Predictors of a suicide attempt one year after entry into substance use disorder treatment

BACKGROUND: The present study examined the patient intake and treatment-related risk factors associated with a suicide attempt in the 30 days before a 1-year posttreatment assessment. METHODS: A national sample of 8,807 patients presenting for treatment of substance use disorders (SUDs) in the Department of Veterans Affairs healthcare system were assessed at treatment intake and follow-up. Using the MacArthur Model, the risk and protective factors for suicide attempt were identified at baseline and during treatment. RESULTS: At follow-up, 4% (314/8,807) of the patients reported a suicide attempt within the past 30 days. Baseline predictors of a suicide attempt before follow-up included elevated suicidal/psychiatric symptoms, more recent problematic alcohol use, and longer duration of cocaine use. Contact with the criminal justice system was a protective factor that reduced the likelihood of a future suicide attempt. Greater engagement in SUD treatment was also associated with a reduction in suicide risk. CONCLUSIONS: More involvement in SUD treatment reduced the likelihood of a future suicide attempt in high-risk patients. Substance use disorder treatment providers interested in reducing future suicidal behavior may want to concentrate their efforts on identifying at-risk individuals and actively engaging these patients in longer treatment episodes.     

Alcohol use disorders in French university hospital patients

The adult patients of the somatic departments of Amiens University Hospital were screened on a randomly selected day by interviewers who examined them using a structured questionnaire regarding lifestyle, with the CAGE questionnaire, and their daily alcohol consumption. The medical histories of all patients were collected. A patient was considered having an alcohol problem if one or more of the following criteria was fulfilled: (1) a CAGE questionnaire score of 2 or more positive answers; (2) an alcohol-related diagnosis. In total, 869 patients fulfilled the entry criteria (377 patients were excluded owing to predefined exclusion criteria). A hundred and sixty-seven patients (19.2%) fulfilled 1 or 2 of the criteria for an alcohol problem. Eighty-eight patients (10.1%) had an alcohol-related discharge diagnosis. The prevalence of patients with a positive CAGE score was 13.5% and was significantly higher among male patients (22.7%) than among female patients (5.5%). The frequency of a higher socioeconomic status or the status of 'living alone' increased significantly with alcohol consumption.     

Threshold and optimal cut-points for alcohol use disorders among patients in the emergency department

Background: Current research suggests that Diagnostic and Statistical Manual of Mental Disorder (DSM)‐IV alcohol abuse and dependence form a unidimensional continuum in emergency department (ED) patients in 4 countries: Argentina, Mexico, Poland, and the United States. In this continuum of alcohol use disorder (AUD), there are no clear‐cut distinctions between the criteria for dependence and abuse in the severity dimension based on prior results from item response theory (IRT) analysis. Nevertheless, it is desirable to find a threshold for identifying cases for clinical practice and cut‐points of clinical utility in this continuum to distinguish between patients more or less affected by an AUD, using a scale of symptoms count. Methods: Data from 5,193 patients in 7 ED sites in the same 4 countries (3,191 current drinkers) were used to study the structure, threshold, and possible cut‐points for the diagnoses of AUD. Results: The proposed changes in the DSM‐V, dropping the abuse item “legal problems” and adding an item on “craving,” did not impact the IRT performance and unidimensionality of AUD in this sample. With a total set of 11 items (deleting “legal problems” and adding “craving” to the current set of DSM criteria), an endorsement of 2 or more criteria can be used as the threshold to define those with an AUD in clinical practice. Furthermore, we can distinguish at least 2 levels of clinical severity, 2 to 3 criteria (moderate), and 4 or more criteria (severe). Conclusions: A dimensional approach to AUD using the proposed new set of criteria for the DSM‐V can be used to propose a threshold and levels of severity. More research in different populations and countries is needed to further substantiate a threshold and cut‐points that could be used in new formulations of substance use disorders.     

Alcohol use disorders in Australia

Alcohol use disorders are common in Australia and are often unrecognised. Alcohol places a significant burden on our healthcare system by increasing the risk of injuries as well as many chronic medical conditions. Diagnosis requires a high index of suspicion and can be aided by the use of specific questionnaires, such as the Alcohol Use Disorder Identification Test‐C. The current available laboratory tests are of limited sensitivity and specificity, but can nevertheless aid in the diagnosis in some circumstances. Newer tests, such as ethyl‐glucuronide and phosphatidylethanol, are more sensitive and specific but are costly and not widely available. The effective management of alcohol use disorder entails psychosocial or pharmacological treatments or a combination of both. In those who cannot reduce alcohol consumption, harm reduction strategies can be applied to reduce the burden of harm to the drinkers as well as the community at large.     

Alcohol use among patients with HIV infection

Objective. To evaluate alcohol use in patients with HIV infection, assess ethnic and social associations, and describe outcomes.Material and methods. Design: cohort study. Setting: Academic HIV-Liver Clinic. Patients: 431 HIV-infected patients (371 men, 60 women); 249 patients with HIV/HCV coinfection, 115 HIV alone, and 67 with HIV/HBV. Intervention: alcohol use was estimated at first interview and reported as the estimated average lifetime consumption in grams/day. Outcome measures: laboratory values, liver fibrosis, decompensation and mortality.Results. Twenty-two percent of patients in the entire cohort had high risk lifetime average alcohol consumption, defined as ≥ 50 mg/day. Fifty-six percent of patients had quit all alcohol when first evaluated, but follow-up showed that 26% continued high risk consumption. By univariate analysis high alcohol consumption was associated with Latino ethnicity, injection drug use (IDU) and hepatitis C (HCV) coinfection. Multivariable analysis showed only IDU to be independently associated with high alcohol consumption (RR = 4.1, p = 0.0005). There were no significant differences in laboratory values, including CD4 cell counts, except for a trend towards higher transaminases and liver fibrosis scores, between high and low alcohol users. All-cause mortality was statistically higher in the high (37%) vs. low (25%, p = 0.03) alcohol use group, and was associated with both IDU (RR = 2.2, p = 0.04) and the amount of alcohol consumed (RR = 1.1, p = 0.04). Liver decompensation and mortality were both higher in the high use group but of borderline significance. Using an ordinal grouping, we found a strong correlation (R = 0.88) between alcohol consumption and the percentage of liver death over total deaths, with lowest mortality rates found in those use of 10 g/day or less.Conclusions. Unsafe use of alcohol is prevalent in HIV-infected patients and stoppage is not universal. There is a significant impact on all-cause mortality and a trend towards higher liver morbidity and mortality. IDU is significantly and independently associated with high ethanol intake. Practitioners should strongly recommend that HIV patients minimize alcohol use.     

Mortality after diagnosis of psychiatric disorders and co-occurring substance use disorders among HIV-infected patients

We examined the associations between psychiatric diagnoses, substance use disorders, health services, and mortality among 9751 HIV-infected patients (≥14 years old) in a large, private medical care program, in a retrospective cohort design over a 12-year period. All study data were extracted from computerized clinical and administrative databases. Results showed that 25.4% (n?=?2472) of the 9751 study subjects had received a psychiatric diagnosis (81.1% had major depression, 17.1% had panic disorder, 14.2% had bipolar disorder, and 8.1% had anorexia/bulimia); and 25.5% (n?=?2489) had been diagnosed with substance use disorder; 1180 (12.1%) patients had received both psychiatric and substance diagnoses. In comparison to patients with neither a psychiatric diagnosis nor a SU diagnosis, the highest risk of death was found among patients with dual psychiatric and substance use diagnoses who had no psychiatric treatment visits and no substance treatment (relative hazards [RH]?=?4.17, 95% confidence interval [CI]?=?2.35 to 7.40). Among dually diagnosed patients, receiving psychiatric and/or substance use disorder treatment somewhat reduced the risk of death compared to patients with neither diagnosis. The lowest risks of death were observed among patients with a single diagnosis who had received corresponding treatment. Our study findings suggest that screening for psychiatric and substance problems at the initiation and during the course of HIV/AIDS treatment and providing psychiatric and substance use disorder treatment may extend life for these vulnerable patients.     

Alcohol use disorders identification test: factor structure in an adolescent emergency department sample

BACKGROUND: This study examined whether the factor structure of a modified version of the Alcohol Use Disorders Identification Test (AUDIT) represented the three intended conceptual domains of consumption, dependence symptoms, and alcohol-related consequences in an adolescent sample. Additionally, the utility of factor-specific cut scores in identifying patients with DSM-IV alcohol diagnoses was investigated. METHODS: Adolescents treated for an injury in an emergency department and who reported alcohol use in the last year (n = 173; 57% male, 72% white) constituted the study sample. A modified version of the AUDIT and the alcohol section of the Diagnostic Interview Schedule for Children were administered. The AUDIT's factor structure was determined by confirmatory factor analysis and exploratory principal components analysis. Factor-specific cut scores that identified adolescents with a DSM-IV alcohol diagnosis were determined by using receiver operating characteristic analysis. RESULTS: A two-factor model representing consumption and dependence/consequences provided the best fit to the data. A cut score of 3 on the consumption factor and a cut score of 1 on the dependence/consequences factor demonstrated optimal performance in identifying patients with alcohol diagnoses. The consumption factor had better overall performance compared with the dependence/consequences factor, and it had similar overall performance compared with the AUDIT total score. CONCLUSIONS: The AUDIT comprised two correlated factors: consumption and dependence/consequences. The better performance of the consumption factor in detecting adolescents with DSM-IV alcohol diagnoses suggests the utility of including consumption items in brief alcohol screens used with adolescents. Results also indicate the need to identify developmentally appropriate alcohol-related problems to enhance screening performance among adolescents.     

Increased risk of suicide attempt among patients receiving blood transfusion: A propensity matched analysis

To examine whether the association between blood transfusion and suicide attempt exists.Utilizing the national insurance database from Taiwan and propensity score matching analysis, the incidence of suicide attempt in a cohort with blood transfusion versus controls was compared.The key finding is that higher incidence of suicide attempt in blood transfusion than control group (with an adjusted hazard ratio of 1.79 with 95% confidence interval, 1.72–1.88) after adjusted for the covariates.Patients receiving blood transfusion are an increased risk of subsequent suicide attempt.     

Alcohol use disorders increase the risk for mechanical ventilation in medical patients

BACKGROUND: Annually, more than 300,000 patients receive mechanical ventilation in an intensive care unit in the United States. The hospital mortality for ventilated patients may approach 50%, depending on the primary diagnosis. In trauma and surgical patients, a diagnosis of alcohol use disorder (AUD) is common and is associated with a prolonged duration of mechanical ventilation. The objective of this study is to determine whether the presence of AUD and the development of alcohol withdrawal are associated with an increased use and duration of mechanical ventilation in patients with medical disorders that commonly require intensive care unit admission. METHODS: We performed a retrospective cohort study using the Nationwide Inpatient Sample, a large all-payer inpatient database representing approximately 1,000 hospitals. For the years 2002 to 2003, adult patients with 1 of the 6 most common diagnoses associated with medical intensive care unit admission were included in the study. Both univariate analysis and multivariable logistic regression were performed to determine whether AUD and alcohol withdrawal were independently associated with the use and duration of mechanical ventilation in these patients. RESULTS: There were a total 785,602 patients who fulfilled 1 of the 6 diagnoses, 26,577 (3.4%) had AUD, 3,967 (0.5%) had alcohol withdrawal, and 65,071 (8.3%) underwent mechanical ventilation (53% <96 hours, 47%> or =96 hours). Independent of the medical diagnosis, AUD was associated with an increased risk of requiring mechanical ventilation (13.7 vs 8.1%, odds ratio=1.49, 95% confidence interval [1.414; 1.574], p<0.0001) but was not associated with a prolonged duration of mechanical ventilation. However, the presence of alcohol withdrawal was associated with a longer duration of mechanical ventilation (57 vs 47%> or =96 hours, odds ratio=1.48, 95% confidence interval [1.266; 1.724], p<0.0001). CONCLUSIONS: In patients with medical diagnoses associated with intensive care unit admission, AUD increases the risk for mechanical ventilation while the development of alcohol withdrawal is associated with a longer duration of mechanical ventilation.     

Alcohol use disorders and the heart

Alcohol use is an important preventable and modifiable cause of non‐communicable disease, and has complex effects on the cardiovascular system that vary with dose. Observational and prospective studies have consistently shown a lower risk of cardiovascular and all‐cause mortality in people with low levels of alcohol consumption when compared to abstainers (the ‘J’‐shaped curve). Maximum potential benefit occurs at 0.5 to one standard drinks (7–14 g pure ethanol) per day for women (18% lower all‐cause mortality, 95% confidence interval (CI) = 13–22%) and one to two standard drinks (14–28 g ethanol) per day for men (17% lower all‐cause mortality, 95% CI = 15–19%). However, this evidence is contested, and overall the detrimental effects of alcohol far outweigh the beneficial effects, with the risk of premature mortality increasing steadily after an average consumption of 10 g ethanol/day. Blood pressure (BP) is increased by regular alcohol consumption in a dose‐dependent manner, with a relative risk for hypertension (systolic BP > 140 mm Hg or diastolic > 90 mm Hg) of 1.7 for 50 g ethanol/day and 2.5 at 100 g/day. Important reductions in BP readings can be expected after as little as 1 month of abstinence from alcohol. Heavy alcohol consumption in a binge pattern is associated with the development of acute cardiac arrhythmia, even in people with normal heart function. Atrial fibrillation is the most common arrhythmia associated with chronic high‐volume alcohol intake, and above 14 g alcohol/day the relative risk increases 10% for every extra standard drink (14 g ethanol). Ethanol and its metabolites have toxic effects on cardiac myocytes, and alcoholic cardiomyopathy (ACM) accounts for a third of all cases of non‐ischaemic dilated cardiomyopathy. Screening people drinking alcohol above low‐volume levels and delivering a brief intervention may prevent the development of cardiovascular complications. Although people with established cardiovascular disease show improved outcomes with a reduction to low‐volume alcohol consumption, there is no safe amount of alcohol to drink and patients with ACM should aim for abstinence in order to optimize medical treatment.     

Alcohol use disorders and the brain

A diagnosis of alcohol use disorder is associated with a higher risk of dementia, but a dose–response relationship between alcohol intake consumption and cognitive impairment remains unclear. Alcohol is associated with a range of effects on the central nervous system at different doses and acts on a number of receptors. Acute disorders include Wernicke's encephalopathy (WE), traumatic brain injury, blackouts, seizures, stroke and hepatic encephalopathy. The most common manifestations of chronic alcohol consumption are Korsakoff's syndrome (KS) and alcohol‐related dementia (ARD). There is limited evidence for benefit from memantine in the treatment of ARD, but stronger evidence for the use of high‐dose parenteral thiamine in the progression of neuropsychiatric symptoms for WE. Accumulating evidence exists for pharmacological treatment in the prevention of hepatic encephalopathy. Rehabilitation of people with ARD may take several years, and requires an approach that addresses physical and psychosocial factors.     

Self-help strategies among patients with substance use disorders

The objective of this study was to determine (1) the type and extent of self-help efforts among patients presenting for treatment of substance use disorders, and (2) the association of self-help with demographic and clinical characteristics. A retrospective report of life self-help methods, current demographic characteristics, and current and lifetime clinical characteristics was used. Six hundred and forty-two patients in treatment for substance use disorder were interviewed at one of two university medical centers with Alcohol-Drug Programs located within departments of psychiatry. A research associate (RA) interviewed patients regarding seven types of self-help involving specific, mutually exclusive behaviors and rated the patient's lifetime self-help methods. The patient, RA, and addiction psychiatrists provided demographic, familial, and clinical information. Most patients (78%) had tried one or more types of self-help, with a mean of 2.7 methods per patient. They more frequently chose methods related to the substance (decreasing amounts or frequency, or changing substance type) or joining a self-help group than methods that involved changing friends, residence, or occupation/job/school. Certain patterns of self-help tended to occur together (e.g., changing substance frequency and dose), whereas others appeared more independent (e.g., joining a self-help group). Some self-help approaches occurred mostly in association with other methods rather than alone (e.g., changing occupation/job/school). More self-help was associated with higher socioeconomic class, more relatives with substance use disorder, greater severity of substance use disorder, and more treatment for substance use disorder. Self-help tends to occur more often after exposure to addicted relatives or addiction treatment. Clinicians and public adult education should promulgate self-help methods in the general population.     

Alcohol use disorders among emergency department-treated older adolescents: a new brief screen (RUFT-Cut) using the AUDIT, CAGE, CRAFFT, and RAPS-QF

BACKGROUND: Early identification of alcohol use disorders (AUD) among emergency department (ED)-treated patients is important for facilitating intervention and further evaluation outside EDs. A number of brief screening instruments have been developed for identifying patients with AUD, but it is not clear whether they are practical and perform well with older adolescents in an ED setting. This study contrasted four brief screening instruments for detecting DSM-IV-defined AUD and tested a newly developed brief screen for use among ED-treated older adolescents. METHODS: The Alcohol Use Disorders Identification Test (AUDIT), the CAGE, the CRAFFT, and a modified RAPS-QF were given to 93 alcohol-using older adolescents (55% men; aged 18-20 years) in an ED. Receiver operator characteristic analyses were used to evaluate the performance of brief screens against the criterion of a lifetime DSM-IV alcohol abuse or dependence diagnosis. RESULTS: Of existing instruments, the AUDIT had the best overall performance in identifying AUD (sensitivity, 82%; specificity, 78%). A new, shorter screening instrument composed of two AUDIT items, two CRAFFT items, and one CAGE item (RUFT-Cut) performed as well as the AUDIT (sensitivity, 82%; specificity, 78%). CONCLUSIONS: Among existing alcohol screening instruments, the AUDIT performed best for identifying ED-treated older adolescents with alcohol use disorders. The RUFT-Cut is a brief screening instrument for AUD that shows promise for identifying ED-treated older adolescents who are in need of intervention or further evaluation. Future research should focus on use of the RUFT-Cut in other settings with larger, more diverse samples of adolescents.