Transcript Jan-Feb 2015

Update on
Alcohol, Other Drugs,
and Health
January–February 2015
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1
Studies on
Interventions &
Assessments
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The Majority of People with
Unhealthy Alcohol Use Do Not
Have Dependence
Esser MB, et al. Prev Chronic Dis. 2014;11(E206):1–11.
Summary by Hillary Kunins, MD, MPH
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Objectives/Methods
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Numerous clinical studies have found that most patients
with unhealthy alcohol use do not have DSM-IV
dependence, but no recent population data exist.
Using the National Survey on Drug Use and Health (2009–
2011), investigators examined evidence of “excessive
drinking” (heavy episodic drinking,* any underage
drinking, and drinking during pregnancy) and DSM-IV
alcohol dependence among 138,000 adults.
* Defined as ≥5 drinks for men or ≥4 for women on at least 1 occasion
in the last 30 days.
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Results
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In the past month, 29% of participants had any
excessive drinking, 27% had heavy episodic
drinking, and 3.5% had alcohol dependence.
Highest rates of each were among men, people
aged 18–24, and unemployed persons.
Dependence was highest among Native
Americans/Alaskan Natives.
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Results (cont’d)
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The prevalence of alcohol dependence was 10% among people
with any excessive drinking, 10.5% among people with heavy
episodic drinking, and 1% among people with alcohol
consumption reporting no heavy episodic drinking. Among
people with heavy episodic drinking, alcohol dependence
increased by frequency of episodes (4% among persons with 1–
2 past-month episodes; 30% with ≥10 episodes).
Alcohol dependence was highest among those with less than a
high school education or some college and with a family income
of ≤$25,000. Heavy episodic drinking rates were higher among
people with family incomes of ≥$75,000 compared with those
with lower incomes.
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Comments
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This study reminds us that the majority of US adults
who consume alcohol, even if they do so excessively,
do not meet criteria for alcohol dependence.
To address this public health problem, both population
and clinical interventions need to focus on reducing
excessive consumption overall.
Although the causality of the differential patterns in
prevalence of alcohol dependence compared with
unhealthy alcohol use cannot be determined from this
cross-sectional study, it raises concern that the risk of
alcohol dependence may not be distributed equally.
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7
Interventions to Reduce
Prenatal Alcohol Use Have
Mixed Results
van der Wulp NY, et al. J Med Internet Res. 2014;16(12):e274.
Summary by Kevin L. Kraemer, MD, MSc
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Objectives

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Researchers sought to test the effectiveness of an internetbased, computer-tailored intervention to reduce prenatal
alcohol use.
They randomized 60 midwifery practices to 1 of 3 arms:
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1) computer-tailored feedback, delivered via webpage and e-mail at
baseline, 6 weeks, and 12 weeks;
2) face-to-face health counseling by the midwives (1 10-minute
session 2 weeks after baseline and 2 1-minute sessions, 8 and 14
weeks after baseline);
3) usual care.
The study enrolled 349 pregnant women (mean age = 33
years, mean gestational age = 7.9 weeks, mean prepregnancy drinks in a week = 5.8, mean pregnancy drinks
in a week = 1.1).
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Results
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At 24-week follow-up, 78% of the computer-tailored arm, 72% of
the health counseling arm, and 55% of the usual care arm reported
abstinence.
In an adjusted model, pregnant women in the computer-tailored
arm were more likely to be abstinent at follow-up (odds ratio, 2.77)
than those in usual care. The health counseling arm did not differ
significantly from usual care.
At follow-up, among the 79 pregnant women who continued
drinking, mean alcohol use was 0.35 drinks in a week in the
computer-tailored arm, 0.77 drinks in a week in the health
counseling arm, and 0.48 drinks in a week in the usual care arm.
Process evaluation indicated “suboptimal implementation of the
health counseling intervention by the midwives.”
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Comments
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These findings suggest that computer-tailored feedback may be an
effective intervention to reduce self-reported prenatal alcohol use.
The authors believe this effect may be due, in part, to the computer
helping maintain the pregnant women’s anonymity. However, it
cannot be determined from this study if the computer-tailored
intervention is superior to face-to-face brief counseling due to
uncertainty about how well the counseling was delivered, and the
questionable accuracy of self-reported drinking in these
circumstances.
Further work is certainly needed, along with an estimation of the
cost-effectiveness of the computer intervention.
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11
Housing First Intervention
Impacts Unhealthy Use of
Alcohol, Not Drugs
Kirst M, et al. Drug Alcohol Depend. 2015;146:24–29.
Summary by Nicolas Bertholet, MD, MSc
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Objectives/Methods
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Housing First (HF) interventions provide homeless individuals with
housing and other support services and have shown efficacy in
improving quality of life, but little is known about substance use
outcomes among its recipients.
This Canadian study investigated the impact of an HF intervention on
alcohol and other substance use outcomes among 575 individuals with
mental illness and homelessness—with or without a co-occurring
substance use disorder—who were randomized to an HF intervention
or treatment as usual and were followed up at 2 years.
Participants were mostly male (68%) and 53% of them had a duration
of homelessness of ≥3 years.
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Results
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At baseline, 31% reported any unhealthy alcohol use in
the past 30 days and 39% reported any drug use.
At 2 years, those who received the HF intervention had
greater reductions in the number of days of unhealthy
alcohol use over the past month (incidence rate ratio,
0.46) and money spent on alcohol.
There were no differences between groups at 2 years for
the number of drug problems over the past 30 days and
money spent on drugs.
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Comments
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This study found that the HF intervention positively
affected alcohol use outcomes but not drug use among
people with homelessness and mental illness, which is
consistent with what other studies have shown.
It remains to be determined how best to impact drug use
outcomes with HF interventions since these individuals
may need additional support.
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15
Buprenorphine Maintenance
is More Effective than Taper
for Treating Prescription
Opioid Use Disorder in
Primary Care

Fiellin DA, et al. JAMA Intern Med. 2014;174:1947–1954.
Summary by Darius A. Rastegar, MD
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Objectives/Methods
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Buprenorphine is an important treatment option for opioid
use disorder and can be prescribed as a gradual taper or
maintenance treatment.
This trial recruited 113 subjects with DSM-IV prescription
opioid dependence in a primary care practice. All participants
underwent a 2-week buprenorphine induction, then
randomly received either a stable dosage of buprenorphine
for 4 weeks, followed by a gradual taper over 3 weeks
(taper), or a stable dose for 14 weeks (maintenance).
All subjects received weekly drug counseling.
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Results
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Subjects assigned to taper had a lower mean percentage of
opioid-negative urine samples than those assigned to
maintenance (35% versus 53%). The difference was
observed primarily during the second half of the trial (33%
versus 64%).
During the second half of the trial, subjects assigned to
taper reported more mean days of opioid use in the past
week than those in the maintenance group (1.3 versus 0.5).
Subjects assigned to taper achieved fewer mean maximum
consecutive weeks of opioid abstinence than those assigned
to maintenance (2.7 versus 5.2) and were less likely to
complete the trial (11% versus 66%).
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Comments
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This study confirms that FOR PRESCRIPTION
OPIOID DEPENDENCE TREATED IN PRIMARY
CARE, opioid agonist maintenance treatment is
more effective than even a prolonged taper and
reinforces that we should not place arbitrary time
limits on treatment or pressure patients to taper
their dose.
It also adds to the growing body of evidence
demonstrating that this treatment can be provided
in a primary care setting, but more primary care
physicians need to do
this in order to meet the 19
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Individuals with Prescription
Opioid Use Disorder May
Respond Better to
Buprenorphine Treatment
than Those with Heroin Use
Disorder
Nielsen S, et al. J Subst Abuse Treat. 2015;48:70–76.
Summary by Jeanette M. Tetrault, MD
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Objectives/Methods
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Prior studies have suggested that buprenorphine plus medical
management can be an effective treatment for individuals with
prescription opioid use disorder, and that these patients may have
more favorable outcomes with buprenorphine treatment than those
with heroin use.
This secondary data analysis compared treatment outcomes among
179 individuals with either prescription opioid (PO), heroin (H), or
combined prescription opioid and heroin (POH) use disorder, drawing
on data from a 16-week randomized clinical trial studying four different
behavioral treatments coupled with buprenorphine and standard
medical management.
A subsequent 16-week buprenorphine-only phase followed. Follow-up
was performed at weeks 40 and 52.
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Results
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At study entry, the PO-only patients were more likely to be white,
married, employed in the last 30 days, and to have shorter duration of
opioid use than those in the other two groups.
The PO group provided more opioid-negative urine drug screens
throughout treatment (PO: 70%, H: 38%, POH: 40%), and at the end
of treatment (PO: 65%, H: 33%, POH: 31%).
Retention was lowest in the heroin group (PO: 80%, H: 57%, POH:
65%).
There were no significant differences in buprenorphine dose across the
groups.
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Comments
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
The authors concluded that those patients with
prescription opioid use disorder had more favorable
buprenorphine treatment outcomes than individuals with
heroin or combined prescription opioid and heroin use
disorder.
However, differences in baseline characteristics between
the three groups may explain some of the outcomes as
the PO group had more social support at treatment
outset.
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Studies on
Health Outcomes
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135,971 Emergency
Department Visits in the US for
Opioid Overdose in 2010
Yokell MA, et al. JAMA Intern Med. 2014;174(12):2034–2037.
Summary by Alexander Y. Walley, MD, MSc
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Objectives/Methods
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Researchers analyzed the 2010 Nationwide
Emergency Department Sample to characterize
opioid overdose-related visits in the US.
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Results
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There were an estimated 135,971 visits in 2010.
Of all visits, prescription opioids (including methadone) were
involved in 68%, heroin in 16%, multiple opioids in 2.7%, and
unidentified opioids in 13%.
Benzodiazepine intoxication co-occurred in 22% of opioid
overdoses.
Among the 45% of patients who were treated and released from
the emergency department (ED), the mean charge was $3397;
conversely, the mean charge for a hospitalized patient was
$29,807 with a mean length of stay of 3.8 days.
1.4% of patients died before hospital discharge.
Total charges for opioid overdose-related visits amounted to $2.3
billion in 2010.
www.aodhealth.org
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Comments
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This study of a nationally representative sample
of ED visits provides volume, financial charges,
and mortality estimates of the burden of opioidrelated ED visits.
In addition to the overdoses reflected in ED
visits, there are many fatal and non-fatal
overdoses that occur elsewhere.
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28
Specific Genetic Factors Modify
the Reduction in Heart Disease
Risk Associated with Alcohol
Consumption
Mehlig K, et al. Alcohol. 2014;48:695–700.
Summary by R. Curtis Ellison, MD
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Objectives/Methods
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A number of genetic and environmental factors modify the association
between alcohol consumption and coronary heart disease (CHD).
Investigators carried out a population-based case-control study to
determine whether there was an interaction between cholesteryl ester
transfer protein (CETP TaqIB) genotypes and alcohol consumption for
its effects on the risk of CHD.
The authors defined three categories of ethanol intake using tertiles of
sex-specific average consumption (lowest = < 3.2 g ethanol in a day
for women, < 6.5 g for men; intermediate = 3.2–6.3 g for women;
6.5–13.1 g for men).
The lowest tertile of alcohol consumption was chosen as the reference
category.
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Results
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Overall, participants with “intermediate” ethanol intake had
lower risk of CHD than those with the lowest ethanol intake
(odds ratio [OR], 0.65).
Participants who were CETP TaqIB B2 homozygotes had the
greatest effect, for intermediate versus lowest ethanol
intake (OR, 0.21). For B1B1 combined with B1B2b
participants, the OR was 1.12 for abstainers and 0.80 for
the intermediate category (versus the lowest).
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Comments
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Participants in this study included not only those with
new cases of CHD but people “who had an exacerbation
of previously diagnosed coronary heart disease,” making
it difficult to compare the results with those of other
studies.
The controls were considerably younger than the cases
and had different medical histories, so residual
confounding remains possible.
The major concern with this paper is the small number of
cases in many categories, limiting the general
applicability of the results.
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Comments (cont’d)
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Further, a number of previous large studies have had very
conflicting results regarding the effects of CETP
polymorphisms on the alcohol-CHD association.
While this paper adds information on one of many factors
that affect the association between alcohol consumption
and CHD, larger studies in different populations will be
needed to determine the overall importance of this
particular genetic polymorphism.
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The Association of Alcohol
Consumption with the Risk of
Death from Colorectal Cancer
Cai S, et al. Eur J Cancer Prev. 2014;23(6):532–539.
Summary by R. Curtis Ellison, MD
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Objectives/Methods
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Data from prospective cohort studies on the association
between alcohol consumption and the occurrence of
colorectal cancer (CRC) are conflicting, with some
suggesting an increase in risk while others failing to show an
effect.
Researchers analyzed data from 9 cohort studies (with a
total of more than 2 million subjects) to evaluate how the
level of alcohol intake relates to CRC mortality.
A total of almost 4000 deaths from CRC were recorded.
www.aodhealth.org
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Results
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The consumption of an average of ≥ 50 g alcohol (about ≥
4 standard drinks) in a day was associated with a modest
increase in the risk of death from CRC (relative risk, 1.21).
“Light” (≤ 12.5 g in a day) and “moderate” average
consumption (12.6–49.9 g in a day) did not increase the
risk of CRC death. Odds ratios were 0.97 and 1.04,
respectively.
www.aodhealth.org
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Comments
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Despite a very large sample size, the authors were unable
to evaluate differences in effect according to type of
beverage consumed, the pattern of drinking, or the
underlying folate levels of subjects, all of which probably
modify the relation between alcohol consumption and
CRC.
Overall, this meta-analysis supports a finding of increased
risk of death from CRC associated with heavy drinking.
However, it shows rather convincingly that regular
consumption of “light” to “moderate” amounts of alcohol
does not increase the risk of death from this disease.
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Studies on
HIV and HCV
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Opioid Agonist Treatment
Is Associated with a Lower
Incidence of Hepatitis C
Infection Among People
with Injection Drug Use
Tsui JI, et al. JAMA Intern Med. 2014;174:1974–1981.
Summary by Darius A. Rastegar, MD
www.aodhealth.org
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Objectives/Methods
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Injection drug use (IDU) is the primary risk factor
for hepatitis C virus (HCV) infection.
Researchers examined data from a cohort of 552
younger adults (< 30 years) with IDU who were
not HCV infected at the time of enrollment. The
outcome of interest was incident HCV infection.
Recruitment began in 2000 and the final
assessment was in 2013, with a total of 680
person-years of observation.
www.aodhealth.org
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Results
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At the time of enrollment, participants’ median
age was 23; 68% were men, 40% did not
graduate from high school, and 69% were
homeless or did not have stable housing in the
last 3 months. The median duration of IDU was
3.6 years and 33% of participants had daily
use; 60% reported that heroin was the drug
they used most often. Most (82%) reported
receiving no substance use treatment in the
prior year and only 4% had received opioid
agonist treatment (OAT).
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Results (cont’d)
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There were a total of 171 incident HCV infections, with an
estimated incidence rate of 25 per 100 person-years.
Participants who reported receiving OAT in the past year
had a significantly lower incidence of HCV (rate ratio [RR],
0.31), while those who reported other forms of treatment
did not. The RR for non-opioid agonist treatment was
0.63, and for opioid agonist detoxification it was 1.45.
www.aodhealth.org
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Comments
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This study shows that HCV is still a common
hazard for people with IDU and confirms prior
observations that OAT reduces the risk of
acquiring this deadly infection.
Unfortunately very few of the participants
received methadone or buprenorphine
maintenance treatment; we need to do more to
improve access.
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43
Awareness of Risk is Not
Enough to Decrease Alcohol Use
Among People with HIV and
Heavy Alcohol Consumption
Elliott JC, et al. Alcohol Clin Exp Res. 2014;38(12):3052–3059.
Summary by Kevin L. Kraemer, MD, MSc
www.aodhealth.org
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Objectives/Methods
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Although alcohol use has known risks for people
with HIV, it is not clear whether those who drink
are aware of these risks and change their alcohol
use accordingly.
In this study, researchers interviewed 254 HIVinfected adults (78% men, 50% black, 45% Latino,
32% co-infected with hepatitis C (HCV), 77%
prescribed antiretroviral medication) who had at
least 1 instance of heavy episodic drinking (≥ 4
drinks on an occasion for men or ≥ 3 drinks for
women) in the past 4 weeks.
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Results
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Participants had heavy alcohol use, with averages
of > 5 drinks in a drinking day and at least weekly
instances of heavy episodic drinking.
63% of the total sample and 67% of HIV/HCV coinfected patients were aware they had a medical
problem made worse by alcohol use. However,
awareness of risk was not associated with
decreased alcohol use.
www.aodhealth.org
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Results (cont’d)
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HIV/HCV co-infected patients were more likely
than HIV mono-infected patients to report
restriction of alcohol use to avoid a medical
problem (72% versus 61%).
Reported alcohol use was lower—but still well
above low-risk levels—among those who reported
restriction of alcohol consumption to avoid a
medical problem.
www.aodhealth.org
47
Comments
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Awareness of having a medical problem that is
exacerbated by alcohol use was not associated
with decreased consumption among people with
HIV and heavy drinking, many of whom were
co-infected with HCV.
These findings suggest that education about risk
in this population should be followed with
behavioral therapy and/or pharmacotherapy.
www.aodhealth.org
48
Prescription Opioid Use and
Risk of HIV/HCV
Transmission Among Young
Adults
Mateu-Gelabert P, et al. J Subst Abuse Treat. 2015;48(1):13–20.
Summary by Jeanette M. Tetrault, MD
www.aodhealth.org
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Objectives/Methods
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The prevalence of non-medical use of prescription opioids
(PO) in the US has been growing exponentially, particularly
among young adults.
This is, in part, due to the perception that PO use is safer
than heroin use.
This qualitative study explored drug use and sexual risk
experiences of young adults with PO use as they relate to
risk of HIV and hepatitis C (HCV) transmission.
Forty-six young adults between the ages of 18-32 were
recruited in New York City for individual in-depth semistructured interviews focusing on key domains of the prespecified research aims.
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Results
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70% of participants reported a pattern of escalating PO use over
time, eventually transitioning from PO use to heroin use; 63%
reported changing their route of administration over time from
oral or intranasal to injection drug use (IDU).
Individuals with IDU reported sporadic syringe-sharing, frequent
sharing of non-syringe injection paraphernalia, and selective
sharing with people who are assumed to be uninfected with HIV
or HCV. Participants reported little knowledge of HCV injectionrelated risks and safer injection practices.
Participants reported engaging in unprotected sex with casual
partners, exchanging sex for POs, and group sex, and that PO
use increased the risk of sexual violence.
www.aodhealth.org
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Comments
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Although these data are obtained from a single
region, it sheds light on a growing concern
regarding the disconnect between the
perception of PO use as relatively innocuous and
the reality of the risk behaviors with which it is
often associated.
Further research should target prevention efforts
within this population.
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52
Psychosocial Factors Affect
Risk Behaviors and HIV
Outcomes Among People with
Injection Drug Use
Mizuno Y, et al. AIDS Behav. 2014 [Epub ahead of print]. doi:
10.1007/s10461-014-0890-0.
Summary by Jessica S. Merlin, MD, MBA
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Objectives/Methods
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Syndemics are interrelated social problems that
may be mutually reinforcing and combine to
negatively influence health outcomes.
Using data from a randomized controlled trial of
HIV transmission prevention among 1052 people
with injection drug use (IDU) from 4 large US
cities that addressed sexual and injection risk
behaviors, the authors investigated syndemic
psychosocial factors and their relationship to both
risk behaviors and HIV outcomes.
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Results
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Participants reported psychosocial factors including
polydrug use (59%), psychological distress (37%),
homelessness (32%), incarceration (25%), and low social
support (13%).
Most participants (80%) had a detectable viral load, and
21% reported no HIV care in the past 6 months. Among
the 501 participants who were receiving antiretroviral
therapy, 25% reported suboptimal adherence.
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Results (cont’d)
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Psychosocial factors commonly co-occurred; this was
especially true for low social support and psychological
distress, homelessness and low social support, and
homelessness and incarceration.
With one exception (adult abuse), all psychosocial factors
investigated were associated with unsafe sex and sharing
needles and at least two suboptimal HIV outcomes.
Homelessness was associated with all suboptimal HIV
outcomes, and low social support was associated with all
but one (adherence).
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Comments
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This study suggests that interventions targeting
people with HIV and IDU should consider the
multiple factors that may influence an
individual’s risk behavior or HIV outcomes.
The authors point out that these psychological
factors often have a common root cause (e.g.,
poverty).
This study supports the importance of exploring
interventions that address these root causes.
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