The Relationship Between Reductions in WHO Risk Drinking Levels During Treatment and Subsequent Healthcare Costs for the ACTIVE Workgroup.

BACKGROUND: Abstinence has historically been considered the target outcome for alcohol use disorder (AUD) treatment, yet recent work has found drinking reductions after AUD treatment, as measured by World Health Organization (WHO) risk drinking levels, are associated with meaningful improvements in functioning, physical health, and quality of life. OBJECTIVES: This study extends previous analyses of AUD treatment outcomes by estimating the association between changes in WHO risk drinking levels (very high, high, medium, and low, based on average daily alcohol consumption) and healthcare costs. METHODS: Secondary data analysis of the COMBINE study, a multisite randomized clinical trial of acamprosate, naltrexone and behavioral interventions for AUD. Generalized gamma regression models were used to estimate relationships between WHOrisk drinking level reductions over the course of treatment and healthcare costs in the year after treatment (N = 964) and up to 3 years following treatment (N = 651). RESULTS: SustainedWHOrisk drinking reductions of 2 or more levels throughout treatment were associated with 52.0% lower healthcare costs ( P < 0.001) in the year following treatment, and 44.0% lower costs ( P < 0.0025) over 3 years. A reduction of exactly 1 level was associated with 34.8% lower costs over 3 years, which was not significant ( P = 0.05). Cost reductions were driven by lower inpatient behavioral health and emergency department utilization. CONCLUSIONS: Reduction in WHO risk drinking levels of at least 2 levels was associated with lower healthcare costs over 1 and 3 years. Our results add to literature showing drinking reductions are associated with improvement in health.

Assessment and treatment of mood disorders in the context of substance abuse.

Recognition and management of mood symptoms in individuals using alcohol and/or other drugs represent a daily challenge for clinicians in both inpatient and outpatient treatment settings. Diagnosis of underlying mood disorders in the context of ongoing substance abuse requires careful collection of psychiatric history, and is often critical for optimal treatment planning and outcomes. Failure to recognize major depression or bipolar disorders in these patients can result in increased relapse rates, recurrence of mood episodes, and elevated risk of completed suicide. Over the past decade, epidemiologic research has clarified the prevalence of comorbid mood disorders in substance-dependent individuals, overturning previous assumptions that depression in these patients is simply an artifact of intoxication and/or withdrawal, therefore requiring no treatment. However, our understanding of the bidirectional relationships between mood and substance use disorders in terms of their course(s) of illness and prognoses remains limited. Like-wise, strikingly little treatment research exists to guide clinical decision making in co-occurring mood and substance use disorders, given their high prevalence and public health burden. Here we overview what is known and the salient gaps of knowledge where data might enhance diagnosis and treatment of these complicated patients.

El reconocimiento y manejo de los síntomas anímicos en los sujetos que emplean alcohol ylu otras drogas es un desafío diario para los clínicos en el tratamiento tanto de pacientes ambulatorios como hospitalizados. El diagnóstico de los trastornos del ánimo que están a la base de un abuso de sustancias requiere de una recopilación cuidadosa de la historia psiquiátrica, y a menudo es clave para lograr una planificación terapéutica y resultados óptimos. Una falla en el reconocimiento en estos pacientes de la depresión mayor o de los trastornos bipolares puede traducirse en un aumento en la frecuencia de recaídas, recurrencias y episodios anímicos, y un riesgo elevado de suicidio consumado. Durante la última década la investigación epidemiológica ha clarificado la prevalencia de los trastornos del ánimo comórbidos en sujetos con dependencia de sustancias, dando un vuelco en los supuestos previos acerca de que la depresión en estos pacientes era simplemente un artefacto de la intoxicación ylo de la abstinencia, y que por tanto no requería de tratamiento. Sin embargo, aun es limitada nuestra comprensión acerca de las relaciones bidireccionales entre los trastornos del ánimo y el abuso de sustancias en cuanto a los cursos y pronósticos de la enfermedad. Asimismo, llama la atención que existe poca investigación terapéutica para guiar la toma de decisiones clínicas cuando co-ocurren trastornos del ánimo y por uso de sustancias, dada su alta prevalencia y la carga para la salud pública. En este artículo se repasa lo que se sabe y los vacíos más destacados del conocimiento donde los datos podrían mejorar el diagnóstico y el tratamiento de estos pacientes complicados.

La reconnaissance et la prise en charge des troubles de l'humeur chez les personnes consommant de l'alcool et/ou d'autres substances sont des défis quotidiens pour les médecins, que ce soit dans le cadre hospitalier ou ambulatoire. Le diagnostic des troubles de l'humeur sous-jacents dans le contexte d'une toxicomanie existante nécessite un recueil soigneux des antécédents psychiatriques ; il est souvent déterminant pour une organisation et des résultats optimaux du traitement. Une absence de reconnaissance de la dépression majeure ou des troubles bipolaires chez ces patients peut entraîner une augmentation des taux de rechute, une récidive des troubles thymiques et un risque élevé de suicide réussi. Ces 10 dernières années, la recherche épidémiologique a clarifié la prévalence des troubles comorbides de l'humeur chez les personnes dépendantes d'une substance, infirmant les hypothèses antérieures considérant la dépression chez ces patients comme un simple artéfact de l'intoxication et/ou du sevrage, ne nécessitant donc aucun traitement. Cependant, notre compréhension des relations bidirectionnelles entre troubles de l'humeur et troubles de l'usage d'une substance en termes d'évolution de la maladie et de pronostic reste limitée. De même, le peu de recherche thérapeutique pour guider la décision clinique en cas de troubles concomitants de l'humeur et de l'usage de substances est marquant, compte tenu de leur haute prévalence et de leur poids dans la santé publique. Nous analysons ici ce qui est connu ainsi que les lacunes importantes dans nos connaissances dans ce domaine ; des résultats de recherche pourraient améliorer le diagnostic et le traitement de ces patients compliqués.

Alcohol treatment effects on secondary nondrinking outcomes and quality of life: the COMBINE study.

OBJECTIVE: To evaluate the full range of alcohol treatment effectiveness, it is important to assess secondary nondrinking outcome dimensions in addition to primary alcohol consumption outcomes. METHOD: We used a large sample (n=1,226) of alcohol-dependent participants entering the National Institute on Alcohol Abuse and Alcoholism-sponsored COMBINE (Combining Medications and Behavioral Interventions) Study, a multisite clinical trial of pharmacological (naltrexone [ReVia] and acamprosate [Campral]) and behavioral interventions, to examine the effects of specific treatment combinations on nondrinking functional outcomes. We assessed the outcomes at baseline and at the end of 16 weeks of alcohol treatment and again at the 26-week and/or 52-week postrandomization follow-ups. RESULTS: (1) Drinking and secondary outcomes were significantly related, especially at the follow-up periods. A higher percentage of heavy drinking days, more drinks per drinking day, and lower percentage of days abstinent were associated with lower quality-of-life measures. (2) All nondrinking outcomes showed improvement at the end of 16 weeks of treatment and most maintained improvement over the 26-week and 52-week follow-ups. Only two measures returned to pretreatment levels at 52 weeks: percentage of days paid for work and physical health. Improvements of nondrinking outcomes remained even after adjusting for posttreatment heavy drinking status. (3) Although nondrinking outcomes showed overall improvement, specific pharmacological and behavioral treatment combinations were not differentially effective on specific secondary outcomes. CONCLUSIONS: In the current study, changes that resulted from treatment were multidimensional, and improvements in nondrinking outcomes reflected the overall significant improvement in drinking but they were not differentiated between treatment combination groups. Findings from this study support the importance of including secondary nondrinking outcomes in clinical alcohol-treatment trials.

Improvement of physical health and quality of life of alcohol-dependent individuals with topiramate treatment: US multisite randomized controlled trial.

BACKGROUND: Topiramate can improve drinking outcomes via a hypothesized mechanism of facilitating gamma-aminobutyric acid function and inhibiting glutaminergic pathways in the corticomesolimbic system. We sought to determine whether topiramate's antidrinking effects are bolstered by improvements in physical and psychosocial well-being. METHODS: In a 17-site, 14-week, double-blind, randomized controlled trial, we compared the effects of topiramate (up to 300 mg/d) vs placebo on physical health, obsessional thoughts and compulsions about using alcohol, and psychosocial well-being among 371 alcohol-dependent subjects who received weekly adherence enhancement therapy. RESULTS: Topiramate was more efficacious than placebo in reducing body mass index (calculated as weight in kilograms divided by height in meters squared) (mean difference, 1.08; 95% confidence interval [CI], 0.81-1.34; P < .001), all liver enzyme levels (P < .01 for all comparisons), plasma cholesterol level (mean difference, 13.30 mg/dL; 95% CI, 5.09-21.44 mg/dL; P = .002), and systolic (mean difference, 9.70 mm Hg; 95% CI, 6.81-12.60 mm Hg; P < .001) and diastolic (mean difference, 6.74 mm Hg; 95% CI, 4.57-8.90 mm Hg; P < .001) blood pressure to about prehypertension levels-effects that might lower the risk of fatty liver degeneration and cirrhosis as well as cardiovascular disease. Topiramate compared with placebo significantly (P < .05 for all comparisons) decreased obsessional thoughts and compulsions about using alcohol, increased subjects' psychosocial well-being, and improved some aspects of quality of life, thereby diminishing the risk of relapse and longer-term negative outcomes. Paresthesia, taste perversion, anorexia, and difficulty with concentration were reported more frequently for topiramate than for placebo. CONCLUSION: Topiramate appears to be generally effective at improving the drinking outcomes and physical and psychosocial well-being of alcoholic subjects.

Alcohol biomarker screening in medical and surgical settings.

This article highlights the proceedings of a symposium presented at the 28th Annual Meeting of the Research Society on Alcoholism in Santa Barbara, CA, on June 28, 2005, organized and chaired by Peter Miller. The presentations included (1) Screening for Alcohol Use Disorders in Surgical and Trauma Patients, presented by Claudia Spies; (2) Are Serum Levels of %CDT and GGT Related to Severity of Liver Biopsy Inflammation, Fibrosis, and Steatohepatitis in Patients with Hepatitis C? by Martin Javors; (3) Biochemical Alcohol Screening in the Treatment of Hypertension, presented by Peter Miller; and (4) The Cost-Effectiveness of a New Biomarker, CDT, in a Primary Care Sample, by Michael Fleming. Presentations were discussed by Raymond Anton.