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Update on Alcohol and Health. Alcohol and Health: Current Evidence May – June 2004. Screening in brief intervention trials targeting excessive drinkers in general practice: systematic review and meta-analysis Beich A, et al. BMJ . 2003;327(7414):536 – 542. Objectives/Methods.

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Update on alcohol and health

Update on Alcohol and Health

Alcohol and Health: Current Evidence

May–June 2004

www.alcoholandhealth.org


Screening in

brief intervention trials targeting excessive drinkers in general practice:

systematic review and meta-analysis

Beich A, et al. BMJ. 2003;327(7414):536 – 542

www.alcoholandhealth.org


Objectives methods
Objectives/Methods

  • To examine the efficiency of screening and efficacy of subsequent brief intervention (BI) for risky drinkers

  • Systematic review and meta-analysis of 8 randomized clinical trials that used screening as a precursor to BI for risky drinkers

www.alcoholandhealth.org


Results
Results

  • 9% screened drank risky amounts; 3% received BI.

  • Pooled absolute risk reduction= 10.5% (from 69% of patients drinking risky amounts to 57%)

    • 10 risky drinkers need BI to yield 1 patient no longer drinking risky amounts.

  • Screening 1000 patients and giving BI to 1/3 of patients with positive screens (the average in the studies reviewed) would yield 2 –3 patients no longer drinking risky amounts.

*Proportion of sensible drinkers at follow-up

www.alcoholandhealth.org


Conclusions comments
Conclusions/Comments

  • Many must be screened for risky drinking (like other conditions) to identify the few who will benefit from intervention.

  • BI in general practice decreases alcohol use by risky drinkers and is at least as effective as other preventive health measures.

www.alcoholandhealth.org


Different measures of

alcohol consumption and risk of

coronary heart disease and

all-cause mortality:

11-year follow-up of the

Whitehall II Cohort Study

Britton A, et al. Addiction. 2004;99:109 – 116

www.alcoholandhealth.org


Objectives methods1
Objectives/Methods

  • To investigate the contributions of alcohol consumption patterns on all-cause mortality and CHD

  • Analysis of self-reported drinking habits and CHD events (angina or fatal/non-fatal myocardial infarction) of

    • 10,308 London-based civil servants

    • followed for a median of 11 years

www.alcoholandhealth.org


Results1
Results

  • Relationship between average consumption and all-cause mortality and CHD was U-shaped.

    • Moderate consumption→ lowest death & CHD rates

www.alcoholandhealth.org


Conclusions comments1
Conclusions/Comments

  • Findings support a U-shaped relationship between average alcohol consumption and all-cause mortality and CHD.

  • Drinking frequency may be an independent predictor of all-cause mortality (further study is needed).

  • Drinking frequency may not have been adequately separated from total volume of consumption in statistical analyses.

www.alcoholandhealth.org


Brief interventions for

hazardous drinkers

delivered in primary care

are equally effective in

men and women

Ballesteros J, et al. Addiction. 2004;99:103 – 108

www.alcoholandhealth.org


Objectives methods2
Objectives/Methods

  • To examine whether BI in primary care for excessive, non-dependent drinkers is equally effective in men and women

  • Meta-analysis of randomized controlled trials of BI in primary care settings that reported outcomes separately by sex

    • Outcomes= consumption at 6- to 12-month follow-up

    • 6 trials including 1980 men and 1001 women

www.alcoholandhealth.org


Results2
Results

  • Reductions in drinking associated with BI were similar for both men and women.

  • As assessed in 4 studies, BI increased odds of drinking below hazardous levels (defined variably in each study).

    • Men (OR 2.3; 95% CI, 1.8 – 2.9)

    • Women (OR 2.3; 95% CI, 1.6 – 3.2)

www.alcoholandhealth.org


Conclusions comments2
Conclusions/Comments

  • BI moderates hazardous drinking equally well in men and women.

  • More studies are needed to determine whether BI works equally well for men and women of diverse ethnic, racial, and national backgrounds.

www.alcoholandhealth.org


Medical and psychiatric conditions of alcohol and drug treatment patients in an hmo

Medical and psychiatric conditions of alcohol and drug treatment patients in an HMO

Mertens JR, et al. Arch Intern Med. 2003;163:2511 – 2517

www.alcoholandhealth.org


Objectives methods3
Objectives/Methods

  • To assess the 12-month prevalence of co-occurring conditions in patients receiving treatment for alcohol and/or other drug (AOD) problems through managed care programs

  • Patient questionnaires and clinical records of

    • 747 patients entering treatment

    • age- and sex-matched controls from the same large HMO

www.alcoholandhealth.org


Results3

Depression (29% vs. 3%)

Anxiety (17% vs. 2%)

Injury/overdoses (26% vs. 12%)

Major psychoses (7% vs. 0.4%)

Lower back pain (11% vs. 6%)

Headache (9% vs. 4%)

Asthma (7% vs. 3%)

Hypertension (7% vs. 3%)

Acid-related disorder

(5% vs. 2%)

Arthritis (4% vs. 1%)

Results

Compared with controls, patients receiving treatment for AOD problems had a higher prevalence of the following:

Findings were similar among patients with alcohol dependence, who were also more likely to have liver cirrhosis (1% vs. 0.1%).

www.alcoholandhealth.org


Conclusions comments3
Conclusions/Comments

  • In private managed care (as in other settings), common medical conditions are more prevalent among patients with AOD problems.

  • These findings support the practice of screening for AOD problems in medical clinics and for medical problems in AOD treatment programs.

www.alcoholandhealth.org


The tweak is weak for alcohol screening among female veterans affairs outpatients

The TWEAK is weak for alcohol screening among female veterans affairs outpatients

Bush KR, et al. Alcohol Clin Exp Res. 2003;27(12):1971 – 1978

www.alcoholandhealth.org


Objectives methods4
Objectives/Methods

  • To evaluate the TWEAK, AUDIT, and AUDIT-C questionnaires to detect alcohol problems in a female outpatient population

  • Self-administered TWEAK, AUDIT, and AUDIT-C questionnaires to 393 female veteran outpatients

    • Results were compared to an interview reference standard.

www.alcoholandhealth.org


Results4
Results

  • 23% met criteria for hazardous drinking (i.e., amounts that placed them at risk for consequences) and/or alcohol abuse or dependence.

  • 10% met criteria for active alcohol abuse or dependence alone.

  • Each questionnaire had a greater sensitivity for detecting active alcohol abuse or dependence than for detecting the whole spectrum including hazardous drinking, abuse, or dependence.

www.alcoholandhealth.org


Results cont
Results (cont.)

Detecting Hazardous Drinking and/or Active Alcohol Abuse or Dependence

www.alcoholandhealth.org


Conclusions comments4
Conclusions/Comments

  • Of the questionnaires tested, the AUDIT-C appears to be the best for detecting hazardous drinking and alcohol use disorders in women.

  • Findings need to be replicated in other groups before widespread use is recommended.

  • The AUDIT-C’s brevity may help solve the greatest deficiency in screening– the failure to use any validated questionnaire at all.

www.alcoholandhealth.org


Effectiveness of opportunistic brief interventions for

problem drinking in a

general hospital setting:

systematic review

Emmen MJ, et al. BMJ. 2004;328(7435):318

www.alcoholandhealth.org


Objectives methods5
Objectives/Methods

  • To test the efficacy of brief intervention (BI) in general hospitals

  • Systematic review of 8 controlled trials comparing effects of BI to usual care in 1597 men and women in general hospitals

    • 2 studies with hospital outpatients; 6 with inpatients on orthopedics, medicine, and surgery services for various reasons

    • BIs ranged from education to simple advice to counseling (or a combination of these).

www.alcoholandhealth.org


Results5
Results

BI was associated with

  • decreases in alcohol-related problems in 4 of 6 studies;

  • decrease in consumption in only 1 study (which was of outpatients) of 7 studies;

  • significant decreases in serum gamma-glutamyltransferase levels in 2 of 4 studies.

www.alcoholandhealth.org


Conclusions comments5
Conclusions/Comments

  • It is notable that any benefit was found in these studies, given their diversity.

  • Universal screening and intervention for all general hospital inpatients may be effective, but evidence is inconclusive.

www.alcoholandhealth.org


Drinking to cope in socially anxious individuals a controlled study

Drinking to cope in socially anxious individuals: a controlled study

Thomas SE, et al. Alcohol Clin Exp Res. 2003;27(12):1937 – 1943

www.alcoholandhealth.org


Objectives methods6
Objectives/Methods

  • To investigate whether people who are socially anxious are more likely to drink to cope with their social fears than are those without anxiety

  • Survey about alcohol use in social situations administered to 23 patients w/ high social anxiety and 23 matched controls w/out social anxiety

www.alcoholandhealth.org


Results6
Results

www.alcoholandhealth.org


Conclusions comments6
Conclusions/Comments

  • People who are socially anxious intentionally drink alcohol to cope with their social fears.

  • Data do not explain whether the relationship between social anxiety and alcohol use is causally related to developing dependence.

  • Given reported associations, primary care clinicians should consider social anxiety a risk factor for alcohol problems.

www.alcoholandhealth.org


Treatment of sleep disturbance in alcohol recovery: a national survey of addiction medicine physicians

Friedmann PD, et al. J Addict Dis. 2003;22(2):91 – 103

www.alcoholandhealth.org


Objectives methods7
Objectives/Methods

  • To investigate how physicians manage sleep disturbance in patients in recovery from alcoholism

  • Survey of a random sample of physician members of the American Society of Addiction Medicine

    • 311 respondents (62% response rate)

www.alcoholandhealth.org


Results7
Results

Physicians reported 65% of their patients in

the first 3 months after detox had a sleep

disturbance.

  • 64% of physicians recommended meds to at least 1 patient to improve sleep.

  • Only 22% offered meds to more than half of these patients.

www.alcoholandhealth.org


Results cont1
Results (cont.)

www.alcoholandhealth.org


Conclusions comments7
Conclusions/Comments

  • Physicians appear reluctant to offer pharmacotherapy for sleep disturbance following detox.

  • Whether treatment of sleep disturbance in early recovery will lower the likelihood of recurrent drinking awaits empiric evaluation.

  • Despite its limitations, this study describes current practices and highlights our limited understanding of pharmacotherapy’s effectiveness for sleep disturbance post-detox.

www.alcoholandhealth.org


Physicians attitudes regarding reporting alcohol impaired drivers

Physicians’ attitudes regarding reporting alcohol-impaired drivers

Mello MJ, et al. Subst Abus. 2003;24(4):233 – 242

www.alcoholandhealth.org


Objectives methods8
Objectives/Methods

  • To examine physicians’ attitudes about reporting alcohol-impaired drivers

  • Questionnaire to physicians of 3 case scenarios involving an alcohol-impaired male driver who presents with minor injuries 1 hour after a motor vehicle crash and has 1 of 3 levels of intoxication

    • clinical diagnosis of intoxication

    • blood alcohol concentration (BAC) of 80 mg/dL

    • BAC of 240 mg/dL

  • 261 responded; 49% response rate

  • www.alcoholandhealth.org


    Results8
    Results

    • Respondents preferred to report the driver to a medical review board of the DMV than to police

      • 66% vs. 36% if clinical diagnosis

      • 63% vs. 32% if BAC 80 mg/dL

      • 81% vs. 53% if BAC 240 mg/dL

  • Most common reasons for not reporting= physician-patient confidentiality and perceived threat of civil action

  • Comfort with reporting did not differ among specialties (PCPs, emergency medicine physicians, and general surgeons).

  • www.alcoholandhealth.org


    Conclusions comments8
    Conclusions/Comments

    • Physicians are willing to report alcohol-impaired drivers to authorities but prefer using a DMV medical board rather than the police.

    • Physician preferences should be heeded when reporting systems in clinical settings are developed and implemented.

    www.alcoholandhealth.org


    Alcohol consumption during pregnancy and the risk of preterm delivery

    Alcohol consumption during pregnancy and the risk of preterm delivery

    Albertsen K, et al. Am J Epidemiol. 2004;159(2):155 – 161

    www.alcoholandhealth.org


    Objectives methods9
    Objectives/Methods delivery

    • To examine the relationship between alcohol consumption during pregnancy and preterm delivery

    • Data from 40,892 women in the Danish National Birth Cohort (a study of pregnant women and offspring) who

      • completed a computer-assisted telephone interview while pregnant

      • gave birth to a liveborn singleton

    www.alcoholandhealth.org


    Results9
    Results delivery

    • 1,880 preterm births (<37 weeks gestation)

    www.alcoholandhealth.org


    Results cont2
    Results (cont.) delivery

    • 1 or more drinks/week increased risk of very preterm birth (<32 weeks gestation), but not significantly.

      • e.g., RR 3.3 for 7 or more drinks/week

    • Type of alcoholic beverage was not associated with preterm birth.

    www.alcoholandhealth.org


    Conclusions comments9
    Conclusions/Comments delivery

    • Increases in preterm birth associated with consuming 4 or more drinks/week were not statistically significant, but are consistent with findings from some previous studies.

    • Advising pregnant women to abstain remains the safest approach.

      • But, patients who have an occasional drink during pregnancy may not be increasing their risk of preterm birth.

    www.alcoholandhealth.org


    Sociodemographic factors associated with comorbid deliverymajor depressive episodes and alcohol dependence in the general population

    Wang JL, et al. Can J Psychiatry. 2004;49(1):37 – 44

    www.alcoholandhealth.org


    Objectives methods10
    Objectives/Methods delivery

    • To examine the association between alcohol dependence (AD) and major depressive episodes (MDEs) in the general population

    • Analysis of interview data from 72,940 people aged 12 and older who participated in the Canadian National Population Health Survey

    www.alcoholandhealth.org


    Results10
    Results delivery

    • Of participants with MDEs, 9% had comorbid AD (compared to 2% without MDE).

    • Of participants with AD, 20% reported having at least one MDE (compared to 4% without AD).

    • Those with comorbidity were much more likely than those with pure AD to use mental health services in the past year (47% vs. 8%, respectively).

    www.alcoholandhealth.org


    Results cont3
    Results (cont.) delivery

    Analyses adjusted for sex, education, and employment

    www.alcoholandhealth.org


    Conclusions comments10
    Conclusions/Comments delivery

    • This study confirms that AD and MDEs often coexist and that certain people have a greater risk of comorbidity.

    • The risk factors for comorbidity reported can help clinicians identify patients in greatest need of mental health services, and hopefully increase receipt of appropriate care.

    www.alcoholandhealth.org


    Folate, methyl-related nutrients, alcohol, and the deliveryMTHFR 677C→T polymorphism affect cancer risk: intake recommendations

    Bailey LB. J Nutr. 2003;133:3748S – 3753S

    www.alcoholandhealth.org


    Objectives methods11
    Objectives/Methods delivery

    • To review the research to examine relationships between…

      • cancer risk

      • folate and other methyl-related nutrients (i.e., methionine, vitamin B6, vitamin B12)

      • alcohol

      • a specific genetic polymorphism that affects folate metabolism (MTHFR 677C →T)

        …and to make intake recommendations

    www.alcoholandhealth.org


    Results11
    Results delivery

    The review found that

    • women who drink alcohol and have a high folate intake are not at increased risk of breast cancer;

    • diets low in methionine and folate but high in alcohol are associated with a higher risk of colorectal adenoma and cancer;

    • people with the MTHFR 677CT polymorphism who have adequate folate intake may have a lower risk of colorectal cancer but are especially sensitive to alcohol’s carcinogenic effects.

    www.alcoholandhealth.org


    Results cont4
    Results (cont.) delivery

    • Intake recommendations include

      • increasing intake of folate-rich foods (e.g., citrus fruits and juices, dark green leafy vegetables, dried beans and peas);

      • increasing intake of methionine-rich foods (e.g., poultry, fish, low-fat dairy); and/or

      • using folate supplements.

    www.alcoholandhealth.org


    Conclusions comments11
    Conclusions/Comments delivery

    • Folate may reduce the risk of breast and colorectal cancer in people who drink alcohol.

    • Advise folate supplementation or increased consumption of foods rich in methyl-related nutrients for those who consume alcohol and have inadequate diets.

      • Because of possible folate toxicity, recommend increased folate intake only to people with inadequate intake and, in particular, to those who also drink alcohol.

    www.alcoholandhealth.org


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