResultsResults During an average follow-up of 18 years, 904 During an average follow-up of 18 years, 904

incident cases of heart failure occurred. incident cases of heart failure occurred. The risk of heart failure decreased as The risk of heart failure decreased as

drinking increased. drinking increased. Hazard ratios: 0.9, 0.8, and 0.6 for 1–4, 5–7, and Hazard ratios: 0.9, 0.8, and 0.6 for 1–4, 5–7, and

>7 drinks per week, respectively, versus <1 drink >7 drinks per week, respectively, versus <1 drink per week; per week; PP for trend=0.01). for trend=0.01).

Drinking was not significantly associated with Drinking was not significantly associated with heart failure risk in subjects without heart failure risk in subjects without antecedent myocardial infarction or coronary antecedent myocardial infarction or coronary artery disease (CAD).artery disease (CAD).


CommentsComments These results support what many, but not all, These results support what many, but not all,

recent prospective epidemiological studies have recent prospective epidemiological studies have shown: shown: a reduced risk of heart failure among moderate a reduced risk of heart failure among moderate

drinkers versus nondrinkers (or, as in this drinkers versus nondrinkers (or, as in this study, occasional drinkers). study, occasional drinkers).

This lower risk was found primarily in patients This lower risk was found primarily in patients with heart failure and CAD, and therefore…with heart failure and CAD, and therefore… may result from alcohol’s protective effects on may result from alcohol’s protective effects on

myocardial infarction or other CAD myocardial infarction or other CAD consequences.consequences.


Assessments and Assessments and InterventionsInterventions


Treating Chronic Back Treating Chronic Back Pain With OpioidsPain With Opioids

Martell BA, et al. Martell BA, et al. Ann Intern Med.Ann Intern Med. 2007;146(2):116–127. 2007;146(2):116–127.Summary by Richard Saitz, MD, MPHSummary by Richard Saitz, MD, MPH


Objectives/MethodsObjectives/Methods Researchers systematically reviewed the Researchers systematically reviewed the

literature to determine the prevalence and literature to determine the prevalence and efficacy of opioid treatment for chronic back efficacy of opioid treatment for chronic back pain. pain.

They also assessed the association between They also assessed the association between this treatment and substance use disorders this treatment and substance use disorders and prescription medication misuse.and prescription medication misuse.


ResultsResults The prevalence of opioid prescribing for The prevalence of opioid prescribing for

chronic back pain ranged from 3% to 66% chronic back pain ranged from 3% to 66% across 11 studies. across 11 studies.

Pain decreased nonsignificantly from Pain decreased nonsignificantly from baseline with opioid treatment in a meta-baseline with opioid treatment in a meta-analysis of data from 5 studies. analysis of data from 5 studies.

Opioids had better efficacy than placebo or Opioids had better efficacy than placebo or nonopioids in 4 of 6 studies of short-term nonopioids in 4 of 6 studies of short-term (<16 weeks) treatment. (<16 weeks) treatment.


Results (cont.)Results (cont.) Across 4 studies, 3% to 43% of patients Across 4 studies, 3% to 43% of patients

receiving opioids for chronic back pain had a receiving opioids for chronic back pain had a current substance use disorder.current substance use disorder. The studies generally were of poor quality. The studies generally were of poor quality. In the highest quality study, prevalence was 23% In the highest quality study, prevalence was 23%

(same as in patients with chronic back pain who (same as in patients with chronic back pain who had not received opioids).had not received opioids).

Across 5 studies, 5% to 24% patients receiving Across 5 studies, 5% to 24% patients receiving opioids for chronic back pain had misused opioids for chronic back pain had misused prescription medications. prescription medications. These studies generally did not consider whether These studies generally did not consider whether

the misuse might have been due to inadequate the misuse might have been due to inadequate pain relief. pain relief.


CommentsComments Obviously, we need better treatments for Obviously, we need better treatments for

chronic back pain. chronic back pain.

Opioids seem to be an option at least in the Opioids seem to be an option at least in the short term. short term.

However, their efficacy is not particularly However, their efficacy is not particularly convincing and long-term benefit is unknown.convincing and long-term benefit is unknown.

Further, the possibility of a co-existing Further, the possibility of a co-existing substance disorder has to be considered and substance disorder has to be considered and addressed.addressed.


Brief Intervention Is Brief Intervention Is Insufficient for Medical Insufficient for Medical

Inpatients With Inpatients With Unhealthy DrinkingUnhealthy Drinking

Saitz R, et al. Saitz R, et al. Ann Intern MedAnn Intern Med. 2007;146(3):167–176.. 2007;146(3):167–176.Summary by Peter D. Friedmann, MD, MPHSummary by Peter D. Friedmann, MD, MPH


Objectives/MethodsObjectives/Methods To assess whether brief interventions work among To assess whether brief interventions work among

medical inpatients with unhealthy drinking,* medical inpatients with unhealthy drinking,* researchers randomized 341 of such patients to…researchers randomized 341 of such patients to… a 30-minute session of motivational counseling a 30-minute session of motivational counseling

in the hospital or usual care. in the hospital or usual care.

Most subjects had alcohol dependence, were Most subjects had alcohol dependence, were unemployed, used other drugs, and had unemployed, used other drugs, and had substantial psychiatric symptoms. substantial psychiatric symptoms.

Almost half were hospitalized for an alcohol-Almost half were hospitalized for an alcohol-related medical diagnosis.related medical diagnosis.

*>14 drinks per week or ≥5 drinks per occasion for men; >11 drinks per week or ≥4 drinks per *>14 drinks per week or ≥5 drinks per occasion for men; >11 drinks per week or ≥4 drinks per occasion for women and people ≥66 years oldoccasion for women and people ≥66 years old


ResultsResultsOutcomesOutcomes InterventioInterventio

nnControlControl

% of subjects with dependence % of subjects with dependence who received alcohol who received alcohol assistance (e.g., specialty assistance (e.g., specialty treatment) at 3 months treatment) at 3 months

49%49% 44%44%

Adjusted mean decreases in Adjusted mean decreases in consumption at 12 months in consumption at 12 months in all subjectsall subjects

1.51.5 3.13.1

None of the above results were significant.None of the above results were significant.


CommentsComments Unlike most brief intervention studies in Unlike most brief intervention studies in

outpatients, this study enrolled a predominantly outpatients, this study enrolled a predominantly alcohol-dependent sample with major alcohol-dependent sample with major comorbidities—comorbidities— a group reflective of the treatment-resistant population a group reflective of the treatment-resistant population

identified when screening occurs in inpatient settings. identified when screening occurs in inpatient settings.

Screening, assessment, and brief counseling are Screening, assessment, and brief counseling are necessary but not sufficient to change drinking in necessary but not sufficient to change drinking in this population. this population.

Although the findings are disappointing, this study Although the findings are disappointing, this study underscores that alcoholism—like other complex underscores that alcoholism—like other complex diseases—will not succumb to simple solutions.diseases—will not succumb to simple solutions.


Video of Patient’s Own Video of Patient’s Own Delirium Tremens Delirium Tremens

Decreases Relapse RiskDecreases Relapse Risk

Mihai M, et al. Mihai M, et al. AddictionAddiction. 2007;102(2):226–231. . 2007;102(2):226–231. Bühringer G, et al. Bühringer G, et al. AddictionAddiction. 2007;102(2):183–184. . 2007;102(2):183–184.

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


Objectives/MethodsObjectives/Methods Researchers assessed whether showing a patient a Researchers assessed whether showing a patient a

videotape of his own delirium tremens (DTs) might videotape of his own delirium tremens (DTs) might decrease relapse. decrease relapse.

60 men hospitalized for alcohol withdrawal 60 men hospitalized for alcohol withdrawal delirium were videotaped and randomly assigned delirium were videotaped and randomly assigned to…to… view the tape and meet with a psychiatrist who view the tape and meet with a psychiatrist who

explained the DTs or explained the DTs or view the tape, if they chose, at the end of view the tape, if they chose, at the end of

follow-up (controls). follow-up (controls).

Patient and family interviews assessed drinking Patient and family interviews assessed drinking and relapse.* and relapse.*

*More than 3 periods of drinking lasting less than 1 week, consumption of >4.5 drinks (approximately) per *More than 3 periods of drinking lasting less than 1 week, consumption of >4.5 drinks (approximately) per day, having an alcohol-related disorder, or receiving inpatient treatmentday, having an alcohol-related disorder, or receiving inpatient treatment


ResultsResultsOutcomeOutcome InterventionIntervention ControlControl

Relapsed at 1 monthRelapsed at 1 month 0%0% 20%20%

Relapsed at 6 monthsRelapsed at 6 months 47%47% 70%70%

Days to relapse Days to relapse 210210 109109

Drinks per week at 6 Drinks per week at 6 monthsmonths

2525 2828

Drinking days per week Drinking days per week at 6 monthsat 6 months

55 66


CommentsComments The results from this unusual treatment are The results from this unusual treatment are

surprising and should be confirmed in other surprising and should be confirmed in other studies given the small and selected sample. studies given the small and selected sample.

An editorialist points out that a single An editorialist points out that a single intervention that might increase motivation intervention that might increase motivation would not improve self-efficacy or provide would not improve self-efficacy or provide skills required to reduce relapse risk. skills required to reduce relapse risk.

Nonetheless, these findings should make Nonetheless, these findings should make clinicians rethink a role, in the context of clinicians rethink a role, in the context of known effective therapies, for showing known effective therapies, for showing patients the consequences of their drinking. patients the consequences of their drinking.


Higher Quality of Higher Quality of Primary Care May Primary Care May Lower Addiction Lower Addiction

SeveritySeverity

Kim TW, et al. Kim TW, et al. Health Serv Res.Health Serv Res. 2007;42(2):755–772. 2007;42(2):755–772. Summary by David A. Fiellin, MDSummary by David A. Fiellin, MD


Objectives/MethodsObjectives/Methods Researchers examined whether patient-reported Researchers examined whether patient-reported

quality of primary care influenced addiction outcomes quality of primary care influenced addiction outcomes in…in… 183 patients who sought primary care after 183 patients who sought primary care after

detoxification from alcohol, heroin, and/or cocaine. detoxification from alcohol, heroin, and/or cocaine.

Using patient interviews, researchers measured… Using patient interviews, researchers measured… primary care quality at baseline and primary care quality at baseline and substance use/addiction severity 6–18 months later. substance use/addiction severity 6–18 months later.

Analyses were adjusted for potential confounders (e.g., Analyses were adjusted for potential confounders (e.g., education, homelessness).education, homelessness).


ResultsResults Of the 9 attributes* of quality primary care Of the 9 attributes* of quality primary care

assessed…assessed… all but preventive counseling were all but preventive counseling were

significantly associated with lower alcohol significantly associated with lower alcohol addiction severity at follow-up.addiction severity at follow-up.

Three attributes (physician knowledge of the Three attributes (physician knowledge of the whole person, organizational access, and visit-whole person, organizational access, and visit-based continuity) were associated with lower based continuity) were associated with lower alcohol and lower drug addiction severity.alcohol and lower drug addiction severity.

*The 9 attributes, measured by the Primary Care Assessment Survey, included communication, interpersonal *The 9 attributes, measured by the Primary Care Assessment Survey, included communication, interpersonal treatment, thoroughness of the physical exam, provider knowledge of the whole person, preventive counseling, treatment, thoroughness of the physical exam, provider knowledge of the whole person, preventive counseling, patient trust of the provider, organizational access, financial access, and visit-based continuity.patient trust of the provider, organizational access, financial access, and visit-based continuity.


Results (cont).Results (cont). Whole-person knowledge and patient trust Whole-person knowledge and patient trust

of the provider were associated with a…of the provider were associated with a…

lower likelihood of any drug use or lower likelihood of any drug use or alcohol intoxication (>3 drinks on any alcohol intoxication (>3 drinks on any occasion) at follow-up.occasion) at follow-up.

ORs, 0.7 for whole-person knowledge and ORs, 0.7 for whole-person knowledge and 0.8 for trust 0.8 for trust


CommentsComments Higher quality of primary care was associated Higher quality of primary care was associated

with decreased addiction severity (particularly with decreased addiction severity (particularly related to alcohol) over time in patients who related to alcohol) over time in patients who had completed detoxification. had completed detoxification.

Two characteristics of the patient-physician Two characteristics of the patient-physician relationship—trust and whole-person relationship—trust and whole-person knowledge—were associated with less knowledge—were associated with less substance use. substance use.

These findings support efforts to link patients These findings support efforts to link patients with substance use disorders to primary care with substance use disorders to primary care and to cultivate key attributes of patient-and to cultivate key attributes of patient-physician relationships.physician relationships.


Substance Use Substance Use Screening Does Not Screening Does Not

Need to Need to Be SubtleBe Subtle

Feldstein SW, et al. Feldstein SW, et al. AddictionAddiction. 2007;102(1):41–50. . 2007;102(1):41–50. Summary by David A. Fiellin, MDSummary by David A. Fiellin, MD


Objectives/MethodsObjectives/Methods The Substance Abuse Subtle Screening The Substance Abuse Subtle Screening

Inventory (SASSI) was designed to assess Inventory (SASSI) was designed to assess substance use disorders in patients who may substance use disorders in patients who may not answer questions truthfully for various not answer questions truthfully for various reasons.reasons.

To summarize research on the SASSI, To summarize research on the SASSI,

investigators conducted a systematic review investigators conducted a systematic review of…of… 36 peer-reviewed articles on the instrument’s 36 peer-reviewed articles on the instrument’s

performance performance in a total of 22,110 patients.in a total of 22,110 patients.


ResultsResults There was high internal consistency* for the There was high internal consistency* for the

direct but not the indirect (or subtle) direct but not the indirect (or subtle) components of the SASSI.components of the SASSI.

The sensitivity** of the SASSI was 70% The sensitivity** of the SASSI was 70% (weighted mean).(weighted mean).

The specificity was 62%.**The specificity was 62%.**

*How consistently questions measure the variable of interest (in this case, substance use *How consistently questions measure the variable of interest (in this case, substance use disorders)disorders)

**Sensitivity is the proportion of patients with a disorder that test positive; specificity is the **Sensitivity is the proportion of patients with a disorder that test positive; specificity is the proportion of patients without a disorder who test negative.proportion of patients without a disorder who test negative.


CommentsComments Screening for substance use disorders is an initial Screening for substance use disorders is an initial

step in diagnosis and treatment. step in diagnosis and treatment.

Clinicians may be concerned that direct questions Clinicians may be concerned that direct questions make it easier for patients to provide socially make it easier for patients to provide socially desirable, rather than honest, answers. desirable, rather than honest, answers.

This research, however, indicates that subtle This research, however, indicates that subtle screening methods do not necessarily have good screening methods do not necessarily have good operating characteristics and clinical utility. operating characteristics and clinical utility.

Further, other studies show that more-direct Further, other studies show that more-direct questions work quite well.questions work quite well.


Benzodiazepine Use in Benzodiazepine Use in Patients Receiving Patients Receiving Opioid TreatmentOpioid Treatment

Nielsen S, et al. Nielsen S, et al. Addiction.Addiction. 2007;102(4):616–622. 2007;102(4):616–622. Summary by Peter D. Friedmann, MD, MPHSummary by Peter D. Friedmann, MD, MPH


Objectives/MethodsObjectives/Methods To examine the risk of adverse effects To examine the risk of adverse effects

(extreme drowsiness, unconsciousness, or (extreme drowsiness, unconsciousness, or overdose) from concurrent benzodiazepine overdose) from concurrent benzodiazepine use, Australian researchers surveyed…use, Australian researchers surveyed… 250 subjects250 subjects recruited from syringe exchange and recruited from syringe exchange and

opioid treatment programsopioid treatment programs who had ever received buprenorphine or who had ever received buprenorphine or

methadone treatment. methadone treatment.


ResultsResults Subjects who had received both methadone Subjects who had received both methadone

and buprenorphine in the past (n=164) were and buprenorphine in the past (n=164) were significantly more likely to report…significantly more likely to report… extreme drowsiness (odds ratio [OR], 2.7) extreme drowsiness (odds ratio [OR], 2.7)

and overdose (OR, 10.0) with methadone and overdose (OR, 10.0) with methadone than with buprenorphine.than with buprenorphine.

Subjects reporting adverse effects with Subjects reporting adverse effects with buprenorphine were significantly more likely buprenorphine were significantly more likely than subjects reporting adverse effects with than subjects reporting adverse effects with methadone to…methadone to… have injected their opioid treatment have injected their opioid treatment (51% versus 21%). (51% versus 21%).


Results (cont.)Results (cont.) Of the 193 subjects who had ever received Of the 193 subjects who had ever received

buprenorphine…buprenorphine… 67% reported ever concurrently using 67% reported ever concurrently using

benzodiazepines (median dose equivalent to 30 benzodiazepines (median dose equivalent to 30 mg of diazepam). mg of diazepam).

In adjusted analyses, concurrent daily In adjusted analyses, concurrent daily benzodiazepine use (vs. no use) increased the odds benzodiazepine use (vs. no use) increased the odds of adverse effects…of adverse effects…

significantly in subjects who had received significantly in subjects who had received methadone (OR, 2.2) and methadone (OR, 2.2) and

borderline significantly in subjects who had borderline significantly in subjects who had received buprenorphine (OR, 2.1).received buprenorphine (OR, 2.1).


CommentsComments Specific adverse effects were less common with Specific adverse effects were less common with

buprenorphine use than with methadone use. buprenorphine use than with methadone use.

Concurrent benzodiazepine use was not associated Concurrent benzodiazepine use was not associated with a higher risk of adverse effects in subjects who with a higher risk of adverse effects in subjects who had received buprenorphine than in those who had had received buprenorphine than in those who had received methadone. received methadone.

These findings require replication in patients taking These findings require replication in patients taking the combined formulation of buprenorphine/naloxone. the combined formulation of buprenorphine/naloxone.

Nonetheless, the results are reassuring to Nonetheless, the results are reassuring to buprenorphine/naloxone prescribers in North America buprenorphine/naloxone prescribers in North America where benzodiazepine use is prevalent but where benzodiazepine use is prevalent but buprenorphine injection is still relatively uncommon. buprenorphine injection is still relatively uncommon.

Update on Alcohol, Other Drugs, and Health

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