Using Death Certificates to Explore Changes in Alcohol-Related Mortality in the United States, 1999 to 2017.

BACKGROUND: Alcohol consumption, alcohol-related emergency department visits, and hospitalizations have all increased in the last 2 decades, particularly among women and people middle-aged and older. The purpose of this study was to explore data from death certificates to assess whether parallel changes in alcohol-related mortality occurred in the United States in recent years. METHODS: U.S. mortality data from the National Center for Health Statistics were analyzed to estimate the annual number and rate of alcohol-related deaths by age, sex, race, and ethnicity between 1999 and 2017 among people aged 16+. Mortality data contained details from all death certificates filed nationally. For each death, an underlying cause and up to 20 multiple or contributing causes were indicated. Deaths were identified as alcohol-related if an alcohol-induced cause was listed as either an underlying or multiple cause. Joinpoint analyses were performed to assess temporal trends. RESULTS: The number of alcohol-related deaths per year among people aged 16+ doubled from 35,914 to 72,558, and the rate increased 50.9% from 16.9 to 25.5 per 100,000. Nearly 1 million alcohol-related deaths (944,880) were recorded between 1999 and 2017. In 2017, 2.6% of roughly 2.8 million deaths in the United States involved alcohol. Nearly half of alcohol-related deaths resulted from liver disease (30.7%; 22,245) or overdoses on alcohol alone or with other drugs (17.9%; 12,954). Rates of alcohol-related deaths were highest among males, people in age-groups spanning 45 to 74 years, and among non-Hispanic (NH) American Indians or Alaska Natives. Rates increased for all age-groups except 16 to 20 and 75+ and for all racial and ethnic groups except for initial decreases among Hispanic males and NH Blacks followed by increases. The largest annual increase occurred among NH White females. Rates of acute alcohol-related deaths increased more for people aged 55 to 64, but rates of chronic alcohol-related deaths, which accounted for the majority of alcohol-related deaths, increased more for younger adults aged 25 to 34. CONCLUSIONS: Death certificates suggest that alcohol-related mortality increased in the United States between 1999 and 2017. Given previous reports that death certificates often fail to indicate the contribution of alcohol, the scope of alcohol-related mortality in the United States is likely higher than suggested from death certificates alone. Findings confirm an increasing burden of alcohol on public health and support the need for improving surveillance of alcohol-involved mortality.

Trends in Alcohol Consumption Among Older Americans: National Health Interview Surveys, 1997 to 2014.

BACKGROUND: The majority of U.S. older adults consume alcoholic beverages. The older population is projected to almost double by 2050. Substantially more drinkers are likely. PURPOSE: To describe gender-specific trends (1997 to 2014) in prevalence of drinking status (lifetime abstention, former drinking, current drinking [including average volume], and binge drinking) among U.S. adults ages 60+ by age group and birth cohort. METHODS: In the 1997 to 2014 National Health Interview Surveys, 65,303 respondents ages 60+ (31,803 men, 33,500 women) were current drinkers; 6,570 men and 1,737 women were binge drinkers. Prevalence estimates and standard errors were computed by age group (60+, 60 to 64, 65 to 69, 70 to 74, 75 to 79, 80+) and birth cohort (<1925, 1925 to 1935, 1936 to 1945, 1946 to 1954). Trends were examined using joinpoint regression and described as average annual percent change (AAPC; overall change 1997 to 2014) and annual percent change (APC; in-between infection points). Primary analyses were unadjusted. All analyses (unadjusted and adjusted for demographics/lifestyle) were weighted to produce nationally representative estimates. Statistical procedures accounted for the complex survey design. RESULTS: Among men ages 60+, unadjusted prevalence of current drinking trended upward, on average, 0.7% per year (AAPC, p = 0.02); average volume and prevalence of binge drinking remained stable. Adjusted results were similar. Among women age 60+, unadjusted prevalence of current drinking trended upward, on average, 1.6% per year (AAPC, p < 0.0001), but average volume remained stable; prevalence of binge drinking increased, on average, 3.7% per year (AAPC, p < 0.0001). Adjusted results were similar. Trends varied by age group and birth cohort. Among men born 1946 to 1954, unadjusted prevalence of current drinking trended upward, on average, 2.4% per year (AAPC, p = 0.02); adjusted results were nonsignificant. CONCLUSIONS: Our finding of upward trends in drinking among adults ages 60+, particularly women, suggests the importance of public health planning to meet future needs for alcohol-related programs.

Emergency Department Visits for Adverse Drug Reactions Involving Alcohol: United States, 2005 to 2011.

BACKGROUND: Alcohol consumption may interfere with absorption, distribution, metabolism, and excretion of medications and increase risk of adverse drug reactions (ADR). Studies report increasing prescription medication use over time, with many U.S. drinkers using alcohol-interactive medication. This study identified trends in incidence of U.S. emergency department (ED) visits for ADR with alcohol involvement (ADR-A), compared characteristics and disposition between ADR-A visits and ADR visits without alcohol involvement (ADR-NA), and examined frequency of implicated medications in such visits for 2005 to 2011. METHODS: ADR visits were identified through the Drug Abuse Warning Network, a national surveillance system monitoring drug-related ED visits. Analysis accounted for sampling design effects and sampling weights. Estimates are presented for totals (ages 12+), age group, and/or sex. Trends were assessed by joinpoint log-linear regression. Differences between ADR-A and ADR-NA visits were compared using two-tailed Rao-Scott chi-square tests. RESULTS: From 2005 to 2011, incidence of ADR-A visits increased for males and females ages 21 to 34 and females ages 55+. An average of 25,303 ADR-A visits ages 12+ occurred annually. Compared with ADR-NA visits, ADR-A visits were more likely to involve males, patients ages 21 to 54, and 2+ implicated drugs. Alcohol involvement increased odds of more serious outcomes from ADR visits. Central nervous system (CNS) agents were the most common medications in ADR-A visits (59.1%), with nearly half being analgesics (mainly opioid). About 13.8% of ADR-A visits involved psychotherapeutic agents, including antidepressants. Besides CNS and psychotherapeutic agents, ADR-A visits involved a higher percentage of genitourinary-tract agents (mainly for impotence) than ADR-NA visits. Sex and age variations were observed with certain implicated medications. CONCLUSIONS: ED visits for alcohol-drug interactions can be prevented by avoiding alcohol when taking alcohol-interactive medications. Our results underscore the need for healthcare professionals to routinely ask patients about alcohol consumption and warn of ADR risks before prescribing and dispensing alcohol-interactive medications.

Treatment Utilization Among Adolescent Substance Users: Findings from the 2002 to 2013 National Survey on Drug Use and Health.

BACKGROUND: Adolescent substance users face serious health and social consequences and benefit from early diagnosis and treatment. The objectives of this study were to observe trends in treatment utilization; examine correlates of treatment utilization and treatment types/settings among adolescent substance users with and without substance use disorder (SUD); and assess gender differences. METHODS: National Survey on Drug Use and Health data were pooled across 2002 to 2013, with a combined sample of 79,885 past-year substance users ages 12 to 17 (17,510 with SUD and 62,375 without SUD). Treatment was defined as receiving treatment or counseling for use of alcohol or any drug, not counting cigarettes. Trends were assessed by joinpoint linear regression, and multivariable logistic regression assessed odds ratios of treatment utilization. RESULTS: Percentages of past-year treatment use did not change in 2002 to 2013. Treatment utilization was more prevalent among adolescents with SUD than without (11.4% vs. 1.4%) and among males than females. Among adolescents with and without SUD, criminal justice involvement and perceiving a need for treatment increased adolescent treatment utilization, while SUDs other than alcohol abuse, older age, and talking to parents increased treatment use among adolescents with SUD, and polysubstance use and male gender increased treatment among those without SUD. Treatment gaps persisted among non-Hispanic Blacks for both groups with and without SUD, male Hispanics with SUD, female non-Hispanic Asians without SUD, and private insurance coverages. Gender differences were observed in SUD, race/ethnicity, and insurance coverage. Most adolescents received treatment for both alcohol and drug use, and self-help group and outpatient rehabilitation facility were the most used treatment settings. CONCLUSIONS: Treatment utilization among adolescents with past-year substance use remained low and unimproved in 2002 to 2013. Treatment gaps among minority populations, insurance coverage, and in educating adolescents on seeking relevant treatment must be addressed. Using screening processes such as Screening, Brief Intervention, and Referral to Treatment, health professionals can help prevent lifelong SUD by recognizing and addressing substance misuse early.

Differences in state drug testing and reporting by driver type in U.S. fatal traffic crashes.

INTRODUCTION: Driving under the influence of drugs, including marijuana, has become more prevalent in recent years despite local, state, and federal efforts to prevent such increases. The Fatality Analysis Reporting System (FARS) is the primary source of drugged driving data for fatal crashes in the United States but lacks the completeness required to calculate unbiased estimates of drug use among drivers involved in fatal crashes. METHODS: This article uses the 2013 FARS dataset to present differences in state drug testing rates by driver type, driver fault type, and state-level factors; discusses limitations related to analysis and interpretation of drugged driving data; and offers suggestions for improvements that may enable appropriate use of FARS drug testing data in the future. RESULTS: Results showed that state drug testing rates were highest among drivers who died at the scene of the crash (median=70.8%) and drivers who died and were at fault in the crash (median=64.4%). The lowest testing rates were seen among surviving drivers who were not transported to a hospital (median=14.0%) and surviving drivers who were not at fault in the crash (median=10.0%). Drug testing rates differed by state blood alcohol content (BAC) testing rate across all driver types and driver fault types, and in general, states that tested a higher percentage of drivers for BAC had higher drug testing rates. DISCUSSION: Testing rates might be increased through standardization and mandatory testing policies. FARS data users should continue to be cautious about the limitations of using currently available data to quantify drugged driving. More efforts are needed to improve drug testing and reporting practices, and more research is warranted to establish drug concentration levels at which driving skills become impaired.

Converging Patterns of Alcohol Use and Related Outcomes Among Females and Males in the United States, 2002 to 2012.

BACKGROUND: Females in the United States consume less alcohol and cause and experience fewer alcohol-related harms than males. However, recent research suggests such gaps might be narrowing. The purpose of this study was to explore changes in alcohol use and associated outcomes among females and males in the United States between 2002 and 2012. METHODS: Data from the National Survey on Drug Use and Health were used to assess the prevalence and trends for females and males aged 12+ in lifetime abstinence, age of onset, current drinking, binge drinking, drinking and driving, reaching DSM-IV criteria for an alcohol use disorder, combining alcohol with other drugs such as marijuana, and other variables. Of particular interest was whether differences between females and males narrowed during the decade under study. RESULTS: Differences in the drinking patterns of females and males aged 12+ narrowed between 2002 and 2012 for current drinking, number of drinking days per month, past year DSM-IV alcohol abuse, and past-year driving under the influence of alcohol. In addition, convergence was noted in 1 or more age subgroups for the prevalence of binge drinking and DSM-IV alcohol dependence and mean age at drinking onset. Divergence in drinking habits did not occur for any measure in any age subgroups with the exception of a greater increase in the prevalence of combining alcohol with marijuana among young adult male drinkers than female drinkers aged 18 to 25. CONCLUSIONS: Between 2002 and 2012, differences in alcohol consumption and related outcomes narrowed for females and males. Reasons for converging patterns of alcohol use are unclear and do not appear to be easily explainable by recent trends in employment status, pregnancy status, or marital status. More research is needed to identify the psychosocial and environmental contributors to these changes and to assess implications for prevention and treatment efforts.

Moderators of Varenicline Treatment Effects in a Double-Blind, Placebo-Controlled Trial for Alcohol Dependence: An Exploratory Analysis.

OBJECTIVES: To explore whether varenicline (Chantix) showed more efficacy in treating certain subgroups of patients. In a recent multisite trial, varenicline was shown to be effective in reducing drinking in alcohol-dependent patients, both smokers and nonsmokers. Given the heterogeneity among alcohol-dependent patients, secondary analyses were conducted to determine whether certain subgroups responded more favorably than others to treatment with varenicline. METHODS: Data were drawn from a phase 2 randomized, double-blind, placebo-controlled multisite 13-week trial of varenicline in alcohol-dependent patients (Litten et al., 2013). Seventeen moderator variables were selected for exploratory testing on the basis of theoretical and scientific interest. RESULTS: Of the 17 moderator variables assessed, 4 were statistically significant, including cigarettes per day reduction, treatment drinking goal, years drinking regularly, and age of the patient. Two other variables­the type of adverse events experienced by patients and the severity of alcohol-related consequences­seemed to moderate the varenicline treatment effect at borderline statistical significance. Individuals who reduced the number of cigarettes per day experienced a significant effect from varenicline in reducing drinking, whereas those who did not change or who increased their number of cigarettes observed no beneficial effect. Reviewing the moderators related to severity, varenicline seemed to have greater efficacy than placebo among less severely dependent patients. CONCLUSIONS: Varenicline seems to be more efficacious in certain subgroups, particularly in those who reduced their smoking and in the "less severe" patient. Additional studies are warranted to confirm the results of these exploratory analyses.

State variation in underreporting of alcohol involvement on death certificates: motor vehicle traffic crash fatalities as an example.

OBJECTIVE: We used motor vehicle traffic (MVT) crash fatalities as an example to examine the extent of underreporting of alcohol involvement on death certificates and state variations. METHOD: We compared MVT-related death certificates identified from national mortality data (Multiple Cause of Death [MCoD] data) with deaths in national traffic census data from the Fatality Analysis Reporting System (FARS). Because MCoD data were not individually linked to FARS data, the comparisons were at the aggregate level. Reporting ratio of alcohol involvement on death certificates was thus computed as the prevalence of any mention of alcohol-related conditions among MVT deaths in MCoD, divided by the prevalence of decedents with blood alcohol concentration (BAC) test results (not imputed) of .08% or greater in FARS. Through bivariate analysis and multiple regression, we explored state characteristics correlated with state reporting ratios. RESULTS: Both MCoD and FARS identified about 450,000 MVT deaths in 1999-2009. Reporting ratio was only 0.16 for all traffic deaths and 0.18 for driver deaths nationally, reflecting that death certificates captured only a small percentage of MVT deaths involving BAC of .08% or more. Reporting ratio did not improve over time, even though FARS indicated that the prevalence of BAC of at least .08% in MVT deaths increased from 19.9% in 1999 to 24.2% in 2009. State reporting ratios varied widely, from 0.02 (Nevada and New Jersey) to 0.81 (Delaware). CONCLUSIONS: The comparison of MCoD with FARS revealed a large discrepancy in reporting alcohol involvement in MVT deaths and considerable state variation in the magnitude of underreporting. We suspect similar underreporting and state variations in alcohol involvement in other types of injury deaths.

The placebo effect in clinical trials for alcohol dependence: an exploratory analysis of 51 naltrexone and acamprosate studies.

BACKGROUND: The placebo effect often undermines efforts to determine treatment effectiveness in clinical trials. A significant placebo response occurs in alcohol trials, but it is not well understood. The purpose of this study was to characterize the placebo response across multiple naltrexone and acamprosate studies. METHODS: Fifty-one trials, 3 with a naltrexone and an acamprosate arm, 31 with at least 1 naltrexone arm, and 17 with at least 1 acamprosate arm, were identified from Cochrane reviews and PubMed search. To be included in this study, patients had to be at least 18 years old, abstinent from alcohol before randomization, and meet a diagnosis of alcohol dependence. Pearson correlation coefficients (rp ) and simple linear regression were used to describe the strength of linear relationships between placebo response and treatment effect size. Spearman's rank correlation coefficients (rs ) were used to examine the strength of associations between study characteristics and placebo response. RESULTS: For the end point measures of percent days abstinent and total abstinence, a negative relationship was evident between placebo response and treatment effect size in the naltrexone trials (rp  = -0.55, p < 0.01 and rp  = -0.20, p = 0.35, respectively) as well as in the acamprosate trials (rp  = -0.45, p = 0.09 and rp  = -0.56, p = 0.01, respectively). The placebo response for percent days abstinent was negatively correlated with mean age of participants (rs  = -0.42, p = 0.05) across naltrexone trials and positively correlated with publication year (rs  = 0.57, p = 0.03) across acamprosate trials. However, these 2 study characteristics were not significantly correlated with treatment effect size. CONCLUSIONS: The placebo response varied considerably across trials and was negatively correlated with the treatment effect size. Additional studies are required to fully understand the complex nature of the placebo response and to evaluate approaches to minimize its effects.