Alcohol-medication interactions: A systematic review and meta-analysis of placebo-controlled trials

A systematic review and meta-analysis of the prevalence of alcohol and other drug use and problematic use among people accessing mental health treatment in Australia

OBJECTIVE

Substance use and use disorders are elevated among people accessing mental health treatment, but the nature and patterns of use are unknown. The current study aimed to identify the prevalence of alcohol and other drug (AOD) use and problematic AOD use (i.e. hazardous, harmful, risky, misuse, abuse, dependence, disorder) in Australian mental health settings and conduct a meta-analysis of studies where sufficient data were available.

METHOD

A systematic review of all papers published up to July 2023 identified 59 eligible studies reporting the prevalence of substance use, problematic use, and use disorders among people accessing mental health treatment in Australia. Overall, 55 studies provided sufficient data for a meta-analysis for past year use and problematic use of any AOD overall, alcohol, cannabis, tobacco, stimulants/amphetamines, and opioids.

RESULTS

Pooled prevalence estimates of past year use and problematic use among clients of mental health treatment settings varied (5%-58% and 7%-53%, respectively). Past year use and past year problematic use of tobacco were particularly prevalent (58% and 53%, respectively), as was cannabis (38% and 37%, respectively). Several key factors, including the type of mental health disorder, may explain some variation in prevalence estimates.

CONCLUSION

The presence of co-occurring and problematic AOD use should be expected among a considerable proportion of clients of mental health treatment settings, and are a significant concern that services must be prepared to address. As such, screening and assessment of AOD use and use disorders should be part of routine clinical care, and clinicians should be familiar with evidence-based management and treatment strategies, including those that address tobacco.

Combined pharmacological and psychosocial interventions for alcohol use disorder

BACKGROUND

Alcohol use disorder (AUD) is a mental disorder characterised by a strong desire to consume alcohol and impaired control of alcohol use, with devastating consequences. Many people with AUD do not respond to psychosocial or pharmacological interventions when these are provided alone. Combining these interventions may improve the response to treatment, though evidence remains limited.

OBJECTIVES

To assess the effects of combined pharmacological and psychosocial interventions for the treatment of AUD in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases, and two trials registers in November 2023, without language restrictions.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing combined pharmacological and psychosocial interventions versus pharmacological or psychosocial interventions alone, or no intervention/treatment as usual (TAU), in adults with AUD. Our primary outcomes were continuous abstinent participants, frequency of use (measured as heavy drinkers, percentages of abstinent days, heavy-drinking days), amount of use (number of drinks per drinking day), adverse events, serious adverse events, dropouts from treatment, and dropouts due to adverse events.

DATA COLLECTION AND ANALYSIS

We assessed risk of bias using Cochrane's RoB 1 tool, performed random-effects meta-analyses, and evaluated the certainty of evidence according to the GRADE approach.

MAIN RESULTS

We included 21 RCTs (4746 participants). The most studied pharmacological and psychosocial interventions were naltrexone (81.0%) and cognitive behavioural therapy (66.7%), respectively. Most participants were men (74%), aged about 44 years, with AUD, without comorbid mental disorders or other substance use disorders; 15 RCTs detoxified participants before treatment. We judged 28.5% of the studies as at low risk of bias for random sequence generation, allocation concealment, performance bias for objective and subjective outcomes, and detection bias for subjective outcomes; all studies were at low risk of detection bias for objective outcomes; 85.7% of studies were at low risk of attrition bias; 14.2% of studies were at low risk of reporting bias. 1) Compared to psychosocial intervention alone, combined pharmacological and psychosocial interventions probably reduce the number of heavy drinkers (above the clinically meaningful threshold (MID) of 2%; absolute difference (AD) -10%, 95% confidence interval (CI) -18% to -2%; risk ratio (RR) 0.86, 95% CI 0.76 to 0.97; 8 studies, 1609 participants; moderate-certainty evidence). They may increase continuous abstinent participants (MID 5%; AD 5%, 95% CI 1% to 11%; RR 1.17, 95% CI 1.02 to 1.34; 6 studies, 1184 participants; low-certainty evidence). They probably have little to no effect on: • the rate of abstinent days (MID 8%; mean difference (MD) 4.16, 95% CI 1.24 to 7.08; 10 studies, 2227 participants); • serious adverse events (MID 1%; AD -2%, 95% CI -3% to 0%; RR 0.20, 95% CI 0.03 to 1.12; 4 studies; 524 participants); • dropouts from treatment (MID 10%; AD -3%, 95% CI -5% to 0%; RR 0.89, 95% CI 0.79 to 1.01; 15 studies, 3021 participants); and • dropouts due to adverse events (MID 5%; AD 2%, 95% CI 0% to 5%; RR 1.91, 95% CI 1.04 to 3.52; 8 studies, 1572 participants) (all moderate-certainty evidence). They may have little to no effect on: • heavy-drinking days (MID 5%; MD -3.49, 95% CI -8.68 to 1.70; 4 studies, 470 participants); • number of drinks per drinking day (MID 1 drink; MD -0.57, 95% CI -1.16 to 0.01; 7 studies, 805 participants); and • adverse events (MID 30%; AD 17%, 95% CI -5% to 46%; RR 1.25, 95% CI 0.93 to 1.68; 4 studies, 508 participants) (all low-certainty evidence). 2) Compared to pharmacological intervention alone, combined pharmacological and psychosocial interventions may have little to no effect on: • the rate of abstinent days (MID 8%; MD -1.18, 95% CI -4.42 to 2.07; 2 studies, 1158 participants); and • dropouts from treatment (MID 10%; AD 1%, 95% CI -10 to 14%; RR 0.98, 95% CI 0.65 to 1.47; 3 studies, 1246 participants) (all low-certainty evidence). We are uncertain about their effect on: • continuous abstinent participants (MID 5%; AD 3%, 95% CI -5% to 18%; RR 1.22, 95% CI 0.62 to 2.40; 1 study, 241 participants); • the number of heavy drinkers (MID 2%; AD 2%, 95% CI -4% to 8%; RR 1.03, 95% CI 0.94 to 1.12; 1 study, 917 participants); • the number of drinks per drinking day (MID 1 drink; MD -2.40, 95% CI -3.98 to -0.82; 1 study, 241 participants); and • dropouts due to adverse events (MID 5%; AD -1%, 95% CI -3% to 6%; RR 0.61, 95% CI 0.14 to 2.72; 2 studies, 1165 participants) (all very low-certainty evidence). 3) We are uncertain about the effect of combined pharmacological and psychosocial interventions, when compared to TAU, on: • the number of heavy drinkers (MID 2%; AD -5%, 95% CI -13% to 2%; RR 0.93, 95% CI 0.83 to 1.03; 1 study, 616 participants); • the rate of abstinent days (MID 8%; MD 3.43, 95% CI -1.32 to 8.18; 1 study, 616 participants); • dropouts from treatment (MID 10%; AD 0%, 95% CI -10% to 15%; RR 0.98, 95% CI 0.58 to 1.65; 2 studies, 696 participants); and • dropouts due to adverse events (MID 5%; AD 3%, 95% CI 0% to 15%; RR 2.97, 95% CI 0.70 to 12.67; 1 study, 616 participants) (all very low-certainty evidence). The certainty of evidence ranged from moderate to very low, downgraded mainly due to risk of bias and imprecision.

AUTHORS' CONCLUSIONS

As implications for practice, our findings indicate that adding pharmacological to psychosocial interventions is safe and helps people with AUD recover. These conclusions are based on low- to moderate-certainty evidence. Given the few studies and very low-certainty evidence, any benefits of adding psychosocial to pharmacological interventions or comparing the combined intervention to TAU are less clear. As implications for research, further studies should investigate the effects of the combined intervention compared to pharmacotherapy or TAU.

Drug interactions in patients with alcohol use disorder: results from a real-world study on an addiction-specific ward

Background

The majority of patients with alcohol use disorder (AUD) regularly take medication. Alcohol interacts negatively with many commonly prescribed drugs. However, little is known about the characteristics and frequency of potential alcohol-medication and drug-drug interactions in patients with AUD.

Objectives

This study aimed to determine the prevalence and characteristics of drug interactions in patients with AUD during withdrawal therapy on an addiction-specific ward.

Design

Retrospective cohort study.

Methods

Medication charts were analyzed and screened for potential alcohol-medication and drug-drug interactions. For the screening of potential alcohol-medication interactions, the drugs.com classification was utilized and potential drug-drug interactions were identified using the mediQ electronic interaction program.

Results

In our study, almost two-thirds (66.3%; 1089/1643) of all patient cases were prescribed at least one drug that could potentially interact with alcohol. Four percent of all alcohol-medication interactions were classified as severe, 91.8% as moderate, and 4.3% as mild. Drug classes commonly involved in serious interactions with alcohol were analgesics and drugs used in diabetes. A total of 811 potential drug-drug interactions were identified, of which 3.3% were classified as severe and 96.5% as moderate. Psychoanaleptics (ATC N06) and psycholeptics (ATC N05) were most frequently associated with moderate to severe interactions.

Conclusion

Potential alcohol-medication and drug-drug interactions are common in hospitalized patients with AUD. Improvements in the quality of prescribing should focus on the use of psychotropic drugs.

Spread the Word: No Amount of Alcohol is Safe!

Excessive use of alcohol is prevalent in the United States, and there are a variety of adverse health effects. The Global Burden of Diseases, Injuries, and Risk Factors Study determined that no amount of alcohol is safe. The American Cancer Society's 2020 guideline for diet and physical activity for cancer prevention is their first to advise that "it is best to not drink alcohol." There is a need for increased awareness by both laypeople and health care professionals of the health and social hazards associated with alcohol. The Healthcare Professional's Core Resource on Alcohol provides such training. The World Health Organization recommends population-based interventions such as increased alcohol taxes, restrictions or bans on alcohol advertising, and limits on places that sell alcohol. Gastroenterology nurses have a special opportunity to intervene with patients because a variety of gastroenterology conditions are alcohol-related. Our advocacy responsibility is to assist with the initiation of workplace, local, state, and national policies that promote the recommendations that no amount of alcohol is safe.

Explore the effect of apparent temperature and air pollutants on the admission rate of acute myocardial infarction in Chongqing, China: a time-series study

OBJECTIVE

Limited research has been conducted on the correlation between apparent temperature and acute myocardial infarction (AMI), as well as the potential impact of air pollutants in modifying this relationship. The objective of this study is to investigate the lagged effect of apparent temperature on AMI and assess the effect modification of environmental pollutants on this association.

DESIGN

A time-series study.

SETTING AND PARTICIPANTS

The data for this study were obtained from the Academy of Medical Data Science at Chongqing Medical University, covering daily hospitalisations for AMI between 1 January 2015 and 31 December 2016. Meteorological and air pollutant data were provided by China's National Meteorological Information Centre.

OUTCOME MEASURES

We used a combined approach of quasi-Poisson generalised linear model and distributed lag non-linear model to thoroughly analyse the relationships. Additionally, we employed a generalised additive model to investigate the interaction between air pollutants and apparent temperature on the effect of AMI.

RESULT

A total of 872 patients admitted to hospital with AMI were studied based on the median apparent temperature (20.43°C) in Chongqing. Low apparent temperature (10th, 7.19℃) has obvious lagged effect on acute myocardial infarction, first appearing on the 8th day (risk ratio (RR) 1.081, 95% CI 1.010 to 1.158) and the greatest risk on the 11th day (RR 1.094, 95% CI 1.037 to 1.153). No lagged effect was observed at high apparent temperature. In subgroup analysis, women and individuals aged 75 and above were at high risk. The interaction analysis indicates that there exist significant interactions between PM2.5 and high apparent temperature, as well as nitrogen dioxide (NO2) and low apparent temperature.

CONCLUSION

The occurrence of decreased apparent temperature levels was discovered to be linked with a heightened relative risk of hospitalisations for AMI. PM2.5 and NO2 have an effect modification on the association between apparent temperature and admission rate of AMI.

Hazardous drinking and alcohol use disorders

Alcohol is one of the most widely consumed psychoactive drugs globally. Hazardous drinking, defined by quantity and frequency of consumption, is associated with acute and chronic morbidity. Alcohol use disorders (AUDs) are psychiatric syndromes characterized by impaired control over drinking and other symptoms. Contemporary aetiological perspectives on AUDs apply a biopsychosocial framework that emphasizes the interplay of genetics, neurobiology, psychology, and an individual's social and societal context. There is strong evidence that AUDs are genetically influenced, but with a complex polygenic architecture. Likewise, there is robust evidence for environmental influences, such as adverse childhood exposures and maladaptive developmental trajectories. Well-established biological and psychological determinants of AUDs include neuroadaptive changes following persistent use, differences in brain structure and function, and motivational determinants including overvaluation of alcohol reinforcement, acute effects of environmental triggers and stress, elevations in multiple facets of impulsivity, and lack of alternative reinforcers. Social factors include bidirectional roles of social networks and sociocultural influences, such as public health control strategies and social determinants of health. An array of evidence-based approaches for reducing alcohol harms are available, including screening, pharmacotherapies, psychological interventions and policy strategies, but are substantially underused. Priorities for the field include translating advances in basic biobehavioural research into novel clinical applications and, in turn, promoting widespread implementation of evidence-based clinical approaches in practice and health-care systems.