Study: Burden of Disease Associated with Alcohol-use Disorders Higher Than Previously Thought

In a paper published online last week in the journal, Alcoholism: Clinical and Experimental Research, a group of international researchers have brought fresh eyes to a familiar data set: the NIAAA's NESARC. Whereas past studies have estimated the alcohol-attributable global burden of disease, or rates of alcohol-attributable deaths and years of life lost, no study has focused specifically on the burden of disease in the United States associated with alcohol-use disorders (AUD). This is important, the authors note, because alcohol-use disorders (including "abuse" and "dependence" from DSM or "the harmful use of alcohol" from ICD) "were identified as the largest disease category contributing to the alcohol-attributable global burden of disease for the year 2004, making up approximately one-third of this burden." By using US-specific data, including population and death statistics as well as Waves 1 and 2 of the NESARC, the authors were able to estimate the burden of disease from AUD in the US in 2005.


Results

"In the United States in 2005, 65,000 deaths, 1,152,000 years of life lost due to premature mortality (YLL), 2,443,000 years of life lost due to disability (YLD), and 3,595,000 disability-adjusted life years (DALYs) lost were associated with AUD. For individuals 18 years of age and older, AUD were associated with 3% of all deaths (5% for men and 1% for women), and 5% of all YLL (7% for men and 2% for women). The majority of the burden of disease associated with AUD stemmed from YLD, which accounted for 68% of DALYs associated with AUD (66% for men and 74% for women). The youngest age group had the largest proportion of DALYs associated with AUD stemming from YLD."

Some figures from the article:

Prevalence of alcohol use disorders by category, sex, and age in 2005. 

And:

Proportion of all deaths associated with alcohol use disorders in 2005, by sex and age


You can read the abstract of the paper by Rehm, et al. here:

http://onlinelibrary.wiley.com/doi/10.1111/acer.12331/abstract

Would love to hear readers reactions to these numbers. 

Are Financial Incentives the Answer to SBIRT Implementation?

Researchers from Imperial College London may have found a way to increase alcohol screening and brief intervention in a primary care setting: financial incentives. The results, published online Dec. 26 in the Journal of Public Health, show that offering a points-based incentive for successful screening, brief intervention and referral to specialists significantly increased the number of patients who were screened. As a result, the authors say, more patients with risky alcohol intake were identified and offered care, reducing hazardous and harmful drinking in some.

While the evidence for SBIRT is abundant and well-known, there have been considerable problems in promoting widespread implementation - especially in primary care. Financial incentives could be one effective means of changing this. (Granted, a large-scale effort by the federal government or the insurance companies would likely be required to provide funding. In this study, data was collected from 2008-2011, until the UK's Quality and Outcomes Framework funding was withdrawn.)

Abstract

Introduction Alcohol screening and brief intervention (ASBI) is effective but underprovided in primary care. Financial incentives may help address this. This study assesses the impact of a local pay-for-performance programme on delivery of ASBI in UK primary care.

Methods Longitudinal study using data from 30 general practices in north-west London from 2008 to 2011 with logistic regression to examine disparities in ASBI delivery.

Results Of 211 834 registered patients, 45 040 were targeted by the incentive (cardiovascular conditions or high risk; mental health conditions), of whom 65.7% were screened (up from a baseline of 4.8%, P< 0.001), compared with 14.7% of non-targeted patients (P < 0.001). Screening rates were lower after adjustment in younger patients, White patients, less deprived areas and in patients with mental health conditions (P < 0.05). Of those screened, 11.5% were positive and 88.6% received BI. Men and White patients were significantly more likely to screen positive. Women and younger patients were less likely to receive BI. 30.1% of patients re-screened were now negative. However, patients with mental health conditions were less likely to re-screen negative than those with cardiovascular conditions.

Conclusion Financial incentives appear to be effective in increasing delivery of ASBI in primary care and may reduce hazardous and harmful drinking in some patients. The findings support universal rather than targeted screening.

Source: http://intljpubhealth.oxfordjournals.org/content/early/2013/12/26/pubmed.fdt121.abstract

If You Build It, They Will Drink

If there were lingering doubts about the effect of alcohol availability on alcohol consumption, a host of new studies seem to lead the reader to the same conclusion: that increases in availability are correlated to increases in consumption. In other words: if you build it (bar, liquor store, etc), we will drink. What's more, in many cases, it's not just drinking that will happen. So-called alcohol outlet density has been linked to interpersonal and intimate partner violence, adolescent consumption and beliefs about alcohol, and even alcohol-attributable deaths. On the other hand, raising the minimum prices or implementing taxes on alcohol sales seems to go a long way in reducing these potential harms.

The journal, Addiction, has published several of these studies online in the past few weeks. Gruenewald and colleagues analyzed survey data from 50 California cities with populations between 50,000 - 500,000. They found "greater on-premise outlet densities were related to greater drinking frequencies and volumes, and use of on-premise drinking places" (like bars and restaurants).  The researchers concluded that, in addition to characteristics of the individual drinkers (e.g. "impulsivity, risky driving), alcohol availability is correlated with consumption and related problems.

Also in-press at Addiction, Paschall and colleagues analyzed the same sample, but instead focused on adolescent drinking. Some 1478 California youths, aged 13-17, responded to survey questions about past-year alcohol consumption, perceived availability, and questions related to underage enforcement and parental views toward drinking. The answers to these questions were then compared against alcohol outlet (bar) density, public policy, law enforcement activity and city demographics. The authors found that adolescent behaviors and attitudes were significantly affected by their environments. For example, past-year alcohol use was positively correlated to bar density and inversely correlated to "the comprehensiveness and stringency of local alcohol policies". In addition, higher rates of adult drinking were associated with greater increases of past-year adolescent drinking over the three-year study period.

Over in Alcohol and Alcoholism, Grubesic and colleagues studied the association between outlet density in Philadelphia and violent crime. Once again, the researchers found consistent association between the two. Here is a pair of maps, the first showing assault density, the second showing outlet density:

Contrary to the popular belief, no association was found between assault density and "transportation nodes and risky retailers". However, alcohol expenditures and general commercial activity were "positively and significantly" associated with assault density. 

The connection between intimate partner violence (IPV) and alcohol outlet density seems to be well established. In 2012, Conradi and colleagues reported that the density of bars in California was positively associated with IPV-related emergency department visits between 2005-2008. Then, earlier this year, Waller and colleagues found alcohol outlet density to be positively correlated to male-to-female physical - but not sexual - IPV among a national sample. Finally, in March, Zhao and colleagues showed that alcohol outlet density was associated with an increase in alcohol-attributable deaths in British Columbia between 2002-2009. In fact, they calculated that a 10% increase in private liquor stores was associated with a 2.45%, 2.36% and 1.99% increase in acute, chronic and total alcohol-associated (AA) mortality rates.

Interestingly, the single policy that seemed to have the biggest impact in turning these numbers around: raising the minimum price for alcohol. A 10% increase in the minimum price was associated with a 31.72% reduction in "wholly AA deaths". Pretty big numbers. As Dr W observed recently, "raising taxes on alcohol would do more for public health than all the treatment in the world." 

What do you think?

Sunday Alcohol Blue Laws: Keeping consumption in-check?

In a brand new paper by SUNY economist Bans Yoruk, the author analyzes alcohol consumption rates in five states which recently repealed laws banning the sale of alcohol on Sundays. The findings, published online this month in the journal Addiction, show that in three of the five states, per capita alcohol consumption rose significantly in the years following the repeals. Beer seems to be the type of alcohol responsible for most of the increase across the states, with wine and spirits seeing small, if any, changes in demand.

The five states studied were Delaware, which repealed its law against Sunday alcohol sales in 2003, as did Massachusetts and Pennsylvania; Rhode Island, which repealed in 2004; and New Mexico, where the law was changed in 1995. The three states whose per capita consumption increased were Delaware (from 4% pre-repeal to 4.7% post-repeal), Pennsylvania (4% to 4.6%), and New Mexico (6.5% to 7.1%). The increase in Rhode Island was “small and statistically insignificant,” and there was no change in Massachusetts. (Interestingly, the demand for beer seemed to drive the up-tick in sales – all three states where the overall demand rose saw beer consumption increase by about a full percentage point.) The five states were then compared to control states, like our beautiful Minnesota, where alcohol Blue Laws remain in effect. 

Here's the graph from the paper:

Professor Yoruk's analysis falls on the heels of another study which tracked the effects of, among other variables, perceived alcohol availability and bar density on adolescent alcohol consumption. Paschall, et al. found such environmental factors contributed significantly to higher rates of past-year alcohol use. Could it be that an archaic and puritanical relic could actually be saving some lives? Will be interesting to see what readers think about the issue…

Sources:

        Paschall, M. J., Lipperman‐Kreda, S., & Grube, J. W. (2013). Effects of the Local Alcohol Environment on Adolescents’ Drinking Behaviors and Beliefs.Addiction.

        Yörük, B. K. (2013). Legalization of Sunday alcohol sales and alcohol consumption in the United States. Addiction.

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a randomized clinical trial

This week's entry comes from Dr Reid K Hester, PhD. He is Director of the Research Division at Behavior Therapy Associates, LLC, where they have been conducting some exciting new research using a web-based application, Overcoming Addictions. Thank you, Dr Hester, for the guest post:

Overcoming Addictions, a web-based application, & SMART Recovery: Outcomes of a 

randomized clinical trial

My research staff and I recently published the early outcomes of a new web app, Overcoming Addictions in the Journal of Medical Internet Research (http://www.jmir.org/2013/7/e134). Overcoming Addictions (OA, www.overcomingaddictions.net) is an abstinence-oriented, cognitive behavioral program based on the protocol of SMART Recovery. SMART Recovery (www.smartrecovery.org) is an organization that has adapted empirically supported treatment strategies for use in a mutual help framework with in-person meetings, online meetings, a forum and other resources.

A firm believer of “In God we trust, everyone else has to show their data,” we evaluated the effectiveness of OA and SMART Recovery (SR) with problem drinkers in a randomized clinical trial. We recruited 189 heavy problem drinkers primarily through SMART Recovery’s web site and their online and in-person meetings. We randomly assigned them to: (1) OA alone, (2) OA+ attend SMART Recovery meetings (OA +SR), or to (3) attend SMART Recovery meetings (SR) only. Outcome measures included self-reported percent days abstinent, mean drinks per day when they did drink , and alcohol/drug related consequences. We also interviewed significant others to corroborate the participant’s self-report.

We predicted that: (1) All groups would reduce their drinking and alcohol/drug related consequences at follow-up compared to their baseline levels; (2) the OA groups would reduce their drinking and alcohol/drug related consequences more than the control group (SR).

There were several striking features of our participants. First, 60% of them were female. While this is consistent with the clinical trials of our other web applications like the Drinker’s Check-up (www.drinkerscheckup.com) and Moderate Drinking (www.moderatedrinking.com), it is significantly more than what one would predict given the prevalence of problem drinking in women versus men (35 vs. 65% respectively) in the epidemiological data. Second, this was a highly educated group with an average of 16 years of education. Third, while these folks were not seeking formal treatment, they had a level of alcohol problems comparable to the outpatient arm of Project MATCH.

At the 3 month follow-up both the intent-to-treat analyses and the actual use analyses showed highly significant improvement from baseline to follow-ups.  Mean within-subject effect sizes were large (d > .8) overall. There were, however, no significant differences between groups. Participants in all groups significantly increased their percent days abstinent from 44% to 72% (P<.001), decreased their mean drinks per drinking day from 8.0 to 4.6 (P<.001), and decreased their alcohol/drug-related problems (P<.001) by about 50%. These are clinically meaningful improvements in outcomes.

These outcomes indicate that both our Overcoming Addictions web app and attending SMART Recovery meetings and using their resources online (www.smartrecovery.org) were effective in helping people recover from their problem drinking.

These graphs reflect outcomes of the actual use analyses.

Relapse Prevention Strategies and Anti-Relapse Medications

A recent commenter asked these questions:

Anonymous has left a new comment on your post "Is Maintenance the Best Therapy for Opioid Addicti...": 

Dr. Willenbring,

Would you agree that a person in recovery should have a solid relapse prevention plan in place regardless of the recovery path they choose. For example a person could choose abstinence-based recovery (AA/NA, CBT, counseling, etc.), Medication Management, or a combination of those, in whatever multitude of variations. Isn't it still imperative that they stay away from their former lifestyle as much as possible?

-Stay away from the places you obtained your drug of choice?
-Stay away from the places you used your drug of choice?
-Stay away from the people that provided your drug of choice?
-Stay away from the people you used with?

What are your thoughts regarding these and other common relapse prevention measures with regard any treatment/recovery option available? 

The simplest answer is that yes, a relapse prevention plan is essential to recovery from any SUD. The examples this reader gives are common-sense strategies designed to reduce exposure to cues that might trigger urges, craving, preoccupation and, most importantly, opportunity. An old saying in AA is, "If you hang around a barber shop long enough, sooner or later you're going to get a haircut." I like the CBT approach of "Recognize, Avoid, Cope." First, do what you can to Recognize higher-risk situations, such as a social event that involves drinking (for someone with alcohol use disorder,) or where you are likely to be stressed or sleep-deprived (you have to work long hours for some reason, or a close family member is seriously ill.) For many people, a trip out of town to a work meeting, or, often worse, their spouse is going to be out of town (when the cat's away...) are high risk. Recognizing allows you to plan your strategy to reduce your risk of a recurrence. 

Second, Avoid the high-risk situation if you can. If a social event is going to involve a lot of drinking or drug use, and it's an optional event, skip it. Why put yourself in that situation? Why stress about it? Besides, one of the first things most people realize is that being sober while the other people are intoxicated isn't any fun. Although they (and you, in the past) may think that they're witty, charming and sexy, the reality is anything but. Typically, intoxicated people are dull and sometimes obnoxious. Unfortunately, avoiding intoxicated people too often means that you have to develop new friends, and you may have to endure some lonely times as that develops. Community support groups such as AA can help by providing you with a built-in social system to bridge that gap, but there are many other opportunities: book clubs, hiking clubs, bicycling organizations, volunteering, spiritual or religious activities, among many others. Be creative!

Finally, if you can't avoid the higher risk situation, develop strategies to Cope with it before you get there. Take a supportive friend, or identify another non-user within the group. Plan an early exit if possible. Practice drink/drug refusal skills. Take an anti-relapse medication (ARM). Remember, no one has any right to know your personal business, including whether you decide to use intoxicants or not. Have one or two stock phrases that 1) don't give a lot of information but don't lie, and 2) don't invite further questions. For example: "Hey, what's up? What's with you not drinking any more? Too stuck up for your bros? Let my buy you a drink, come on!" "No thanks. I just don't like the way I feel when I drink," or "You know, these days it pays to stay sharp, and I get too fuzzy headed if I drink." I'm sure you can come up with others. If the other person persists, you might retort, "Does my not drinking make you uncomfortable? What's the problem?"

One more thing, though, is that I think it's time to give up the false "abstinence-based recovery" vs. "medication-assisted treatment" dichotomy. It's a remnant of 1955. Is someone taking insulin for diabetes on "medication-assisted therapy" versus someone who tries to manage it by lifestyle changes alone? Is someone taking an antipsychotic or mood stabilizer "not abstinent?" My patients struggle at least as much with having to take medications for arthritis, MS, or depression as they do with taking anti-relapse medications. How about ARMs like naltrexone, or disulfiram (Antabuse), or topiramate (Topamax)? If you take those, are you "abstinent?" What if, by trying to "be abstinent," you are a miserable wretch with a high relapse risk, while if you take a medication such as buprenorphine (Suboxone), you are a happy, productive person with a low relapse risk? Why is "being abstinent" automatically thought to be superior, better, and to reflect more positively on you? Is it because we "should" be able to "do it ourselves?" Is it because "God should be enough?" Is it because it shows we are stronger, morally superior, more capable? Why "should" we be "able to recover without medications"? Who says? On what basis? This one idea kills more people with SUDs than almost any other, and I mean that quite literally. Get over it. The brain is flesh and blood. It gets dysregulated just like any other organ and sometimes it is incapable of healing or fixing itself. Sometimes it needs help with medication, as well as social support, psychotherapy, spirituality, exercise, and other non-medication supports and treatments. So what? 

New Report Outlines Global Strategy to Reduce Harmful Drinking

New Report Recommends Public Health Focus on Harmful Drinking vs. Eliminating Consumption

Tuesday, February 26, 2013

International Center for Alcohol Policies (ICAP)  

Findings Run Counter to Current Public Health Approach, Discredit Traditional Perspectives

WASHINGTON, DC--(Marketwire) - The traditional public health perspective on alcohol and noncommunicable diseases is indicted in a new report from the International Center for Alcohol Policies (ICAP). "Alcohol misuse and global health: The case for an inclusive approach to harmful drinking" discredits the traditional public health perspective that focuses on a narrow group of stakeholders and ignores individual factors and social norms.

"Unfortunately, some widely-held public policy perspectives on reducing harmful drinking are based on questionable and misleading data," said ICAP President Marcus Grant. "This report draws on a wide pool of research to clarify misconceptions and propose a more effective model that involves a broader group of stakeholders and resources, including alcohol producers."

In the past decade, there is greater recognition of the impact of noncommunicable diseases (NCDs) in both developed and developing countries. Harmful alcohol consumption is a contributing lifestyle factor for several of the most widespread and harmful of these diseases, with alcohol misuse accounting for four percent of global disease burden.

The report notes that a reduction in heavy-drinking patterns will have a more significant impact on public health than limiting alcohol's physical and economic availability. Unlike tobacco use, which is harmful at any level, light to moderate drinking can have healthful benefits for some groups. There is little to be gained from stigmatizing what is, for many people, a normal behavior.

The WHO Global Strategy to Reduce the Harmful Use of Alcohol recognizes this distinction, and that including a wider array of stakeholders than historically have been engaged contributes to a more effective public health response. In an era of shrinking economies, the fight against such a critical public health issue cannot afford to exclude key influencers, such as alcohol producers, or the unique resources they can provide.

The focus of the public health community, policymakers, non-governmental organizations and yes, even producers, should be on mitigating the risk of unhealthy consumption patterns, rather than eliminating consumption altogether.

"Alcohol misuse and global health: The case for an inclusive approach to harmful drinking" is available:

http://icap.org/LinkClick.aspx?fileticket=C35rkfX54Mk%3d&tabid=159

The International Center for Alcohol Policies (ICAP; www.icap.org) is a not-for-profit organization supported by major international producers of beverage alcohol. Established in 1995, ICAP's mission is to promote understanding of the role of alcohol in society and to help reduce harmful drinking worldwide. ICAP's efforts to foster dialogue and partnerships in the alcohol policy field are shaped by its commitment to pragmatic and feasible solutions to reducing harm that can be tailored to local and cultural considerations and needs. ICAP has been recognized by the United Nations Economic and Social Council (UN ECOSOC) as a non-governmental organization in Special Consultative Status.

Why SBIRT Is Dead in the Water

In the latest issue of Health Affairs, Grace Lin et al. describe an effort to introduce decision-making aids to facilitate shared decision-making regarding back pain and colo-rectal cancer screening. Essentially, nothing changed, in spite of making the aids easily accessible, conducting training sessions, and so on. What's important is the authors' conclusion that "The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy."

Their experience mirrors my own in trying for over 20 years to get substance use addressed in primary care. Most recently, I have two separate but relate experiences here in Minnesota where I essentially ran up against a brick wall. Why? First, primary care doctors are besieged by quality improvement initiatives aimed at reducing variability of practice and improving outcomes for depression, diabetes, heart failure, back pain, asthma, hypertension and many others. These are typically mandated from the top of health care organizations (remember that most primary care physicians are now employees of a large health care organization (HCO.) By attempting to implement not only SBIRT but treatment of alcohol dependence in primary care (I call it Screening, Evaluation and Treatment, or SET, but another term could be SBIRT+) by asking physicians to voluntarily take it on was a non-starter. Typical comments were "It's a good idea but we can't take on anything more right now," or "We're having enough trouble trying to get this clinic's operations running smoothly, and until we do, it wouldn't work." 

A second factor is one of priorities. I have argued for years that universal SBIRT is not cost-effective, but should be more targeted. Related to this is a crucial question: since visit length is not going to increase, what do you want the doctor to stop doing so they can do these new things, like shared decision-making and SBIRT+?  In other words, in a typical visit, the patient has certain expectations about why they are there and what they want, and most patients have multiple chronic diseases like obesity, arthritis, hypertension and diabetes. Oh, and of course they smoke. So, do you want the doctor to not address the patient's presenting complaint (e.g., arthritis pain, insomnia), or not address their hypertensive control so they have the time to spend on shared decision-making for back pain, or to conduct SBIRT+? How do you think patients would feel about this? This applies especially to SBIRT, because it is attempting to identify a problem they patient is unaware of and not concerned about. "Doctor, I came here because my right knee is all swollen and painful, and you want to take 2 out of the 8 minutes you spend with me asking me about drinking!?"

So have come to a similar conclusion: until the medical home concept is fully implemented, with team care that includes a focus on health behaviors of all types, SBIRT or SET are DOA. My most recent attempt has been to start with something that has the attention of every primary care doctor: pain management. I'm providing training to all the primary care doctors in Allina Health in management of chronic pain, and the response so far has been overwhelmingly positive. I'm hoping that by getting to know so many primary care physicians in this HCO, they will be more receptive to introducing SET. However, it has also become clear that the only way this will occur is if the top leadership of the organization decides that SET is important enough to get it into the queue of quality improvement projects, and thus mandate its implementation. 

Primary care, even with the medical home, is not going to be all things to all people, and choices are going to have to be made about what is important enough to include and what might ideally be included but which doesn't make the cut because it is not cost-effective or clinically significant enough.

Besides, if we were serious about addressing the heavy disease burden associated with heavy drinking, we would triple the taxes on alcoholic beverages. That would have a greater public health impact than implementing SBIRT in every primary care practice in the country. 

MW

Here's the abstract:

An Effort To Spread Decision Aids In Five California Primary Care Practices Yielded Low Distribution, Highlighting Hurdles

1. Grace A. Lin1, 
2. Meghan Halley2, 
3. Katharine A.S. Rendle3,
4. Caroline Tietbohl4, 
5. Suepattra G. May5, 
6. Laurel Trujillo6 and
7. Dominick L. Frosch7,*

+Author Affiliations

1. ¹Grace A. Lin is an assistant professor in the Division of General Internal Medicine and at the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco.
2. ²Meghan Halley is an assistant research anthropologist in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute, in California.
3. ³Katharine A.S. Rendle is a research associate in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
4. ⁴Caroline Tietbohl is a research assistant in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
5. ⁵Suepattra G. May is an assistant research anthropologist in the Department of Health Services Research at the Palo Alto Medical Foundation Research Institute.
6. ⁶Laurel Trujillo is medical director of quality at the Palo Alto Foundation Medical Group and chair of the Quality Improvement Steering Committee, both at the Palo Alto Medical Foundation, in Los Altos, California.
7. ⁷Dominick L. Frosch (dominick.frosch@moore.org) is an associate adjunct professor in the Division of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles.

1. ↵*Corresponding author

Abstract

Despite the proven efficacy of decision aids as interventions for increasing patient engagement and facilitating shared decision making, they are not used routinely in clinical care. Findings from a project designed to achieve such integration, conducted at five primary care practices in 2010–12, document low rates of distribution of decision aids to eligible patients due for colorectal cancer screening (9.3 percent) and experiencing back pain (10.7 percent). There were also no lasting increases in distribution rates in response to training sessions and other promotional activities for physicians and clinic staff. The results of focus groups, ethnographic field notes, and surveys suggest that major structural and cultural changes in health care practice and policy are necessary to achieve the levels of use of decision aids and shared decision making in routine practice envisioned in current policy. Among these changes are ongoing incentives for use, physician training, and a team-based practice model in which all care team members bear formal responsibility for the use of decision aids in routine primary care.

NIDA/NIAAA Merger Called Off!

This morning, Francis Collins, MD, PhD, the Director of the National Institutes of Health announced that he had decided to reverse his earlier decision to proceed with the merger of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and the National Institute on Drug Abuse (NIDA). This is a cause for celebration, as the merger was a solution in search of a problem right from the start.

For most of us at NIAAA (this process started when I was still there) it always looked like a simple power grab by NIDA and a relatively small but influential group of researchers and policymakers closely affiliated with it. The White House Office of Drug Control Policy (ONDCP; the Drug Czar), former NIDA Director Alan Leschner (who coveted NIAAA when he was at NIDA,) and current NIDA Director Nora Volkow all pushed very hard to make this happen. The "problem" it was supposed to solve were "missed opportunities" to pursue research involving both alcohol and drug disorders, but that's actually never been a problem in reality. The two institutes collaborate on multiple initiatives, and both alcohol and other drug disorders are frequently studied together, if only because they often occur together. But few of us involved with this ever thought there was a problem with the two institutes.

At any rate, without getting into details right now, I think this is very good news indeed.

MW

Benzos for Recovering People?

Recently, a colleague asked my opinion on the use of anti-anxiety medications called benzodiazepines in people either struggling with or recovering from an addiction (to something else of course.) Benzodiazepines (benzos for short) include common medications such as alprazolam (Xanax,) lorazepam (Ativan) and clonazepam (Klonapin.) Here is my reply:

First, I personally think that the idea that no-one who is in recovery from an addiction should ever ever be prescribed another potential intoxicant is a remnant of the all or none thinking in 12 step groups and programs. It's not based in fact. Yes, there may be a relative increase in risk, but the risk of true addiction to benzos (as opposed to development of tolerance and physical dependence) in an anxious pt is near zero in most people so the absolute risk is pretty low in someone with alcohol or opioid addiction, for example. The same holds true for pain medication in alcohol dependent people. I try to balance risks and benefits as I do with any patient or treatment. The science tells us for most people that an addiction is specific to a drug, not to "addiction" or intoxication of any type. There is no such thing as an "addictive personality." The other thing I'm impressed with is how poor any current pharmacotherapy is for chronic anxiety. The best treatment is good CBT, but it's hard to find and many pts aren't good candidates (although they might be for skillful psychodynamic therapy.) So I don't know about you, but I often find myself and the pt between a rock and a hard place.

An example patient is someone who had childhood onset of moderate to severe anxiety, often starting with separation anxiety and school refusal. Some patients report the onset of panic attack before the age of 10. Most of these people are extremely anxious all of their lives. I see them because they have became alcohol dependent. I generally prescribe an antidepressant, an SSRI or SNRI, but these seem to have poor efficacy in these primary anxiety patients, as opposed to people with depression and anxiety together. In one recent patient I  stopped benzos and the patient got to the point where I thought she would relapse to drinking w/o relief so I prescribed lorazepam and she almost immediately got much better, more stable, and with markedly reduced desire to drink. To my knowledge she hasn't used benzos in an addictive fashion, although the other problems of tolerance and lack of long-term efficacy haven't gone away. I usually try everything else I can: beta blockers, anticonvulsants, antidepressants, rarely antipsychotics if nothing else works. I always prescribe relaxation training and breathing exercises, give patients info about mindfulness approaches and also always recommend a CBT workbook for anxiety. I may recommend seeing a therapist. But sometimes it's only benzos that seem to help.

Some years ago a colleague of mine studied vets with severe chronic PTSD who were on benzos, expecting their outcomes to be worse than others. Theirs were better than others. Now that may simply be due to this group being more stable/adherent so therefore benzos were continued. But still, where is the evidence in the published lit that shows that long-term benzo use is often damaging? I worry that we prescribe truly toxic drugs like antipsychotics and depakote or lamotrigine to avoid benzos. And where is the evidence that many of these drugs actually help anxiety or are safe to treat it?

I think also there is a bias here: with very weak evidence of risk, we withhold benzos and with no evidence of efficacy or safety we prescribe toxic risky drugs instead. Make sense?

Also, underlying the bias is the pervasive idea, spread by 12 step treatment programs that 12 step treatment or groups are 100% effective if the person just does as they're told. You and I both know that's absurd and untrue. Medicine frequently involves compromise between ideal and pragmatic goals, and balancing various risks and benefits.

Finally, there is fairly strong evidence that untreated insomnia, pain and anxiety contribute substantially to increased relapse risk. It's easy to say "they should just tough it out or go to more meetings" but that seems pretty unreasonable and unsupportable to me.

In the end, I view it as all coming down to outcomes. Is the pt better off? Are their sxs less? Are they more functional? Does a rx for benzos help them recover more fully?

Be good to discuss some time....

Mark

An Ordinary Weekend

Last weekend I was on call for psychiatry at United, the hospital in St. Paul that I work for. It's been a moderately busy weekend for me, but not because there isn't any more demand for services, but because our inpatient beds are full. And guess what? So are the inpatient psychiatry beds not only throughout the Twin Cities Metro Area, but also the entire state! Halfway through the weekend we sent a patient to the last open adolescent psychiatry bed in Fargo, ND! So there are two patients this weekend who have had to stay in the emergency department, because there is no place to admit them. I continue to be amazed that I live in a country that would send its mentally ill children hundreds of miles away from their families because it's not willing to pay for the services they need locally.

And as usual, among the patients newly hospitalized whom I saw, about half were addicted to a psychoactive substance, usually alcohol. This is also typical. Now that I'm cutting back on my clinical practice, I'm unable to offer them a new form of treatment, one that is oriented around treating the disease as it is, rather than as we would like it to be. I was able to offer that for the last 2 years, but now I'm moving more into efforts to change things more broadly, to help others provide that kind of service and thus leverage my knowledge and skill. And that is going well and finally seems to be picking up speed. This stuff really takes a lot of time and effort!

But I still find it hard not to offer these patients an alternative to another run through a rehab program they've already experienced multiple times before. Any treatment that has been shown to be ineffective in a particular patient ought no longer to be pursued. I don't continue to prescribe naltrexone or Prozac to someone after it repeatedly fails to alter the course of illness, thinking that perhaps someday it will become effective! But embracing fully another approach is not without its problems too.

That's because to do so takes us right into some painful insights. Our treatments are modestly effective at best. There are many people for whom we have no effective treatment. And it's not their fault, it's because the science isn't yet at a point where we can understand what's wrong and help correct it. Our instruments are crude, primitive. Well-meaning, yes. We can always provide comfort, understanding, and a willingness to stay with someone to the end. But all too often, there is nothing we can do to change what we see as the inevitable conclusion of a process we don't understand: addiction. And I can tell you that it is difficult indeed to stay engaged with someone who is dying of an addiction neither she nor I nor you nor AA nor rehab nor medication nor the criminal justice system nor anyone else can help. We accept that grim reality with other diseases like heart disease or cancer. But we have a hard time accepting that brain diseases like addiction or bipolar disorder can be incurable and ultimately fatal. And most importantly, it's not because the person dying does not want to live or isn't trying in every way to stop the march towards death. We have to stop blaming the victims when our treatments fail and at least offer them succor along the way.

Revolutionizing Health Care Related to Alcohol Use

My current organization, Allina Hospitals and Clinics, has embarked on an ambitious and to my knowledge unprecedented effort to rationalize our approach to alcohol throughout the system. (The Veterans Health Administration has been addressing alcohol use in primary care for several decades and is as usual way ahead of private care, yet another example where government beats private care by a wide margin. However, their system is so unlike private practice that what happens in the VHA is difficult to translate.) I am leading Allina's effort and we've developed an ambitious agenda and a very aggressive timeline. If we're successful it will be almost a revolution across a large HCO (health care organization.) Allina consists of 11 hospitals, about 60 primary care clinics and many speciality clinics. Last year, there were more than 1 million hospital admissions and almost 4 million clinic visits within the Allina system.

I'm excited about this. It is nothing short of amazing that a large HCO would choose alcohol as a major focus across the organization. So far, the response has been enthusiastic. Physicians and other clinicians are very frustrated with the lack of consistency across parts of the system. They are frustrated that there seem to be so few options for patients admitted to hospital. Even if someone has been through 12 step rehab a dozen or more times, that is still the only option available: another run through rehab. They are desperate for something new. Clinicians are realistic. Most of what we do in medicine is care for chronic incurable conditions. Although we sometimes make people completely well, more often we help mitigate the ravages of an incurable condition. And sometimes we are pretty poor at even that. In cases with really severe, progressive illness we are often pretty helpless, along with the patients and families. So health care professionals are comfortable with care that is less than curative but is at least comforting, and perhaps that slows the rate of deterioration. And they want to be involved and active in managing chronic diseases.

Allina's initiative is remarkable in that it will address alcohol across an entire HCO. This includes emergency departments, primary care, hospital and ICU care and specialty addiction treatment. The goal is to create a fully integrated system that addresses alcohol wherever a heavy drinker interacts with the system and that coordinates the flow of care across boundaries such as inpatient/outpatient care and primary/specialty care. All of this is intended to be as fully evidence based as possible, which is always a challenge but it's an important aspiration. The vision is very ambitious and I am unaware of any other quite like it. If it succeeds, it can serve as an example for other HCOs.

Translating the science to practice is a daunting challenge. Allina is to be commended for choosing alcohol as a focus for such an effort. I'll keep you updated as this progresses.

Hope for Hospitalized Alcoholics?

A new study found that even severely alcohol addicted patients in the hospital responded to a 20 minute counseling session after leaving the hospital. This has not been found in all studies, however. As is the case with many medical or psychological treatments, some studies are positive, some are negative. In the end, it's the balance. This balance is determined in a synthetic process called systematic reviews and meta-analysis. These are techniques to examine the findings of multiple high quality randomized controlled trials (RCTs) to determine if a treatment is effective overall. I think the jury is still out on this one, but this study had some pretty impressive findings and a reasonably large number of participants. What's more interesting is what happens when you combine a brief counseling session in the hospital with ongoing follow up in an outpatient setting. That's what I am currently doing with the patients I see in the hospital - I start the treatment there and ask them to schedule a follow up in the my clinic. This is what's done in every other medical specialty. Why not addiction medicine? MW Brief interventions in dependent drinkers: a comparative prospective analysis in two hospitals. Cobain K., Owens L., Kolamunnage-Dona R. et al. Request reprint Alcohol and Alcoholism: 2011, 46(4), p. 434–440. In the north of England just a few (and often just one) counselling sessions by a specialist nurse had a remarkable impact on dependent drinkers seeking medical care at an accident and emergency department. Summary Unusually this study in England's north west region assessed the impact of relatively brief advice, not on adult drinkers selected to be at risk from their drinking, but those likely already to be dependent. As with studies of non-dependent drinkers, despite their heavy drinking they were not seeking treatment for drink problems but attending a hospital accident and emergency department for some other reason. Patients whose attendance was thought to be related to drinking were referred for assessment to specialist hospital or research nurses by emergency department triage staff in two hospitals in neighbouring cities. The assessments included the AUDIT questionnaire and for patients who scored as possibly dependent, the Severity of Alcohol Dependence Questionnaire. Patients indicated by both to possibly be at least mildly dependent were asked to join the study. In Liverpool the assessments were done by specialist alcohol nurses who immediately engaged possibly dependent patients in about 20 minutes of advice based on the FRAMES model, prioritising exploration of patients' perceptions of the link between their drinking and their hospital attendance. At the nurses' and patients' discretion, further sessions could be arranged. In practice, of the 100 patients recruited to the study, 46 attended typically four further sessions. In the other hospital in nearby Warrington, the same referral and research recruitment procedures operated, but instead patients were referred to a nurse who was part of the research team who did not offer any alcohol-related advice. Again, 100 patients were recruited at this site to act as a control group against which to benchmark any improvements associated with counselling. At both sites most patients were daily drinkers who consumed on average about 27 UK units (216g) of alcohol a day, tested as severely dependent, and were taking alcohol withdrawal medication. Typically they were single, unemployed white men in their mid-40s suffering from gastrointestinal or cardiovascular complaints. Six months later research nurses were able to reassess about half the patients to evaluate changed in their drinking and drink-related problems since they joined the study. Main findings Six months later the general picture was (despite some reductions) of continued severe drinking and drink-related problems in the control group, but substantial remission among patients who had been counselled by specialist alcohol nurses. The controls were still drinking on average 23 units (184g) of alcohol on nearly six days a week, while counselled patients had cut back to nearly four days a week and eight units (64g). These averages reflected the fact that none of the controls but 39% of the counselled patients had stopped drinking altogether. Also, just 17% of the counselled patients scored as severely dependent on the Severity of Alcohol Dependence Questionnaire compared to 56% of the controls chart. The greater reductions in drinking days and intensity and in scores on the two alcohol problem questionnaires were all highly statistically significant. Not statistically significant but almost so was the difference in the times patients returned to accident and emergency departments – about 90 times among the 50 control patients but only 34 times (or 36 extrapolated to 50 patients) among those counselled. The authors' conclusions The study demonstrates that treatment can be accepted and effective among dependent drinkers who have not come seeking treatment for their drinking. Generally it has not been ethically acceptable to deny treatment to dependent drinkers who are seeking it, complicating the evaluation of whether treatment works. In contrast, because patients were not seeking or expecting treatment, this study was able to compare structured treatment with no specific treatment. It showed that treatment is effective, and that even severely dependent patients can substantially benefit from relatively brief treatment. The patients in this study were usually medically ill; providing alcohol treatment in a general hospital offers a way to reach them even if they do not present to alcohol treatment clinics, and may reduce their need for further medical care. The greater drinking reductions among patients at the hospital offering counselling were due to the greater abstinence rate – 39% v. 0%. It seems likely that their medical conditions would have mandated advice to abstain for 8 in 10 patients and that this was the advice given by the specialist nurses, advice often well responded to. From previous research, it seems likely that planned follow-up counselling augmented the impact of the evaluated intervention. Though striking, the results have emerged from a study in which patients were not randomly allocated and attended different hospitals. On the assessed variables, the patients seemed similar but there may have been remaining differences between them and between how they were treated at the hospitals which contributed to the findings. Moreover, the research nurse who conducted the follow-up assessments was not always 'blinded' to whether patients had been counselled. Despite its general brevity, it is a moot point whether the open-ended treatment could be called a 'brief intervention'. Half the patients could not followed up, potentially biasing the findings. These impressive results are weakened somewhat by the low follow-up rate. But even if we assume bad outcomes (severe alcohol dependence, death or imprisonment) in all patients not followed up, at most 60% of the counselled patients met these fates compared to 88% not counselled. Similarly, assuming continued drinking among patients not re-assessed, the abstinence rate would be 19% among counselled patients but zero among those not counselled. Yet on average these patients drank at least as much as those at specialist alcohol clinics in the UKATT trial in England and Wales, who were seeking treatment and offered what was intended to be a full course of psychosocial therapy in addition to medical treatments like detoxification and anti-relapse medications. In that study, 12 months after starting treatment a minimum of 12% of patients had sustained abstinence over the past three months, compared to 19% at six months (over an unspecified period) in the featured study. Despite its successes, for most patients the intervention was not enough. If abstinence is the yardstick of success, 8 in 10 could not be shown to have achieved it; if not being severely dependent was the yardstick, the corresponding proportion was 6 in 10. Whether more extended or intensive intervention would have been accepted by the patients and helped reduce the failure rate is unclear. The main limitation on delivering it might have been staying in touch with the patients. Few were homeless, yet two letters and two phone calls were unable to recall half for follow-up assessments. As the authors speculated, it could be that the nurses and perhaps ward staff were in a position in most cases to credibly counsel abstinence on medical grounds, helping bolster the results. Few patients were there because of injuries which could be avoided by continuing to drink but taking greater care to avoid getting drunk in dangerous situations. Instead, most seemed to be suffering from chronic conditions which would be aggravated by continued drinking. They were also generally the type of people research suggests are most receptive to abstinence as a goal of treatment and least able to sustain non-problem drinking. Among the issues raised by the study are whether extended treatment is always required before dependent patients – especially those with the disadvantages shared by most of the study's sample – can attain non-dependent drinking or abstinence. Along with other research, it clearly indicates that this is not the case for many patients. More generally, added benefits from longer versus shorter treatments (as opposed to post-treatment aftercare) has yet to be adequately established. Another issue is whether brief interventions will only benefit non-dependent patients. Again this study along with other research strongly suggests this is not always (but sometimes) the case. What makes the difference may be whether the patient makes (or can be led to make) a link between their drinking and the medical misfortune which led them to the emergency department. These issues are explored in greater detail in the background notes. Perhaps the most serious of the limitations acknowledged by the authors is that the hospitals may have differed not just in the availability of specialist alcohol counselling, but in how drinking was addressed by other medical staff. With counsellors available to handle the aftermath, in Liverpool they may have been more willing to expose the need for counselling by assessing and discussing alcohol problems with their patients. A hospital which hosts four specialist alcohol nurses is likely to have a different and perhaps more serious attitude to drinking than one which hosts none. But even if this were the case, it would not affect the strength of the intervention's impact, just relocate a greater part of that intervention to usual medical staff