The clinical course of alcohol use disorders: Using joinpoint analysis to aid in interpretation of growth mixture models

Background

The clinical course of alcohol use disorders (AUD) is marked by great heterogeneity both within and between individuals. One approach to modeling this heterogeneity is latent growth mixture modeling (LGMM), which identifies a number of latent subgroups of drinkers with drinking trajectories that are similar within a latent subgroup but different between subgroups. LGMM is data-driven and uses an iterative process of testing a sequential number researcher-selected of latent subgroups then selecting the best fitting model. Despite the advantages of LGMM (e.g., identifying subgroups among heterogeneous longitudinal data), one limitation is the lack of precision of LGMM to model abrupt changes in drinking during treatment that are often observed by clinicians. Joinpoint analysis (JPA) is a data analysis procedure that is used to identify discrete change points in longitudinal data (e.g., changes from increasing to decreasing or decreasing to increasing).

Method

This study presents a demonstration of using JPA as a post hoc procedure for LGMM to improve accuracy in modeling abrupt changes in clinical course of AUD.

Results

Results from this secondary data analysis of 549 AUD participants participating in the NIAAA sponsored relapse replication and extension project uncovered four latent classes of drinking trajectories.

Discussion

Within these trajectories the addition of JPA improved precision in modeling the clinical course of AUDs.     

Smoke-free policies in drinking venues predict transitions in alcohol use disorders in a longitudinal U.S. sample

Background

Smoke-free legislation prohibiting smoking in indoor public venues, including bars and restaurants, is an effective means of reducing tobacco use and tobacco-related disease. Given the high comorbidity between heavy drinking and smoking, it is possible that the public health benefits of smoke-free policies extend to drinking behaviors. However, no prior study has examined whether tobacco legislation impacts the likelihood of alcohol use disorders (AUDs) over time. The current study addresses this gap in the literature using a large, prospective U.S. sample.

Method

Using data from the National Epidemiological Survey on Alcohol and Related Conditions (NESARC), we utilized logistic regression to examine whether the implementation of state-wide smoke-free legislation in bars and restaurants between Waves I (2001–2002) and II (2004–2005) predicted changes in DSM-IV AUD status (remission, onset, recurrence) in current drinkers at Wave I (n = 19,763) and participants who drank in public ≥once per month (n = 5913).

Results

Individuals in states that implemented smoke-free legislation in drinking venues had a higher likelihood of AUD remission compared to participants in states without such legislation. Among public drinkers, smoke-free legislation was associated with a greater likelihood of AUD remission and a lower likelihood of AUD onset. These findings were especially pronounced among smokers, men, and younger age groups.

Discussion

These results demonstrated the protective effects of smoke-free bar and restaurant policies on the likelihood of AUDs; furthermore, these findings call attention to an innovative legislative approach to decrease the morbidity and mortality associated with AUDs.     

Alcohol stigma and persistence of alcohol and other psychiatric disorders: A modified labeling theory approach

Background

We sought to apply modified labeling theory in a cross-sectional study of alcohol use disorder (AUD) to investigate the mechanisms through which perceived alcohol stigma (PAS) may lead to the persistence of AUD and risk of psychiatric disorder.

Methods

We conducted structural equation modeling (SEM) including moderated mediation analyses of two waves (W1 and W2) of data from the National Epidemiologic Survey on Alcohol and Related Conditions. We analyzed validated measures of PAS, perceived social support, social network involvement, and psychiatric disorders among (n = 3608) adults with two or more DSM-5 AUD symptoms in the first two of the three years between the W1 and W2 survey. Cross-sectional analyses were conducted owing to the assessment of PAS only at W2.

Results

Per mediation analyses, lower levels of perceived social support explained the association of PAS with past-year AUD and past-year internalizing psychiatric disorder at W2. The size of the mediated relationship was significantly larger for those classified as labeled (i.e., alcoholic) per their prior alcohol treatment or perceived need (n = 938) as compared to unlabeled (n = 2634), confirming a hypothesis of moderated mediation. Unexpectedly, mediation was also present for unlabeled individuals.

Conclusions

Lower levels of social support may be an important intermediate outcome of alcohol stigma. Longitudinal data are needed to establish the temporal precedence of PAS and its hypothesized intermediate and distal outcomes. Research is needed to evaluate direct measures of labeling that could replace proxy measures (e.g., prior treatment status) commonly employed in studies of the stigma of psychiatric disorders.     

Childhood abuse and neglect and transitions in stages of alcohol involvement among women: A latent transition analysis approach

Background

Childhood abuse and neglect have been linked with alcohol disorders in adulthood yet less is known about the potential of early trauma to influence transitions in stages of alcohol involvement among women. Study aims were to (1) identify stages of women's alcohol involvement, (2) examine the probability of transitions between stages, and (3) investigate the influence of four domains of childhood abuse and neglect (sexual abuse, physical abuse, neglect, and witness to domestic violence), assessed individually and as poly-victimization, on transitions.

Methods

The sample consisted of 11,750 adult female current drinkers identified in Wave 1 (2001–2002) and re-interviewed in Wave 2 (2004–2005) of the National Epidemiological Survey on Alcohol and Related Conditions.

Results

Three stages of alcohol involvement emerged from latent class analysis of 11 DSM-IV abuse/dependence criteria: severe (1.5% at Wave 1, 1.9% at Wave 2), hazardous (13.6% at Wave 1, 16.0% at Wave 2), and non-problem drinking (82.1% at Wave 1, 84.5% at Wave 2). Adjusted latent transition analyses determined transition probabilities between stages across waves. Women reporting any childhood abuse and neglect were more likely to advance from the non-problem drinking class at Wave 1 to severe (AOR = 3.90, 95% CI = 1.78–8.53) and hazardous (AOR = 1.56, 95% CI = 1.22–2.01) drinking classes at Wave 2 relative to women without this history. Associations were also observed between individual domains and transition from no problems to severe alcohol stage.

Conclusions

Results suggest a long-term impact of childhood abuse and neglect as drivers of progression in women's alcohol involvement.     

A multidimensional assessment of the validity and utility of alcohol use disorder severity as determined by item response theory models

Background

The relative severity of the 11 DSM-IV alcohol use disorder (AUD) criteria are represented by their severity threshold scores, an item response theory (IRT) model parameter inversely proportional to their prevalence. These scores can be used to create a continuous severity measure comprising the total number of criteria endorsed, each weighted by its relative severity.

Methods

This paper assesses the validity of the severity ranking of the 11 criteria and the overall severity score with respect to known AUD correlates, including alcohol consumption, psychological functioning, family history, antisociality, and early initiation of drinking, in a representative population sample of U.S. past-year drinkers (n = 26,946).

Results

The unadjusted mean values for all validating measures increased steadily with the severity threshold score, except that legal problems, the criterion with the highest score, was associated with lower values than expected. After adjusting for the total number of criteria endorsed, this direct relationship was no longer evident. The overall severity score was no more highly correlated with the validating measures than a simple count of criteria endorsed, nor did the two measures yield different risk curves. This reflects both within-criterion variation in severity and the fact that the number of criteria endorsed and their severity are so highly correlated that severity is essentially redundant.

Conclusions

Attempts to formulate a scalar measure of AUD will do as well by relying on simple counts of criteria or symptom items as by using scales weighted by IRT measures of severity.     

Perceptions of alcohol policy and drinking behavior: Results of a latent class analysis of college student drinkers

Objective

The purpose of this study was to extend the limited research on college student support for alcohol control policies by using a latent class analysis to examine the shared characteristics of drinking students who support or oppose such policies.

Methods

We used data from a sample of 2393 students drawn from a larger study on high risk drinking at a mid-western university. Data was collected between October 2005 and May 2007. We conducted a latent class analysis to identify sub-groups of drinking students based on relevant variables.

Results

The results of the latent class analysis yielded a model which could correctly classify 90% of the students taking the survey into one of four “classes” based upon their response to four items on the questionnaire.

Conclusions

Interventions would benefit from approaches that target both student perceptions and specific policies that are most conducive to student support and engagement.     

Characteristics of developmentally early alcohol use disorder symptom reports: A prospective-longitudinal community study

Background

There is little prospective-epidemiological information on symptoms of DSM-IV-alcohol use disorder (alcohol abuse and dependence; AUD) that may be typical for early AUD stages or the developmental periods of adolescence and early adulthood.

Aims

To investigate AUD symptoms (AUDS) cross-sectionally at three subsequent assessment waves regarding prevalence rates, symptom counts, associated drinking patterns, positive predictive values (PPV) for DSM-IV-alcohol dependence (AD), and AUDS stability over time.

Methods

N = 2039 community subjects (baseline age 14–24 years) participated in a baseline and two follow-up assessment(s) over up to ten years. DSM-IV-AUDS, DSM-IV-AUD and craving were assessed with the DSM-IV/M-CIDI.

Results

Over the assessment waves, tolerance and much time were most and role obligations and withdrawal least frequent. Most subjects with DSM-IV-AUDS reported only one symptom (47.2–55.1%). PPV for DSM-IV-AD only exceeded 70% for activities, problem, withdrawal, and desired control; PPV were lowest for tolerance and hazardous use. For most AUDS, AUDS report compared to non-report was associated with elevated drinking frequency and amounts. Stability of baseline AUDS at four-year and ten-year follow-up did not exceed 36.4% for any symptom.

Conclusions

The overall pattern of most/least frequent AUDS reported in adolescence and early adulthood resembles findings in older adults and does not suggest a developmentally specific symptom pattern. Moderate AUDS-stability and considerable remission rates indicate that AUDS in this age group are transient for a considerable proportion of subjects. However, the associations with elevated consumption indicate that AUDS reports early in life need to be taken seriously in prevention and intervention.     

Vitamin D deficiency in alcohol-use disorders and its relationship to comorbid major depression: A cross-sectional study of inpatients in Nepal

Background

Mounting evidence suggests that deficiency of vitamin D may be associated with major health problems, including alcohol-use disorders (AUD) and major depression (MD). This study aimed to identify the vitamin D status of Nepalese inpatients with an AUD. We explored socio-demographic and alcohol-use related correlates and the relationship between vitamin D deficiency and comorbid MD.

Methods

A cross-sectional study was conducted on AUD inpatients (N = 174) at eight alcohol/drug treatment centres around Kathmandu. Structured questionnaires were administered to assess the socio-demographic and alcohol-use parameters and to establish DSM-IV diagnoses of AUD and MD. Vitamin D deficiency was defined as a serum 25-hydroxyvitamin D (25(OH)D) concentration of <50 nmol/L.

Results

The prevalence of vitamin D deficiency was 64%. Higher age, having a stable job or business, shorter time since last alcohol intake and winter serum samples were related to having lower 25(OH)D levels. Several features of AUD severity were associated with low vitamin D levels: guilt about drinking, using alcohol as eye-opener, and history of relapse after alcohol treatment (p ≤ 0.03). Patients with a comorbid major depression, in particular secondarily depressed cases, were less likely to have vitamin D deficiency (X² = 6.8; p = 0.01).

Conclusions

This study confirms high rates of vitamin D deficiency in alcohol treatment sample and shows a positive association between vitamin D deficiency and severity of alcohol-use disorders. Competing risk and other confounders may help explain the vitamin D status among patients with alcohol-use disorders and comorbid major depression.     

Brief screens for detecting alcohol use disorder among 18-20 year old young adults in emergency departments: Comparing AUDIT-C,CRAFFT, RAPS4-QF,FAST, RUFT-Cut,and DSM-IV 2-Item Scale

Background

This study compared six of the briefest screening instruments for detecting DSM-IV-defined Alcohol Use Disorder (AUD) among older adolescents treated in Emergency Departments (ED).

Methods

The AUDIT-C, the RAPS4-QF, the FAST, the CRAFFT, the RUFT-Cut, and 2-Items from the Diagnostic and Statistical Manual IV of the American Psychiatric Association [American Psychiatric Association (1994). Diagnostic and Statistical Manual of Psychiatric Disorders, (1994) (DSM-IV). 4th ed. Washington D.C.: American Psychiatric Association] criteria for AUD (heretofore referred to as the DSM-IV 2-Item Scale) were evaluated against the criterion of a current DSM-IV diagnosis of either alcohol abuse or dependence. The instruments were administered to 181 alcohol-using older adolescents (57% males; age range 18–20 years) in an ED and compared using Receiver Operator Characteristic (ROC) analyses against the criterion of a current DSM-IV diagnosis of alcohol abuse or dependence.

Results

Of these instruments, the DSM-IV 2-Item Scale performed best for identifying AUD (88% sensitivity and 90% specificity), followed by the FAST and the AUDIT-C.

Conclusions

Two items from the DSM-IV criteria for AUD performed best for identifying ED-treated older adolescents with alcohol use disorders. The FAST and AUDIT-C performed well, but are longer and more difficult to score in the hectic environment of the Emergency Department.     

Comparative performance of the AUDIT-C in screening for DSM-IV and DSM-5 alcohol use disorders

Objective

Under the proposed DSM-5 revision to the criteria for alcohol use disorder (AUD), a substantial proportion of DSM-IV AUD cases will be lost or shifted in terms of severity, with some new cases added. Accordingly, the performance of the AUDIT-C in screening for DSM-IV AUD cannot be assumed to extend to DSM-5 AUD. The objective of this paper is to compare the AUDIT-C in screening for DSM-IV and DSM-5 AUD.

Methods

Using a broad range of performance metrics, the AUDIT-C was tested and contrasted as a screener for DSM-IV AUD (any AUD, abuse and dependence) and DSM-5 AUD (any AUD, moderate AUD and severe AUD) in a representative sample of U.S. adults aged 21 and older and among past-year drinkers.

Results

Optimal AUDIT-C cutpoints were identical for DSM-IV and DSM-5 AUD: ≥4 for any AUD, ≥3 or ≥4 for abuse/moderate AUD and ≥4 or ≥5 for dependence/severe AUD. Screening performance was slightly better for DSM-5 severe AUD than DSM-IV dependence but did not differ for other diagnoses. At optimal screening cutpoints, positive predictive values were slightly higher for DSM-5 overall AUD and moderate AUD than for their DSM-IV counterparts. Sensitivities were slightly higher for DSM-5 severe AUD than DSM-IV dependence. Optimal screening cutpoints shifted upwards for past-year drinkers but continued to be identical for DSM-IV and DSM-5 disorders.

Conclusions

Clinicians should not face any major overhaul of their current screening procedures as a result of the DSM-5 revision and should benefit from fewer false positive screening results.     

Effect of motivational interviewing on reduction of alcohol use

Background

Methadone-maintained (MM) clients who engage in excessive alcohol use are at high risk for HIV and hepatitis B virus (HBV) infection. Nurse-led hepatitis health promotion (HHP) may be one strategy to decrease alcohol use in this population.

Objective

To evaluate the impact of nurse-led HHP, delivered by nurses compared to motivational interviewing (MI), delivered by trained therapists in group sessions or one-on-one on reduction of alcohol use.

Methods

A three-arm randomized, controlled trial, conducted with 256 MM adults attending one of five MM outpatient clinics in the Los Angeles area. Within each site, moderate-to-heavy alcohol-using MM participants were randomized into one of three conditions: (1) nurse-led hepatitis health promotion group sessions (n = 87); (2) MI delivered in group sessions (MI-group; n = 79), or (3) MI delivered one-on-one sessions (MI-single, n = 90).

Results

Self-reported alcohol use was reduced from a median of 90 drinks/month at baseline to 60 drinks/month at 6-month follow-up. A Wilcoxon sign-rank test indicated a significant reduction in alcohol use in the total sample (p < .05). In multiple logistic regression analysis controlling for alcohol consumption at baseline and other covariates, no differences by condition were found.

Discussion

As compared to two programs delivered by MI specialists, a culturally-sensitive and easy to implement nurse-led HHP program produced similar reductions in alcohol use over 6 months. Employing nurse-led programs may allow cost savings for treatment programs as well as a greater integration of alcohol reduction counseling along with a more comprehensive focus on general health-related issues than previously conducted.     

A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization

Background

Alcohol use disorders (AUDs) are highly prevalent and associated with non-adherence to antiretroviral therapy, decreased health care utilization and poor HIV treatment outcomes among HIV-infected individuals.

Objectives

To systematically review studies assessing the impact of AUDs on: (1) medication adherence, (2) health care utilization and (3) biological treatment outcomes among people living with HIV/AIDS (PLWHA).

Data sources

Six electronic databases and Google Scholar were queried for articles published in English, French and Spanish from 1988 to 2010. Selected references from primary articles were also examined.

Review methods

Selection criteria included: (1) AUD and adherence (N = 20); (2) AUD and health services utilization (N = 11); or (3) AUD with CD4 count or HIV-1 RNA treatment outcomes (N = 10). Reviews, animal studies, non-peer reviewed documents and ongoing studies with unpublished data were excluded. Studies that did not differentiate HIV+ from HIV− status and those that did not distinguish between drug and alcohol use were also excluded. Data were extracted, appraised and summarized.

Data synthesis and conclusions

Our findings consistently support an association between AUDs and decreased adherence to antiretroviral therapy and poor HIV treatment outcomes among HIV-infected individuals. Their effect on health care utilization, however, was variable.     

The effect of rumination on craving across the continuum of drinking behaviour

Background

Rumination is an abstract, persistent, and repetitive thinking style that can be adopted to control negative affect. Recent studies have suggested the role of rumination as direct or indirect cognitive predictor of craving experience in alcohol-related problems.

Aims

The goal of this study was to explore the effect of rumination induction on craving across the continuum of drinking behaviour.

Methods

Participants of three groups of alcohol-dependent drinkers (N = 26), problem drinkers (N = 26) and social drinkers (N = 29) were randomly allocated to two thinking manipulation tasks: distraction versus rumination. Craving was measured before and after manipulation and after a resting phase.

Results

Findings showed that rumination had a significant effect on increasing craving in alcohol-dependent drinkers, relative to distraction, but not in problem and social drinkers. This effect was independent of baseline depression and rumination and was maintained across the resting phase. Conclusions: Rumination showed a direct causal impact on craving that is specific for a population of alcohol-dependent drinkers.     

Associations between alcohol outlet densities and adolescent alcohol consumption: A study in Australian students

Objective

To assess whether the density of alcohol sales outlets in specific geographic communities is associated with adolescent alcohol consumption.

Method

A cross-sectional representative sample of secondary school students from Victoria, Australia (N = 10,143), aged between 12 and 17 years, self-reported on alcohol use in the last 30 days in 2009. The density of alcohol outlets per local community area was merged with this information.

Results

After controlling for risk factors, multilevel modelling (MLM) revealed a statistical interaction between age and density on alcohol consumption. While older adolescents had higher alcohol consumption, increases in the density of alcohol outlets were only significantly associated with increased risk of alcohol consumption for adolescents between the ages of 12 and 14.

Conclusion

Increased alcohol availability was associated with an increased risk of alcohol consumption specifically for early adolescents (12 and 14 years). Potential mechanisms as to how density is associated with direct and indirect alcohol availability, such as through parents or older siblings, need to be explored in future research.     

Double-blind placebo-controlled trial of fluoxetine in adolescents with comorbid major depression and an alcohol use disorder

Objective

This study compared the acute phase (12-week) efficacy of fluoxetine versus placebo for the treatment of the depressive symptoms and the drinking of adolescents with comorbid major depression (MDD) and an alcohol use disorder (AUD). We hypothesized that fluoxetine would demonstrate efficacy versus placebo for the treatment of both the depressive symptoms and the drinking of comorbid MDD/AUD adolescents.

Methods

We conducted the first double-blind placebo-controlled study of fluoxetine in adolescents with comorbid MDD/AUD. All participants in both treatment groups also received intensive manual-based Cognitive Behavioral Therapy (CBT) and Motivation Enhancement Therapy (MET).

Results

Fluoxetine was well tolerated in this treatment population. No significant group-by-time interactions were noted for any depression-related or drinking-related outcome variable. Subjects in both the fluoxetine group and the placebo group showed significant within-group improvement in both depressive symptoms and level of alcohol consumption. End-of-study levels of depression and drinking were low in both treatment groups.

Conclusions

The lack of a significant between-group difference in depressive symptoms and in drinking may reflect limited medication efficacy, or may result from limited sample size or from efficacy of the CBT/MET psychotherapy. Large multi-site studies are warranted to further clarify the efficacy of SSRI medications in this adolescent MDD/AUD population.     

Effects of caffeinated vs. non-caffeinated alcoholic beverage on next-day hangover incidence and severity,perceived sleep quality,and alertness

Aims

Beliefs about the effects of mixing caffeine and alcohol on hangover or sleep may play a role in motivation to consume these mixtures; therefore, information is needed about actual effects. We investigated whether intoxication with caffeinated vs. non-caffeinated beer differentially affected perceived sleep quality, sleepiness, and hangover incidence and severity the next morning.

Methods

University students (89%) and recent graduate drinkers were randomized to receive: (1) beer with the equivalent of 69 mg caffeine/12 oz glass of regular beer (n = 28) or (2) beer without caffeine (n = 36), in sufficient quantity to attain a BrAC of 0.12 g%. After an 8-h supervised sleep period, participants completed measures of hangover, sleep quality, sleep latency and time asleep, and sleepiness.

Results

While caffeinated beer improved perceived sleep quality, effect sizes were greater for morning alertness than for quality while sleeping, with no effect on sleep latency or total sleep time. No effects were seen on hangover incidence or severity.

Conclusions

Mixing caffeine and alcohol does not significantly impair amount of sleep or sleep latency, hangover, or sleepiness the morning after drinking to intoxication in this population.     

Biological markers of problem drinking in homeless patients

Objective

In the search for optimal biomarkers of excessive drinking, a central limitation has been the lack of sensitivity of measures. Many patients have apparently normal values of liver markers despite a considerable alcohol intake. This study aimed to test a novel combined indicator of alcohol drinking.

Material and methods

Concentrations of carbohydrate-deficient transferrin (%CDT), γ glutamyl transferase (γGT), aspartate aminotransferase (ASAT), and mean corpuscular volume (MCV), together with a combined index of the %CDT and γGT, the Antilla Index (AI), were studied in 104 homeless patients with (n = 87) or without (n = 24) problem drinking according to the Fast Alcohol Screening Test.

Results

Concentrations of all markers were significantly higher in the alcoholic patients than in other homeless patients. The best agreement between liver markers and self-reported status was found between the combined %CDT and γGT index (kappa = 0.61, p < 0.001, sensitivity = 63%, specificity = 94%).

Conclusions

The combined AI is a relatively efficient measure of current drinking in homeless populations.     

Television-supported self-help for problem drinkers: A randomized pragmatic trial

Objectives

To test the effectiveness of a television-supported self-help intervention for problem drinking.

Methods

Dutch television viewers (N = 181) drinking in excess of the guidelines for low-risk alcohol use were randomly assigned either to the Drinking Less TV self-help course (consisting of five televised sessions supplemented by a self-help manual and a self-help website) or to a waitlisted control group. To ensure trial integrity, intervention delivery was mimicked beforehand by sending intervention participants weekly DVDs in advance of the actual telecasts in 2006. Pre-post assessments were carried out on both groups, as well as a 3-month follow-up assessment on the intervention group to study effect maintenance. The primary outcome measure was low-risk drinking.

Results

The intervention group was more successful than the waitlist group in achieving low-risk drinking at post-intervention (OR = 9.4); the effects were maintained in the intervention group at 3-month follow-up.

Conclusions

The low-threshold television-based course Drinking Less appears effective in reducing problem drinking.     

Test–retest reliability of an online measure of past week alcohol consumption (the TOT-AL), and comparison with face-to-face interview

Objective

This paper reports on the development of a new online measure of beverage-specific past week alcohol consumption (the TOT-AL), its test–retest reliability, and comparability with the face-to-face approach of ascertaining alcohol intake.

Methods

University students participating in the reliability study completed the TOT-AL twice on the same day with at least 3 h apart. Students in the comparability study attended a face-to-face interview and completed the TOT-AL on the same day, in a randomised order, at least 3 h apart.

Results

There was a strong correlation between the repeated measurements of the TOT-AL (r = 0.99; 95% CI: 0.98, 0.99) and between the units calculated by the TOT-AL and the face-to face interview (r = 0.97; 95% CI: 0.95, 0.99). A high level of agreement between measurements was also observed in a Bland–Altman analysis.

Conclusions

The TOT-AL is a reliable, time efficient means of ascertaining alcohol intake, equivalent to that obtained face-to-face. These findings support the use of this approach to online alcohol assessment in populations with access to the Internet.