Download May-June 2014 - Boston University

Update on
Alcohol, Other Drugs,
and Health
May–June 2014
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1
Studies on
Interventions &
Assessments
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2
Implementation of Screening
and Brief Intervention with
Fidelity in Trauma Centers:
Challenging but Not
Impossible
Zatzick D, Donovan DM, Jurkovich G, et al.
Addiction. 2014;109:754–765.
Summary by Peter D. Friedmann, MD, MPH
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3
Objectives/Methods


This study randomized 20 trauma centers either
to receive enhanced training in motivational
interviewing (MI) for nursing and social work
screening and brief intervention (SBI) providers
(1 day of training and 4 30-minute follow-up
coaching sessions), or to no additional training for
SBI staff (control).
To assess MI skills, providers from both groups
participated in 7 20-minute standardized
telephone MI sessions with patient-actors, and
the sessions were scored using a coding system.
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4
Objectives/Methods (cont’d)

The study then enrolled 878 in-patient
trauma patients with positive blood alcohol
levels who were assessed for alcohol
consumption and consequences (using the
AUDIT) at the initial trauma visit and at 6and 12-month follow-up.
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5
Results



Providers who received the training demonstrated
greater MI skills and spent twice as much time at the
bedside delivering alcohol SBI than those who did not.
The rates of hazardous alcohol use declined in both
groups, but the MI group experienced an 8% greater
reduction and had a greater increase in days abstinent
over the follow-up year.
The MI had a greater effect (15%) on hazardous alcohol
use in patients without traumatic brain injury (TBI).
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6
Comments



Implementation of SBI with fidelity in health care
settings is challenging, but this study shows that even
brief training of providers can have a positive clinical
effect.
If these findings generalize to the 30 million patients
who present with traumatic injury annually in the US,
the reductions in alcohol use—particularly among
patients without TBI—would have an important
population impact.
However, replication and dissemination of the intensive
training, practice, and coaching required might also
prove challenging but not impossible.
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7
Predictors of Sustained
Heavy Episodic Drinking
Among Young Adults
Wellman RJ, Contreras GA, Dugas EN, et al.
Alcohol Clin Exp Res. 2014;38(5):1409–1415.
Summary by Kevin L. Kraemer, MD, MSc
www.aodhealth.org
8
Objectives


To assess predictors of sustained heavy episodic drinking
during the young adult years, researchers analyzed data
from 2 assessments (average ages 20 and 24 years,
respectively) of 609 participants, who at the first
assessment reported heavy episodic drinking (defined as
≥5 alcoholic beverages on at least 1 occasion in the past
year).
Participants who reported heavy episodic drinking at both
assessments were categorized as “sustainers,” whereas
those who reported it at the first assessment only were
categorized as “stoppers.”
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9
Results



Of all participants, 85% were categorized as “sustainers”
and 15% as “stoppers.”
“Sustainers” were more likely to be younger, male, less
educated, younger at first drink, have higher frequency
of heavy episodic drinking at a younger age, and to
report greater novelty seeking and impulsivity.
Among “sustainers,” 20% had heavy episodic drinking
weekly, 44% monthly, and 36% less than monthly. A
higher frequency of heavy episodic drinking at the
second assessment was predicted by similar factors as
above, with the addition of depressive symptoms at an
earlier age.
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10
Comments



This study identified factors associated with sustained
heavy episodic drinking during young adulthood that may
be useful for identifying those at greatest risk.
Future research should assess whether frequent heavy
drinking and alcohol use disorders are “sustained” at this
same level.
The more salient finding may be that 77% of young
adults in the study reported heavy episodic drinking and
85% of those sustained some level of it over 4 years.
This suggests that all young adults should be screened
for unhealthy alcohol use.
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11
No Clear Advantage of InPerson Versus ComputerBased Brief Interventions for
Illicit Drug Use
Schwartz RP, Gryczynski J, Mitchell SG, et al.
Addiction. 2014;109(7):1091–1098.
Summary by Nicolas Bertholet, MD, MSc
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12
Objectives/Methods


The implementation of screening, brief
intervention, and referral to treatment for illicit
drug use in primary care has been supported by
the US government despite a clear evidence base,
and several barriers to delivery exist, notably
medical providers’ time constraints or the need to
hire behavioral health counselors.
These barriers may be overcome with the use of
computer-based brief interventions.
www.aodhealth.org
13
Objectives/Methods (cont’d)


Researchers compared computer-based with in-person
brief interventions in a parallel randomized controlled trial
among 360 adult primary care patients with Alcohol,
Smoking and Substance Involvement Screening Test
(ASSIST) scores of 4–26, indicating “moderate risk” drug
use.
At baseline, 88% of patients scored in the moderate risk
range for marijuana use, 28% for alcohol, 20% for
opioids, 18% for cocaine, 12% for sedatives, and 11% for
amphetamines or methamphetamines.
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14
Results



There was no change in the overall prevalence of drug-positive hair
tests from baseline to 3 months (62% positive at both baseline and
follow-up, no difference by treatment group).
At 3 months, there were no differences in global ASSIST drug use
scores or hair tests for drug use between participants who received
the in-person and those who received the computer-based brief
interventions.
There were significant advantages for the computer-based over the
in-person brief intervention for specific ASSIST scores for marijuana
use (mean difference = -1.73 [n = 314]) and cocaine use (mean
difference = -4.48 [n = 66]). No differences were observed on other
specific ASSIST scores (alcohol, amphetamines or
methamphetamines, sedatives, or opioids).
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15
Comments


By comparing two modes of brief intervention
delivery, this study did not demonstrate efficacy
of screening and brief intervention for drug use
or the superiority of an in-person or computerbased intervention.
Additional evidence of the efficacy of screening
and brief intervention for drug use, independent
of its delivery mode, is still needed.
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16
Patients at Risk for Opioid
Overdose can be Identified
through Prescription Drug
Monitoring Programs
Baumblatt JA, Wiedeman C, Dunn JR, et al.
JAMA Intern Med. 2014;174(5):796–801.
Summary by Darius A. Rastegar, MD
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17
Objectives/Methods


Prescription opioid overdose deaths have increased
dramatically in the U.S. in recent years. To address this
problem, most states have established prescription drug
monitoring programs (PDMP).
Researchers used data from the Tennessee PDMP to
compare individuals who had an opioid-related death in
2009/2010 with randomly selected age and sex-matched
controls who had also received at least one opioid
prescription in the year prior to the death of the matched
case.
www.aodhealth.org
18
Results



Each year, approximately 2 million Tennessee residents
filled an opioid prescription, nearly one-third of the state
population. Rates increased from 2007 to 2011 and were
higher for women and for people in rural counties.
There were 932 opioid-related deaths during the 24 months
studied; 592 (64%) were patients in the PDMP.
Opioid-related deaths were associated with having 4 or
more prescribers (adjusted odds ratio [aOR], 6.5), using 4
or more pharmacies (aOR, 6.0), and receiving more than
100 mg of morphine milligram equivalents daily (aOR,
11.2); 55% of individuals who died had at least 1 of these
risk factors and 6% had all 3.
www.aodhealth.org
19
Comments


This study confirms prior observations that
dose prescribed and number of prescribers
and pharmacies are associated with an
increased risk of opioid overdose.
The number of individuals at risk steadily
increased during this time period despite the
availability of the PDMP, suggesting that
access to this data alone does not change
practitioner behavior.
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20
What is the Optimal T-ACE
Screening Cut-Point for AtRisk Alcohol Use in Pregnant
Women?
Chiodo LM, Delany-Black V, Sokol RJ, et al.
Alcohol Clin Exp Res. 2014;38(5):1401–1408.
Summary by Kevin L. Kraemer, MD, MSc
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21
Objectives/Methods

The T-ACE* screener was developed to detect atrisk alcohol use among pregnant women; however,
in some settings the usual cut-point of ≥2 points
may produce false-positives.
* T-ACE screener: Tolerance – “How many drinks does it take to make you feel high?”
(2 points for “2 or more drinks”); Annoy – “Has anybody ever annoyed you by
complaining about your drinking?” (1 point for “Yes”); Cut Down – “Have you ever felt
you ought to cut down on your drinking?” (1 point for “Yes”); Eye-opener – “Have you
ever needed a drink first thing in the morning to get going?” (1 point for “Yes”). A TACE score of ≥3 is labeled “TACER-3” by the authors of the report.
www.aodhealth.org
22
Objectives/Methods (cont’d)


To assess the potential advantage of increasing the T-ACE
cut-point to 3 points, researchers administered the T-ACE
to 239 urban-dwelling African-American pregnant women
(mean age = 25 years; gestational age at screen = 23
weeks) at their first prenatal visit and compared different
T-ACE scores for detecting alcohol use at conception, at
the first prenatal visit, and across pregnancy.
Alcohol use was measured by validated semi-structured
interview.
www.aodhealth.org
23
Results


Of all participants, 42% had a T-ACE score of ≥2
and 12% had a T-ACE of ≥3.
Participants with a T-ACE score of ≥3 were
significantly more likely to have greater mean daily
alcohol consumption and consumption on a
drinking day at conception, the first prenatal visit,
and across pregnancy than participants with a TACE equal to 2 (30% of participants), and those
with a T-ACE of <2.
www.aodhealth.org
24
Comments



This study found that women in this cohort with a T-ACE score of ≥3
points reported higher levels of alcohol use at several key points in
pregnancy than those with lower scores.
Unfortunately, the study’s implications for screening in the prenatal
setting are not clear because an “at-risk” alcohol use screening
target was not defined; the main comparison T-ACE cut-point was a
score equal to 2 points rather than ≥2; and the usual screening tool
measures of sensitivity, specificity, positive predictive value, and
negative predictive value were not reported.
Regardless, it remains important to identify and address any drinking
during pregnancy to reduce the risk for fetal alcohol effects.
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25
Studies on
Health Outcomes
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26
Methadone Results in Longer
Treatment Retention than
Buprenorphine; Higher Doses
are Associated with Longer
Retention for both Medications
Hser Y, Saxon AJ, Huang D et al.
Addiction. 2014;109:79–87.
Summary by Alexander Y. Walley, MD, MSc
www.aodhealth.org
27
Objectives/Methods




Previous studies have demonstrated similar effects of methadone
and buprenorphine in reducing heroin use, but worse treatment
retention among patients receiving buprenorphine.
Many treatment providers cap buprenorphine doses at 16 mg
because neuroimaging studies show high opioid receptor
occupancy at that dose level, and some insurers discourage higher
doses.
Researchers conducted a 24-week multi-site open-label
randomized controlled trial of buprenorphine versus methadone
among 1267 subjects with opioid use disorder to measure
retention in treatment.
Medications were administered daily (except Sundays and
holidays) by staff at opioid treatment programs.
www.aodhealth.org
28
Results


At 24 weeks, 74% of the patients receiving
methadone remained in treatment (mean
days = 141), versus 46% of those receiving
buprenorphine (mean days = 104).
Within the first 30 days, 25% of the patients
receiving buprenorphine versus 8% of those
receiving methadone dropped out of
treatment.
www.aodhealth.org
29
Results (cont’d)

For both methadone and buprenorphine patients, higher
dose was associated with more time in treatment.



For methadone, doses of ≥60 mg resulted in retention rates of
>80%, whereas rates for doses of ≤40 mg were <40%.
For buprenorphine, doses of 30–32 mg resulted in retention rates
close to 60%, whereas rates for doses of ≤10 mg were <20%.
During the first 9 weeks of treatment, opioid positive urine
results were lower in the buprenorphine versus methadone
groups (odds ratio, 0.63), but were similar for weeks 10–
24 at approximately 40% in both groups.
www.aodhealth.org
30
Comments



This study demonstrated substantially better
treatment retention for methadone compared
with buprenorphine.
Furthermore, retention was better at higher
doses for both medications.
Dose limits on buprenorphine at 16 mg should
be reconsidered and warrant examination in
controlled trials.
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31
Symptoms—Not Frequency of
Use—Predict Adverse Health
Effects Associated with
Cannabis Use in Young Men
Baggio S, N’Goran AA, Deline S, et al.
Addiction. 2014;109(6):937–945.
Summary by Peter D. Friedmann, MD, MPH
www.aodhealth.org
32
Objectives/Methods



This prospective cohort study examined cannabis use and selfreported health issues among 5084 men in their early twenties
over an average of 15 months follow-up.
Researchers used the Cannabis Use Disorder Identification Test
(CUDIT) to measure symptoms of cannabis use disorder; the
Major Depressive Inventory to measure depression; and the
Short-Form Health Survey (SF-12) to measure physical and
mental health.
Health consequences included accident/injury, emergency
department admission, suicide attempt, need for medical
treatment, overnight hospitalization, and outpatient surgery.
www.aodhealth.org
33
Results



Of all participants, 62% reported no cannabis use; 23% had
continuing use throughout the study; 8% initiated use
during the follow-up period; and 7% had use at baseline
and then stopped.
Among the 1149 participants who continued cannabis use,
49% reported monthly use or less, and 16% daily or almost
daily. They averaged 7 symptoms of cannabis use disorder
on the CUDIT.
In cross-lagged longitudinal models, the number of
symptoms of cannabis use disorder—not the frequency of
use—predicted depression, other mental health, and
physical health consequences over follow-up.
www.aodhealth.org
34
Comments



Without intervention, the pattern of cannabis use is
stable among young men and daily use is common.
In assessing the risk of developing health problems, a
formal assessment of the number of symptoms of
cannabis use disorder has greater prognostic value than
the frequency or magnitude of cannabis use.
Whether these findings generalize to women and more
diverse populations, and how to use them in a targeted
intervention, will require further study.
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35
Maintenance Therapy as
Harm Reduction: Reducing
Overdose Deaths with
Opioid Agonist Treatment
Volkow ND, Frieden TR, Hyde PS, Cha SS.
N Engl J Med. 2014;370(22):2063–2066.
Summary by Jeanette M. Tetrault, MD
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36
Objectives/Methods

In this perspective piece, Nora Volkow, MD, the
Director of the National Institute on Drug Abuse
(NIDA), and colleagues from the Substance Abuse
and Mental Health Services Administration, the
Centers for Disease Control and Prevention, and the
Centers for Medicare and Medicaid Services outline
some of the efforts made by multiple agencies to
reduce harmful opioid use and safeguard legitimate
and appropriate access to opioid agonist treatment
(OAT).
www.aodhealth.org
37
Results

There are a number of barriers contributing to the
underutilization of and poor access to OAT:



A lack of trained providers as well as misunderstandings about addiction
pharmacotherapy, including the notion that OAT simply replaces one addiction with
another, abstinence-based treatment models, and systematic under-dosing of OAT.
Policy barriers, including dosage limits, annual or lifetime medication limits, prior
authorization and reauthorization requirements, minimal coverage of counseling,
“fail first” criteria, and lack of coverage of certain OAT by commercial insurance
plans.
Department of Health and Human Services agencies are
working collaboratively to reduce these barriers by
improving utilization of and expanding access to OAT along
with other efforts to reduce opioid overdoses.
www.aodhealth.org
38
Comments



Implementation of the Affordable Care Act along
with the Mental Health Parity and Addiction
Equity Act will increase access to addiction
treatment services for many Americans.
One aspect of reducing opioid overdose deaths is
to improve utilization of and access to OAT,
which is recognized as a priority area by many
federal agencies.
However, to be successful, these efforts require
buy-in from the medical community as a whole.
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39
Buprenorphine Treatment:
A Missed Opportunity to
Offer Smoking Cessation
Treatment
Nahvi S, Blackstock O, Sohler NL, et al. J Subst Abuse Treat.
2014 [Epub ahead of print]. doi:10.1016/j.jsat.2014.04.001.
Summary by Jeanette M. Tetrault, MD
www.aodhealth.org
40
Objectives/Methods



Patients with opioid use disorder are three-to-four times more
likely than the general population to have tobacco use, yet
smoking cessation treatment is rarely offered in substance use
treatment settings.
Office-based buprenorphine treatment provides a unique
opportunity to engage patient populations with a high prevalence
of tobacco use disorder.
The authors of this study investigated smoking status,
prescription of smoking cessation medications, and factors
associated with receipt of smoking cessation medications among
319 patients treated for opioid use disorder in an office-based
buprenorphine treatment program over a 5-year period.
www.aodhealth.org
41
Results


Of the sample, 67% smoked at initiation of
buprenorphine treatment; 16% were
prescribed smoking cessation medications.
Buprenorphine treatment retention at 6 months
was associated with prescription of smoking
cessation medications (25% of retained
patients versus 10% of non-retained patients
were prescribed medications for smoking
cessation).
www.aodhealth.org
42
Comments


Although tobacco use is common among patients
with opioid use disorder at buprenorphine
treatment initiation, documentation of both
smoking status and motivation to quit throughout
treatment—as well as provision of medications for
smoking cessation—are uncommon.
This represents a missed opportunity to make an
impact on a highly prevalent disease that has
widespread consequences.
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43
Heavy Episodic Drinking
Greatly Increases Mortality
Risk Among People with
Low-Risk Alcohol Use
Holahan CJ, Schutte KK, Brennan PL, et al.
Alcohol Clin Exp Res. 2014;38(5):1432–1438.
Summary by R. Curtis Ellison, MD
www.aodhealth.org
44
Objectives/Methods


An association between heavy episodic drinking
and adverse health outcomes has been
demonstrated in epidemiologic studies for decades.
This study evaluated total mortality among 446
people aged 55–65 with an average consumption
of ≤½ drink in a day for women or ≤2 for men,
comparing those with heavy episodic drinking*
(N=74) with those without (N=372).
* Defined as ≥4 drinks in an occasion for women and ≥5 for men.
www.aodhealth.org
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Results


Compared with subjects who engaged in heavy
episodic drinking, those who did not were
significantly higher in socio-economic status and
were less likely to smoke, or have depressive
symptoms or obesity.
In analyses adjusted for potential confounders,
subjects with heavy episodic drinking had more
than 2 times higher odds of 20-year mortality than
those without heavy episodic drinking.
www.aodhealth.org
46
Comments

The results of this study support previous findings of an
association between heavy episodic drinking and
mortality. However, the study had some weaknesses:



There were relatively few participants with heavy episodic
drinking in the analysis; and
There were no data on potential changes in drinking habits over
20 years.
A key implication is that simply knowing a subject’s
average consumption is inadequate for classification;
details on patterns of drinking are crucial.
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47
Underreporting of Alcohol
Intake Affects the Relation
of Alcohol to the Risk of
Cancer
Klatsky AL, Udaltsova N, Li Y, et al.
Cancer Causes Control. 2014;25(6):693–699.
Summary by R. Curtis Ellison, MD
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48
Objectives/Methods


People with certain adverse health effects who
report very low levels of alcohol consumption are
often assumed to be underreporting their intake.
Investigators reviewed 127,176 patients’ medical
records for diseases and conditions that are
known to occur predominantly in people with
heavy alcohol use (e.g., liver cirrhosis, alcoholic
neuropathy, and alcoholism).
www.aodhealth.org
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Objectives/Methods (cont’d)



Subjects with such diagnoses who reported “light”
(average <1 drink in a day) or “moderate” (average 1–2
drinks in a day) alcohol use were considered to be “likely
underreporters” of their alcohol intake (18%).
Subjects reporting the same levels of consumption with
no evidence of risky alcohol use in their records (47%)
were classified as “unlikely underreporters.”
During an average follow-up period of 18 years, 14,880
subjects developed cancer. There were 23,363 subjects
who reported “light” or “moderate” alcohol consumption.
www.aodhealth.org
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Results


Compared with abstainers, in subjects considered to be
unlikely underreporters with “moderate” alcohol use the
relative risk of any type of cancer was 0.98. In contrast, for
those categorized as likely underreporters the relative risk
of cancer was 1.33.
Similar results were seen for “alcohol-related cancers.” The
risk of breast cancer among women was less than one-half
as high among those with “moderate” alcohol use who
were considered unlikely underreporters compared with
those considered likely underreporters.
www.aodhealth.org
51
Comments


This study shows that the increase in the risk of
any cancer among people who consume <1 to 2
drinks in a day seems to occur primarily among
those who may be underreporting their alcohol
intake.
This approach could be a valuable strategy for
seeking the relation between alcohol intake and
cancer as well as other health outcomes.
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52
Studies on
HIV and HCV
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53
Identification and Treatment of
People with HIV and Injection
Drug Use will Help Reduce
Transmission of HIV
de Vos AS, Prins M, Coutinho RA, et al.
AIDS. 2014;28(6):911–918.
Summary by Darius A. Rastegar, MD
www.aodhealth.org
54
Objectives/Methods


One approach to reducing the transmission of HIV
infection is a “test and treat” strategy: regular
testing of individuals at risk for HIV and initiation
of treatment among those who test positive.
Researchers used data from a cohort of people
with injection drug use in Amsterdam to model the
effect of initiating combined antiretroviral
treatment (cART) at different stages among those
with HIV.
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55
Results



Initiating cART at low CD4 counts (<350 cells/mm3) did not
reduce transmission because the reduced infectiousness
was largely offset by the lengthening of infectious lifetime.
A test and treat strategy would reduce about half of new
infections over a 30-year time period.
HIV infection could eventually be eliminated in the
population if individuals began cART on average 1.6
months after becoming infected. This would require testing
at least every 3.2 months.
www.aodhealth.org
56
Comments



This study demonstrates how identifying and
treating individuals newly infected with HIV can
have a significant impact on transmission.
However, this requires frequently testing at-risk
individuals and having them initiate and adhere to
lifelong treatment during an asymptomatic phase of
the disease.
The results of this study underscore the vital
importance of reaching out to and engaging at-risk
populations.
www.aodhealth.org
57
Older Adults with HIV and
Multiple Substance Use have
Worse HIV Medication
Adherence
Parsons JT, Starks TJ, Millar BM, et al.
Drug Alcohol Depend. 2014:139;33–40.
Summary by Seonaid Nolan, MD† and Alexander Y. Walley, MD, MSc
†Contributing Editorial Intern and St Paul's Goldcorp Addiction Medicine Fellow and Research in Addiction
Medicine Scholar (RAMS), Clinical Addiction Research and Education (CARE) Unit, Boston University School of
Medicine, Boston, MA.
www.aodhealth.org
58
Objectives/Methods


Substance use is associated with poor adherence
to HIV medication, but less is known about
adherence and specific patterns of substance use
among older patients.
Researchers conducted telephone interviews with
557 adults with HIV aged ≥50 years who were
prescribed ≥1 HIV medications to identify patterns
of substance use and determine associations with
self-reported medication adherence.
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59
Results


Across all participants, 71% were >90% adherent.
Four patterns of substance use were identified
among the 469 (84%) participants who reported
any substance use within the past 30 days: alcohol
and cocaine/crack use only (31%); multiple
substance use including alcohol, marijuana,
cocaine/crack, opiates and other drugs (sedatives,
amphetamines, PCP, psychedelics or solvents)
(28%); alcohol use only (23%); and alcohol and
marijuana use only (18%).
www.aodhealth.org
60
Results (cont’d)



Medication non-adherence was significantly higher in those reporting
multiple substance use (43%); alcohol and cocaine/crack use only
(36%); and alcohol and marijuana use only (35%), compared with
alcohol use only (16%) and no substance use (8%).
Participants with both alcohol and cocaine/crack use only had the
greatest number of missed medication days (mean 4.3 days), followed
by multiple substance use (mean 3.5 days), and alcohol and marijuana
use only (mean 2.9 days).
Alcohol and cocaine/crack use only and multiple substance use were
associated with higher rates of a self-reported detectable viral load
(>200 copies/mL).
www.aodhealth.org
61
Comments



The majority of older adults with HIV and substance use
reported adherence to HIV medications.
However, those reporting multiple substance use, alcohol
and cocaine/crack use only or alcohol and marijuana use
only in the preceding 30 days had higher rates of HIV
medication non-adherence and a greater number of
missed medication days compared to alcohol use only
and no substance use.
Adherence interventions may be improved if they are
tailored to and address patterns of substance use.
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