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Abstract
Unhealthy alcohol use-the consumption of alcohol at a level that has caused or has the potential to cause adverse physical, psychological, or social consequences-is common, underrecognized, and undertreated. For example, data from the 2020 National Survey on Drug Use and Health indicate that 7.0% of adults reported heavy alcohol use in the previous month, and only 4.2% of adults with alcohol use disorder received treatment. Primary care is an important setting for optimizing screening and treatment of unhealthy alcohol use to promote individual and public health.
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Affiliation(s)
- Joseph H Donroe
- Yale Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut (J.H.D.)
| | - E Jennifer Edelman
- Yale Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, and Yale Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut (E.J.E.)
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Faulkner CS, White CM, Manatsathit W, Lamb B, Vatsalya V, McClain CJ, Jophlin LL. Positive blood phosphatidylethanol concentration is associated with unfavorable waitlist-related outcomes for patients medically appropriate for liver transplantation. Alcohol Res 2022; 46:581-588. [PMID: 35102553 PMCID: PMC9150771 DOI: 10.1111/acer.14786] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 01/23/2022] [Accepted: 01/25/2022] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Excessive alcohol use is a leading etiology of liver disease and indication for liver transplantation. Accurate measurement of alcohol use remains a challenge in the management of patients in the pre-, peri-, and post-liver transplant settings. Blood 16:0-18:1 phosphatidylethanol (PEth) concentration is a sensitive and specific biomarker of binge and moderate, chronic alcohol use. As PEth has the longest detection window of available blood-based direct alcohol biomarkers for moderate to heavy drinking, it shows promise as an indicator of patterns and chronicity of drinking. However, the utility of PEth in clinical liver transplantation is understudied. This study examines the association of PEth results with liver transplantation waitlist-focused patient outcomes. METHODS Retrospective data for all patients tested for PEth for a one-year period at a tertiary care medical center with an active liver transplantation program were abstracted. Indications for PEth testing, liver transplantation waitlist-related outcomes (e.g., listing and delisting) following testing and associations of PEth results with other parameters were analyzed. RESULTS Over a one-year period, 153 PEth tests were performed on 109 individuals. The most frequent indications for PEth testing were as an objective indicator of alcohol use patterns (86.3%) and to assess alcohol as a putative etiology of liver injury (13.7%). Of the 109 patients, 56 were medically appropriate for liver transplantation. Medically acceptable candidates with unfavorable transplantation waitlist-related outcomes (delisting, deferment of transplant evaluation, deferment of listing until completion of recommended alcohol rehabilitation, and being deemed not a transplant candidate) were at least 3.41 times more likely to have a positive PEth test than those with favorable transplantation waitlist-related outcomes (odds ratio 3.41, confidence interval 3.41 to ∞, p = 0.001). CONCLUSION This single-center study reporting a comprehensive account of PEth utilization at a liver transplant center demonstrates that liver transplantation waitlist-related outcomes are associated with PEth test results. Patients with positive PEth tests were more likely to have unfavorable transplant waitlist-related outcomes. PEth testing has not been validated as a predictor of relapse to drinking in post-transplant patients and because its utility in the pre-transplant setting is unclear its use could lead to disparities in the selection of patients for liver transplantation.
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Affiliation(s)
- Claire S Faulkner
- Department of Medicine, University of Arizona, College of Medicine, Phoenix, Arizona, USA.,Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Collin M White
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA
| | - Wuttiporn Manatsathit
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Bernadette Lamb
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Vatsalya Vatsalya
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA.,University of Louisville Alcohol Research Center, University of Louisville, Louisville, Kentucky, USA.,Robley Rex VA Medical Center, Louisville, Kentucky, USA.,Hepatobiology and Toxicology Program, University of Louisville, Louisville, Kentucky, USA
| | - Craig J McClain
- Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA.,University of Louisville Alcohol Research Center, University of Louisville, Louisville, Kentucky, USA.,Robley Rex VA Medical Center, Louisville, Kentucky, USA.,Hepatobiology and Toxicology Program, University of Louisville, Louisville, Kentucky, USA.,Department of Pharmacology and Toxicology, University of Louisville, Louisville, Kentucky, USA
| | - Loretta L Jophlin
- Department of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, USA.,Division of Gastroenterology, Hepatology and Nutrition, University of Louisville, Louisville, Kentucky, USA.,University of Louisville Alcohol Research Center, University of Louisville, Louisville, Kentucky, USA.,Hepatobiology and Toxicology Program, University of Louisville, Louisville, Kentucky, USA
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3
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Yue JK, Phelps RRL, Winkler EA, Deng H, Upadhyayula PS, Vassar MJ, Madhok DY, Schnyer DM, Puccio AM, Lingsma HF, Yuh EL, Mukherjee P, Valadka AB, Okonkwo DO, Manley GT. Substance use on admission toxicology screen is associated with peri-injury factors and six-month outcome after traumatic brain injury: A TRACK-TBI Pilot study. J Clin Neurosci 2020; 75:149-156. [PMID: 32173156 DOI: 10.1016/j.jocn.2020.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 02/10/2020] [Indexed: 01/07/2023]
Abstract
Substance use is commonly associated with traumatic brain injury (TBI). We investigate associations between active substance use, peri-injury factors, and outcome after TBI across three U.S. Level I trauma centers. TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot (TRACK-TBI Pilot) with Marshall computed tomography (CT) score 1-3, no neurosurgical procedure/operation, and admission urine toxicology screen (tox+/-) were extracted. Associations between tox+/-, comorbidities, hospital variables, and six-month functional (GOSE) and neuropsychiatric (PCL-C, BSI18, RPQ-13, SWLS) outcomes were analyzed. Multivariable regression was performed for associations significant on univariate analysis with odds ratios (mOR) presented. Significance assessed at p < 0.05. In 133 subjects, tox+/tox- were 29.1%/72.9%. Tox+ was younger (35.5/43.6-years, p = 0.018), trended toward male sex (80.6%/63.9%, p = 0.067), was associated with history of seizures (27.8%/10.3%, p = 0.012), self-reported substance use (44.4%/17.5%, p = 0.001), prior TBI (58.8%/34.1%, p = 0.009), GCS < 15 (69.4%/48.4%, p = 0.031) and blood alcohol level >0.08-mg/dl (55.6%/30.8%, p = 0.022). In CT-negative subjects, tox+ was associated with increased hospital admission (95.7%/66.7%, p = 0.034). At six-months, tox+ was associated with screening positive for post-traumatic stress disorder (PCL-C: 40.0%/15.9%; mOR = 8.24, p = 0.022) and psychiatric symptoms (BSI18: 40.0%/14.3%, mOR = 11.06, p = 0.023). Active substance use in TBI may confound GCS assessment, triage to higher level of care, and be associated with increased six-month neuropsychiatric symptoms. Substance use screening should be integrated into standard emergency/acute care TBI protocols to optimize management and resource utilization. Clinicians should be vigilant in providing education, counselling, and follow-up for TBI patients with substance use.
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Affiliation(s)
- John K Yue
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Ryan R L Phelps
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Ethan A Winkler
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Hansen Deng
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Pavan S Upadhyayula
- Department of Neurosurgery, University of California San Diego, San Diego, CA, USA
| | - Mary J Vassar
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA
| | - Debbie Y Madhok
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA, USA
| | - David M Schnyer
- Department of Psychology, University of Texas in Austin, Austin, TX, USA
| | - Ava M Puccio
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Esther L Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA; Department of Radiology, University of California San Francisco, San Francisco, CA, USA
| | - Alex B Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Geoffrey T Manley
- Department of Neurosurgery, University of California San Francisco, San Francisco, CA, USA; Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA, USA.
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Donroe JH, Tetrault JM. Substance Use, Intoxication, and Withdrawal in the Critical Care Setting. Crit Care Clin 2017; 33:543-558. [PMID: 28601134 DOI: 10.1016/j.ccc.2017.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Substance use is common among individuals admitted to the critical care setting and may complicate treatment of underlying disorders. Management issues include the effects of intoxication as well as the risk posed by substance-withdrawal syndromes in patients being treated for critical illness. This article reviews the epidemiology of substance use in this population and the identification and treatment of common intoxication and withdrawal syndromes. The authors stress the importance of long-term planning as part of the overall treatment protocol beyond the acute presentation.
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Affiliation(s)
- Joseph H Donroe
- Department of Internal Medicine, Yale University School of Medicine, St. Raphael Campus, Office M330, 1450 Chapel Street, New Haven, CT 06511, USA.
| | - Jeanette M Tetrault
- Department of Internal Medicine, Yale University School of Medicine, 367 Cedar Street, Suite 305, New Haven, CT 06510, USA
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