1 / 62

Update on Alcohol, Other Drugs, and Health

Update on Alcohol, Other Drugs, and Health. September–October 2008. Studies on Interventions. Brief Intervention for Illicit Drug Use in Primary Health Care Settings: Does It Work?.

amandamullins
Download Presentation

Update on Alcohol, Other Drugs, and Health

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Update on Alcohol, Other Drugs, and Health September–October 2008 www.aodhealth.org

  2. Studies on Interventions www.aodhealth.org

  3. Brief Intervention for Illicit Drug Use in Primary Health Care Settings: Does It Work? Humeniuk R, et al. Technical Report of Phase III Findings of the WHO ASSIST Randomized Controlled Trial. Geneva, Switzerland: WHO, 2008. Summary by Richard Saitz MD, MPH www.aodhealth.org

  4. Objectives/Methods • World Health Organization researchers conducted the first randomized trial on the efficacy of brief intervention (BI) to decrease illicit drug use. • Patients (N=731) with current drug use identified using the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were recruited from sexually transmitted disease clinics, walk-in clinics, a dental clinic, and community medical care sites in 4 countries. • Patients scoring in the moderate-risk range were randomly assigned to BI or no BI (until after the study). Patients who scored in the low- or high-risk range were excluded. www.aodhealth.org

  5. Results • Brief intervention was associated with a 3-point greater decrease (compared with no BI) in a substance use score with a maximum of 336 points. • Cannabis and stimulant scores also decreased more for BI subjects (by about 2–3 points on scales with a maximum of 39 points); opioid scores did not. • Substance use was not significantly impacted by BI in the US. www.aodhealth.org

  6. Comments • Brief intervention for drugs may have some benefit in general health settings. However, the clinical significance in this study is unclear. • The use of the same interviewers for the BI and follow-up assessments could introduce a bias favoring BI. • Patients were not recruited from what is usually considered primary care. • The clinical meaning of small differences in substance use scores has not been established. • Screening and BI for illicit drug use is more complex than it is for alcohol. Whether BI will have important clinical benefits in primary care remains unknown. www.aodhealth.org

  7. Buprenorphine with Drug Counseling Is Superior to Oral Naltrexone with Counseling or Counseling Alone for Heroin Dependence Schottenfeld RS, et al. Lancet. 2008;371(9631): 2192–2200. Summary by Peter D. Friedmann, MD, MPH www.aodhealth.org

  8. Objectives/Methods • Opiate dependence and injection drug use are major vectors for HIV transmission across the globe, yet many nations prohibit opioid agonist treatment (OAT). • Researchers conducted a randomized, double-blind, placebo-controlled trial of OAT in patients who had completed standardized 14-day residential detoxification and begun group drug counseling. • Patients were assigned to either placebo (n=39), oral naltrexone (n=43), or sublingual buprenorphine (n=44). www.aodhealth.org

  9. Results • Over 24 weeks of follow-up, • treatment retention was significantly higher for buprenorphine compared with naltrexone. • time to first heroin use was significantly higher for buprenorphine compared with naltrexone or placebo. • time to heroin relapse was significantly higher for buprenorphine compared with naltrexone or placebo. • no differences were detected between oral naltrexone and placebo. • HIV risk behaviors did not differ between groups. www.aodhealth.org

  10. Comments • Studies from around the world have demonstrated that OAT with counseling is superior both to counseling alone and to oral naltrexone with or without counseling. • Nonetheless, significant barriers to OAT remain both within the US and internationally. • Policy initiatives are needed to change regulations about these evidence-based treatments for opiate dependence. www.aodhealth.org

  11. Johnson BA, et al. Arch Intern Med. 2008;168(11):1188–1199.Summary by Kevin L. Kraemer, MD, MSc Topiramate, Physical Health, and Psychosocial Function in Adults with Alcohol Dependence www.aodhealth.org

  12. Objectives/Methods • Topiramate combined with adherence enhancement counseling can decrease alcohol use in some alcohol-dependent individuals. • To assess whether topiramate also improves physical health and psychosocial function, researchers analyzed data from 364 patients in a 14-week multisite double-blind trial. • Patients were randomized to receive either topiramate (up to 300 mg/day) or placebo. www.aodhealth.org

  13. Objectives/Methods (cont’d) • Eligibility criteria included: • diagnosis of alcohol dependence per DSM-IV. • consumption of ≥35 drinks per week (men) and ≥28 drinks per week (women). • negative screens for opioids, cocaine, amphetamines, antidepressants, propoxyphene, and barbiturates. • No additional psychiatric diagnosis (e.g., depression). • No clinically significant withdrawal symptoms. www.aodhealth.org

  14. Results • Sixty-three percent (112 of 179 patients) receiving topiramate completed the trial. More than half of those who withdrew (34 of 67 patients) did so due to side effects. • Seventy-eight percent (144 of 185 patients) receiving placebo completed the trial. Three percent (6 of 185 patients) withdrew due to side effects. • Patients who received topiramate had significantly greater decreases in… www.aodhealth.org

  15. Results (cont’d) • These physical health findings were similar whether excluding or using multiple imputation for patients who did not complete the study. www.aodhealth.org

  16. Comments • These findings suggest topiramate can improve physical health and psychosocial function in people with alcohol dependence. • Some physical health improvements may have been due to the weight loss associated with topiramate. • The generalizability of the findings is uncertain because: • The study eligibility criteria were restrictive. • Sixty-seven patients (nearly 40%) in the topiramate group did not finish the trial despite weekly adherence counseling. www.aodhealth.org

  17. Drug-related HIV Risk Behaviors Decrease during Treatment with Buprenorphine/Naloxonein Primary Care Sullivan LE, et al. J Subst Abuse Treat. 2008;35(1):87–92. Alexander Y. Walley, MD, MSc www.aodhealth.org

  18. Objectives/Methods • The impact of primary-care based buprenorphine/ naloxone maintenance treatment on HIV risk behaviors has not been examined. • Researchers studied changes in HIV risk behaviors among 155 opioid dependent subjects receiving buprenorphine/naloxone maintenance treatment in a primary care setting. • Subjects were enrolled in a randomized controlled trial of 2 levels of psychosocial counseling. • Neither counseling arm received HIV-specific risk reduction counseling. www.aodhealth.org

  19. Results • No changes in HIV risk behaviors were detected by counseling group assignment. www.aodhealth.org

  20. Comments • This secondary analysis of a randomized con-trolled trial demonstrates that drug-related HIV risk behaviors decrease during buprenorphine/ naloxone maintenance in primary care. • Additional risk-reduction counseling interventions are needed to increase condom use and decrease non-drug–related sexual risk behaviors among buprenorphine/ naloxone maintenance patients. www.aodhealth.org

  21. Levetiracetam (Keppra) Shows Promise in Treating Alcohol Dependence Sarid-Segal O, et al. Am J Drug Alcohol Abuse. 2008;34(4):441–447. Summary by Marc N. Gourevitch, MD, MPH www.aodhealth.org

  22. Objectives/Methods • Preliminary evidence suggests that levetiracetam (Keppra), used in treating partial onset seizures, diminishes symptoms of alcohol withdrawal. • In an open label study, investigators assessed the impact of a 10-week course of levetiracetam (1000 mg twice daily) on alcohol consumption in 20 alcohol dependent persons. www.aodhealth.org

  23. Results • Mean daily drinks consumed diminished from >5 per day at baseline to <2 per day during weeks 5–10 (p=.0005). • Significant improvements were also observed in alcohol craving and alcohol composite scores (but not other composite scores) on the ASI-Lite.* • Alcohol withdrawal scores (CIWA-Ar**) were low at baseline and remained low during the course of the study. • Side effects, including irritability and sedation, were reported in 4 of the 20 participants. *Addiction Severity Index, Lite version; **Clinical Institute Withdrawal Assessment for Alcohol, Revised version. www.aodhealth.org

  24. Comments • Although levetiracetam significantly diminished alcohol consumption in this study, the proportion of patients achieving abstinence was not reported. • Open-label studies cannot distinguish the impact of the medication from that of participants’ motivation to drink less. • Nonetheless, because of its potential to treat alcohol dependence, levetiracetam should be studied in a double-blind randomized controlled trial. www.aodhealth.org

  25. Reid MS, et al. J Subst Abuse Treat. 2008;35(1):68–77.Summary by Julia H. Arnsten, MD, MPH Effectiveness of a Smoking Cessation Intervention in Substance Abuse Treatment Programs www.aodhealth.org

  26. Objectives/Methods • Although patients with substance abuse disorders often smoke, treating nicotine dependence in substance abuse treatment (SAT) settings is uncommon. • Researchers conducted a randomized trial to evaluate the effectiveness of a smoking cessation intervention in SAT programs. • They compared nicotine replacement therapy plus 9 weekly cognitive-behavioral group counseling sessions with treatment-as-usual (TAU) in 225 smokers from 5 methadone maintenance programs and 2 drug- and alcohol-dependence treatment programs. www.aodhealth.org

  27. Results • Intervention-arm participants also had significantly greater reductions in cigarettes smoked, cigarette craving, and nicotine withdrawal during treatment. • No differences in SAT retention, abstinence from primary substance of abuse, or craving for primary substance of abuse was observed between groups. www.aodhealth.org

  28. Comments • Combining nicotine replacement therapy and counseling can be effective in reducing smoking, although the effect was diminished at follow-up. • Results of this study indicate that SAT programs offer a unique means of integrating nicotine dependence treatment with treatment for substance abuse. www.aodhealth.org

  29. Studies of Health Outcomes www.aodhealth.org

  30. Goler NC, et al.J Perinatol. 2008;28(9):597–603.Summary by Peter D. Friedmann, MD, MPH Universal Screening, Assessment, and Treatment of Substance Use at Prenatal Visits Improves Obstetric Outcomes www.aodhealth.org

  31. Objectives/Methods • This retrospective cohort study examined whether Early Start, a coordinated program of prenatal substance abuse screening, treatment, and patient/ provider education, including a licensed substance-use treatment specialist onsite in the obstetric clinic, improved perinatal outcomes. • Investigators compared obstetric outcomes for: • 2073 women treated by Early Start. • 1203 women who screened positive for alcohol or drug use and were assessed by Early Start, but did not receive treatment. • 156 women who screened positive but were never assessed or treated. www.aodhealth.org

  32. Results • Adjusting for maternal age, ethnicity, and number of prenatal visits, women who screened positive for substance use but were not treated had more: • preterm deliveries (odds ratio [OR], 2.1) • placental abruption (OR, 6.8) • intrauterine fetal demise (OR, 16.2) compared with women treated by Early Start. www.aodhealth.org

  33. Comments • This study suggests that screening and treatment of substance-involved pregnant women during prenatal visits improves obstetric outcomes. • The study design cannot eliminate the possibility that greater motivation, not the intervention, improved outcomes in the treatment group. • Nonetheless, these results add to growing evidence that onsite screening and treatment for alcohol and drug use can improves obstetrical outcomes in pregnant women. www.aodhealth.org

  34. Adolescent Cannabis Use Has a Dose-Response Association with Adverse Social Outcomes in Adulthood Fergusson DM, et al. Addiction. 2008;103(6):969–976. Summary by Alexander Y. Walley, MD, MSc www.aodhealth.org www.aodhealth.org 34

  35. Objectives/Methods Investigators in New Zealand studied a birth cohort of 1003 subjects to determine whether cannabis use at age 14–21 had an adverse effect on education, income, employment, relationship quality, and life satisfaction at age 25. Subjects were divided into 6 groups based on self-reported cannabis use ranging from no use to use on greater than 400 occasions. Potential confounding factors, (e.g., socioeconomic status, family functioning, and comorbid mental health and substance use disorders) were adjusted for in the final analyses. www.aodhealth.org www.aodhealth.org 35

  36. Results Subjects with increased adolescent cannabis use showed significant linear trends for: decreased university degree attainment decreased income increased welfare dependence increased unemployment decreased relationship satisfaction decreased life satisfaction This dose-response relationship was consistent for all outcomes in unadjusted and adjusted analyses. www.aodhealth.org www.aodhealth.org 36

  37. Comments These findings may be subject to reporting bias and may not be immune to residual confounding. However, a consistent dose-response association between adolescent cannabis use and subsequent adverse social outcomes is demonstrated. Supporting evidence for a causation will require: similarly findings in other populations of different ages. studies with more direct measures of cannabis use and consequences than self-reports. www.aodhealth.org www.aodhealth.org 37

  38. Dunn W, et al. Hepatology. 2008;47(6):1947–1954.Summary by R. Curtis Ellison, MD Moderate Wine Drinking Is Associated with Decreased Prevalence of Nonalcoholic Fatty Liver Disease www.aodhealth.org

  39. Objectives/Methods • Researchers sought to determine the relation-ship between moderate alcohol consumption and nonalcoholic fatty liver disease (NAFLD) . • Data were analyzed from the 3rd National Health and Nutrition Examination Survey (NHANES III). • Subjects included 7211 nondrinkers and 4543 moderate drinkers of wine (n=945), beer (n=2237), liquor (n=688), and mixed drinks (n=673). www.aodhealth.org

  40. Objectives/Methods (cont’d) • Suspected NAFLD was based on unexplained serum alanine aminotransferase (ALT) elevation using: • the NHANES III reference laboratory cut point (ALT>43), and • the 95th percentile of healthy subjects cut point (ALT>30 for men and >19 for women). • Analyses were adjusted for age, gender, race, income, neighborhood, education, caffeine intake, and physical activity. www.aodhealth.org

  41. Results • Using the reference-laboratory cut point, suspected NAFLD was observed in… • 3.2% of nondrinkers • 0.4% of moderate wine drinkers (adjusted odds ratio [OR], 0.15). • Using the healthy-subject cut point, suspected NAFLD was observed in… • 14.3% of nondrinkers • 8.6% of moderate wine drinkers (OR, 0.51). • No significant associations were seen for moderate consumers of beer or spirits. www.aodhealth.org

  42. Comments • Moderate wine consumption may have a protective effect against NAFLD. • Although the authors adjusted for many factors that relate to beverage preference in the US, other lifestyle habits of wine drinkers could explain these findings. www.aodhealth.org

  43. College-Student Drinking Patterns during the First 4 Years Johnsson KO, et al. Eur Addict Res. 2008;14(1):11–18. Summary by Nicolas Bertholet, MD, MSc www.aodhealth.org

  44. Objectives/Methods • To identify drinking trajectories in college students, researchers in Sweden examined AUDIT* scores in a cohort of 359 students each year over their first 4 college years. • Trajectories of students with risky drinking at college admission (AUDIT scores ≥11 for men and ≥7 for women) and a random sample of those with lower risk scores were analyzed. • Prevalence of risky drinking at baseline was 27%. *Alcohol Use Disorders Identification Test. www.aodhealth.org

  45. Results • Sixteen percent of students consistently reported risky drinking and 13% increased consumption from lower risk to risky drinking over the study period. • Among students with risky drinking at admission, the majority (59%) continued risky drinking. • 41% reported a decrease in drinking. • Among those with lower risk drinking at baseline, most continued lower risk drinking (83%). • Gender differences influenced trajectories. Men were more likely to report consistent risky drinking, while women were more likely to report a decrease. www.aodhealth.org

  46. Comments • Students with risky drinking do not appear to reduce this risk behavior on their own. • Risky drinking may increase during this period for young adults. • Periodic reassessment and interventions regarding drinking and consequences over the course of the college years are needed. www.aodhealth.org

  47. Cook JA, et al. AIDS. 2008;22(11):1355–1363.Summary by Jeffrey H. Samet, MD, MA, MPH Crack Cocaine’s Effect on HIV Disease Progression in Women: What Are the Major Outcomes? www.aodhealth.org

  48. Objectives/Methods • To assess the impact of crack cocaine on HIV disease progression in women, investigators analyzed data from 1686 HIV-positive participants in the Women’s Interagency Cohort Study between 1996–2004. • Analyses were based on patterns of crack cocaine use: • 1203 women (71%) were nonusers. • 429 (25%) were intermittent users (use reported previously with abstinence reported at current visit). • 54 (3%) were persistent users (use reported at every visit). www.aodhealth.org

  49. Objectives/Methods (cont’d) • Outcomes examined included death, AIDS-defining illness, CD4 count, and HIV viral load. • Potential confounders controlled for in multi-variable analyses included: www.aodhealth.org

  50. Results • Persistent use was significantly associated with increased death, AIDS-defining illness, and HIV viral load and with a decrease in CD4 count compared with nonusers. • Intermittent users had an increase in AIDS-defining illnesses compared with nonusers and had intermediate CD4 counts and HIV viral loads. www.aodhealth.org

More Related