The Cochrane 2018 Review on Brief Interventions in Primary Care for Hazardous and Harmful Alcohol Consumption: A Distillation for Clinicians and Policy Makers.

AIMS: An updated Cochrane systematic review assessed effectiveness of screening and brief intervention to reduce hazardous or harmful alcohol consumption in general practice or emergency care settings. This paper summarises the implications of the review for clinicians. METHODS: Cochrane methods were followed. Reporting accords with PRISMA guidance. We searched multiple resources to September 2017, seeking randomised controlled trials of brief interventions to reduce hazardous or harmful alcohol consumption in people attending general practice, emergency care or other primary care settings for reasons other than alcohol treatment. Brief intervention was defined as a conversation comprising five or fewer sessions of brief advice or brief lifestyle counselling and a total duration of less than 60 min. Our primary outcome was alcohol consumption, measured as or convertible to grams per week. We conducted meta-analyses to assess change in consumption, and subgroup analyses to explore the impact of participant and intervention characteristics. RESULTS: We included 69 studies, of which 42 were added for this update. Most studies (88%) compared brief intervention to control. The primary meta-analysis included 34 studies and provided moderate-quality evidence that brief intervention reduced consumption compared to control after one year (mean difference -20 g/wk, 95% confidence interval -28 to -12). Subgroup analysis showed a similar effect for men and women. CONCLUSIONS: Brief interventions can reduce harmful and hazardous alcohol consumption in men and women. Short, advice-based interventions may be as effective as extended, counselling-based interventions for patients with harmful levels of alcohol use who are presenting for the first time in a primary care setting.

[Adaptation of a peer pressure scale in French and German: the Peer Pressure Inventory]. / Adaptation en français et en allemand d'une échelle de pression des pairs pour jeunes adultes : le Peer Pressure Inventory.

BACKGROUND: Peer pressure is regarded as an important determinant of substance use, sexual behavior and juvenile delinquency. However, few peer pressure scales are validated, especially in French or German. Little is known about the factor structure of such scales or the kind of scale needed: some scales takes into account both peer pressure to do and peer pressure not to do, while others consider only peer pressure to do. The aim of the present study was to adapt French and German versions of the Peer Pressure Inventory, which is one of the most widely used scales in this field. We considered its factor structure and concurrent validity. METHODS: Five thousand eight hundred and sixty-seven young Swiss men filled in a questionnaire on peer pressure, substance use, and other variables (conformity, involvement) in a cohort study. RESULTS: We identified a four-factor structure, with the three factors of the initial Peer Pressure Inventory (involvement, conformity, misconduct) and adding a new one (relationship with girls). A non-valued scale (from no peer pressure to peer pressure to do only) showed stronger psychometric qualities than a valued scale (from peer pressure not to do to peer pressure to do). Concurrent validity was also good. Each behavior or attitude was significantly associated with peer pressure. CONCLUSION: Peer pressure seems to be a multidimensional concept. In this study, peer pressure to do showed the strongest influence on participants. Indeed, peer pressure not to do did not add anything useful. Only peer pressure to do affected young Swiss men's behaviors and attitudes and was reliable.

[Learning motivational interviewing to help patients change their health-related behaviors: medical students confirm it]. / Se former à l'entretien motivationnel pour aider ses patients à changer: Les étudiants en médecine le confirment.

At the Lausanne University, 5th year medical students were trained in Motivational interviewing (MI). Eight hours of training improved their competence in the use of this approach. This experience supports the implementation of MI training in medical schools. Motivational interviewing allows the health professional to actively involve the patient in this behavior change process (drinking, smoking, diet, exercise, medication adherence, etc.), by encouraging reflection and reinforcing personal motivation and resources.

[Medical students and community health care centers: preparing the future]. / Etudiants en médecine et centres médico-sociaux: préparer l'avenir.

Since 2011, second year medical students from Lausanne University follow a single day course in the community health care centers of the Canton of Vaud. They discover the medico-social network and attend to patients' visits at home. They experience the importance of the information transmission and the partnership between informal caregivers, professional caregivers, general practitioner and hospital units. The goal of this course is to help the future physicians to collaborate with the community health care centers teams. This will be particularly important in the future with an aging and more dependant population.

[The spirit of community medicine: students learning from students]. / Penser la médecine communautaire s'apprend avec les pairs.

At the University of Lausanne third-year medical students are given the task of spending a month investigating a question of community medicine. In 2009, four students evaluated the legitimacy of health insurers intervening in the management of depression. They found that health insurers put pressure on public authorities during the development of legislation governing the health system and reimbursement for treatment. This fact emerged during the scientific investigation led jointly by the team in the course of the "module of immersion in community medicine." This paper presents each step of their study. The example chosen illustrates the learning objectives covered by the module.

Alcohol drinking, the metabolic syndrome and diabetes in a population with high mean alcohol consumption.

AIMS: To investigate the relationship of alcohol consumption with the metabolic syndrome and diabetes in a population-based study with high mean alcohol consumption. Few data exist on these conditions in high-risk drinkers. METHODS: In 6172 adults aged 35-75 years, alcohol consumption was categorized as 0, 1-6, 7-13, 14-20, 21-27, 28-34 and ≥ 35 drinks/week or as non-drinkers (0), low-risk (1-13), medium-to-high-risk (14-34) and very-high-risk (≥ 35) drinkers. Alcohol consumption was objectively confirmed by biochemical tests. In multivariate analysis, we assessed the relationship of alcohol consumption with adjusted prevalence of the metabolic syndrome, diabetes and insulin resistance, determined with the homeostasis model assessment of insulin resistance (HOMA-IR). RESULTS: Seventy-three per cent of participants consumed alcohol, 16% were medium-to-high-risk drinkers and 2% very-high-risk drinkers. In multivariate analysis, the prevalence of the metabolic syndrome, diabetes and mean HOMA-IR decreased with low-risk drinking and increased with high-risk drinking. Adjusted prevalence of the metabolic syndrome was 24% in non-drinkers, 19% in low-risk (P<0.001 vs. non-drinkers), 20% in medium-to-high-risk and 29% in very-high-risk drinkers (P=0.005 vs. low-risk). Adjusted prevalence of diabetes was 6.0% in non-drinkers, 3.6% in low-risk (P<0.001 vs. non-drinkers), 3.8% in medium-to-high-risk and 6.7% in very-high-risk drinkers (P=0.046 vs. low-risk). Adjusted HOMA-IR was 2.47 in non-drinkers, 2.14 in low-risk (P<0.001 vs. non-drinkers), 2.27 in medium-to-high-risk and 2.53 in very-high-risk drinkers (P=0.04 vs. low-risk). These relationships did not differ according to beverage types. CONCLUSIONS: Alcohol has a U-shaped relationship with the metabolic syndrome, diabetes and HOMA-IR, without differences between beverage types.

Acute and usual drinking among emergency trauma patients: a study on alcohol consumption and injury patterns.

OBJECTIVE: To investigate the relationship between usual and acute alcohol consumption among injured patients and, when combined, how they covary with other injury attributes. METHODS: Data from a randomised sample of 486 injured patients interviewed in an emergency department (Lausanne University Hospital, Switzerland) were analysed using the chi(2) test for independence and cluster analysis. RESULTS: Acute alcohol consumption (24.7%) was associated with usual drinking and particularly with high volumes of consumption. Six injury clusters were identified. Over-representations of acute consumption were found in a cluster typical of injuries sustained through interpersonal violence and in another formed by miscellaneous circumstances. A third cluster, typical of sports injuries, was linked to a group of frequent heavy episodic drinkers (without acute consumption). CONCLUSIONS: Among injured patients, acute alcohol consumption is common and associated with usual drinking. Acute and/or usual consumption form part of some, but not all, injury clusters.

Squamous cell carcinoma of the head and neck - screening in patients who misuse alcohol and tobacco in Switzerland: a prospective pilot study.

Squamous cell carcinoma (SCC) of the head and neck is the sixth most common cancer worldwide. It is preceded by early asymptomatic lesions which, if identified early enough and removed, would prevent malignant transformation or avoid delaying diagnosis to advanced stages. Our aim was to evaluate the feasibility of a screening programme for SCC of the head and neck in a group of high-risk patients, and to investigate their addiction profile. Patients admitted to an inpatient alcohol addiction centre (n=101) were prospectively enrolled and asked to fill in a questionnaire about their use of tobacco and alcohol, and the presence of warning symptoms for SCC of the head and neck from 23 June 2014 to 21 January2016. Participants in the study had a physical examination by an alcohol addiction physician followed by a full examination of the head and neck by an otorhinolaryngologist to rule out premalignant or malignant lesions of the upper aerodigestive tract. Of the 101 patients, 62 (60%) had at least one warning symptom. Alcohol addiction physicians identified leukoplakia in six (6%) and erythroplakia in two. No pre-malignant or malignant lesions were confirmed on examination by the otolaryngologist. We were unable to draw conclusions about the cost-effectiveness or the yield of the screening programme. Despite our negative findings, we may need further investigation to clarify the relevance of such a programme on health-related outcome given the high compliance rate and minimal delay that was achieved by taking advantage of an in-patient alcohol rehabilitation centre.

[Does disulfiram still have a role in alcoholism treatment?]. / L'Antabus a-t-il encore sa place dans le traitement de la dépendance à l'alcool?

What is the place of disulfiram in the treatment of alcohol dependence since anti-craving pharmacological molecules (acamprosate, naltrexone) were launched on the market? Considering methodological limitations, available studies do not allow to conclude about disulfiram's efficacy. Clinical observations indicate however that disulfiram should keep a place in the treatment of alcohol-dependence considering favourable outcome for some patients. Disulfiram implants have however to be avoided. Side effects and possible adverse reactions should not be a barrier to its use. Disulfiram shouldn't be given during pregnancy and to patients with instable cardio-vascular disease. Its prescription justifies a close monitoring of liver tests for patients with abnormal hepatic function.

[Prevalence, prophylaxis and treatment of Wernicke encephalopathy. Thiamine, how much and how do we give it?]. / Prévalence, prophylaxie et traitement de l'encéphalopathie de Gayet-Wernicke. Quelle dose et quel mode d'administration de la thiamine?

Wernicke's encephalopathy (WE) is an acute neuropsychiatric condition due to thiamine deficiency (vitamin B1) most commonly associated with chronic alcohol abuse. WE is difficult to diagnose because the classical triad of signs (confusion, ataxia and ophthalmoplegia) occurs in only 10% of cases. The presentation is often one of a non-specific confusional state which may easily be attributed to intoxication, alcohol withdrawal or to a concurrent morbidity such as head injury. To improve the outcome, it is important to make a presumptive diagnosis of WE and treat the patients as soon as possible with high-dose parenteral thiamine. Patients with an alcohol problem associated with malnutrition should all be offered a preventive treatment with parenteral thiamine in view of the impaired oral thiamine absorption.

[Content and efficacy of remedial interventions with drinking and driving offenders]. / Contenu et efficacité des programmes de prévention après une première infraction pour ivresse au volant.

In Switzerland, 20% adults drove under the influence of alcohol over the last 12 month, 30% motor vehicle crashes are related to alcohol and over 18,000 people were sentenced for driving under the influence in 2001, 15-25% for repeated offence. This article reviews the scientific literature about the current prevention measures in Europe and North America, assessing the effectiveness of prevention measures. On average, prevention programs reduce repeated offence of 40%. The effectiveness of such programs appears superior for programs combining various measures, educational and behavioral, matched with repression measures, i.e., probation and driving license suspension. Efforts should be undertaken to pursue research and development in this major domain of public health concern.

[Helping patients with risky health behaviors: some suggestions for motivational interviewing]. / "Combien de fois il faut que je vous dise...". Quelques pistes données par l'entretien motivationnel.

Helping patients modify risky health behaviors, including cigarette smoking, at-risk alcohol use, sedentary lifestyle and unhealthy diet, is a common and sometimes frustrating task. Motivational interviewing was developed from the notion that simple advice usually does not lead to behavioral change and may be even misperceived by patients. Based on active listening and an empathic attitude, some principles of motivational interviewing may be easily adapted to a primary care consultation. These principles facilitate positive, relaxed and constructive atmosphere for behavior change discussions and have been associated with promising results. This article presents key concepts of motivational interviewing such as ambivalence, resistance and stages of change, illustrated with practical examples.

[Assessment and treatment of coexisting mental illness or dual diagnosis]. / Prise en charge des patients "double diagnostic": comment sortir du carrousel institutionnel?

Substance abuse touches around a quarter of psychiatric patients, which brings up various therapeutic problems. Literature shows us that between the "parallel", "series" and "integrated" approaches, it is the integrated approach which proves to be the most effective in terms of reducing symptoms, hospitalisations and criminality. An improvement in the patients' quality of life can also be observed. The integrated approach is developed by a team of in-patient and out-patient workers, whose job is to identify and evaluate clinically the motivation and the psychological and social functioning of the patients, and to propose suitable treatments according to the pathology and context of each case. A designated "case manager" guarantees the long term therapeutic project for each patient.

Clinical relevance of the distinction between alcohol dependence with and without a physiological component.

OBJECTIVE: DSM-IV indicates that diagnoses of substance dependence should be further characterized with regard to the presence of a physiological component, defined by tolerance or withdrawal. This study evaluated the possible meaning of this distinction in alcohol-dependent men and women. METHOD: As part of the Collaborative Study on the Genetics of Alcoholism, structured interviews were carried out with 3,395 DSM-III-R-defined alcohol-dependent individuals divided into 2,949 subjects (86.9%) with evidence of tolerance and/or withdrawal (group 1), 51.3% of whom evidenced withdrawal symptoms, and 446 subjects (13.1%) without a physiological component (group 2). Data were evaluated to determine differences between the two groups. RESULTS: Group 1 reported greater severity of alcohol dependence as demonstrated by a larger maximum number of drinks in 24 hours, more persons reporting binges, more alcohol-related life problems, more relevant DSM-III-R criteria endorsed, more physiological complications, and more alcohol-related emotional/psychiatric symptoms such as depression and anxiety. Each of these severity indicators for problems in group 1 was significant in the presence of the others in a logistic regression, and similar items remained significant when tolerance alone, withdrawal alone, or their combination was used as the criterion for group 1 membership; however, for withdrawal a larger proportion of the variance was explained by the predictor variables. The regression results were independent of gender, proband status, and history of antisocial personality disorder. CONCLUSIONS: The results support the clinical relevance of distinguishing between alcohol-dependent patients with and without a physiological component. The data indicate a potential advantage to limiting that definition to withdrawal only.

Clinical implications for four drugs of the DSM-IV distinction between substance dependence with and without a physiological component.

OBJECTIVE: The DSM-IV work group asked researchers and clinicians to subtype substance dependent individuals according to the presence or absence of physiological symptoms. A recent report from the Collaborative Study on the Genetics of Alcoholism demonstrated that among alcohol-dependent men and women, a history of tolerance or withdrawal was associated with a more severe clinical course, especially for individuals with histories of alcohol withdrawal. This article evaluates similar distinctions among subjects in the collaborative study who were dependent on marijuana, cocaine, amphetamines, or opiates. METHOD: Structured interviews gathered information from 1,457 individuals with a lifetime diagnosis of marijuana dependence, 1,262 with histories of cocaine dependence, 647 with amphetamine dependence, and 368 subjects with opiate dependence. For each drug, the clinical course was compared for subjects whose dependence included a history of withdrawal (group 1), those dependent on each drug who denied withdrawal but reported tolerance (group 2), and those who denied both tolerance and withdrawal (group 3). RESULTS: The proportion of dependent individuals who denied tolerance or withdrawal (group 3) ranged from 30% for marijuana to 4% for opiates. For each substance, individuals in groups 1 and 2 evidenced more severe substance-related problems and at least a trend for greater intensities of exposure to the drug; those reporting withdrawal (group 1) showed the greatest intensity of problems. CONCLUSIONS: The designation of dependence in the context of tolerance or withdrawal identifies individuals with more severe clinical histories. These results support the importance of the designation of a physiological component to dependence, especially for people who have experienced a withdrawal syndrome.

Ultra-rapid opiate detoxification using deep sedation and prior oral buprenorphine preparation: long-term results.

BACKGROUND: New methods of ultra-rapid opiate detoxification (URD) under intravenous sedation have been criticized because of limited data on safety and long-term follow-up. Premedication with buprenorphine has been advocated to improve safety by decreasing vomiting. Prior research has not explored URD in socially impaired patients. METHOD: Sixteen patients were detoxified with URD and prospectively evaluated over at least 30 months. Data of this procedure were compared with those of our previous study without buprenorphine preparation (Drug Alcohol Depend. 52(3) (1998) 243). The 16 patients were followed up by a general practitioner (GP) before and after URD. The GPs also supervised the 7-day course of buprenorphine treatment prescribed for the 16 patients prior to URD. RESULTS: During the procedure, only one episode of vomiting occurred instead of 13 out of 20 in our previous study. Post-procedure, only two patients experienced moderate withdrawal symptoms, such as persistent nausea, abdominal cramps and vomiting lasting from 24 to 48 h, in comparison with most patients in the previous study without buprenorphine. After a period of at least 30 months (36.0+/-6.38), the 16 patients were still alive and were regularly monitored by their GP. Only two of the 16 never relapsed after URD and reported total opiate abstinence. Fourteen patients relapsed; 12 of these were prescribed a licensed methadone substitution program and two were still using heroin. CONCLUSION: In this small sample, the data indicated that URD with buprenorphine preparation was safe and that it markedly decreased post-procedure morbidity. No patient died over a minimum 30-month follow-up period. Furthermore, the procedure was employed with socially impaired patients. In the long term, a few patients were still free of opiates, while the majority opted for a methadone maintenance program, showing that URD can serve as one possible step in a long-term treatment program.

Validation of the Addiction Severity Index in French-speaking alcoholic patients.

OBJECTIVE: Evaluation of a French translation of the Addiction Severity Index (ASI) in 100 (78 male) alcoholic patients. METHOD: Validity of the instrument was assessed by measuring test-retest and interrater reliability, internal consistency and convergence and discrimination between items and scales. Concurrent validity was assessed by comparing the scores from the ASI with those obtained from three other clinimetric instruments. RESULTS: Test-retest reliability of ASI scores (after a 10-day interval) was good (r = 0.63 to r = 0.95). Interrater reliability was evaluated using six video recordings of patient interviews. Severity ratings assigned by six rates were significantly different (p < .05), but 72% of the ratings assigned by those who viewed the videos were within two points of the interviewer's severity ratings. Cronbach alpha coefficient of internal consistency varied from 0.58 to 0.81 across scales. The average item-to-scale convergent validity (r value) was 0.49 (range 0.0 to 0.84) for composite scores and 0.35 (range 0.00 to 0.68) for severity ratings, whereas discriminant validity was 0.11 on average (range-0.19 to 0.46) for composite scores and 0.12 (range-0.20 to 0.52) for severity ratings. Finally, concurrent validity with the following instruments was assessed: Severity of Alcoholism Dependence Questionnaire (40% shared variance with ASI alcohol scale), Michigan Alcoholism Screening Test (2% shared variance with ASI alcohol scale) and Hamilton Depression Rating Scale (31% shared variance with ASI psychiatric scale). CONCLUSIONS: The Addiction Severity Index covers a large scope of problems encountered among alcoholics and quantifies need for treatment. This French version presents acceptable criteria of reliability and validity.

Characteristics of alcohol dependent subjects with very elevated levels of Gamma-Glutamyltransferase (GGT).

OBJECTIVE: This article examines characteristics of a subgroup of alcohol dependent men with very elevated serum Gamma-Glutamyltransferase (GGT) activity. METHOD: GGT was measured in 196 men soon after admission to an inpatient alcohol and drug treatment program. Subjects were split into two groups based on the a priori GGT value of > or =150 U/L for Group 1 (n = 20), and <150 U/L for Group 2 (n = 176). Serum aspartate amino-transferase (AST), serum alanine amino-transferase (ALT) and mean corpuscular volume (MCV), as well as several aspects of the drinking history, were compared cross-sectionally between the two groups. The stability of GGT in the context of drinking was evaluated prospectively over 12 months in a subsample of 35 individuals. RESULTS: Most measures of the drinking pattern and severity of dependence were similar between the two groups, although subjects in Group 1 demonstrated higher levels for AST (p < .01), MCV (p < .01) and ALT (p < .01). Subjects in Group 1 reported more drinking days per month (23.8 +/- 3.98 vs 17.8 +/- 8.71, t = 5.43, p < .001), and more related history of alcoholic liver disease (30.0% vs 8.5%, chi2 = 8.66, p < .01). In the presence of the variables significantly different between the two groups, AST, the number of drinking days per month and the proportion with alcoholic liver disease predicted membership to Group 1, although their influence was moderate (pseudo R between 0.16 and 0.20). The correlation between GGT at intake and follow-up in 35 individuals who returned to drinking was r = .56, p < .001, while two out of three subjects with high GGT at intake were also high at follow-up. CONCLUSIONS: Subjects with very high GGT seem to demonstrate a more intense vulnerability to alcohol, a characteristic which appears to be stable over time.

The clinical course of alcohol-related problems in alcohol dependent and nonalcohol dependent drinking women and men.

OBJECTIVE: This article examines the differences in the clinical course of alcohol dependence in men and women, interpreting results in light of the gender differences in nonalcoholics and potential findings from the general population. METHOD: As part of the Collaborative Study on the Genetics of Alcoholism (COGA) protocol, a detailed semistructured interview was administered to 1,085 alcohol dependent women and 2,120 alcohol dependent men, along with 1,936 women and 1,233 men who were drinkers but not alcoholic. Subjects were alcohol dependent probands, controls, and relatives of each. RESULTS: The men's and women's rank orders of alcohol-related life events were similar for alcohol dependent subjects, with a rho (rho) of .95, a figure that remained constant even when only primary alcoholics were considered. In general, those items for which the two genders evidenced differences in either the mean age of occurrence or the proportion of people who experienced an event were similar to gender differences in drinking among nonalcoholics or the literature on the general population. These included for women a lower maximum number of drinks per day, a 1- to 2-year later onset of several early alcohol-related problems and fewer years between the onset of problems and seeking help. Female alcoholics also showed a lower proportion with legal, job or personal problems related to alcohol. There were also high levels of similarity (p = .76, p > .001) for 28 life events related to alcohol for 1,936 women and 1,233 men who were drinkers but not alcohol dependent. CONCLUSIONS: Overall, the time course of alcohol-related problems for men and women were more similar than different. While there was evidence of a "telescoping" of the time between the onset of problems and treatment for women, the gender differences in ages of onset of events were relatively small. These data support the conclusion that, after considering gender differences in drinking in society, there is little evidence that the natural history of alcohol dependence in women is substantially different than in men.

[High risk alcohol consumption in a sample of patients of the Lausanne University Medical Polyclinic]. / Consommation d'alcool à risque dans un collectif de patients de la Policlinique médicale universitaire de Lausanne.

OBJECTIVES AND METHODS: This study indicates the prevalence, the characteristics, and the screening methods of patients with at risk alcohol drinking at the University Medical Clinic of Lausanne. RESULTS: The results reported demonstrate that one patient out of six is a drinker at risk without criteria for alcohol-dependance. The questionnaire AUDIT (Alcohol Use Disorders Identification Test) with a cut-off of five points seems to be the best screening test for at risk alcohol consumption. CONCLUSIONS: The high prevalence of at risk drinking in this study, combined with scientific evidence of the efficiency of brief interventions in changing drinking habits, emphasises the importance of alcohol screening for all patients attending outpatient medical settings.