Update on Alcohol and Health

www.alcoholandhealth.orgwww.alcoholandhealth.org 11

Update on Update on Alcohol and HealthAlcohol and Health

Alcohol and Health: Current EvidenceAlcohol and Health: Current Evidence

July-August 2006July-August 2006


Studies on Studies on Assessments and Assessments and

InterventionsInterventions


Combining Medication Combining Medication With Specialist Behavioral With Specialist Behavioral

Intervention for Intervention for Alcoholism: the COMBINE Alcoholism: the COMBINE

StudyStudy

Anton RF, et al. Anton RF, et al. JAMA. JAMA. 2006;295(17):2003–2017.2006;295(17):2003–2017.


Objectives/MethodsObjectives/Methods To study the effects of pharmacotherapy with To study the effects of pharmacotherapy with

behavioral intervention for alcohol dependencebehavioral intervention for alcohol dependence

1383 recently abstinent patients with 1383 recently abstinent patients with alcoholism randomized to 1 of 9 treatments for alcoholism randomized to 1 of 9 treatments for 16 weeks: 16 weeks:

Placebo;Placebo; Naltrexone (100 mg per day), acamprosate Naltrexone (100 mg per day), acamprosate

(3 g per day), or both; or (3 g per day), or both; or Combined behavioral intervention (CBI) Combined behavioral intervention (CBI)

alone, with active pills, or with placebo alone, with active pills, or with placebo


Objectives/Methods Objectives/Methods (cont.)(cont.)

CBI: CBI: Offered by a specialist Offered by a specialist Included elements of cognitive behavioral therapy, Included elements of cognitive behavioral therapy,

motivational interviewing, and 12-step facilitation motivational interviewing, and 12-step facilitation Up to 20 50-minute sessionsUp to 20 50-minute sessions

““Medical management” (MM) provided to all but CBI Medical management” (MM) provided to all but CBI alone groupalone group 9 counseling and education sessions (45-minute initial 9 counseling and education sessions (45-minute initial

session and session and ≈≈20-minute follow-up sessions)20-minute follow-up sessions) Provided by a generalist healthcare professional Provided by a generalist healthcare professional Focused on medication side effects, adherence, and Focused on medication side effects, adherence, and

alcohol abstinencealcohol abstinence

94% follow-up at 16 weeks; 82% a year later94% follow-up at 16 weeks; 82% a year later


ResultsResults

Drinking outcomes improved substantially Drinking outcomes improved substantially in all groups. in all groups.

The range of mean percent days The range of mean percent days abstinent across groups was… abstinent across groups was…

23%–30% at baseline, 23%–30% at baseline, 67%– 81% at 16 weeks, and 67%– 81% at 16 weeks, and 59%–69% a year later.59%–69% a year later.


Results (cont.)Results (cont.)

Naltrexone/MM Naltrexone/MM Better than placebo/MM at increasing Better than placebo/MM at increasing percent days abstinent (81% vs 75%) and percent days abstinent (81% vs 75%) and delaying a return to heavy drinking* (hazard delaying a return to heavy drinking* (hazard ratio 0.7)ratio 0.7)

Adding CBI did not improve these outcomesAdding CBI did not improve these outcomes

CBI/MM with any pills CBI/MM with any pills Better than placebo/MM at increasing Better than placebo/MM at increasing percent days abstinent (e.g., 79% versus percent days abstinent (e.g., 79% versus 75%)75%)

CBI alone (without MM CBI alone (without MM or pills) or pills)

Less effective than placebo/MM at increasing Less effective than placebo/MM at increasing days abstinent (67% versus 74%)days abstinent (67% versus 74%)

Acamprosate/MM Acamprosate/MM Did not significantly affect drinking Did not significantly affect drinking outcomesoutcomes

Key Findings at 16 WeeksKey Findings at 16 Weeks

*>=5 standard drinks per day for men, >=4 for women*>=5 standard drinks per day for men, >=4 for women



One year after treatment…One year after treatment…

drinking outcomes did not drinking outcomes did not significantly differ among groups.significantly differ among groups.


Conclusions/CommentsConclusions/Comments

This large, rigorous, and complex study This large, rigorous, and complex study showed that...showed that... naltrexone and specialist counseling have naltrexone and specialist counseling have

similar modest efficacy when each is offered similar modest efficacy when each is offered with MM, and with MM, and

specialist counseling alone has less efficacy specialist counseling alone has less efficacy than when combined with MM. than when combined with MM.

These findings support the use of naltrexone These findings support the use of naltrexone and intensive MM in primary care settings as a and intensive MM in primary care settings as a potential alternative to specialized treatment. potential alternative to specialized treatment.


Conclusions/Comments Conclusions/Comments (cont.)(cont.)

Delivering the type of medical Delivering the type of medical management provided in this study management provided in this study requires substantial training and a requires substantial training and a collaborative care model. collaborative care model.

This requirement and other concerns (e.g., This requirement and other concerns (e.g., need for chronic treatment, acamprosate’s need for chronic treatment, acamprosate’s perplexing lack of efficacy) require further perplexing lack of efficacy) require further investigation. investigation.


Acamprosate May Work Acamprosate May Work

Only When Abstinence Only When Abstinence Is the GoalIs the Goal

Mason BJ, et al. Mason BJ, et al. J Psychiatr ResJ Psychiatr Res. 2006;40(5):382–392.. 2006;40(5):382–392.


Objectives/MethodsObjectives/Methods

To evaluate acamprosate’s efficacy in U.S. patientsTo evaluate acamprosate’s efficacy in U.S. patients

Randomized controlled trial of the drug (the first in Randomized controlled trial of the drug (the first in this country) in 21 alcohol treatment clinicsthis country) in 21 alcohol treatment clinics

Subjects assigned to either…Subjects assigned to either…

the standard 2 g of acamprosate per day the standard 2 g of acamprosate per day (n=258), (n=258),

3 g per day (n=83), or 3 g per day (n=83), or placebo (n=260)placebo (n=260)

All received self-help materials and 8 sessions of All received self-help materials and 8 sessions of brief counselingbrief counseling


ResultsResults The percentage of days abstinent at 6 months The percentage of days abstinent at 6 months

did not significantly differ across groups in did not significantly differ across groups in unadjusted analyses. unadjusted analyses.

However, in analyses adjusted for potential However, in analyses adjusted for potential confounders (e.g., readiness to change, confounders (e.g., readiness to change, treatment goal of abstinence), the treatment goal of abstinence), the percentage was…percentage was…

significantly higher in subjects who significantly higher in subjects who received acamprosate: received acamprosate:

52% for placebo, 58% for subjects on 2 g, and 52% for placebo, 58% for subjects on 2 g, and 63% for subjects on 3 g.63% for subjects on 3 g.



Patients who stated at baseline that Patients who stated at baseline that abstinence was their goal achieved the abstinence was their goal achieved the best results: best results:

58% days abstinent for placebo 58% days abstinent for placebo 70% for subjects on 2 g70% for subjects on 2 g 73% for subjects on 3 g 73% for subjects on 3 g


Comments/ConclusionsComments/Conclusions

Acamprosate’s lack of efficacy in this large, well-Acamprosate’s lack of efficacy in this large, well-designed trial is surprising, though also noted in designed trial is surprising, though also noted in another recent study.* another recent study.*

The U.S. subjects may have been abstinent for a The U.S. subjects may have been abstinent for a shorter time than were subjects in international shorter time than were subjects in international studies showing acamprosate’s efficacy. studies showing acamprosate’s efficacy.

The link between having abstinence as a goal and The link between having abstinence as a goal and benefit from acamprosate may guide clinicians’ benefit from acamprosate may guide clinicians’ prescribing practices and merits confirmation. prescribing practices and merits confirmation.

*Anton RF, et al. *Anton RF, et al. JAMA. JAMA. 2006;295(17):2003–2017.2006;295(17):2003–2017.


Most Medical Inpatients Most Medical Inpatients With Unhealthy Alcohol With Unhealthy Alcohol

Use Have Alcohol Use Have Alcohol DependenceDependence

Saitz R, et al. Saitz R, et al. J Gen Intern Med.J Gen Intern Med. 2006;21(4):381–385. 2006;21(4):381–385.



To determine the prevalence and To determine the prevalence and severity of unhealthy alcohol use on a severity of unhealthy alcohol use on a medicine servicemedicine service

5813 medical inpatients screened for 5813 medical inpatients screened for drinking risky amounts*drinking risky amounts*

341 who drank risky amounts were 341 who drank risky amounts were evaluated furtherevaluated further

*>14 standard drinks per week or >=5 drinks per occasion for men (>11 and >=4, *>14 standard drinks per week or >=5 drinks per occasion for men (>11 and >=4, respectively, for both women and people >=66 years)respectively, for both women and people >=66 years)


ResultsResults 17% of inpatients screened drank risky amounts.17% of inpatients screened drank risky amounts.

Of those drinking risky amounts…Of those drinking risky amounts…

97% exceeded per occasion limits,* and 97% exceeded per occasion limits,* and most scored >=8 on the Alcohol Use Disorders most scored >=8 on the Alcohol Use Disorders

Identification Test (strongly correlating with a Identification Test (strongly correlating with a current alcohol diagnosis).current alcohol diagnosis).

Of the 341 inpatients who drank risky amounts Of the 341 inpatients who drank risky amounts and received more detailed evaluation…and received more detailed evaluation…

77% had alcohol dependence.77% had alcohol dependence.

*>=5 drinks for men, >=4 for women and people >=66 years *>=5 drinks for men, >=4 for women and people >=66 years



According to this study, almost 1 in 5 medical According to this study, almost 1 in 5 medical inpatients has unhealthy alcohol use…inpatients has unhealthy alcohol use…

a number identical to that found in a recent a number identical to that found in a recent systematic review of hospital alcohol screening systematic review of hospital alcohol screening studies.*studies.*

Of note, most medical inpatients with Of note, most medical inpatients with unhealthy alcohol use have alcohol unhealthy alcohol use have alcohol dependence. dependence.

*Roche AM, et al. *Roche AM, et al. Drug Alcohol Depend.Drug Alcohol Depend. 2006;83(1):1–14. 2006;83(1):1–14.



Because brief intervention—the Because brief intervention—the currently recommended practice—has currently recommended practice—has established efficacy only for established efficacy only for nondependent unhealthy alcohol use…nondependent unhealthy alcohol use…

new strategies to address alcohol new strategies to address alcohol dependence on a medicine service are dependence on a medicine service are warranted.warranted.


Another Single-Item Another Single-Item Screening Test?Screening Test?

O’Brien MC, et al. O’Brien MC, et al. Acad Emerg Med. Acad Emerg Med. 2006;13(6):6292006;13(6):629––636.636.



To examine whether one question (“In a To examine whether one question (“In a typical week, how many days do you get typical week, how many days do you get drunk?”) could identify drinkers at risk of drunk?”) could identify drinkers at risk of injuryinjury

Web-based survey completed by 3909 Web-based survey completed by 3909 college students in North Carolina college students in North Carolina

36% response rate36% response rate


ResultsResults

Of 2488 current (past 30-day) drinkers…Of 2488 current (past 30-day) drinkers…

54% got drunk at least once in a typical 54% got drunk at least once in a typical week.week.

Drunkenness was a better indicator of injury Drunkenness was a better indicator of injury outcomes than was heavy episodic outcomes than was heavy episodic drinking.*drinking.*

*>=5 drinks in a row on at least 1 day in the past 30 days for men, >=4 for women*>=5 drinks in a row on at least 1 day in the past 30 days for men, >=4 for women



Odds of Injury in Students Who Had Been Drunk in Odds of Injury in Students Who Had Been Drunk in a Typical Week Vs. Those Who Had Nota Typical Week Vs. Those Who Had Not

Injured because of their drinkingInjured because of their drinking OR* 5.0OR* 5.0

Had a fall that required treatmentHad a fall that required treatment OR 2.2OR 2.2

Taken advantage of sexually as a result of Taken advantage of sexually as a result of another’s drinkinganother’s drinking

OR 2.6OR 2.6

Caused injury to another that required Caused injury to another that required treatmenttreatment

OR 2.6OR 2.6

*Odds ratios adjusted for potential confounders (e.g., race, current drinking)*Odds ratios adjusted for potential confounders (e.g., race, current drinking)


Conclusions/CommentsConclusions/Comments This study did not assess for alcohol use disorders, a This study did not assess for alcohol use disorders, a

significant limitation that precludes recommending the significant limitation that precludes recommending the single question as a clinical screening test. single question as a clinical screening test.

But the results are interesting because they suggest But the results are interesting because they suggest that…that… a question about drunkenness might identify college-a question about drunkenness might identify college-

student drinking with consequences better than a student drinking with consequences better than a question about heavy drinking on an occasion would. question about heavy drinking on an occasion would.

For now, it seems reasonable for clinicians to ask the For now, it seems reasonable for clinicians to ask the question when discussing drinking with college students.question when discussing drinking with college students.


Intensive Referral to Intensive Referral to 12-Step Groups 12-Step Groups

Improves OutcomesImproves Outcomes

Timko C, et al. Timko C, et al. AddictionAddiction. 2006;101(5):678–688. . 2006;101(5):678–688.


Objectives/MethodsObjectives/Methods To assess whether intensive referral is more To assess whether intensive referral is more

effective than standard referral at…effective than standard referral at…

increasing involvement with Alcoholics Anonymous increasing involvement with Alcoholics Anonymous (AA) and Narcotics Anonymous (NA), and (AA) and Narcotics Anonymous (NA), and

subsequently improving substance use outcomessubsequently improving substance use outcomes

Study of 345 veterans entering outpatient Study of 345 veterans entering outpatient substance abuse treatment substance abuse treatment

Almost all had attended 12-step meetings Almost all had attended 12-step meetings previouslypreviously

46% preferred alcohol to other substances46% preferred alcohol to other substances


Objectives/Methods Objectives/Methods (cont.)(cont.)

Subjects were randomized to either…Subjects were randomized to either…

standard referral, including a schedule standard referral, including a schedule of and encouragement to attend local of and encouragement to attend local 12-step meetings, or12-step meetings, or

intensive referral, including additional intensive referral, including additional information and clinician support (e.g., information and clinician support (e.g., linkage to AA/NA volunteers, follow-up linkage to AA/NA volunteers, follow-up on meeting attendance, encouragement on meeting attendance, encouragement to obtain a sponsor)to obtain a sponsor)


ResultsResults

At 6 months, attendance at 12-step At 6 months, attendance at 12-step meetings did not significantly differ among meetings did not significantly differ among the groups. the groups.

But, of subjects with less exposure to 12-But, of subjects with less exposure to 12-step groups at study entry, those assigned step groups at study entry, those assigned to intensive referral had better attendance. to intensive referral had better attendance.

The intensive referral group had The intensive referral group had significantly greater…significantly greater… 12-step involvement (e.g., obtained a 12-step involvement (e.g., obtained a

sponsor) and improvement in substance sponsor) and improvement in substance use problems.use problems.



The intensive referral group was also more The intensive referral group was also more likely to be abstinent from…likely to be abstinent from…

drugs (78% versus 70%, drugs (78% versus 70%, PP<0.05) and <0.05) and alcohol (76% versus 70%, alcohol (76% versus 70%, PP<0.12). <0.12).

Involvement in 12-step groups partially Involvement in 12-step groups partially mediated improvements in alcohol mediated improvements in alcohol outcomes.outcomes.


Conclusions/CommentsConclusions/Comments Because 12-step groups do not sponsor Because 12-step groups do not sponsor

research, rigorous trials of their effectiveness research, rigorous trials of their effectiveness are difficult to perform. are difficult to perform.

This study provides strong evidence that This study provides strong evidence that clinicians should support patients’ participation clinicians should support patients’ participation in AA/NA. in AA/NA.

Linking patients with AA/NA volunteers, Linking patients with AA/NA volunteers, following up on attendance, and encouraging following up on attendance, and encouraging sponsorship are essential to successful 12-step sponsorship are essential to successful 12-step facilitation. facilitation.


Help Seeking Quadruples Help Seeking Quadruples the Likelihood of the Likelihood of

AbstinenceAbstinence

Dawson DA, et al. Dawson DA, et al. Addiction. Addiction. 2006;101(6):824–834.2006;101(6):824–834.



To quantify the effect of help seeking on To quantify the effect of help seeking on recovery from alcoholismrecovery from alcoholism

Analysis of data from 4422 adults in the U.S. Analysis of data from 4422 adults in the U.S. who had…who had…

participated in a nationally representative participated in a nationally representative survey and survey and

developed alcohol dependence at least 1 developed alcohol dependence at least 1 year before their participationyear before their participation


ResultsResults Only 26% of subjects had ever sought help for Only 26% of subjects had ever sought help for

their alcohol problems:their alcohol problems:

3% participated in a 12-step program only, 3% participated in a 12-step program only, 6% in formal treatment only, and 6% in formal treatment only, and 17% in both. 17% in both.

Help seekers drank more than subjects who Help seekers drank more than subjects who had not sought help and had higher lifetime had not sought help and had higher lifetime prevalences of…prevalences of…

other drug use, mood disorders, and other drug use, mood disorders, and personality disorders.personality disorders.


Results (cont.)Results (cont.) In analyses adjusted for potential confounders, help In analyses adjusted for potential confounders, help

seeking significantly increased the likelihood of…seeking significantly increased the likelihood of…

any recovery* (OR 2.4) and any recovery* (OR 2.4) and abstinence (OR 4.0). abstinence (OR 4.0).

The odds of recovery were greater for those who The odds of recovery were greater for those who had…had…

participated in 12-step programs with or without participated in 12-step programs with or without formal treatment than for those who had formal treatment than for those who had participated in formal treatment only. participated in formal treatment only.

*In the past year, having no symptoms of alcohol abuse or dependence and either drinking low-risk *In the past year, having no symptoms of alcohol abuse or dependence and either drinking low-risk amounts (<=14 drinks per week and <=4 drinks on any day for men; <=7 drinks per week and amounts (<=14 drinks per week and <=4 drinks on any day for men; <=7 drinks per week and <=3 drinks on any day for women) or abstaining<=3 drinks on any day for women) or abstaining



Even though they had more comorbidity, Even though they had more comorbidity, seekers of formal and informal treatment had seekers of formal and informal treatment had better odds of recovery from alcohol better odds of recovery from alcohol dependence. dependence.

This study could not separate the motivation This study could not separate the motivation inherent in seeking help from the therapeutic inherent in seeking help from the therapeutic effects of help received. effects of help received.

However, help seeking—regardless of the However, help seeking—regardless of the patient’s level of readiness—should be patient’s level of readiness—should be encouraged. encouraged.


Should Screening for Should Screening for Colorectal Cancer Start Colorectal Cancer Start Earlier for Drinkers and Earlier for Drinkers and

Smokers?Smokers?

Zisman AL, et al. Zisman AL, et al. Arch Intern Med. Arch Intern Med. 2006;166(6):629–2006;166(6):629–634.634.



To explore whether earlier screening for To explore whether earlier screening for colorectal cancer (CRC) is warranted in colorectal cancer (CRC) is warranted in patients who smoke and drinkpatients who smoke and drink

166,172 cases of CRC identified through a 166,172 cases of CRC identified through a national medical registry; age at diagnosis national medical registry; age at diagnosis assessedassessed

Analyses controlled for sex, race, and Analyses controlled for sex, race, and insurance statusinsurance status


Results Results CRC was diagnosed significantly earlier in current CRC was diagnosed significantly earlier in current

and past drinkers* than in subjects who never and past drinkers* than in subjects who never drank. drank.

Diagnosis occurred even earlier among current and Diagnosis occurred even earlier among current and past drinkers who currently smoked (e.g., 7.8 years past drinkers who currently smoked (e.g., 7.8 years earlier in current drinkers who also smoked than in earlier in current drinkers who also smoked than in subjects who never drank or smoked). subjects who never drank or smoked).

The likelihood of distal CRC was significantly higher The likelihood of distal CRC was significantly higher among…among… current and past drinkers than in subjects who current and past drinkers than in subjects who

never drank (ORs 1.2 and 1.1, respectively) and never drank (ORs 1.2 and 1.1, respectively) and current smokers than in subjects who never current smokers than in subjects who never

smoked (OR 1.2).smoked (OR 1.2).

*Current use defined as use in the past year; past use defined as having quit at least 1 year before *Current use defined as use in the past year; past use defined as having quit at least 1 year before CRC diagnosisCRC diagnosis


Conclusions/CommentsConclusions/Comments This large retrospective study found that CRC This large retrospective study found that CRC

was diagnosed in current and past drinkers at a was diagnosed in current and past drinkers at a younger age, especially if they currently younger age, especially if they currently smoked. smoked.

While the study helps clarify the association While the study helps clarify the association between alcohol, tobacco, and CRC, it…between alcohol, tobacco, and CRC, it… neither addressed whether screening could neither addressed whether screening could

have detected the earlier diagnoses have detected the earlier diagnoses nor accounted for many important nor accounted for many important

confounding factors confounding factors (e.g., quantity/frequency of drinking and smoking, diet, (e.g., quantity/frequency of drinking and smoking, diet, comorbidities that potentially lead to earlier comorbidities that potentially lead to earlier gastrointestinal evaluation). gastrointestinal evaluation).



Thus, more investigation is needed to Thus, more investigation is needed to determine whether…determine whether…

CRC screening guidelines should be CRC screening guidelines should be modified according to a patient’s modified according to a patient’s history of alcohol and tobacco use. history of alcohol and tobacco use.


Studies on Studies on Alcohol and Alcohol and

Health OutcomesHealth Outcomes


Is Drinking Unsafe Is Drinking Unsafe for Patients on for Patients on

Warfarin or Statins?Warfarin or Statins?

Mukamal KJ, et al. Mukamal KJ, et al. Am J Med.Am J Med. 2006;119(5):434– 2006;119(5):434–440. 440.



To assess drinking’s safety in warfarin or statin usersTo assess drinking’s safety in warfarin or statin users

1244 men with previous coronary artery bypass graft 1244 men with previous coronary artery bypass graft surgery who had enrolled in a randomized trial of surgery who had enrolled in a randomized trial of daily…daily…

lovastatin (mean dose of 4 mg or 76 mg), lovastatin (mean dose of 4 mg or 76 mg), low-dose warfarin (1–4 mg to achieve an INR* of 1.8–2), or low-dose warfarin (1–4 mg to achieve an INR* of 1.8–2), or placebo-warfarinplacebo-warfarin

54% drank <1 drink per week; 9 men drank >21 54% drank <1 drink per week; 9 men drank >21 drinks per weekdrinks per week

*International normalized ratio*International normalized ratio


ResultsResults During about 5 years of follow-up, alcohol use did During about 5 years of follow-up, alcohol use did

not significantly affect the risk of having elevated not significantly affect the risk of having elevated INR or ALT* levels:INR or ALT* levels:

Standard Drinks Standard Drinks per Week per Week

ALT>=80 IU/L (% ALT>=80 IU/L (% of subjects) of subjects)

INR>=2 (% ofINR>=2 (% of

(warfarin subjects (warfarin subjects only) only)

<1 <1 88 6767

1–6 1–6 1010 6666

7–13 7–13 99 6868

>=14 >=14 66 6161

ALT results were similar when the analysis was restricted to patients taking the ALT results were similar when the analysis was restricted to patients taking the higher dose of lovastatin.higher dose of lovastatin.

*Alanine aminotransferase*Alanine aminotransferase


Conclusions/CommentsConclusions/Comments Few men drank >21 drinks per week, so this Few men drank >21 drinks per week, so this

study could not address the risks associated with study could not address the risks associated with warfarin or statin use and heavy drinking. warfarin or statin use and heavy drinking.

Reporting abnormal creatine kinase levels by Reporting abnormal creatine kinase levels by drinking categories would have helped readers to drinking categories would have helped readers to judge risk. judge risk.

These results should somewhat reassure patients These results should somewhat reassure patients with coronary artery disease that…with coronary artery disease that…

drinking moderately while taking warfarin or drinking moderately while taking warfarin or lovastatin is not harmful (or at least does not lovastatin is not harmful (or at least does not increase the risk of developing 2 specific lab increase the risk of developing 2 specific lab abnormalities).abnormalities).


Alcohol and the Alcohol and the Risk of InjuryRisk of Injury

Gmel G, et al. Gmel G, et al. Alcohol Clin Exp Res.Alcohol Clin Exp Res. 2006;30(3):501–509.2006;30(3):501–509.


Objectives/MethodsObjectives/Methods To examine whether specific patterns of alcohol To examine whether specific patterns of alcohol

use affect the risk of injuryuse affect the risk of injury

Assessment of 8736 patients admitted to an Assessment of 8736 patients admitted to an emergency department in Switzerland (5077 with emergency department in Switzerland (5077 with an injury)an injury)

Measures:Measures:

Usual volume of drinkingUsual volume of drinking Past-month heavy episodic drinking (>=5 drinks on at Past-month heavy episodic drinking (>=5 drinks on at

least one occasion for men, >=4 for women)least one occasion for men, >=4 for women) Recent drinking (in the 24 hours before the emergency-Recent drinking (in the 24 hours before the emergency-

department visit)department visit)


ResultsResults Heavy episodic drinking and recent drinking Heavy episodic drinking and recent drinking

increased the risk of injury.increased the risk of injury.

As the volume of usual and recent drinking As the volume of usual and recent drinking increased, the risk of injury increased.increased, the risk of injury increased.

Risk was highest in patients who…Risk was highest in patients who… usually drank moderately* usually drank moderately* andand reported both reported both

past-month and recent heavy episodic drinking. past-month and recent heavy episodic drinking. Odds ratios (ORs) 6.4 for men and 7.4 for women, Odds ratios (ORs) 6.4 for men and 7.4 for women,

compared with abstainerscompared with abstainers

*<14 drinks per week for men, <7 for women *<14 drinks per week for men, <7 for women



Past-month heavy episodic drinking tended to Past-month heavy episodic drinking tended to confer a higher risk in patients who usually drank confer a higher risk in patients who usually drank moderately than in patients who usually drank moderately than in patients who usually drank heavily. heavily.

Almost half of the alcohol-attributable injuries Almost half of the alcohol-attributable injuries among women were suffered by those…among women were suffered by those…

who usually drank moderately,who usually drank moderately, without past-month heavy episodic drinking, without past-month heavy episodic drinking,

and and drank >0 but <4 drinks in the 24 hours before drank >0 but <4 drinks in the 24 hours before

their emergency-department visit.their emergency-department visit.



This study indicates that patterns of This study indicates that patterns of drinking, particularly heavy episodic drinking, particularly heavy episodic drinking, influence the risk of injury. drinking, influence the risk of injury.

Interventions to reduce alcohol-related Interventions to reduce alcohol-related injury should focus on…injury should focus on…

preventing heavy episodic drinking preventing heavy episodic drinking among both moderate and heavy among both moderate and heavy drinkers.drinkers.


Lifetime Drinking, Lifetime Drinking, Confounders, and Confounders, and Breast Cancer RiskBreast Cancer Risk

Terry MB, et al. Terry MB, et al. Ann EpidemiolAnn Epidemiol. 2006;16(3):230–. 2006;16(3):230–240.240.



To examine whether confounding factors To examine whether confounding factors can explain the association between can explain the association between moderate drinking and an increased risk of moderate drinking and an increased risk of breast cancerbreast cancer

Data from a population-based study Data from a population-based study

Comparison of 1508 women with breast Comparison of 1508 women with breast cancer and 1556 matched controlscancer and 1556 matched controls

Analyses adjusted for potential Analyses adjusted for potential confounders confounders


ResultsResults Risk was not significantly associated with lifetime* or Risk was not significantly associated with lifetime* or

current alcohol use, except for current drinking of current alcohol use, except for current drinking of <0.5 grams per day (OR 0.7).<0.5 grams per day (OR 0.7).

Subgroup Subgroup Breast Cancer Risk Breast Cancer Risk Associated With Lifetime Associated With Lifetime

Intake of 15-30 g of Alcohol Intake of 15-30 g of Alcohol per Dayper Day

BMI <25BMI <25 OR** 2.1OR** 2.1

Post-menopausal and never Post-menopausal and never used hormone replacement used hormone replacement therapytherapy

OR 2.0OR 2.0

Results from Subgroup Results from Subgroup AnalysesAnalyses

*Calculation based on average intake during various periods across *Calculation based on average intake during various periods across the lifetimethe lifetime

**Versus nondrinking**Versus nondrinking



Lifetime drinking of >=15 g per day was Lifetime drinking of >=15 g per day was significantly associated with…significantly associated with…

estrogen receptor positive tumors (OR estrogen receptor positive tumors (OR 1.9) and invasive tumors (OR 1.6), 1.9) and invasive tumors (OR 1.6),

but only in women with a BMI <25.but only in women with a BMI <25.

Results did not differ in analyses that Results did not differ in analyses that examined alcohol intake during a examined alcohol intake during a particular decade of life.particular decade of life.


Conclusions/CommentsConclusions/Comments These findings are consistent with those of most These findings are consistent with those of most

previous studies that show a weak positive previous studies that show a weak positive relationship between alcohol use and breast cancer relationship between alcohol use and breast cancer risk. risk.

There was no dose-response curve for any of the There was no dose-response curve for any of the observed associations, and only the subgroup observed associations, and only the subgroup analyses were significant. analyses were significant.

Additional studies are needed to help clinicians Additional studies are needed to help clinicians identify women at higher risk of breast cancer from identify women at higher risk of breast cancer from current or lifetime moderate drinking. current or lifetime moderate drinking.


Discrimination Against Discrimination Against People With AlcoholismPeople With Alcoholism

Schomerus G, et al.Schomerus G, et al. Drug Alcohol DependDrug Alcohol Depend. . 2006;82(3):204–210.2006;82(3):204–210.


Objectives/MethodsObjectives/Methods To examine whether public attitudes and To examine whether public attitudes and

beliefs about alcohol dependence…beliefs about alcohol dependence…

are more negative than those about other are more negative than those about other diseases anddiseases and

affect public preferences for resource affect public preferences for resource allocationallocation

Other diseases = schizophrenia, depression, Other diseases = schizophrenia, depression, Alzheimer’s disease, rheumatism, diabetes, Alzheimer’s disease, rheumatism, diabetes, AIDS, myocardial infarction, and cancerAIDS, myocardial infarction, and cancer

Phone interviews of 1012 German adultsPhone interviews of 1012 German adults


ResultsResultsRespondents…Respondents… % of Respondents With % of Respondents With

Belief/AttitudeBelief/Attitude

Would spare alcohol treatment Would spare alcohol treatment from budget cuts if resources from budget cuts if resources were scarcewere scarce

7%7%

Would distance themselves from Would distance themselves from people with alcoholismpeople with alcoholism

78%78%

(moreso than any other disease)(moreso than any other disease)

Believed alcoholism is self-Believed alcoholism is self-inflictedinflicted

85%85%

(moreso than any other disease)(moreso than any other disease)

Believed alcoholism is severeBelieved alcoholism is severe 55%55%

Thought alcoholism can be treated Thought alcoholism can be treated effectivelyeffectively

30%30%

Felt at risk for alcoholismFelt at risk for alcoholism 4%4%



Respondents were more likely to choose Respondents were more likely to choose budget cuts for alcohol treatment if they budget cuts for alcohol treatment if they believed that…believed that…

alcoholism was self-inflicted,alcoholism was self-inflicted,

alcoholism was not as severe as other alcoholism was not as severe as other conditions, and conditions, and

their risk of alcoholism was low. their risk of alcoholism was low.


Conclusions/CommentsConclusions/Comments This study highlights…This study highlights…

the public’s lack of understanding about the public’s lack of understanding about alcohol dependence and alcohol dependence and

the severe stigma faced by people with the severe stigma faced by people with the disease. the disease.

Increasing awareness and destigmatizing Increasing awareness and destigmatizing alcoholism are essential to improve the alcoholism are essential to improve the delivery of quality care.delivery of quality care.


Lifetime Drinking and Lifetime Drinking and the Metabolic the Metabolic

SyndromeSyndrome

Fan AZ, et al. Fan AZ, et al. Euro J EpidemiolEuro J Epidemiol. 2006;21(2):129–. 2006;21(2):129–138. 138.



To determine whether lifetime drinking To determine whether lifetime drinking affects the risk of the metabolic syndrome affects the risk of the metabolic syndrome

Population-based sample of 2818 subjects Population-based sample of 2818 subjects aged 35–79 yearsaged 35–79 years

Subjects drank >=1 a month for >=6 Subjects drank >=1 a month for >=6 months during their lifetimes and had no months during their lifetimes and had no cardiovascular disease or cancer when cardiovascular disease or cancer when they were interviewedthey were interviewed

Analyses adjusted for potential Analyses adjusted for potential confoundersconfounders


ResultsResultsAs lifetime drinking intensity* increased… As lifetime drinking intensity* increased… the prevalence of the metabolic syndrome and the prevalence of the metabolic syndrome and

most of its components significantly increased. most of its components significantly increased.

Quartile of Quartile of Lifetime Drinking Lifetime Drinking

IntensityIntensity

Prevalence Ratios of Prevalence Ratios of

Metabolic Syndrome Metabolic Syndrome

(vs. subjects in the lowest (vs. subjects in the lowest quartile)quartile)

SecondSecond 1.21.2

ThirdThird 1.41.4

FourthFourth 1.61.6

*Total number of drinks over a lifetime divided by the total number of drinking days over *Total number of drinks over a lifetime divided by the total number of drinking days over a lifetimea lifetime


ResultsResults

As the number of lifetime drinking days As the number of lifetime drinking days increasedincreased……

the prevalence of abdominal obesity in the prevalence of abdominal obesity in women and low high-density lipoprotein women and low high-density lipoprotein cholesterol significantly cholesterol significantly decreaseddecreased. .


Conclusions/CommentsConclusions/Comments Studies of lifetime drinking are desirable, but their Studies of lifetime drinking are desirable, but their

validity can be difficult to judge because they are validity can be difficult to judge because they are rarely prospective. rarely prospective. Results depend on the recall of amounts consumed in the Results depend on the recall of amounts consumed in the

distant past; any errors in these estimates get multiplied distant past; any errors in these estimates get multiplied when calculating lifetime intake. when calculating lifetime intake.

But, at least in this study, the researchers used an But, at least in this study, the researchers used an extensively studied, intensive interview method with extensively studied, intensive interview method with known reliability. known reliability.

Further, the results support past findings: increasing Further, the results support past findings: increasing per-occasion amounts of alcohol are harmful, while per-occasion amounts of alcohol are harmful, while more frequent drinking may be protective.more frequent drinking may be protective.

Update on Alcohol and Health

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