Update on Alcohol and Health

1. Update on Alcohol and Health Alcohol and Health: Current Evidence July–August 2004 www.alcoholandhealth.org

2. Studies on Alcohol and Health Conditions www.alcoholandhealth.org

3. Alcohol, Hypertension, and Cardiovascular Disease Mortality Malinski MK, et al. Arch Intern Med. 2004;164(6):623–628. www.alcoholandhealth.org

4. Objectives/Methods • To assess the relationship between drinking and mortality among patients with hypertension • Self-reported data from the Physicians’ Health Study • 14,125 males with a history of current or past treatment for hypertension and without myocardial infarction, stroke, cancer, or liver disease at baseline • analyses adjusted for potential confounders (e.g., age, smoking, diabetes) www.alcoholandhealth.org

5. Results *Compared with Those who Rarely or Never Drank www.alcoholandhealth.org

6. Conclusions/Comments • In this cohort of physicians with hypertension who consumed low amounts, moderate alcohol consumption reduced risk of CVD mortality and total mortality. • There are limits to applying these results to broader primary care populations. • Clinicians should individualize recommendations about alcohol use and help patients determine whether the cardiovascular benefits from moderate drinking outweigh any potential risks. www.alcoholandhealth.org

7. Changes in Alcohol Consumption and Their Effects on Mortality, Cancer, and Coronary Heart Disease Grønbaek M, et al. Epidemiology. 2004;15(2):222–228. www.alcoholandhealth.org

8. Objectives/Methods • To examine how changes in intake affect risk of mortality, coronary heart disease (CHD), and cancer • Data from a longitudinal study • 6644 men and 8010 women • completed 2 health exams at 5-year intervals • analyses adjusted for possible confounders (e.g., age, sex, smoking) www.alcoholandhealth.org

9. Results Non-drinkers consumed <1 drink per week. Light drinkers consumed 1-6 drinks per week. Heavy drinkers consumed >13 drinks per week. www.alcoholandhealth.org

10. Conclusions/Comments • This study found that moderate drinkers who decreased their consumption to little or no alcohol increased their risk of death from all causes. • According to these findings, adult moderate drinkers—to lower their risk of death—should not be advised to reduce their intake or to abstain. www.alcoholandhealth.org

11. Drinking Patterns—Not Just Total Amount—Affect Risk Trevisan M, et al. Addiction. 2004;99(3):313–322. Tolstrup JS, et al. Addiction. 2004;99(3):323–330. www.alcoholandhealth.org

12. Objectives/Methods Trevisan study: • To determine the effect of drinking patterns on the risk of myocardial infarction (MI) • Case-control study • 427 white males with incident MI • 905 healthy white male controls selected randomly from 2 Western New York counties • analyses adjusted for multiple risk factors (e.g., age, smoking, diet, physical activity) www.alcoholandhealth.org

13. Results *past 1-2 years www.alcoholandhealth.org

14. Objectives/Methods Tolstrup study: • To learn how drinking patterns affect risk of all-cause mortality • Questionnaire data from a population-based Danish cohort • 26,909 men and 29,626 women • analyses adjusted for multiple risk factors (e.g., age, smoking, diet, physical activity) www.alcoholandhealth.org

15. Results • Frequent drinkers (≥2 times per week) had a lower hazard of death than non-frequent drinkers. • Compared with males drinking <1 drink per week, male frequent drinkers who consumed 1–20 drinks per week had significantly lower mortality. • Compared with females drinking <1 drink per week, female frequent drinkers who consumed larger amounts did not have significantly lower mortality. www.alcoholandhealth.org

16. Conclusions/Comments • These studies add to the accumulating evidence that drinking patterns do matter. • Result of these and similar studies should be viewed with caution because small numbers of infrequent drinkers in the high consumption categories make it difficult to adjust adequately for total alcohol intake. • While they wait for better data, clinicians should steer moderate drinkers towards more frequent drinking of small amounts rather than less frequent drinking of larger amounts. www.alcoholandhealth.org

17. Risky Sex:It’s the Alcohol Ehrenstein V, et al. Drug Alcohol Depend. 2004;73(2)159–166. www.alcoholandhealth.org

18. Objectives/Methods • To better understand alcohol’s effect on inconsistent condom use • Data from a prospective cohort of adults with HIV and current or past alcohol problems • 345 subjects • analyses adjusted for possible confounders (e.g., race, education, other drug use) www.alcoholandhealth.org

19. Results • Alcohol consumption was significantly associated with inconsistent condom use (<100% over the last 6 months). www.alcoholandhealth.org

20. heavier drinking in users of injection drugs being female identifying as gay or lesbian living with a partner having 2 or more sexual partners agreeing that condoms are a hassle to use Results (cont.) Factors associated with significant increases in risk of inconsistent condom use (odds ratios between 2 and 4): Factors associated with borderline significant increases in risk: recently testing HIV-positive, selling sex for drugs or money, having a higher CD4 cell count www.alcoholandhealth.org

21. Conclusions/Comments • Whether the findings in this cohort (30% employed, 67% non-white, 29% homeless) will hold true for others with HIV is unknown. • Drinking >1–2 drinks per day appears to increase risk of inconsistent condom use, particularly among users of injection drugs. • When addressing this risk, clinicians, public health practitioners, and others must consider factors that contribute to inconsistent use—many of which are modifiable. www.alcoholandhealth.org

22. Lasting Effects of Alcohol on Cognitive Function in HIV Infection Green JE, et al. Am J Psychiatry. 2004;161(2):249–254. www.alcoholandhealth.org

23. Objectives/Methods • To better understand the effects of heavy alcohol use on cognitive function in people infected with HIV • Assessment of various neuropsychological functions and symptoms of anxiety and depression in 80 gay or bisexual men • 50 with HIV (21 who also had past alcohol abuse or dependence) • 30 without HIV (12 who had past alcohol abuse or dependence) www.alcoholandhealth.org

24. Results • Overall cognitive impairment did not differ significantly between those with and without HIV. • Men with past alcohol abuse or dependence, compared with those without, showed cognitive impairment on a significantly greater number of measures. www.alcoholandhealth.org

25. Conclusions/Comments • This study’s strength is its detailed assessments of participants. • Given the study’s small sample size, researchers could not adjust for factors that could have explained the association between past alcohol use disorders and cognitive impairment. • Nonetheless, the findings suggest that the association between alcohol abuse or dependence and cognitive dysfunction in HIV-infected men is particularly pronounced. www.alcoholandhealth.org

26. Another Complication of Drinking during Pregnancy Avaria MD, et al. J Pediatr. 2004;144(3)338–343. www.alcoholandhealth.org

27. Objectives/Methods • To examine the effects of alcohol exposure in utero on the peripheral nervous system • Study of 30 neonates born to women identified during prenatal care • 17 exposed neonates; 13 unexposed www.alcoholandhealth.org

28. Results • No neonates had classic signs of fetal alcohol syndrome; 1 had possible fetal alcohol effects. • Alcohol-exposed neonates had significantly slower nerve conduction velocities and response amplitudes in some nerves. • Differences weresignificant in the ulnar motor nerve and borderline significant in the tibial motor nerve. • No significant differences were found in peroneal, median, or sensory nerve conduction. www.alcoholandhealth.org

29. Conclusions/Comments • This small study could not determine the length and intensity at which alcohol exposure causes harm, nor could it inform us of the clinical implications of its findings. • Despite its sample size, the study did demonstrate yet another complication of alcohol consumption during pregnancy. • The best advice to pregnant women or to those planning pregnancy is abstinence. www.alcoholandhealth.org

30. Alcohol Consumption and Diabetes Mellitus Howard AA, et al. Ann Intern Med. 2004;140(3):211–219. www.alcoholandhealth.org

31. Objectives/Methods • To summarize the findings of studies on alcohol consumption and the risk and control of diabetes • Systematic review • 32 studies, 27 involving type 2 diabetes only www.alcoholandhealth.org

32. Results • Moderate drinking (defined variably in each study), compared with not drinking, reduced diabetes risk in 11 of 18 studies. • Drinking (defined variably, but as little as 1.4 drinks per day) significantly increased diabetes risk in 4 of 18 studies. • Consumption (about 1–6 drinks on an occasion under experimental conditions) did not impair, and sometimes improved, glycemic control. www.alcoholandhealth.org

33. Results (cont.) • In patients with diabetes, moderate drinking, compared with not drinking, significantly decreased risk of • death from coronary heart disease (CHD) (by up to 79% in 3 of 4 studies); • CHD-related events (by up to 55% in 2 of 3 studies). • Consuming about 3 drinks on an occasion with troglitazone or a sulfonylurea did not affect glycemic control. • Heavy use (defined variably) significantly increased diabetic retinopathy in 1 study and had no effect in another. www.alcoholandhealth.org

34. Conclusions/Comments • Moderate alcohol use may decrease risk of type 2 diabetes and diabetes-related cardiovascular events. • However, results from this review are inconsistent, and some included studies suggest increased risk at drinking levels often considered to be moderate. • Given current evidence, it is likely safe for people with type 2 diabetes to follow usual drinking recommendations (≤1 drink per day for women and people over 65 years; ≤ 2drinks per day for men aged 65 and under). www.alcoholandhealth.org

35. Studies on Interventions www.alcoholandhealth.org

36. Efficacy of Brief Interventions in Primary Care to Reduce Risky and Harmful Alcohol Use Whitlock EP, et al. Ann Intern Med. 2004;140(7):557–568. www.alcoholandhealth.org

37. Objectives/Methods • To inform clinical guidelines of the U.S. Preventive Services Task Force (USPSTF) about brief behavioral counseling interventions • Systematic review of studies on the efficacy of these interventions • 12 controlled trials included www.alcoholandhealth.org

38. Results • Those receiving brief multi-contact interventions (initial session up to 15 minutes and at least 1 follow-up) reduced their average weekly alcohol intake by 13%–34% more than controls in 4 of 7 trials. • 10%–19% more intervention participants than controls drank safe amounts. • Very brief (up to 5 minutes) or brief single-contact interventions were ineffective or less effective in reducing risky or harmful alcohol use. www.alcoholandhealth.org

39. Results (cont.) • All effective interventions included at least 2 of 3 key elements: • feedback, advice, and goal setting. • No significant differences were found among men and women receiving brief interventions. www.alcoholandhealth.org

40. Conclusions/Comments • USPSTF gave a grade B recommendation (at least fair evidence of improved health outcomes and benefits outweighing potential harms) to screening and brief counseling in primary care to reduce risky or harmful alcohol use among adults. • Better strategies to implement screening and more effective brief interventions in actual clinical practice must be developed. www.alcoholandhealth.org

41. Alcohol Screening and Referral on College Campuses Foote J, et al. J Am Coll Health. 2004;52(4):149–157. www.alcoholandhealth.org

42. Objectives/Methods • To assess alcohol screening and referral on college campuses • Survey of a state-stratified random sample of 4-year colleges/universities with health centers • 76% response rate; 234 schools analyzed www.alcoholandhealth.org

43. Results • 33% of the schools conducted routine alcohol screening of most or all (96%) students visiting their health centers. • Urban, large, and especially public schools were significantly more likely to routinely screen. • Screening was typically part of a standard medical history and physical. • 12% of schools used a standardized instrument (most often the CAGE) to screen. www.alcoholandhealth.org

44. Results (cont.) • On average, health centers offered 3 referral options. The most common included • the campus counseling center; • substance abuse treatment in the community; • 12-step programs; • individual therapy. www.alcoholandhealth.org

45. Conclusions/Comments • These findings highlight both the lack of alcohol screening in college health centers as well as potential inadequacies in practices used by those who do screen. • Given the harm caused by—and few successful strategies to curb—heavy drinking, college health centers should receive the necessary support to implement effective screening and referral. www.alcoholandhealth.org

46. Does Experience Influence Hospitals’ Resource Use in Treating Alcohol and Other Drug Diagnoses Bramble JD, et al. J Gen Intern Med. 2004;19(1):36–42. www.alcoholandhealth.org

47. Objectives/Methods • To investigate whether a hospital’s experience with alcohol and other drug diagnoses or its teaching status impacts resource use • National data from 1996 Healthcare Costs and Utilization Project and other large administrative databases • Analyses adjusted for multiple hospital and patient characteristics www.alcoholandhealth.org

48. Results • Relative experience was significantly associated with lower charges but also associated (borderline significance) with greater length of stay. • Teaching hospital status was not significantly associated with either charges or length of stay. www.alcoholandhealth.org

49. Conclusions/Comments • The authors speculated that the lower charges and longer lengths of stay in high volume hospitals might have resulted from managing patients with substance-related disorders in less expensive settings. • They did not address the quality of care, readmissions, or other outcomes. • Thus, whether this less expensive care leads to better or worse clinical outcomes remains unknown. www.alcoholandhealth.org

50. Studies on Special Populations www.alcoholandhealth.org