Predictors of injury‐related and non‐injury‐related mortality among veterans with alcohol use disorders

Aims To describe the association between alcohol use disorders (AUDs) and mortality and to examine risk factors for and all‐cause, injury‐related and non‐injury‐related mortality among those diagnosed with an AUD. Setting Department of Veterans Affairs, Veterans Health Administration (VHA). Participants A cohort of individuals who received health care in VHA during the fiscal year (FY) 2001 (n = 3 944 778), followed from the beginning of FY02 through the end of FY06. Measurements Demographics and medical diagnoses were obtained from VHA records. Data on mortality were obtained from the National Death Index. Findings Controlling for age, gender and race and compared to those without AUDs, individuals with AUDs were more likely to die by all causes [hazard ratio (HR) = 2.30], by injury‐related (HR = 3.29) and by non‐injury‐related causes (HR = 2.21). Patients with AUDs died 15 years earlier than individuals without AUDs on average. Among those with AUDs, Caucasian ethnicity and all mental illness diagnoses that were assessed were associated more strongly with injury‐related than non‐injury‐related mortality. Also among those with AUDs, individuals with medical comorbidity and older age were at higher risk for non‐injury related compared to injury‐related mortality. Conclusions In users of a large health‐care system, a diagnosis of an AUD is associated significantly with increased likelihood of dying by injury and non‐injury causes. Patients with a diagnosis of an AUD who die from injury differ significantly from those who die from other medical conditions. Prevention and intervention programs could focus separately upon selected groups with increased risk for injury or non‐injury‐related death.     

Efficacy and Safety of Aripiprazole in Alcohol Dependence

Dopaminergic agonists and antagonists have both been examined for the treatment of substance abuse with contrasting results. To the best of our knowledge dopamine receptor partial agonists have not been investigated in alcohol use disorders. Thirteen detoxified alcohol-dependent subjects were treated with flexible doses of aripiprazole for 16 weeks. Six patients maintained an alcohol free condition for all the study period. All the subjects experienced a reduction of craving in both OCDS (p < .05) and VAS (p < .05), and a decrease of the SCL-90 General Severity Index (GSI) (p < .05). The data of this pilot clinical study, suggest a possible role for this drug in the treatment of individuals with alcohol problems.     

The epidemiology of cannabis use and cannabis‐related harm in Australia 1993–2007

Aims To examine trends in patterns of cannabis use and related harm in the Australian population between 1993 and 2007. Design Analysis of prospectively collected data from: (1) the National Drug Strategy Household Survey (NDSHS) and Australian Secondary Student Alcohol and Drug Survey (ASSADS); (2) the National Hospital Morbidity Database (NHMD); and (3) the Alcohol and Other Drug Treatment Services National Minimum Dataset (AODTS‐NMDS). Participants Australians aged 14 years and over from the general population; students aged 12–17 years; public and private hospital in‐patients; public and private in‐patients and out‐patients attending for drug treatment. Measurement Prevalence of 12‐month cannabis use among the general population and secondary students. Proportions in the general population by age group reporting: daily cannabis use; difficulties in controlling cannabis use; and heavy cannabis use on each occasion. Number of hospital and treatment presentations for cannabis‐related problems. Findings Prevalence of past‐year cannabis use has declined in the Australian population since the late 1990s. Among those reporting past‐year use, daily use is prevalent among 40–49‐year‐olds, while heavy patterns of use are prevalent among 14–19‐year‐olds. Hospital presentations for cannabis‐related problems reflect similar trends. Past‐year cannabis use has decreased among the 10–19‐year age group, but those who are daily users in this age group report using large quantities of cannabis. Conclusions Despite declines in the prevalence of cannabis use, continued public health campaigns warning of the harms associated with cannabis use are essential, aimed particularly at users who are already experiencing problems. The increasing demand for treatment for cannabis problems in Australia suggests the need for more accessible and more effective interventions for cannabis use disorders.     

Coadministration of disulfiram and lorazepam in the treatment of alcohol dependence and co-occurring anxiety disorder: an open-label pilot study

ABSTRACT

Background: Anxiety is common among persons with alcohol use disorder during early abstinence from alcohol. Although benzodiazepines are effective for short-term treatment of anxiety, they are rarely used beyond acute detoxification due to concerns about misuse or interactions with alcohol. Objectives: We conducted an open-label trial to explore the effects of coadministering lorazepam and disulfiram to alcohol-dependent patients with anxiety disorder symptoms. The rationale for this model is to minimize the risks of the benzodiazepine, while also potentially enhancing adherence to disulfiram. Methods: Forty-one participants with DSM-IV alcohol dependence who also met syndromal criteria for anxiety disorder with or without co-occurring major depressive syndrome initiated treatment with lorazepam (starting dose 0.5 mg three times daily) and disulfiram (starting dose 500 mg three times weekly). Participants received 16 weeks of monitored pharmacotherapy with manualized medical management. Results: Adherence to treatment decreased steadily with time (85.4% at 4 weeks, 36.6% at 16 weeks). Participants showed significant increases in percent abstinent days during treatment and at 24 weeks follow-up. Large reductions in anxiety, depression, and craving were observed during treatment, and improvement remained significant at 24 weeks. Duration of adherence with disulfiram strongly predicted abstinence at 16 weeks. There was no evidence of misuse of lorazepam or dose escalation during the study. Conclusion: Lorazepam can be safely used for short-term treatment of anxiety in combination with disulfiram treatment of alcohol use disorder. However, it is not clear that making lorazepam dispensing contingent on adherence to disulfiram enhances retention in disulfiram treatment.     

Prevalence and correlates of DSM‐IV alcohol abuse and dependence in Australia: findings of the 2007 National Survey of Mental Health and Wellbeing

Aims To report nationally representative data on the prevalence and correlates (including psychiatric comorbidity and treatment) of DSM‐IV alcohol abuse and dependence in Australian adults. Design The 2007 National Survey of Mental Health and Wellbeing (NSMHWB). Setting Australian nationally representative household survey. Participants 8841 Australian adults (16–85 years). Measurements Interview schedule that assessed symptoms of the most prevalent DSM‐IV mental disorders in the life‐time and the past 12 months. Findings Prevalence of life‐time and 12‐month disorders was 18.3% and 2.9% for alcohol abuse and 3.9% and 1.4% for alcohol dependence. Current alcohol abuse and dependence was significantly more common in males and younger adults. There were significant associations between current alcohol use and other drug use disorders (OR 18.2) and between anxiety disorders and alcohol use disorders (OR 2.6). Only 22.4% of those with alcohol use disorders were treated for their alcohol disorder. Conclusions Alcohol use disorders are highly prevalent, especially among young adult males. Comorbidity between anxiety and other drug use disorders is common and remains a significant challenge for the delivery of effective health‐care services and treatment. The low rate of effective interventions for alcohol problems is a significant public health concern.     

Area of residence and alcohol‐related mortality risk: a five‐year follow‐up study

Aims To examine differences in alcohol‐related mortality risk between areas, while adjusting for the characteristics of the individuals living within these areas. Design A 5‐year longitudinal study of individual and area characteristics of those dying and not dying from alcohol‐related deaths. Setting The Northern Ireland Mortality study. Participants A total of 720 627 people aged 25–74, enumerated in the Northern Ireland 2001 Census, not living in communal establishments. Measurements Five hundred and seventy‐eight alcohol‐related deaths. Findings There was an increased risk of alcohol‐related mortality among disadvantaged individuals, and divorced, widowed and separated males. The risk of an alcohol‐related death was significantly higher in deprived areas for both males [hazard ratio (HR) 3.70; 95% confidence interval (CI) 2.65, 5.18] and females (HR 2.67 (95% CI 1.72, 4.15); however, once adjustment was made for the characteristics of the individuals living within areas, the excess risk for more deprived areas disappeared. Both males and females in rural areas had a reduced risk of an alcohol‐related death compared to their counterparts in urban areas; these differences remained after adjustment for the composition of the people within these areas. Conclusions Alcohol‐related mortality is higher in more deprived, compared to more affluent areas; however, this appears to be due to characteristics of individuals within deprived areas, rather than to some independent effect of area deprivation per se. Risk of alcohol‐related mortality is lower in rural than urban areas, but the cause is unknown.     

Alcohol Expectancies and Drinking Refusal Self‐Efficacy Mediate the Association of Impulsivity With Alcohol Misuse

Background: Recent work suggests that 2 biologically based traits convey risk for alcohol misuse: reward sensitivity/drive and (rash) impulsiveness. However, the cognitive mechanisms through which these traits convey risk are unclear. This study tested a model predicting that the risk conveyed by reward sensitivity is mediated by a learning bias for the reinforcing outcomes of alcohol consumption (i.e., positive alcohol expectancy). The model also proposed that the risk conveyed by rash impulsiveness (RI) is mediated by drinkers’ perceived ability to resist alcohol (i.e., drinking refusal self‐efficacy). Methods: Study 1 tested the model in a sample of young adults (n = 342). Study 2 tested the model in a sample of treatment‐seeking substance abusers (n = 121). All participants completed a battery of personality, cognitive, and alcohol use questionnaires and models were tested using structural equation modeling. Results: In both studies, the hypothesized model was found to provide a good fit to the data, and a better fit than alternative models. In both young adults and treatment‐seeking individuals, positive alcohol expectancy fully mediated the association between reward sensitivity and hazardous alcohol use. For treatment seekers, drinking refusal self‐efficacy fully mediated the association between RI and hazardous drinking. However, there was partial mediation in the young adult sample. Furthermore, neither trait was directly associated with the other cognitive mediator. Conclusions: The hypothesized model was confirmed on a large sample of young adults and replicated on a sample of treatment‐seeking substance abusers. Taken together, these findings shed further light on the mechanisms through which an impulsive temperament may convey risk for alcohol misuse.     

Validity of the indicator ‘death in low‐mortality diagnosis‐related groups’ for measuring patient safety and healthcare quality in hospitals

The indicator ‘death in low‐mortality diagnosis‐related groups (DRG)’ is a patient safety indicator (PSI) that can be derived from routinely collected administrative data sources. It is included in a group of PSI that have been proposed to compare and monitor standards of hospital care in Australia. To summarize the attributes of this indicator as a measure of quality and safety in healthcare and examine issues regarding the development process, definitions and use of the indicator in practice. A structured literature search was conducted using the Ovid Medline database to identify peer‐reviewed published literature which used ‘death in low‐mortality DRG’ as a quality/safety indicator. Key quality websites were also searched. The studies were critically appraised using a standardized method. A total of 12 articles was identified which met our search criteria. Most were of low methodological quality because of their retrospective study designs. Only three studies provided evidence that the quality of care gap is higher in ‘deaths in low‐mortality DRG’ than in other cases. Most of the studies reviewed show that there are several limitations of the indicator for assessing patient safety and quality of care. The few studies that have assessed associations with other measures of hospital quality have shown only weak and inconsistent associations. Higher quality, prospective, analytic studies are required before ‘death in low‐mortality DRG’ is used as an indicator of quality and safety in healthcare. Based on current evidence, the most appropriate use is as a screening tool for institutions to quickly and easily identify a manageable number of medical records to investigate in more detail.     

ADH1B*3 and Response to Alcohol in African‐Americans

Background:  Variations in the alleles for the alcohol‐metabolizing enzymes have been shown to influence risk for alcohol dependence. One variant, ADH1B*3, is observed almost exclusively in populations of African ancestry and has been shown to be associated with reduced rates of alcohol dependence. We conducted an alcohol challenge study to test whether ADH1B*3 is associated with differences in subjective and physiological response to alcohol. Method:  We administered a moderate dose of alcohol (0.72 g/kg for males, 0.65 g/kg for females) to a sample of African‐American young adults (n = 91; ages 21 to 26). Participants were genotyped for ADH1B, as well as additional polymorphisms that might contribute to alcohol response. Breath alcohol concentration, self‐reported sedation and stimulation, and pulse rate were assessed prior to alcohol administration and for 2.5 hours following administration. Results:  ADH1B*3 was associated with higher levels of sedation and a sharper increase in pulse rate immediately following alcohol consumption. Conclusions:  These findings suggest that the lower rates of alcohol dependence in those with ADH1B*3 alleles may be because of differences in alcohol response, particularly increased sedation.