Update-on-Alcohol-and-Health：在酒精和健康更新課件

1、Update on Alcohol and HealthAlcohol and Health: Current EvidenceJuly-August 20061Update on Alcohol and HealthAStudies on Assessments and Interventions2Studies on Assessments and InCombining Medication With Specialist Behavioral Intervention for Alcoholism: the COMBINE StudyAnton RF, et al. JAMA. 200

2、6;295(17):20032017.3Combining Medication With SpecObjectives/MethodsTo study the effects of pharmacotherapy with behavioral intervention for alcohol dependence1383 recently abstinent patients with alcoholism randomized to 1 of 9 treatments for 16 weeks: Placebo;Naltrexone (100 mg per day), acamprosa

3、te (3 g per day), or both; or Combined behavioral intervention (CBI) alone, with active pills, or with placebo 4Objectives/MethodsTo study theObjectives/Methods (cont.)CBI: Offered by a specialist Included elements of cognitive behavioral therapy, motivational interviewing, and 12-step facilitation

4、Up to 20 50-minute sessions“Medical management” (MM) provided to all but CBI alone group9 counseling and education sessions (45-minute initial session and 20-minute follow-up sessions)Provided by a generalist healthcare professional Focused on medication side effects, adherence, and alcohol abstinen

5、ce94% follow-up at 16 weeks; 82% a year later5Objectives/Methods (cont.)CBI:ResultsDrinking outcomes improved substantially in all groups. The range of mean percent days abstinent across groups was 23%30% at baseline, 67% 81% at 16 weeks, and 59%69% a year later.6ResultsDrinking outcomes improResult

6、s (cont.)Naltrexone/MM Better than placebo/MM at increasing percent days abstinent (81% vs 75%) and delaying a return to heavy drinking* (hazard ratio 0.7)Adding CBI did not improve these outcomesCBI/MM with any pills Better than placebo/MM at increasing percent days abstinent (e.g., 79% versus 75%)

7、CBI alone (without MM or pills) Less effective than placebo/MM at increasing days abstinent (67% versus 74%)Acamprosate/MM Did not significantly affect drinking outcomesKey Findings at 16 Weeks*=5 standard drinks per day for men, =4 for women 7Results (cont.)Naltrexone/MM BResults (cont.)One year af

8、ter treatmentdrinking outcomes did not significantly differ among groups.8Results (cont.)One year after Conclusions/CommentsThis large, rigorous, and complex study showed that.naltrexone and specialist counseling have similar modest efficacy when each is offered with MM, and specialist counseling al

9、one has less efficacy than when combined with MM. These findings support the use of naltrexone and intensive MM in primary care settings as a potential alternative to specialized treatment. 9Conclusions/CommentsThis largeConclusions/Comments (cont.)Delivering the type of medical management provided

10、in this study requires substantial training and a collaborative care model. This requirement and other concerns (e.g., need for chronic treatment, acamprosates perplexing lack of efficacy) require further investigation. 10Conclusions/Comments (cont.)DeAcamprosate May Work Only When Abstinence Is the

11、 Goal Mason BJ, et al. J Psychiatr Res. 2006;40(5):382392. 11Acamprosate May Work Only WheObjectives/MethodsTo evaluate acamprosates efficacy in U.S. patientsRandomized controlled trial of the drug (the first in this country) in 21 alcohol treatment clinicsSubjects assigned to eitherthe standard 2 g

12、 of acamprosate per day (n=258), 3 g per day (n=83), or placebo (n=260)All received self-help materials and 8 sessions of brief counseling12Objectives/MethodsTo evaluate ResultsThe percentage of days abstinent at 6 months did not significantly differ across groups in unadjusted analyses. However, in

13、 analyses adjusted for potential confounders (e.g., readiness to change, treatment goal of abstinence), the percentage wassignificantly higher in subjects who received acamprosate: 52% for placebo, 58% for subjects on 2 g, and 63% for subjects on 3 g.13ResultsThe percentage of days Results (cont.)Pa

14、tients who stated at baseline that abstinence was their goal achieved the best results: 58% days abstinent for placebo 70% for subjects on 2 g73% for subjects on 3 g 14Results (cont.)Patients who stComments/ConclusionsAcamprosates lack of efficacy in this large, well-designed trial is surprising, th

15、ough also noted in another recent study.* The U.S. subjects may have been abstinent for a shorter time than were subjects in international studies showing acamprosates efficacy. The link between having abstinence as a goal and benefit from acamprosate may guide clinicians prescribing practices and m

16、erits confirmation. *Anton RF, et al. JAMA. 2006;295(17):20032017.15Comments/ConclusionsAcamprosatMost Medical Inpatients With Unhealthy Alcohol Use Have Alcohol DependenceSaitz R, et al. J Gen Intern Med. 2006;21(4):381385.16Most Medical Inpatients With Objectives/MethodsTo determine the prevalence

17、 and severity of unhealthy alcohol use on a medicine service5813 medical inpatients screened for drinking risky amounts*341 who drank risky amounts were evaluated further*14 standard drinks per week or =5 drinks per occasion for men (11 and =4, respectively, for both women and people =66 years)17Obj

18、ectives/MethodsTo determineResults17% of inpatients screened drank risky amounts.Of those drinking risky amounts97% exceeded per occasion limits,* and most scored =8 on the Alcohol Use Disorders Identification Test (strongly correlating with a current alcohol diagnosis).Of the 341 inpatients who dra

19、nk risky amounts and received more detailed evaluation77% had alcohol dependence.*=5 drinks for men, =4 for women and people =66 years 18Results17% of inpatients screeConclusions/CommentsAccording to this study, almost 1 in 5 medical inpatients has unhealthy alcohol usea number identical to that fou

20、nd in a recent systematic review of hospital alcohol screening studies.* Of note, most medical inpatients with unhealthy alcohol use have alcohol dependence. *Roche AM, et al. Drug Alcohol Depend. 2006;83(1):114.19Conclusions/CommentsAccording Conclusions/Comments (cont.)Because brief interventionth

21、e currently recommended practicehas established efficacy only for nondependent unhealthy alcohol usenew strategies to address alcohol dependence on a medicine service are warranted.20Conclusions/Comments (cont.)BeAnother Single-Item Screening Test?OBrien MC, et al. Acad Emerg Med. 2006;13(6):629636.

22、21Another Single-Item Screening Objectives/MethodsTo examine whether one question (“In a typical week, how many days do you get drunk?”) could identify drinkers at risk of injuryWeb-based survey completed by 3909 college students in North Carolina 36% response rate22Objectives/MethodsTo examine wRes

23、ultsOf 2488 current (past 30-day) drinkers54% got drunk at least once in a typical week. Drunkenness was a better indicator of injury outcomes than was heavy episodic drinking.*=5 drinks in a row on at least 1 day in the past 30 days for men, =4 for women23ResultsOf 2488 current (past 3Results (cont

24、.)Odds of Injury in Students Who Had Been Drunk in a Typical Week Vs. Those Who Had NotInjured because of their drinkingOR* 5.0Had a fall that required treatmentOR 2.2Taken advantage of sexually as a result of anothers drinkingOR 2.6Caused injury to another that required treatmentOR 2.6*Odds ratios

25、adjusted for potential confounders (e.g., race, current drinking)24Results (cont.)Odds of Injury Conclusions/CommentsThis study did not assess for alcohol use disorders, a significant limitation that precludes recommending the single question as a clinical screening test. But the results are interes

26、ting because they suggest thata question about drunkenness might identify college-student drinking with consequences better than a question about heavy drinking on an occasion would. For now, it seems reasonable for clinicians to ask the question when discussing drinking with college students.25Conc

27、lusions/CommentsThis studyIntensive Referral to 12-Step Groups Improves OutcomesTimko C, et al. Addiction. 2006;101(5):678688. 26Intensive Referral to 12-StepObjectives/MethodsTo assess whether intensive referral is more effective than standard referral atincreasing involvement with Alcoholics Anony

28、mous (AA) and Narcotics Anonymous (NA), and subsequently improving substance use outcomesStudy of 345 veterans entering outpatient substance abuse treatment Almost all had attended 12-step meetings previously46% preferred alcohol to other substances27Objectives/MethodsTo assess whObjectives/Methods

29、(cont.)Subjects were randomized to eitherstandard referral, including a schedule of and encouragement to attend local 12-step meetings, orintensive referral, including additional information and clinician support (e.g., linkage to AA/NA volunteers, follow-up on meeting attendance, encouragement to o

30、btain a sponsor)28Objectives/Methods (cont.)SubjResultsAt 6 months, attendance at 12-step meetings did not significantly differ among the groups. But, of subjects with less exposure to 12-step groups at study entry, those assigned to intensive referral had better attendance. The intensive referral g

31、roup had significantly greater12-step involvement (e.g., obtained a sponsor) and improvement in substance use problems.29ResultsAt 6 months, attendanceResults (cont.)The intensive referral group was also more likely to be abstinent fromdrugs (78% versus 70%, P0.05) and alcohol (76% versus 70%, P0.12

32、). Involvement in 12-step groups partially mediated improvements in alcohol outcomes.30Results (cont.)The intensive rConclusions/CommentsBecause 12-step groups do not sponsor research, rigorous trials of their effectiveness are difficult to perform. This study provides strong evidence that clinician

33、s should support patients participation in AA/NA. Linking patients with AA/NA volunteers, following up on attendance, and encouraging sponsorship are essential to successful 12-step facilitation. 31Conclusions/CommentsBecause 12Help Seeking Quadruples the Likelihood of AbstinenceDawson DA, et al. Ad

34、diction. 2006;101(6):824834.32Help Seeking Quadruples the LiObjectives/MethodsTo quantify the effect of help seeking on recovery from alcoholismAnalysis of data from 4422 adults in the U.S. who hadparticipated in a nationally representative survey and developed alcohol dependence at least 1 year bef

35、ore their participation33Objectives/MethodsTo quantify ResultsOnly 26% of subjects had ever sought help for their alcohol problems:3% participated in a 12-step program only, 6% in formal treatment only, and 17% in both. Help seekers drank more than subjects who had not sought help and had higher lif

36、etime prevalences ofother drug use, mood disorders, and personality disorders.34ResultsOnly 26% of subjects haResults (cont.)In analyses adjusted for potential confounders, help seeking significantly increased the likelihood ofany recovery* (OR 2.4) and abstinence (OR 4.0). The odds of recovery were

37、 greater for those who hadparticipated in 12-step programs with or without formal treatment than for those who had participated in formal treatment only. *In the past year, having no symptoms of alcohol abuse or dependence and either drinking low-risk amounts (=14 drinks per week and =4 drinks on an

38、y day for men; =7 drinks per week and =3 drinks on any day for women) or abstaining35Results (cont.)In analyses adjConclusions/CommentsEven though they had more comorbidity, seekers of formal and informal treatment had better odds of recovery from alcohol dependence. This study could not separate th

39、e motivation inherent in seeking help from the therapeutic effects of help received. However, help seekingregardless of the patients level of readinessshould be encouraged. 36Conclusions/CommentsEven thougShould Screening for Colorectal Cancer Start Earlier for Drinkers and Smokers? Zisman AL, et al

40、. Arch Intern Med. 2006;166(6):629634.37Should Screening for ColorectaObjectives/MethodsTo explore whether earlier screening for colorectal cancer (CRC) is warranted in patients who smoke and drink166,172 cases of CRC identified through a national medical registry; age at diagnosis assessedAnalyses

41、controlled for sex, race, and insurance status38Objectives/MethodsTo explore wResults CRC was diagnosed significantly earlier in current and past drinkers* than in subjects who never drank. Diagnosis occurred even earlier among current and past drinkers who currently smoked (e.g., 7.8 years earlier

42、in current drinkers who also smoked than in subjects who never drank or smoked). The likelihood of distal CRC was significantly higher amongcurrent and past drinkers than in subjects who never drank (ORs 1.2 and 1.1, respectively) and current smokers than in subjects who never smoked (OR 1.2).*Curre

43、nt use defined as use in the past year; past use defined as having quit at least 1 year before CRC diagnosis39Results CRC was diagnosed signConclusions/CommentsThis large retrospective study found that CRC was diagnosed in current and past drinkers at a younger age, especially if they currently smok

44、ed. While the study helps clarify the association between alcohol, tobacco, and CRC, itneither addressed whether screening could have detected the earlier diagnoses nor accounted for many important confounding factors (e.g., quantity/frequency of drinking and smoking, diet, comorbidities that potent

45、ially lead to earlier gastrointestinal evaluation). 40Conclusions/CommentsThis largeConclusions/Comments (cont.)Thus, more investigation is needed to determine whetherCRC screening guidelines should be modified according to a patients history of alcohol and tobacco use. 41Conclusions/Comments (cont.

46、)ThStudies on Alcohol and Health Outcomes42Studies on Alcohol and HealtIs Drinking Unsafe for Patients on Warfarin or Statins?Mukamal KJ, et al. Am J Med. 2006;119(5):434440. 43Is Drinking Unsafe for PatienObjectives/MethodsTo assess drinkings safety in warfarin or statin users1244 men with previous

47、 coronary artery bypass graft surgery who had enrolled in a randomized trial of dailylovastatin (mean dose of 4 mg or 76 mg), low-dose warfarin (14 mg to achieve an INR* of 1.82), or placebo-warfarin54% drank 21 drinks per week*International normalized ratio44Objectives/MethodsTo assess drResultsDur

48、ing about 5 years of follow-up, alcohol use did not significantly affect the risk of having elevated INR or ALT* levels:Standard Drinks per Week ALT=80 IU/L (% of subjects) INR=2 (% of(warfarin subjects only) =14 661ALT results were similar when the analysis was restricted to patients taking the hig

49、her dose of lovastatin.*Alanine aminotransferase45ResultsDuring about 5 years ofConclusions/CommentsFew men drank 21 drinks per week, so this study could not address the risks associated with warfarin or statin use and heavy drinking. Reporting abnormal creatine kinase levels by drinking categories

50、would have helped readers to judge risk. These results should somewhat reassure patients with coronary artery disease thatdrinking moderately while taking warfarin or lovastatin is not harmful (or at least does not increase the risk of developing 2 specific lab abnormalities).46Conclusions/CommentsF

51、ew men drAlcohol and the Risk of InjuryGmel G, et al. Alcohol Clin Exp Res. 2006;30(3):501509. 47Alcohol and the Risk of InjurObjectives/MethodsTo examine whether specific patterns of alcohol use affect the risk of injuryAssessment of 8736 patients admitted to an emergency department in Switzerland

52、(5077 with an injury)Measures:Usual volume of drinkingPast-month heavy episodic drinking (=5 drinks on at least one occasion for men, =4 for women)Recent drinking (in the 24 hours before the emergency-department visit)48Objectives/MethodsTo examine wResultsHeavy episodic drinking and recent drinking

53、 increased the risk of injury.As the volume of usual and recent drinking increased, the risk of injury increased.Risk was highest in patients whousually drank moderately* and reported both past-month and recent heavy episodic drinking. Odds ratios (ORs) 6.4 for men and 7.4 for women, compared with a

54、bstainers*14 drinks per week for men, 0 but 4 drinks in the 24 hours before their emergency-department visit.50Results (cont.)Past-month heavConclusions/CommentsThis study indicates that patterns of drinking, particularly heavy episodic drinking, influence the risk of injury. Interventions to reduce

55、 alcohol-related injury should focus onpreventing heavy episodic drinking among both moderate and heavy drinkers.51Conclusions/CommentsThis studyLifetime Drinking, Confounders, and Breast Cancer RiskTerry MB, et al. Ann Epidemiol. 2006;16(3):230240.52Lifetime Drinking, ConfoundersObjectives/MethodsTo examine whether confounding factors can explain the association between moderate drinking and an increased risk of breast cancerData from a population-based study Comparison of 1508 women with breast cancer and 1556 matched controlsAnalyses ad