Www.aodhealth.org 1 Update on Alcohol, Other Drugs, and Health November–December 2011.

www.aodhealth.orgwww.aodhealth.org 11

Update on Update on Alcohol, Other Alcohol, Other

Drugs, and HealthDrugs, and Health

November–December 2011November–December 2011


Studies on Studies on Interventions & Interventions &

AssessmentsAssessments


Buprenorphine-Naloxone Buprenorphine-Naloxone Works for Prescription Works for Prescription

Opioid Dependence As Long Opioid Dependence As Long As It Is MaintainedAs It Is Maintained

Weiss RD, et al. Weiss RD, et al. Arch Gen Psychiatry. Arch Gen Psychiatry. 2011;68(12):1238–1246.2011;68(12):1238–1246.

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


Objectives/MethodsObjectives/Methods This multisite randomized clinical trial examined This multisite randomized clinical trial examined

the effectiveness of buprenorphine-naloxone the effectiveness of buprenorphine-naloxone (BUP/NX) treatment among 653 patients with (BUP/NX) treatment among 653 patients with prescription opioid dependence and assessed prescription opioid dependence and assessed whether intensive counseling provided any whether intensive counseling provided any additional benefit. additional benefit.

The study had 2 phases: Poor responseThe study had 2 phases: Poor response** to brief to brief treatment in Phase 1 (2-week BUP/NX treatment in Phase 1 (2-week BUP/NX stabilization followed by 2-week taper and 8-stabilization followed by 2-week taper and 8-week post-medication follow-up) determined week post-medication follow-up) determined whether patients would continue on to receive whether patients would continue on to receive extended treatment in Phase 2 (12-week BUP/NX extended treatment in Phase 2 (12-week BUP/NX stabilization followed by 4-week taper and 8-stabilization followed by 4-week taper and 8-week follow-up). week follow-up). *Self-reported opioid use on >4 days in a month, 2 consecutive opioid-positive *Self-reported opioid use on >4 days in a month, 2 consecutive opioid-positive urine tests, additional substance use disorder treatment (other than self-help), urine tests, additional substance use disorder treatment (other than self-help), or >1 missing urine sample.or >1 missing urine sample.


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

In each phase, patients were randomized In each phase, patients were randomized to eitherto either standard medical management (SSM) (15–20 standard medical management (SSM) (15–20

minute visits with a physician certified to minute visits with a physician certified to prescribe BUP/NX), or prescribe BUP/NX), or

SSM plus intensive opioid-dependence SSM plus intensive opioid-dependence counseling (45–60 minute sessions with a counseling (45–60 minute sessions with a trained mental-health professional).trained mental-health professional).


ResultsResults

Only 6.6% of patients were opioid-free Only 6.6% of patients were opioid-free after brief BUP/NX treatment, with no after brief BUP/NX treatment, with no improvement added by intensive drug improvement added by intensive drug counseling.counseling.

Forty-nine percent of patients were opioid-Forty-nine percent of patients were opioid-free after extended BUP/NX treatment, but free after extended BUP/NX treatment, but 8 weeks after the taper, this rate dropped 8 weeks after the taper, this rate dropped to 8.6%, again with no improvement added to 8.6%, again with no improvement added by intensive drug counseling.by intensive drug counseling.


CommentsComments

This study shows, yet again, that BUP/NX is This study shows, yet again, that BUP/NX is an effective treatment for opioid an effective treatment for opioid dependence as long as it is maintained, dependence as long as it is maintained, and that a tapering detoxification strategy, and that a tapering detoxification strategy, regardless of duration, fails the majority of regardless of duration, fails the majority of patients.patients.

As with the treatment of hypertension or As with the treatment of hypertension or diabetes, as long as the patient takes the diabetes, as long as the patient takes the medication, it works; when the medication medication, it works; when the medication is stopped, the disorder returns. is stopped, the disorder returns.


Comments Comments (cont’d)(cont’d) The chronic nature of opioid dependence is The chronic nature of opioid dependence is

worth reiterating in light of recovery-oriented worth reiterating in light of recovery-oriented orthodoxy and insurance requirements that orthodoxy and insurance requirements that mandate time limits on opioid agonist mandate time limits on opioid agonist treatment.treatment.

This study also found intensive counseling This study also found intensive counseling added nothing to SSM. Perhaps the time is added nothing to SSM. Perhaps the time is coming when appropriate treatment will be coming when appropriate treatment will be called “counseling-assisted called “counseling-assisted pharmacotherapy” rather than “medication- pharmacotherapy” rather than “medication- assisted treatment,” an acknowledgment that assisted treatment,” an acknowledgment that medication, not detoxification with medication, not detoxification with counseling, should be the first-line treatment counseling, should be the first-line treatment for opioid dependence.for opioid dependence.


Ongoing Primary and Ongoing Primary and Specialty Care Is Associated Specialty Care Is Associated

with Improved Substance with Improved Substance Use OutcomesUse Outcomes

Chi FW, et alChi FW, et al. . Psychiatr Serv.Psychiatr Serv. 2011;62(10):1194–1200. 2011;62(10):1194–1200.Summary by Summary by Darius A. Rastegar, MDDarius A. Rastegar, MD

1010

Objectives/MethodsObjectives/Methods

This study analyzed data from 2 This study analyzed data from 2 randomized trials conducted in a private randomized trials conducted in a private managed-care health plan:managed-care health plan:

1 study compared day-hospital treatment for 1 study compared day-hospital treatment for substance use disorders with traditional substance use disorders with traditional outpatient treatment;outpatient treatment;

the other studied integrated delivery of medical the other studied integrated delivery of medical and addiction services. and addiction services.

Follow-up was at 1, 5, 7, and 9 years in Follow-up was at 1, 5, 7, and 9 years in both studies. both studies.

www.aodhealth.orgwww.aodhealth.org

1111


The sample included 991 subjects (56% of The sample included 991 subjects (56% of the combined cohorts) who had at least 1 the combined cohorts) who had at least 1 follow-up interview and were with the plan follow-up interview and were with the plan for at least 5.4 years after intake.for at least 5.4 years after intake.

The association between remission and The association between remission and service use (yearly primary care, service use (yearly primary care, psychiatric services, and substance abuse psychiatric services, and substance abuse treatment) was examined using nonlinear treatment) was examined using nonlinear mixed-effects multivariable logistic mixed-effects multivariable logistic regression.regression.


1212

ResultsResults Baseline characteristics associated with Baseline characteristics associated with

remission included being female (odds ratio remission included being female (odds ratio [OR], 1.44), being older (OR, 1.02), completing [OR], 1.44), being older (OR, 1.02), completing prior substance abuse treatment (OR, 2.72), and prior substance abuse treatment (OR, 2.72), and being married or living as married (OR, 1.38).being married or living as married (OR, 1.38).

A yearly primary care visit was also positively A yearly primary care visit was also positively associated with remission (OR, 1.39), as was associated with remission (OR, 1.39), as was continuing care (OR, 2.34), defined as:continuing care (OR, 2.34), defined as: having at least 1 yearly primary care visit,having at least 1 yearly primary care visit, completing substance abuse treatment or receiving completing substance abuse treatment or receiving

further treatment,further treatment, receiving alcohol or drug treatment when the alcohol or receiving alcohol or drug treatment when the alcohol or

drug Addiction Severity Index (ASI) score at last drug Addiction Severity Index (ASI) score at last assessment was higher than 0, and assessment was higher than 0, and

receiving psychiatric services when the psychiatric ASI receiving psychiatric services when the psychiatric ASI score at last assessment was higher than 0.score at last assessment was higher than 0.


CommentsComments This study provides further support for the This study provides further support for the

concept of substance use disorders as a concept of substance use disorders as a chronic illness best treated with ongoing chronic illness best treated with ongoing care, and underscores the association care, and underscores the association between ongoing primary care and between ongoing primary care and improved outcomes for this population.improved outcomes for this population.

It would be interesting to see if patients It would be interesting to see if patients receiving integrated care, like those in this receiving integrated care, like those in this study, have better remission outcomes than study, have better remission outcomes than patients receiving nonintegrated care.patients receiving nonintegrated care.


Patients Who Receive Patients Who Receive Opioids for Chronic Pain Opioids for Chronic Pain

Are Inadequately ManagedAre Inadequately Managed

Morasco BJ, et al. Morasco BJ, et al. J Gen Intern Med. J Gen Intern Med. 2011;26(9):965–2011;26(9):965–971.971.

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


Objectives/MethodsObjectives/Methods Approximately 10% of primary-care patients Approximately 10% of primary-care patients

with chronic noncancer pain (CNCP) have a with chronic noncancer pain (CNCP) have a current substance use disorder (SUD). current substance use disorder (SUD). Treatment guidelines recommend that patients Treatment guidelines recommend that patients with an SUD who are treated with opioids with an SUD who are treated with opioids require more intensive monitoring and require more intensive monitoring and treatment.treatment.

This study of 5814 Department of Veterans This study of 5814 Department of Veterans Affairs patients prescribed opioids for 90 or Affairs patients prescribed opioids for 90 or more consecutive days in 2008 compared more consecutive days in 2008 compared provider adherence to guideline-recommended provider adherence to guideline-recommended practices among patients with and without an practices among patients with and without an SUD diagnosis in the prior year.SUD diagnosis in the prior year.


ResultsResults

Twenty percent of patients prescribed Twenty percent of patients prescribed opioids had an SUD.opioids had an SUD.

Patients with an SUD were more likely than Patients with an SUD were more likely than those without to have had a mental health those without to have had a mental health appointment (30% versus 17%) and a urine appointment (30% versus 17%) and a urine drug screen (47% versus 18%).drug screen (47% versus 18%).

Only 35% of patients with an SUD received Only 35% of patients with an SUD received substance abuse treatment.substance abuse treatment.


Results Results (cont’d)(cont’d)

There was no difference between groups There was no difference between groups in:in:

primary-care follow-up ≥4 times per year (63% primary-care follow-up ≥4 times per year (63% versus 61%),versus 61%),

use of long-acting opioids (27% versus 26%),use of long-acting opioids (27% versus 26%), antidepressant use among those with antidepressant use among those with

depression (88% versus 86%), or depression (88% versus 86%), or participation in physical therapy (31% versus participation in physical therapy (31% versus

29%).29%).


CommentsComments This study shows that the use of guideline-This study shows that the use of guideline-

recommended management practices among recommended management practices among patients prescribed opioids for CNCP is suboptimal. patients prescribed opioids for CNCP is suboptimal. Less than half of patients with an SUD who received Less than half of patients with an SUD who received opioids for CNCP underwent urine toxicology opioids for CNCP underwent urine toxicology screening, and the limited uptake of substance abuse screening, and the limited uptake of substance abuse treatment is noteworthy.treatment is noteworthy.

Unless clinical practices improve, greater restrictions Unless clinical practices improve, greater restrictions on the use of opioids are inevitable. on the use of opioids are inevitable.

Physicians should embrace the national momentum Physicians should embrace the national momentum toward education and practice improvement in the toward education and practice improvement in the management of patients who benefit from management of patients who benefit from prescription opioids.prescription opioids.


Northcote J, Livingston M. Northcote J, Livingston M. Alcohol Alcohol. Alcohol Alcohol. 2011;46(6):709–713.2011;46(6):709–713.

Summary by Nicolas Bertholet, MD, MScSummary by Nicolas Bertholet, MD, MSc

Accuracy of “Last Occasion” Accuracy of “Last Occasion” Self-Reported Drinking in Self-Reported Drinking in

Young AdultsYoung Adults


Objectives/MethodsObjectives/Methods Many studies rely on self-reported alcohol Many studies rely on self-reported alcohol

consumption, which may lead to biased estimates consumption, which may lead to biased estimates of use. of use.

To assess the accuracy of "last occasion" self-To assess the accuracy of "last occasion" self-reported alcohol consumption, researchers reported alcohol consumption, researchers conducted a field study wherein individuals aged conducted a field study wherein individuals aged 18–25 reported their alcohol consumption 1–2 18–25 reported their alcohol consumption 1–2 days after being observed by peer-based days after being observed by peer-based researchers at various nightlife locations. researchers at various nightlife locations.

The relationship between observed and reported The relationship between observed and reported consumption was assessed using multilevel consumption was assessed using multilevel models (129 observations for 48 individuals).models (129 observations for 48 individuals).


ResultsResults Overall, participants reported 9% fewer Overall, participants reported 9% fewer

drinks than they actually drank.drinks than they actually drank.

There was a nonlinear relationship between There was a nonlinear relationship between reported and actual consumption:reported and actual consumption: Individuals drinking >8 drinks underestimated their Individuals drinking >8 drinks underestimated their

consumption by increasing amounts (for example, consumption by increasing amounts (for example, those who consumed 12 drinks underestimated by those who consumed 12 drinks underestimated by 10.3% (1.3 drinks), while those who consumed 20 10.3% (1.3 drinks), while those who consumed 20 drinks underestimated by 17.6% (3.5 drinks).drinks underestimated by 17.6% (3.5 drinks).

Individuals engaging in less drinking (≤4 drinks and Individuals engaging in less drinking (≤4 drinks and 5–8 drinks, respectively) accurately estimated their 5–8 drinks, respectively) accurately estimated their consumption.consumption.

Venue type did not impact the accuracy of Venue type did not impact the accuracy of self-report.self-report.

2121


CommentsComments This study brings into question the This study brings into question the

accuracy of self-report measures used in accuracy of self-report measures used in population surveys, especially since population surveys, especially since reporting "last consumption" is easier than reporting "last consumption" is easier than reporting "usual consumption," which reporting "usual consumption," which requires individuals not only to recall past requires individuals not only to recall past drinking accurately but also to estimate a drinking accurately but also to estimate a "usual mean." "usual mean."

It is, therefore, likely that the It is, therefore, likely that the underestimation of consumption among underestimation of consumption among heavy drinkers in this study will be also be heavy drinkers in this study will be also be found, possibly to a greater extent, in found, possibly to a greater extent, in general population surveys.general population surveys.


Havard A, et al.Havard A, et al. Alcohol Clin Exp Res.Alcohol Clin Exp Res. October 20, 2011 October 20, 2011 [E-pub ahead of print]. doi: 0.1111/j.1530-[E-pub ahead of print]. doi: 0.1111/j.1530-

0277.2011.01632.x0277.2011.01632.x..Summary by Kevin L. Kraemer, MD, MScSummary by Kevin L. Kraemer, MD, MSc

Does Mailed Feedback Does Mailed Feedback Decrease Risky Drinking Decrease Risky Drinking

After an Emergency After an Emergency Department Visit?Department Visit?

2424

Objectives/MethodsObjectives/Methods Intervention in the emergency department Intervention in the emergency department

(ED) for patients with risky alcohol use can (ED) for patients with risky alcohol use can be difficult due to time constraints and be difficult due to time constraints and other barriers.other barriers.

To test a more viable intervention option, To test a more viable intervention option, researchers identified 304 risky drinkersresearchers identified 304 risky drinkers** aged ≥14 years in the ED and randomized aged ≥14 years in the ED and randomized them to either mailed personalized them to either mailed personalized feedback 7 days after ED discharge or to feedback 7 days after ED discharge or to usual care (no contact after discharge). usual care (no contact after discharge). *Score of ≥8 on the Alcohol Use Disorders Identification Test *Score of ≥8 on the Alcohol Use Disorders Identification Test (AUDIT).(AUDIT).

2525


Participants were young (mean age, 29 Participants were young (mean age, 29 years), 74% male, and reported a median of years), 74% male, and reported a median of 16 drinks per week and 4 heavy drinking 16 drinks per week and 4 heavy drinking daysdays** per month at baseline. per month at baseline.

Alcohol use was assessed 6 weeks after ED Alcohol use was assessed 6 weeks after ED discharge, and cost-effectiveness of the discharge, and cost-effectiveness of the intervention was calculated. Eighty percent intervention was calculated. Eighty percent of participants completed follow-up.of participants completed follow-up.

*Defined as ≥5 drinks per day for women and ≥7 drinks per day for *Defined as ≥5 drinks per day for women and ≥7 drinks per day for men.men.

2626www.aodhealth.orgwww.aodhealth.org

ResultsResults

Seventy-one percent of the intervention Seventy-one percent of the intervention group recalled receiving the mailed group recalled receiving the mailed feedback.feedback.

Among participants with alcohol-related ED Among participants with alcohol-related ED presentations (23% of the total sample), presentations (23% of the total sample), the intervention group had significantly the intervention group had significantly lower alcohol use at 6 weeks than the lower alcohol use at 6 weeks than the usual care group (12 drinks per week usual care group (12 drinks per week versus 24 drinks per week, respectively).versus 24 drinks per week, respectively).

2727www.aodhealth.orgwww.aodhealth.org


Among women, the intervention group had Among women, the intervention group had significantly fewer heavy drinking days per significantly fewer heavy drinking days per month than the usual care group (1.6 days month than the usual care group (1.6 days versus 4.5 days, respectively).versus 4.5 days, respectively).

The adjusted cost of the intervention was The adjusted cost of the intervention was $0.48 AUD (US equivalent, $0.49) per 1 $0.48 AUD (US equivalent, $0.49) per 1 standard drinkstandard drink** per week reduction among per week reduction among participants with an alcohol-related ED participants with an alcohol-related ED presentation. Cost-effectiveness for the presentation. Cost-effectiveness for the entire sample was not calculated.entire sample was not calculated.

*In Australia, 1 standard drink=10 g alcohol.*In Australia, 1 standard drink=10 g alcohol.


CommentsComments These findings suggest mailed These findings suggest mailed

personalized feedback can produce short-personalized feedback can produce short-term reductions in risky drinking after an term reductions in risky drinking after an ED visit. However, this effect was seen in ED visit. However, this effect was seen in only a minority of the sample, and the only a minority of the sample, and the longer term outcomes are unknown. longer term outcomes are unknown.

Further research is needed to measure Further research is needed to measure long-term outcomes and to assess how long-term outcomes and to assess how mailed feedback can be integrated with mailed feedback can be integrated with direct intervention in the ED and with direct intervention in the ED and with primary-care follow-up.primary-care follow-up.


Buprenorphine Treatment Is Buprenorphine Treatment Is Not Associated with Not Associated with

Significant Impairment of Significant Impairment of Driving AbilityDriving Ability

Shmygalev S, et alShmygalev S, et al. . Drug Alcohol Depend.Drug Alcohol Depend. 2011;117(2–3):190– 2011;117(2–3):190–197.197.

Summary by Summary by Darius A. Rastegar, MDDarius A. Rastegar, MD

3030

Objectives/MethodsObjectives/Methods Researchers in Germany assessed the impact Researchers in Germany assessed the impact

of buprenorphine (BUP) treatment for opioid of buprenorphine (BUP) treatment for opioid dependence on cognitive and psychomotor dependence on cognitive and psychomotor function using tests designed to predict function using tests designed to predict driving ability.driving ability.

Test scores in the domains of attention, Test scores in the domains of attention, reaction time under pressure, visual reaction time under pressure, visual orientation, motor coordination, and vigilance orientation, motor coordination, and vigilance among 30 subjects receiving BUP for at least among 30 subjects receiving BUP for at least 6 months (and on stable doses for ≥12 days 6 months (and on stable doses for ≥12 days [mean, 7.7 mg per day; range, 1.2–16.0 mg [mean, 7.7 mg per day; range, 1.2–16.0 mg per day]) were compared with those of 90 per day]) were compared with those of 90 healthy volunteers. healthy volunteers.


3131

Objectives/MethodsObjectives/Methods (cont’d) (cont’d) Subjects taking antihistamines or prescribed Subjects taking antihistamines or prescribed

benzodiazepines, barbiturates, or high-dose benzodiazepines, barbiturates, or high-dose antidepressants were excluded.antidepressants were excluded.

Initial urine screening for illicit substances in Initial urine screening for illicit substances in the BUP groupthe BUP group** found no other substances in found no other substances in 11 subjects, while 10 subjects were positive 11 subjects, while 10 subjects were positive for cannabinoids, 6 for opioids, 3 for for cannabinoids, 6 for opioids, 3 for amphetamines, 4 for benzodiazepines, and 1 amphetamines, 4 for benzodiazepines, and 1 for cocaine.for cocaine.

Results among controls were adjusted to Results among controls were adjusted to obtain values equivalent to test performance obtain values equivalent to test performance under the influence of 0.05% alcohol.under the influence of 0.05% alcohol.


*Controls were not screened.*Controls were not screened.


ResultsResults Controls passed an average of 4.8 tests Controls passed an average of 4.8 tests

compared with 4.6 in the BUP group (not compared with 4.6 in the BUP group (not significant). significant).

Eighty-one percent of controls passed all 5 Eighty-one percent of controls passed all 5 tests compared with 63% in the BUP group tests compared with 63% in the BUP group (not significant). (not significant).

In a separate evaluation of performance In a separate evaluation of performance among the 11 BUP subjects with negative among the 11 BUP subjects with negative urine tests for illicit substances, results urine tests for illicit substances, results were not significantly different from those were not significantly different from those of the entire BUP group (n=30) or controls.of the entire BUP group (n=30) or controls.


CommentsComments Cognitive and psychomotor function among Cognitive and psychomotor function among

subjects receiving BUP for opioid dependence subjects receiving BUP for opioid dependence was not significantly worse than that of healthy was not significantly worse than that of healthy controls in this study—allowing that control-group controls in this study—allowing that control-group results were adjusted to estimate the influence of results were adjusted to estimate the influence of moderate alcohol intake. moderate alcohol intake.

Although these results provide reassurance about Although these results provide reassurance about the driving performance of people receiving BUP, the driving performance of people receiving BUP, subjects received fairly modest doses in this subjects received fairly modest doses in this study. The effect of higher doses on complex study. The effect of higher doses on complex cognitive and psychomotor function is not known. cognitive and psychomotor function is not known.

The influence of other substances on driving The influence of other substances on driving ability always needs to be taken into ability always needs to be taken into consideration.consideration.


Studies on Studies on Health OutcomesHealth Outcomes


““Moderate” Drinking Is a Risk Moderate” Drinking Is a Risk Factor for Breast CancerFactor for Breast Cancer

Chen WY, et al. Chen WY, et al. JAMA.JAMA. 2011;306(17):1884–1890. 2011;306(17):1884–1890.Narod SA [comment]. Narod SA [comment]. JAMA. JAMA. 2011:306(17):1920–1921.2011:306(17):1920–1921.

Summary by Summary by Richard Saitz, MD, MPHRichard Saitz, MD, MPH


Objectives/MethodsObjectives/Methods Alcohol is classified by the World Health Alcohol is classified by the World Health

Organization and the US Department of Health Organization and the US Department of Health and Human Services as a carcinogen and is a and Human Services as a carcinogen and is a known risk factor for breast cancer. But, the level known risk factor for breast cancer. But, the level of consumption associated with breast cancer of consumption associated with breast cancer has not been well-defined. has not been well-defined.

A prospective cohort study of 105,986 women A prospective cohort study of 105,986 women ages 30–55 years at study entry had alcohol ages 30–55 years at study entry had alcohol consumption assessed repeatedly over ≤28 consumption assessed repeatedly over ≤28 years, during which time 7690 cases of invasive years, during which time 7690 cases of invasive breast cancer were diagnosed (>95% confirmed breast cancer were diagnosed (>95% confirmed by pathology reports). by pathology reports).


Results Results In adjusted analyses,In adjusted analyses,

drinking 3–6 drinksdrinking 3–6 drinks** per week was associated with per week was associated with a 15% increase in the risk of invasive breast cancer a 15% increase in the risk of invasive breast cancer compared with abstaining (333 versus 281 cases compared with abstaining (333 versus 281 cases per 100,000 person-years, respectively). Risk was per 100,000 person-years, respectively). Risk was 51% higher at >2 drinks per day and increased 51% higher at >2 drinks per day and increased 10% for every additional 10 g alcohol consumed 10% for every additional 10 g alcohol consumed per day.per day.

10% of all breast cancers were attributable to 10% of all breast cancers were attributable to alcohol, 60% of which were due to drinking <2 alcohol, 60% of which were due to drinking <2 drinks per day. Although the risk appeared to be drinks per day. Although the risk appeared to be greater for post-menopausal cancers, drinking greater for post-menopausal cancers, drinking before and after age 40 was similarly associated before and after age 40 was similarly associated with this risk. Heavy drinking episodes only with this risk. Heavy drinking episodes only marginally increased the risk already accounted for marginally increased the risk already accounted for by average consumption.by average consumption.*In this study, a drink was defined as one 4-oz glass of wine (11 g alcohol).*In this study, a drink was defined as one 4-oz glass of wine (11 g alcohol).


CommentsComments Low amounts of alcohol appear to increase Low amounts of alcohol appear to increase

the risk of breast cancer, likely related to the risk of breast cancer, likely related to effects on estrogens. Although the increase effects on estrogens. Although the increase might be considered small, it is identical to might be considered small, it is identical to the decrease in breast-cancer mortality from the decrease in breast-cancer mortality from mammography, the cornerstone of breast-mammography, the cornerstone of breast-cancer prevention.cancer prevention.

An accompanying editorial states, “[T]here An accompanying editorial states, “[T]here are no data to provide assurance that giving are no data to provide assurance that giving up alcohol will reduce breast cancer risk,” up alcohol will reduce breast cancer risk,” while the authors recommend weighing the while the authors recommend weighing the risks against “the beneficial effects [of light to risks against “the beneficial effects [of light to moderate use] on cardiovascular disease.”moderate use] on cardiovascular disease.”


Comments Comments (cont’d)(cont’d) I find these statements bizarre. We usually do I find these statements bizarre. We usually do

not require evidence that avoiding a not require evidence that avoiding a carcinogen reduces cancer risk, and we require carcinogen reduces cancer risk, and we require randomized trial evidence that the benefits of randomized trial evidence that the benefits of chemopreventive agents outweigh the risks chemopreventive agents outweigh the risks before recommending them. A drug approval before recommending them. A drug approval agency such as the Food and Drug agency such as the Food and Drug Administration would not approve a carcinogen Administration would not approve a carcinogen a day (even a small amount) to prevent heart a day (even a small amount) to prevent heart disease. disease.

Data about alcohol’s risks should be weighed Data about alcohol’s risks should be weighed against benefits that individuals perceive (e.g., against benefits that individuals perceive (e.g., enjoyment), but not potential disease enjoyment), but not potential disease prevention benefits.prevention benefits.


French DD, et al. French DD, et al. J Glaucoma. J Glaucoma. 2011;20(7):452–457.2011;20(7):452–457.Summary by Summary by Alexander Y. Walley, MD, MScAlexander Y. Walley, MD, MSc

Association between Open-Association between Open-Angle Glaucoma and Cocaine Angle Glaucoma and Cocaine

UseUse



Cocaine has been shown to change Cocaine has been shown to change intraocular fluid dynamics in animal studies.intraocular fluid dynamics in animal studies.

Researchers conducted a cross-sectional Researchers conducted a cross-sectional comparison study using diagnostic codes comparison study using diagnostic codes and prescription history from a national and prescription history from a national Veterans Administration (VA) database to Veterans Administration (VA) database to determine whether persons with cocaine determine whether persons with cocaine abuse or dependence were more likely to abuse or dependence were more likely to have a diagnosis of open-angle glaucoma have a diagnosis of open-angle glaucoma than a comparable population with no than a comparable population with no cocaine use. cocaine use.


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

Of 5,373,205 VA enrollees who made Of 5,373,205 VA enrollees who made outpatient visits in 2009, 82,900 (1.5%) outpatient visits in 2009, 82,900 (1.5%) had open-angle glaucoma and 177,929 had open-angle glaucoma and 177,929 (3.3%) had cocaine use or dependence.(3.3%) had cocaine use or dependence.

Analyses adjusted for age, race/ethnicity, Analyses adjusted for age, race/ethnicity, gender, and other drug use were limited to gender, and other drug use were limited to subjects with complete information.subjects with complete information.


ResultsResults

Among patients with primary open-angle Among patients with primary open-angle glaucoma, the mean age of those with glaucoma, the mean age of those with cocaine abuse or dependence was 54 years, cocaine abuse or dependence was 54 years, while the mean age of those without was 73 while the mean age of those without was 73 years.years.

Men with cocaine abuse or dependence Men with cocaine abuse or dependence were more likely to have a diagnosis of were more likely to have a diagnosis of open-angle glaucoma (adjusted odds ratio open-angle glaucoma (adjusted odds ratio [AOR), 1.45). No association was detected [AOR), 1.45). No association was detected among women (AOR, 0.98). among women (AOR, 0.98).


CommentsComments These results provide some evidence These results provide some evidence

supporting cocaine as a glaucoma risk supporting cocaine as a glaucoma risk factor in men. It is not clear why this factor in men. It is not clear why this association would be present in men and association would be present in men and not in women.not in women.

Further study is warranted to confirm this Further study is warranted to confirm this association and determine whether association and determine whether cocaine-associated glaucoma might be cocaine-associated glaucoma might be reversible.reversible.


Heavier Alcohol Heavier Alcohol Consumption Linked to Consumption Linked to

Colorectal Cancer Colorectal Cancer

Fedirko V, et al. Fedirko V, et al. Ann Oncol.Ann Oncol. 2011;22(9):1958–1972. 2011;22(9):1958–1972. Summary by R. Curtis Ellison, MDSummary by R. Curtis Ellison, MD


Objectives/MethodsObjectives/Methods Researchers conducted a meta-analysis Researchers conducted a meta-analysis

of case-control and cohort studies to of case-control and cohort studies to assess the dose-response relationship assess the dose-response relationship between alcohol consumption and between alcohol consumption and colorectal cancer. colorectal cancer.

Categories of alcohol intake were defined Categories of alcohol intake were defined as follows: as follows: light (≤1 standard drink* per day), light (≤1 standard drink* per day), moderate (>1–<4 drinks per day), and moderate (>1–<4 drinks per day), and heavy (≥4 drinks per day). heavy (≥4 drinks per day).

*Standard drink converted to 12.5 g ethanol in this analysis to adjust for *Standard drink converted to 12.5 g ethanol in this analysis to adjust for differing units used across studies.differing units used across studies.


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

Results were adjusted for sex, colorectal Results were adjusted for sex, colorectal cancer site, and study location. cancer site, and study location.

Twenty-two studies from Asia, 2 from Twenty-two studies from Asia, 2 from Australia, 13 from Western Europe, and Australia, 13 from Western Europe, and 24 from North America were included in 24 from North America were included in the analysis. the analysis.

Nondrinkers or occasional drinkers were Nondrinkers or occasional drinkers were used as the reference category.used as the reference category.


Results Results

Higher levels of alcohol consumption were Higher levels of alcohol consumption were associated with an increased risk of associated with an increased risk of colorectal cancer.colorectal cancer.

Although there was no increased risk for Although there was no increased risk for light drinking, an increase of 21% was seen light drinking, an increase of 21% was seen for moderate drinking (12.5–for moderate drinking (12.5– 49.9 g alcohol 49.9 g alcohol per day), while an increase of 52% was per day), while an increase of 52% was seen for heavy drinking (≥50 g per day).seen for heavy drinking (≥50 g per day).


CommentsComments According to this well-done study, alcohol intake, According to this well-done study, alcohol intake,

especially heavier intake, is associated with an especially heavier intake, is associated with an increased risk of colorectal cancer.increased risk of colorectal cancer.

However, the upper limit of “moderate” drinking However, the upper limit of “moderate” drinking used in this study is well above recommended used in this study is well above recommended limits, narrower categories of consumption (e.g., limits, narrower categories of consumption (e.g., 1–2 or 2–3 drinks per day) were not assessed, 1–2 or 2–3 drinks per day) were not assessed, and results were not adjusted for beverage type and results were not adjusted for beverage type or drinking pattern. or drinking pattern.

Future studies are needed to determine whether Future studies are needed to determine whether a threshold level of alcohol intake exists with a threshold level of alcohol intake exists with relation to colorectal cancer risk and the effect of relation to colorectal cancer risk and the effect of beverage type and drinking pattern (regular beverage type and drinking pattern (regular versus heavy episodic drinking) on that risk.versus heavy episodic drinking) on that risk.


Heavy Beer Consumption Is Heavy Beer Consumption Is a Risk Factor for Gastric a Risk Factor for Gastric

CancerCancer

Duell EJ, et al. Duell EJ, et al. Am J Clin Nutr. Am J Clin Nutr. 2011;94(5):1266–1275.2011;94(5):1266–1275.Summary by Daniel Fuster, MD, PhD, & Richard Saitz, MD, Summary by Daniel Fuster, MD, PhD, & Richard Saitz, MD,

MPHMPH

5151


The etiological role of alcohol in gastric The etiological role of alcohol in gastric cancer is uncertain: although suspected to cancer is uncertain: although suspected to be a risk factor, alcohol also appears to be a risk factor, alcohol also appears to reduce Helicobacter pylori (H. pylori) reduce Helicobacter pylori (H. pylori) infection.infection.

Investigators used data from the European Investigators used data from the European Prospective Investigation into Cancer and Prospective Investigation into Cancer and Nutrition (EPIC) study to evaluate the Nutrition (EPIC) study to evaluate the association between baseline alcohol association between baseline alcohol consumption and the risk of gastric cancer. consumption and the risk of gastric cancer.


5252

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

People who drank very light amountsPeople who drank very light amounts** (0.1 (0.1 to 4.9 g, or less than half a drinkto 4.9 g, or less than half a drink**** daily) daily) were compared with those who drank were compared with those who drank more (5 to ≥60 g daily). more (5 to ≥60 g daily).

Among 478,459 participants who Among 478,459 participants who contributed >4 million person-years, there contributed >4 million person-years, there were 444 incident cases of gastric cancer. were 444 incident cases of gastric cancer.


*Nondrinkers were not used as the referent group because 56% of those *Nondrinkers were not used as the referent group because 56% of those who reported no alcohol consumption at baseline were former drinkers. who reported no alcohol consumption at baseline were former drinkers.

**Standard drink = 13.5 g alcohol in this study.**Standard drink = 13.5 g alcohol in this study.


ResultsResults In Cox proportional hazards models,In Cox proportional hazards models,

alcohol consumption of ≥60 g per day was alcohol consumption of ≥60 g per day was associated with gastric cancer (hazard ratio [HR], associated with gastric cancer (hazard ratio [HR], 1.7) but only with intestinal-type and noncardia 1.7) but only with intestinal-type and noncardia gastric cancers. gastric cancers.

after adjusting for beverage type, beer (but not after adjusting for beverage type, beer (but not wine or liquor) consumption of ≥30 g per day wine or liquor) consumption of ≥30 g per day was associated with gastric cancer (HR, 1.8). was associated with gastric cancer (HR, 1.8).

the association between alcohol and gastric the association between alcohol and gastric cancer was independent of smoking status and cancer was independent of smoking status and H. pylori infection and was more apparent in men H. pylori infection and was more apparent in men than in women.than in women.


CommentsComments This prospective cohort study suggests that This prospective cohort study suggests that

there is an increased risk of intestinal-type there is an increased risk of intestinal-type and noncardia gastric cancer with heavy and noncardia gastric cancer with heavy alcohol consumption. alcohol consumption.

Why these cancers were associated with Why these cancers were associated with beer consumption only, and whether there beer consumption only, and whether there was a threshold level of exposure or a linear was a threshold level of exposure or a linear association, was not clear from the association, was not clear from the analyses. analyses.

Nonetheless, the results raise concerns that Nonetheless, the results raise concerns that 2–3 standard servings of beer a day could 2–3 standard servings of beer a day could increase gastric cancer risk, particularly in increase gastric cancer risk, particularly in men.men.


Sun Q, et al. Sun Q, et al. PLoS Med. PLoS Med. 2011;8(9):e1001090.2011;8(9):e1001090.Summary by R. Curtis Ellison, MDSummary by R. Curtis Ellison, MD

Regular Moderate Alcohol Regular Moderate Alcohol Intake Associated with Intake Associated with “Successful Aging” in “Successful Aging” in

WomenWomen


Objectives/MethodsObjectives/Methods The association between moderate alcohol intake The association between moderate alcohol intake

and health and well-being in aging populations is and health and well-being in aging populations is not known. not known.

Investigators prospectively examined midlife Investigators prospectively examined midlife alcohol use in relation to successful agingalcohol use in relation to successful aging** among among 13,894 participants in the Nurses’ Health Study. 13,894 participants in the Nurses’ Health Study.

The sample included women age ≥70 years whose The sample included women age ≥70 years whose health status had been updated throughout the health status had been updated throughout the study. Those who reported drinking heavily at study. Those who reported drinking heavily at midlife (>45 g of ethanol per day) were excluded. midlife (>45 g of ethanol per day) were excluded.

*Defined as survival to age 70 years; not having a major chronic disease (e.g., *Defined as survival to age 70 years; not having a major chronic disease (e.g., coronary disease, cancer, stroke, diabetes); and having no major cognitive or coronary disease, cancer, stroke, diabetes); and having no major cognitive or physical impairment or mental health problems.physical impairment or mental health problems.


ResultsResults Only 11% (1491) of the women met Only 11% (1491) of the women met

successful aging criteria. successful aging criteria.

Compared with nondrinkers, Compared with nondrinkers, moderate drinkers, especially those who moderate drinkers, especially those who

consumed wine and drank regularly, were more consumed wine and drank regularly, were more likely to exhibit successful aging. The largest likely to exhibit successful aging. The largest benefit (an increase of 28%) was seen in women benefit (an increase of 28%) was seen in women who reported drinking 15.1–30 g alcohol* per who reported drinking 15.1–30 g alcohol* per day.day.

women who drank only 1 to 2 days per week had women who drank only 1 to 2 days per week had little increase in their likelihood of achieving little increase in their likelihood of achieving successful aging, while those who drank at least successful aging, while those who drank at least 5 days per week had almost a 50% greater 5 days per week had almost a 50% greater chance of successful aging.chance of successful aging.

5757

*A serving was defined as 13.2 g alcohol for 1 bottle of beer, 10.8 g for 1 glass *A serving was defined as 13.2 g alcohol for 1 bottle of beer, 10.8 g for 1 glass of wine, and 15.1 g for 1 drink of liquor in this study.of wine, and 15.1 g for 1 drink of liquor in this study.


CommentsComments The definition of successful aging used in this The definition of successful aging used in this

study is questionable in that a large percentage study is questionable in that a large percentage of people who did not meet these criteria may of people who did not meet these criteria may have made substantial contributions to society have made substantial contributions to society and should be considered “successful.” and should be considered “successful.”

Nevertheless, these results support earlier Nevertheless, these results support earlier findings showing that many aspects of findings showing that many aspects of successful aging, in addition to just survival, are successful aging, in addition to just survival, are associated with regular moderate alcohol associated with regular moderate alcohol consumption.consumption.

As usual for observational studies, how much, if As usual for observational studies, how much, if any, of the association is causal cannot be any, of the association is causal cannot be determined from these data.determined from these data.


Unhealthy Alcohol Use Is Unhealthy Alcohol Use Is Associated with Unhealthy Associated with Unhealthy

Eating PatternsEating Patterns

Valencia-Martin JL, et alValencia-Martin JL, et al. . Alcohol Clin Exp Res.Alcohol Clin Exp Res. 2011; 2011;35(11):2075–2081.35(11):2075–2081.

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

6060

Objectives/MethodsObjectives/Methods Researchers conducted a telephone survey Researchers conducted a telephone survey

of 12,037 adults aged 18–64 years living in of 12,037 adults aged 18–64 years living in and around Madrid, Spain, to measure the and around Madrid, Spain, to measure the association between unhealthy alcohol use association between unhealthy alcohol use and poor dietary choices.and poor dietary choices.

Participants completed detailed 30-day Participants completed detailed 30-day alcohol and 24-hour food consumption alcohol and 24-hour food consumption questionnaires. questionnaires.


6161


Alcohol use was characterized as follows:Alcohol use was characterized as follows:

never drinker.never drinker. former drinker.former drinker. moderate drinker with or without heavy episodic moderate drinker with or without heavy episodic

drinking.drinking. excessive drinker with or without heavy episodic excessive drinker with or without heavy episodic

drinking.* drinking.*

Reported consumption was compared with Reported consumption was compared with adherence to healthy eating guidelines. adherence to healthy eating guidelines.


*In this study, moderate drinking was defined as <40 g alcohol per day in men *In this study, moderate drinking was defined as <40 g alcohol per day in men and <24 g per day in women; excessive drinking was defined as ≥40 g alcohol and <24 g per day in women; excessive drinking was defined as ≥40 g alcohol per day for men and ≥24 g per day for women; and heavy episodic drinking was per day for men and ≥24 g per day for women; and heavy episodic drinking was defined as ≥80 g alcohol per occasion for men and ≥60 g per occasion for women defined as ≥80 g alcohol per occasion for men and ≥60 g per occasion for women in the last 30 days.in the last 30 days.

6262

ResultsResults Ten percent of participants reported heavy Ten percent of participants reported heavy

episodic drinking, and 4% reported episodic drinking, and 4% reported excessive drinking.excessive drinking.

Moderate drinkers with heavy episodic Moderate drinkers with heavy episodic drinking were more likely than never drinking were more likely than never drinkers to have >1 serving of meat per day drinkers to have >1 serving of meat per day (odds ratio [OR], 1.25).(odds ratio [OR], 1.25).

Excessive drinkers without heavy episodic Excessive drinkers without heavy episodic drinking were more likely than never drinking were more likely than never drinkers to have <2 servings of milk drinkers to have <2 servings of milk products per day (OR, 1.54), >2 servings of products per day (OR, 1.54), >2 servings of meat, fish, and eggs per day (OR 1.46), and meat, fish, and eggs per day (OR 1.46), and to skip meals (OR, 1.76).to skip meals (OR, 1.76).www.aodhealth.orgwww.aodhealth.org

6363

ResultsResults (cont’d)(cont’d) Excessive drinkers with heavy episodic Excessive drinkers with heavy episodic

drinking were more likely than never drinkers drinking were more likely than never drinkers to haveto have <3 servings of fruits and vegetables per day (OR, 1.71);<3 servings of fruits and vegetables per day (OR, 1.71); <2 servings of milk products per day (OR, 1.47);<2 servings of milk products per day (OR, 1.47); >1 serving of meat per day (OR, 1.47);>1 serving of meat per day (OR, 1.47); >2 servings of meat, fish, and eggs per day (OR 1.57); >2 servings of meat, fish, and eggs per day (OR 1.57);

andand to skip meals (OR, 2.73).to skip meals (OR, 2.73).

Participants who preferred beer or spirits Participants who preferred beer or spirits were less likely than those with no beverage were less likely than those with no beverage preference to meet healthy eating guidelines.preference to meet healthy eating guidelines.

Participants who drank alcohol during meals Participants who drank alcohol during meals (24% of sample) were less likely to adhere to (24% of sample) were less likely to adhere to healthy eating guidelines.healthy eating guidelines.www.aodhealth.orgwww.aodhealth.org


CommentsComments These findings suggest that adults with These findings suggest that adults with

unhealthy alcohol use are less likely to unhealthy alcohol use are less likely to adhere to healthy dietary guidelines.adhere to healthy dietary guidelines.

Although this study took place in Spain and Although this study took place in Spain and generalizability to other countries is generalizability to other countries is uncertain, clinicians should keep in mind uncertain, clinicians should keep in mind that patients with unhealthy alcohol use that patients with unhealthy alcohol use also need to be counseled about healthy also need to be counseled about healthy eating habits.eating habits.


Studies on Studies on HIV and HCVHIV and HCV


A Multidisciplinary Approach A Multidisciplinary Approach to Hepatitis-C Treatment to Hepatitis-C Treatment Reduced Viral Load and Reduced Viral Load and Increased Abstinence in Increased Abstinence in

Patients with Patients with Co-Occurring Alcohol Co-Occurring Alcohol

DependenceDependence

Le Lan C, et alLe Lan C, et al. . J Hepatol.J Hepatol. 2012;56(2):334–340. 2012;56(2):334–340.Summary by Judith Tsui, MD, MPHSummary by Judith Tsui, MD, MPH

6767

Objectives/MethodsObjectives/Methods Current guidelines recommend that Current guidelines recommend that

alcohol-dependent patients with hepatitis alcohol-dependent patients with hepatitis C virus (HCV) should abstain from drinking C virus (HCV) should abstain from drinking for 6 months prior to HCV treatment for 6 months prior to HCV treatment (interferon and ribavirin).(interferon and ribavirin).

Yet, patients who drink heavily have the Yet, patients who drink heavily have the highest risk for developing HCV-associated highest risk for developing HCV-associated disease and, therefore, most strongly disease and, therefore, most strongly stand to benefit from treatment. stand to benefit from treatment.


6868


This prospective observational study examined This prospective observational study examined HCV treatment outcomes in 73 alcohol-HCV treatment outcomes in 73 alcohol-dependent patients with ongoing consumption dependent patients with ongoing consumption or abstinence of <6 months.or abstinence of <6 months.

Participants were enrolled in a 24–Participants were enrolled in a 24– 48 week 48 week multidisciplinary program that included care by multidisciplinary program that included care by hepatologists and addiction specialists. hepatologists and addiction specialists.

Moderation of drinking was strongly encouraged Moderation of drinking was strongly encouraged but not required.but not required.


6969

ResultsResults At the start of treatment, 62% of participants At the start of treatment, 62% of participants

reported “high-risk” consumption,reported “high-risk” consumption,** with a with a median consumption of 50 drinks per week median consumption of 50 drinks per week (interquartile range, 30–98 drinks per week). (interquartile range, 30–98 drinks per week).

During treatment, 30% of participants During treatment, 30% of participants continuously abstained, 34% consumed continuously abstained, 34% consumed “low-risk” amounts, and 36% consumed “low-risk” amounts, and 36% consumed high-risk amounts. Fifty-three percent of high-risk amounts. Fifty-three percent of patients abstained for at least 3 months.patients abstained for at least 3 months.


*High-risk consumption was any amount exceeding “low-risk” consumption *High-risk consumption was any amount exceeding “low-risk” consumption (defined as ≤21 standard (10 g ethanol) drinks per week for men, ≤14 drinks per (defined as ≤21 standard (10 g ethanol) drinks per week for men, ≤14 drinks per week for women, and ≤4 drinks per occasion in this study).week for women, and ≤4 drinks per occasion in this study).

7070

ResultsResults (cont’d)(cont’d) Sustained viral response (SVR) was achieved Sustained viral response (SVR) was achieved

in 48% of patients, which did not differ in 48% of patients, which did not differ significantly from matched controls with low-significantly from matched controls with low-risk alcohol use. risk alcohol use.

Among patients who drank high-risk Among patients who drank high-risk amounts during the study, 33% achieved amounts during the study, 33% achieved SVR.SVR.

Drug use severity and duration of abstinence Drug use severity and duration of abstinence during treatment significantly predicted SVR during treatment significantly predicted SVR in multivariable models.in multivariable models.



CommentsComments This study demonstrated that patients with This study demonstrated that patients with

alcohol dependence can be successfully alcohol dependence can be successfully treated for HCV in a multidisciplinary treated for HCV in a multidisciplinary program.program.

Although abstinence during treatment was Although abstinence during treatment was associated with better outcomes, one-third associated with better outcomes, one-third of patients who continued to drink heavily of patients who continued to drink heavily during treatment achieved SVR. during treatment achieved SVR.


A New Piece of the Harm A New Piece of the Harm Reduction Puzzle? Directly Reduction Puzzle? Directly

Observed Antiretroviral Observed Antiretroviral Therapy for HIV-infected Therapy for HIV-infected

Opioid-Dependent Opioid-Dependent IndividualsIndividuals

Nahvi S, et al. Nahvi S, et al. Drug Alcohol Depend.Drug Alcohol Depend. 2012;120(1- 2012;120(1-3):174–180.3):174–180.

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


Objectives/MethodsObjectives/Methods Antiretroviral therapy (ART) adherence improves Antiretroviral therapy (ART) adherence improves

treatment outcomes and reduces antiretroviral treatment outcomes and reduces antiretroviral drug resistance in patients with HIV, however, drug resistance in patients with HIV, however, illicit drug use threatens antiretroviral illicit drug use threatens antiretroviral adherence. adherence.

The impact of measures to promote ART The impact of measures to promote ART adherence in HIV-infected patients with opioid adherence in HIV-infected patients with opioid dependence who receive methadone dependence who receive methadone maintenance treatment (MMT), but who maintenance treatment (MMT), but who continue to use illicit drugs, has not been continue to use illicit drugs, has not been systematically assessed. systematically assessed.

This 24-week randomized clinical trial compared This 24-week randomized clinical trial compared directly observed antiretroviral therapy (DOT) directly observed antiretroviral therapy (DOT) with treatment as usual among 77 HIV-infected with treatment as usual among 77 HIV-infected opioid-dependent patients receiving MMT. opioid-dependent patients receiving MMT.


ResultsResults Median duration of MMT was 10 years, and Median duration of MMT was 10 years, and

the median dose was 125 mg.the median dose was 125 mg.

Active drug use was common throughout Active drug use was common throughout the trial:the trial:

74% of participants used cocaine.74% of participants used cocaine. 67% used opioids.67% used opioids. 42% used both cocaine and opioids.42% used both cocaine and opioids.



Among participants randomized to Among participants randomized to treatment as usual, adherence was treatment as usual, adherence was compromised in those engaged in active compromised in those engaged in active opioid use compared with no drug use (63% opioid use compared with no drug use (63% versus 75%, p=0.04) and in those engaged versus 75%, p=0.04) and in those engaged in polysubstance use compared with no in polysubstance use compared with no drug use (60% versus 73%, p=0.01). drug use (60% versus 73%, p=0.01).

Adherence (ranging from 82–85%) was not Adherence (ranging from 82–85%) was not affected in participants randomized to DOT, affected in participants randomized to DOT, regardless of active drug use. regardless of active drug use.


CommentsComments Despite the small sample size and the site Despite the small sample size and the site

having been limited to a single having been limited to a single methadone clinic, these findings suggest methadone clinic, these findings suggest DOT attenuates the adverse effects of DOT attenuates the adverse effects of active drug use on ART adherence in HIV-active drug use on ART adherence in HIV-infected patients with opioid dependence.infected patients with opioid dependence.

Thus, DOT could be considered a Thus, DOT could be considered a component of harm reduction for this component of harm reduction for this population. population.


Orwat J, et al. Orwat J, et al. J Subst Abuse Treat. J Subst Abuse Treat. 2011;41(3):233–242.2011;41(3):233–242.Summary by Summary by Jeanette M. Tetrault, MDJeanette M. Tetrault, MD

Factors Associated with Factors Associated with Substance-Abuse Treatment Substance-Abuse Treatment Utilization among Patients Utilization among Patients

Living with HIV/AIDS Who Use Living with HIV/AIDS Who Use Alcohol and Other DrugsAlcohol and Other Drugs


Objectives/MethodsObjectives/Methods Use of alcohol and other drugs (AOD) is high Use of alcohol and other drugs (AOD) is high

among patients living with HIV/AIDS and is among patients living with HIV/AIDS and is associated with medication nonadherence, associated with medication nonadherence, poor treatment outcomes, and engagement poor treatment outcomes, and engagement in HIV/AIDS risk behaviors. in HIV/AIDS risk behaviors.

This analysis explored the factors associated This analysis explored the factors associated with self-reported substance-abuse treatment with self-reported substance-abuse treatment utilization in a prospective cohort of utilization in a prospective cohort of individuals living with HIV/AIDS with AOD individuals living with HIV/AIDS with AOD problems ranging from risky use to problems ranging from risky use to dependence (N=369). The Anderson model dependence (N=369). The Anderson model was used to identify independent variables was used to identify independent variables potentially associated with substance-abuse potentially associated with substance-abuse treatment utilization.treatment utilization.


ResultsResults Twelve percent of the sample met criteria for Twelve percent of the sample met criteria for

current alcohol dependence, while 43% met current alcohol dependence, while 43% met criteria for current drug dependence.criteria for current drug dependence.

The following factors had an inverse The following factors had an inverse relationship with substance-abuse treatment relationship with substance-abuse treatment utilization: utilization:

alcohol dependence (adjusted odds ratio [AOR], alcohol dependence (adjusted odds ratio [AOR], 0.36).0.36).

sexual orientation other than heterosexual (AOR, sexual orientation other than heterosexual (AOR, 0.46).0.46).

social supports who use AOD (AOR, 0.62).social supports who use AOD (AOR, 0.62).

7979



The following factors were directly The following factors were directly associated with substance-abuse treatment associated with substance-abuse treatment utilization:utilization:

hepatitis-C positive (AOR, 3.37).hepatitis-C positive (AOR, 3.37). history of physical or sexual abuse (AOR, 2.12). history of physical or sexual abuse (AOR, 2.12). social supports promoting sobriety (AOR, 1.92).social supports promoting sobriety (AOR, 1.92). homelessness (AOR, 2.40). homelessness (AOR, 2.40). drug dependence (AOR, 2.64).drug dependence (AOR, 2.64). depressive symptoms (AOR, 1.52).depressive symptoms (AOR, 1.52).

8080


CommentsComments This study identified several non-need This study identified several non-need

factors associated with substance-abuse factors associated with substance-abuse treatment utilization including sexual treatment utilization including sexual orientation, history of physical or sexual orientation, history of physical or sexual abuse, depression, homelessness, and abuse, depression, homelessness, and characteristics of social support.characteristics of social support.

Although treatment utilization was self-Although treatment utilization was self-reported and these associations do not reported and these associations do not reflect causality, the findings may inform reflect causality, the findings may inform development of strategies to motivate this development of strategies to motivate this population both to engage in substance population both to engage in substance abuse treatment and to make use of abuse treatment and to make use of resources provided by treatment providers.resources provided by treatment providers.

Date post:	26-Dec-2015
Category:	Documents
Upload:	jared-hopkins
View:	218 times
Download:	0 times

Www.aodhealth.org 1 Update on Alcohol, Other Drugs, and Health November–December 2011.

Documents