Reduction in Nonabstinent WHO Drinking Risk Levels and Change in Risk for Liver Disease and Positive AUDIT-C Scores: Prospective 3-Year Follow-Up Results in the U.S. General Population

Reduced drug use as an alternative valid outcome in individuals with stimulant use disorders: Findings from 13 multisite randomized clinical trials

BACKGROUND AND AIMS

Total abstinence has historically been the goal of treatment for substance use disorders; however, there is a growing recognition of the health benefits associated with reduced use as a harm reduction measure in stimulant use disorders treatment. We aimed to assess the validity of reduced stimulant use as an outcome measure in randomized controlled trials (RCTs) of pharmacological interventions for stimulant use disorder.

DESIGN

We conducted a secondary analysis of a pooled dataset of 13 RCTs.

SETTING AND PARTICIPANTS

Participants were individuals seeking treatment for cocaine or methamphetamine use disorders (N = 2062) in a wide range of treatment facilities in the United States.

MEASUREMENTS

We validated reduced stimulant use against a set of clinical indicators drawn from harmonized measurements, including severity of problems caused by drug use, comorbid depression, global severity of substance use and improvement, severity of drug-seeking behavior, craving and high-risk behaviors, all assessed at the end of the trial, as well as follow-up urine toxicology. A series of mixed effect regression models was conducted to validate reduction in frequency of use against no reduction in use and abstinence.

FINDINGS

More participants reduced frequency of primary drug use than achieved abstinence (18.0% vs. 14.2%, respectively). Reduced use was significantly associated with decreases in craving for the primary drug [60.1%, 95% confidence interval (CI) = 54.3%-64.7%], drug seeking behaviors (41.0%, 95% CI = 36.6%-45.7%), depression severity (39.9%, 95% CI = 30.9%-48.3%), as well as multiple measures of global improvement in psychosocial functioning and severity of drug-related problems, albeit less strongly so than abstinence. Moreover, reduced use was associated with sustained clinical benefit at follow-up, as confirmed by negative urine tests (adjusted odds ratio compared with those with no reduction in use: 0.50, 95% CI = 0.35-0.71).

CONCLUSION

Reduced frequency of stimulant use appears to be associated with meaningful improvement in various clinical indicators of recovery. Assessment of reduced use, in addition to abstinence, could broaden the scope of outcomes measured in randomized controlled trials of stimulant use disorders and facilitate the development of more diverse treatment approaches.

Reductions in World Health Organization Risk Drinking Level Are Associated With Reductions in Alcohol Use Disorder Diagnosis and Criteria: Evidence From an Alcohol Pharmacotherapy Trial

OBJECTIVES

This study aimed to evaluate the validity of World Health Organization (WHO) risk drinking level reductions as meaningful endpoints for clinical practice and research. This study examined whether such reductions were associated with a lower likelihood of a current alcohol use disorder (AUD) diagnosis and fewer AUD criteria.

METHODS

We conducted a secondary data analysis to address these objectives using data from a multisite randomized controlled trial of gabapentin enacarbil extended release in treating moderate to severe AUD among adults (N = 346). Participants received gabapentin enacarbil extended release or placebo for 6 months. The timeline follow-back was used to assess WHO risk drinking level reductions, and the Mini-International Neuropsychiatric Interview was used to assess Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) AUD diagnosis and criteria at baseline (past year) and end of treatment (past month).

RESULTS

Most participants (80.1%) achieved at least a 1-level reduction in the WHO risk drinking levels from baseline to end of treatment, and nearly half of participants (49.8%) achieved at least a 2-level reduction. At least a 1-level reduction or at least a 2-level reduction in WHO risk drinking level predicted lower odds of an active AUD diagnosis (1-level: odds ratio, 0.74 [95% confidence interval (CI), 0.66-0.84]; 2-level: odds ratio, 0.71 [95% CI, 0.64-0.79]) and fewer AUD criteria (1-level: B, -1.66 [95% CI, -2.35 to -0.98]; 2-level: B, -1.76 [95% CI, -2.31 to -1.21]) at end of treatment.

CONCLUSIONS

World Health Organization risk drinking level reductions correlate with Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) AUD diagnosis and criteria, providing further evidence for their use as endpoints in alcohol intervention trials, which has potential implications for broadening the base of AUD treatment.

Designing and testing treatments for alcohol use disorder

This chapter provides a succinct overview of several recommendations for the design and analysis of treatments for AUD with a specific focus on increasing rigor and generalizability of treatment studies in order to increase the reach of AUD treatment. We recommend that researchers always register their trials in a clinical trial registry and make the protocol accessible so that the trial can be replicated in future work, follow CONSORT reporting guidelines when reporting the results of the trial, carefully describe all inclusion and exclusion criteria as well as the randomization scheme, and always use an intent to treat design with attention to analysis of missing data. In addition, we recommend that researchers pay closer attention to recruitment and engagement strategies that increase enrollment and retention of historically marginalized and understudied populations, and we end with a plea for more consideration of implementation science approaches to increase the dissemination and implementation of AUD treatment in real-world settings.

Reductions in WHO risk drinking levels correlate with alcohol craving among individuals with alcohol use disorder

BACKGROUND

Abstinence has historically been considered the preferred goal of alcohol use disorder (AUD) treatment. However, most individuals with AUD do not want to abstain and many are able to reduce their drinking successfully. Craving is often a target of pharmacological and behavioral interventions for AUD, and reductions in craving may signal recovery. Whether reductions in drinking during AUD treatment are associated with reductions in craving has not been well examined.

METHODS

We conducted secondary analyses of data from three AUD clinical trials (N's= 1327, 346, and 200). Drinking reductions from baseline to the end of treatment were measured as changes in World Health Organization (WHO) risk drinking levels; alcohol craving was measured using validated self-report measures. Regression analyses tested whether drinking reductions were associated with end-of-treatment craving reductions; moderation analyses tested whether associations between drinking reduction and end-of-treatment craving differed across AUD severity.

RESULTS

Reductions of at least 1 or at least 2 WHO risk drinking levels were associated with lower craving (all p's < 0.05). Results were substantively similar after removing abstainers at the end-of-treatment. Associations between drinking reductions and craving were generally not moderated by AUD severity.

CONCLUSIONS

Individuals with WHO risk drinking level reductions reported significantly lower craving, as compared to those who did not achieve meaningful reductions in drinking. The results demonstrate the utility of WHO risk drinking levels as AUD clinical trial endpoints and provide evidence that drinking reductions mitigate craving.

Medications for alcohol use disorder promote abstinence in alcohol-associated cirrhosis: Results from a systematic review and meta-analysis

BACKGROUND AND AIMS

The role of medications for alcohol use disorder (MAUD) in patients with cirrhosis is not well established. Evidence on the efficacy and safety of these drugs in these patients is scarce.

APPROACH AND RESULTS

We performed a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocol guidelines on the efficacy of MAUD in patients with cirrhosis. A search was conducted in PubMed, Embase, and Scopus, including all studies until May 2022. The population was defined as patients with AUD and cirrhosis. The primary outcome was alcohol abstinence. Safety was a secondary outcome. We performed a random-effect analysis and expressed the results as relative risk of alcohol consumption. Heterogeneity was measured by I2 . Out of 4095 unique references, 8 studies on 4 different AUD treatments [baclofen (n = 6), metadoxine (n = 1), acamprosate (n = 1), and fecal microbiota transplant (n = 1)] in a total of 794 patients were included. Four were cohort studies, and 4 were RCTs. Only RCTs were included in the meta-analysis. MAUD was associated with a reduced rate of alcohol consumption [relative risk = 0.68 (CI: 0.48-0.97), P = 0.03], increasing alcohol abstinence by 32% compared to placebo or standard treatment, despite high heterogeneity ( I2 = 67%). Regarding safety, out of 165 serious adverse events in patients treated with MAUD, only 5 (3%) were possibly or probably related to study medications.

CONCLUSION

MAUD in patients with cirrhosis is effective in promoting alcohol abstinence and has a good safety profile. Larger studies on the effects of MAUD are needed, especially in patients with advanced liver disease.

Regional cortical brain volumes at treatment entry relates to post treatment WHO risk drinking levels in those with alcohol use disorder

BACKGROUND

Abstinence following treatment for alcohol use disorder (AUD) is associated with significant improvements in psychiatric and physical health, however, recent studies suggest resumption of low risk levels of alcohol use can also be beneficial. The present study assessed whether post-treatment levels of alcohol use were associated with cortical brain volumedifferences at treatment entry.

METHODS

Individuals seeking treatment for AUD (n=75) and light/non-drinking controls (LN, n=51) underwent 1.5T magnetic resonance imaging. The volumes of 34 bilateral cortical regions of interest (ROIs) were quantitated via FreeSurfer. Individuals with AUD were classified according to post-treatment alcohol consumption using the WHO risk drinking levels (abstainers: AB; low risk: RL; or higher risk: RH). Regional volumes for AB, RL and RH, at treatment entry, were compared to LN.

RESULTS

Relative to LN, AB demonstrated smaller volumes in 18/68 (26%), RL in 24/68 (35%) and RH in 34/68 (50%) ROIs with the largest magnitude volume differences observed between RH and LN. RH and RL reported a higher frequency of depressive disorders than AB. Among RH and RL, level of depressive and anxiety symptomatology were associated with daily number of drinks consumed after treatment.

CONCLUSIONS

Volumetric differences, at treatment entry, in brain regions implicated in executive function and salience networks corresponded with post-treatment alcohol consumption levels suggesting that pre-existing differences in neural integrity may contribute to treatment outcomes. Depressive and anxiety symptomatology was also associated with brain morphometrics and alcohol use patterns, highlighting the importance of effectively targeting these conditions during AUD treatment.

Comorbid alcohol use disorder and posttraumatic stress disorder: A proof-of-concept randomized placebo-controlled trial of buprenorphine and naltrexone combination treatment

BACKGROUND

Effective pharmacologic treatments for comorbid alcohol use disorder (AUD) and posttraumatic stress disorder (PTSD) are lacking. Kappa (κ) opioid receptor antagonists may address this unmet need. Buprenorphine is a κ-opioid antagonist and a partial agonist of mu (μ) opioid receptors. Whereas naltrexone blocks all μ-mediated effects combining it with buprenorphine yields a pharmacologic net effect of opioid receptor antagonism. Because no κ-opioid receptor antagonist it available for clinical use, we tested this combination in a proof-of-concept study.

METHODS

Consenting participants were enrolled in a Phase II, multisite, double-blind, randomized, placebo-controlled trial evaluating the effectiveness of sublingual (SL) buprenorphine combined with extended-release (XR) injectable naltrexone for the treatment of comorbid AUD and PTSD. Eligible participants (n = 75) were randomized (1:1:1) to receive either buprenorphine 2 mg/day plus naltrexone-XR (n = 35), buprenorphine 8 mg/day plus naltrexone-XR (n = 6) or SL plus injectable placebo (n = 34) for 12 weeks. The buprenorphine 8 mg/day plus naltrexone-XR arm was dropped early in the trial due to the negative impact of COVID-19 on enrollment. A binary primary outcome of response at week 8 was defined as a decrease from baseline of ≥10 points on the past week Clinician-Administered PTSD Scale (CAPS-5) and a reduction of ≥1 of past month alcohol risk level, as defined by the World Health Organization (WHO) and measured by the Timeline Follow-Back.

RESULTS

Based on the results of a futility analysis, enrollment was stopped prior to reaching the initial goal of 90 participants. At the week eight primary timepoint, there were no statistically significant differences between buprenorphine plus naltrexone-XR and placebo group for the primary composite outcome (OR = 0.63; p-value = 0.52), or the subcomponents of the PTSD outcome (OR = 0.76; p-value = 0.69) and AUD outcome (OR = 0.17; p-value = 0.08). The placebo arm had a significantly higher proportion of participants with ≥1 WHO risk level reduction than the buprenorphine plus naltrexone-XR arm (OR = 0.18, p value = 0.02).

CONCLUSIONS

This is the first study to evaluate the potential of κ-opioid receptor antagonism for the treatment of comorbid AUD and PTSD. The combination of buprenorphine and naltrexone-XR showed no significant improvement over placebo for the composite, PTSD, or alcohol measures.

Alcohol use disorder in community management of chronic liver diseases

Rising rates of alcohol use disorder (AUD) combined with increases in alcohol-related liver disease (ALD) and other liver disease have resulted in the need to develop alcohol management strategies at all levels of patient care. For those with pre-existing liver disease, whether ALD or others, attention to alcohol use treatment and abstinence becomes critical to avoiding worsening liver-related consequences. Modalities to help patients reduce or stop alcohol include screening/brief intervention/referral to treatment, various therapeutic modalities including cognitive behavioral therapy, motivational enhancement therapy and 12-step facilitation, and alcohol relapse prevention medications. Harm reduction approaches versus total abstinence may be considered, but for those with existing ALD, particularly advanced ALD (cirrhosis or acute alcoholic hepatitis), total abstinence from alcohol is the recommendation, given clear data that ongoing alcohol use worsens mortality and liver-related morbidity. For certain populations, alcohol cessation is even more critically important. For those with hepatitis C or NAFLD, alcohol use accelerates negative liver-related outcomes. In women, alcohol use accelerates liver damage and results in worsened liver-related mortality. Efforts to integrate AUD and liver disease care are urgently needed and can occur at several levels, with establishment of multidisciplinary ALD clinics for fully integrated co-management as an important goal.

Combination treatment with varenicline and naltrexone reduces World Health Organization risk drinking levels

BACKGROUND

The U.S. Food and Drug Administration identifies abstinence and the absence of heavy drinking days as outcomes for pharmacotherapy trials for alcohol use disorder (AUD). However, many individuals with AUD struggle to achieve these outcomes, which may discourage them from seeking treatment. World Health Organization (WHO) risk drinking levels have garnered attention in the alcohol field as potential non-abstinent outcomes for AUD medication trials. Further, testing combination pharmacotherapy for AUD represents an important direction in the field, particularly using medications such as naltrexone and varenicline, which are approved for treating AUD and smoking, respectively. The objective of the current study was to test the utility of the WHO risk drinking levels as a drinking outcome in a randomized clinical trial of combined varenicline and naltrexone for smoking cessation and drinking reduction. These analyses provide additional tests of the efficacy of this combination treatment.

METHODS

The current study is a secondary analysis of a phase 2, randomized, double-blind clinical trial, wherein participants (N = 165) who were daily smokers and heavy drinkers were randomly assigned to receive either 2 mg/day of varenicline plus 50 mg/day of naltrexone or 2 mg/day of varenicline plus placebo for 12 weeks. Medication effects on 1- and 2-level reductions in WHO risk drinking levels were assessed at 4, 8, and 12 weeks into the active medication period.

RESULTS

In logistic growth curve models individuals receiving the combined treatment had greater reductions in WHO risk drinking levels than individuals taking varenicline alone when assessed at 4 weeks into the active medication period. Among individuals who were WHO high and very high risk drinkers at baseline, the largest effect sizes favoring combination treatment were at Week 4 for the WHO 2-level reduction outcome (Cohen's h = 0.202) and Week 12 for the WHO 1-level reduction outcome (Cohen's h = 0.244), although these effects did not reach statistical significance.

CONCLUSIONS

These findings provide evidence that combined varenicline plus naltrexone treatment is effective at reducing WHO risk drinking levels, particularly among individuals who smoke cigarettes daily and drink heavily. These results add to a growing body of literature validating reductions in WHO risk drinking levels as outcomes of alcohol medication trials.

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.

HealthCall: A randomized trial assessing a smartphone enhancement of brief interventions to reduce heavy drinking in HIV care

INTRODUCTION

Heavy drinking among people living with HIV (PLWH) worsens their health outcomes and disrupts their HIV care. Although brief interventions to reduce heavy drinking in primary care are effective, more extensive intervention may be needed in PLWH with moderate-to-severe alcohol use disorder. Lengthy interventions are not feasible in most HIV primary care settings, and patients seldom follow referrals to outside treatment. Utilizing visual and video features of smartphone technology, we developed the "HealthCall" app to provide continued engagement after brief intervention, reduce drinking, and improve other aspects of HIV care with minimal demands on providers. We conducted a randomized trial of its efficacy.

METHODS

The study recruited alcohol-dependent PLWH (n = 114) from a large urban HIV clinic. Using a 1:1:1 randomized design, the study assigned patients to: Motivational Interviewing (MI) plus HealthCall (n = 39); NIAAA Clinician's Guide (CG) plus HealthCall (n = 38); or CG-only (n = 37). Baseline MI and CG interventions took ~25 min, with brief (10-15 min) 30- and 60-day booster sessions. HealthCall involved daily use of the smartphone app (3-5 min/day) to report drinking and health in the prior 24 h. Outcomes assessed at 30 and 60 days and at 3, 6 and 12 months included drinks per drinking day (DpDD; primary outcome) and number of drinking days, analyzed with generalized linear mixed models and pre-planned contrasts.

RESULTS

Study retention was excellent (85%-94% across timepoints). At 30 days, DpDD among patients in MI + HealthCall, CG + HealthCall, and CG-only was 3.80, 5.28, and 5.67, respectively; patients in MI + HealthCall drank less than CG-only and CG + HealthCall (IRRs = 0.62, 95% CI = 0.46, 0.84, and 0.64, 95% CI = 0.48, 0.87, respectively). At 6 months (end-of-treatment), DpDD was lower in CG + HealthCall (DpDD = 4.88) than MI + HealthCall (DpDD = 5.88) or CG-only (DpDD = 6.91), although these differences were not significant. At 12 months, DpDD was 5.73, 5.31, and 6.79 in MI + HealthCall, CG + HealthCall, and CG-only, respectively; DpDD was significantly lower in CG + HealthCall than CG-only (IRR = 0.71, 95% CI = 0.51, 0.98).

CONCLUSIONS

During treatment, patients in MI + HealthCall had lower DpDD than patients in other conditions; however, at 12 months, drinking was lowest among patients in CG + HealthCall. Given the importance of drinking reduction and the low costs/time required for HealthCall, pairing HealthCall with brief interventions merits widespread consideration.

Inpatient Gastroenterology Consultation and Outcomes of Cirrhosis-Related Hospitalizations in Two Large National Cohorts

BACKGROUND

Little is known about use of specialty care among patients admitted with cirrhosis complications.

AIMS

We sought to characterize the use and impact of gastroenterology/hepatology (GI/HEP) consultations in hospitalized patients with cirrhosis. We studied two national cohorts-the Veterans Affairs Costs and Outcomes in Liver Disease (VOCAL) and a nationally representative database of commercially insured patients (Optum Clinformatics™ DataMart).

METHODS

Cirrhosis-related admissions were classified by ICD9/10 codes for ascites, hepatic encephalopathy, alcohol-associated hepatitis, spontaneous bacterial peritonitis, or infection related. We included 20,287/222,166 index admissions from VOCAL/Optum from 2010 to 2016. Propensity-matched analyses were conducted to balance clinical characteristics. Mortality and readmission were evaluated using competing risk regression (subhazard ratios, sHR), and length of stay (LOS) was assessed using negative binomial regression.

RESULTS

GI/HEP consultations were completed among 37% and 42% patients in VOCAL and Optum, respectively. In propensity-matched analyses for VOCAL, GI/HEP consultation was associated with adjusted estimates of increased LOS (1.55 + 1.03 additional days), 90-day mortality (sHR 1.23, 95% CI 1.14-1.36), and lower 30-day readmissions (sHR 0.82, 95% CI 0.75-0.89). In Optum, inpatient consultation was associated with higher LOS (1.13 + 1.01 additional days), higher 90-day mortality (sHR 1.57, 95% CI 1.43-1.72), and higher 30-day readmission risk (sHR 1.04, 95% CI 1.02-1.05). Post-discharge primary and specialty care was higher among admissions receiving GI/HEP consultation in both cohorts.

CONCLUSIONS

Use of GI/HEP consultation for cirrhosis-related admissions was low. Patients who received consultation had higher disease severity, and consultation was not associated with lower mortality but was associated with lower 30-day readmissions in the VA cohort only.

Predictors of early and sustained cessation of heavy drinking over 5 years among adult primary care patients

AIMS

To identify factors asociated with early and sustained cessation of heavy drinking.

DESIGN

Retrospective cohort study over 5 years.

SETTING

Kaiser Permanente Northern California, United States.

PARTICIPANTS

Adults reporting heavy drinking during primary care-based alcohol screening between 1 June 2013 and 31 May 2014. The sample (n = 85 434) was 40.7% female and 33.8% non-white; mean age was 50.3 years (standard deviation = 18.1).

MEASUREMENTS

Following US guidelines, early and sustained cessation of heavy drinking was defined as reporting lower-risk drinking or abstinence at 1 year and to 5 years after achieving early cessation, respectively. Associations between patient characteristics and service use and cessation outcomes were examined using logistic regression with inverse probability weights addressing attrition.

FINDINGS

Nearly two-thirds of participants achieved early cessation of heavy drinking. Women [odds ratio (OR) = 1.39, 95% confidence interval (CI) = 1.35, 1.44], middle-age (35-64 years: ORs = 1.16-1.19), non-white race/ethnicity (ORs = 1.03-1.57), medical conditions (OR = 1.05, 95% CI = 1.04, 1.06), psychiatric (OR = 1.10, 95% CI = 1.06, 1.15) and drug use disorders (OR = 1.35, 95% CI = 1.17, 1.56) and addiction treatment (OR = 1.19, 95% CI = 1.09, 1.30) were associated with higher odds of early cessation, while older age (≥ 65 years: OR = 0.91, 95% CI = 0.86, 0.96), smoking (OR = 0.81, 95% CI = 0.77, 0.84), higher index drinking levels (exceeding both daily and weekly limits: OR = 0.30, 95% CI = 0.29, 0.32) and psychiatric treatment (OR = 0.91, 95% CI = 0.84, 0.99) were associated with lower odds. Among those who achieved early cessation (n = 19 200), 60.0% sustained cessation. Associations between patient factors and sustained cessation paralleled those observed in analyses of early cessation. Additionally, routine primary care (OR = 1.57, 95% CI = 1.44, 1.71) and addiction treatment post-1 year (OR = 1.41, 95% CI = 1.19, 1.66) were associated with higher odds of sustained cessation. Lower-risk drinking versus abstinence at 1 year was associated with lower odds of sustained cessation (OR = 0.62, 95% CI = 0.57, 0.66).

CONCLUSIONS

Nearly two-thirds of a large, diverse sample of patients who reported heavy drinking in a Californian health-care system achieved early and sustained cessation of heavy drinking. Vulnerable subgroups (i.e. non-white patients and those with psychiatric disorders), patients who received routine primary care and those who received addiction treatment were more likely to sustain cessation of heavy drinking than other participants.

Rethinking Unhealthy Alcohol Use in the United States: A Structured Review

Greater than moderate alcohol use spans a continuum that includes high levels of total alcohol consumed per period (heavy drinking) as well as episodes of intense drinking (binges) and can give rise to alcohol use disorder (AUD) when associated with an inability to control alcohol use despite negative consequences. Although moderate drinking and AUD have standard, operable definitions in the United States (US), a significant “gray area” remains in which an individual may exceed recommended drinking guidelines but does not meet the criteria for AUD (hereafter referred to as unhealthy alcohol use). To address this need, we conducted a structured literature search to evaluate how this gray area is defined and assess its burden within the US. For purposes of this review, we will refer to this gray area as “unhealthy alcohol use.” Although numerous terms are used to describe various unsafe drinking practices, our review did not find any studies in which the specific prevalence and/or burden of unhealthy alcohol use was evaluated. That is, we found no studies that focus exclusively on individuals who exceed moderate drinking guidelines but do not meet AUD criteria. Furthermore, we did not discover an established framework for identifying individuals with unhealthy alcohol use. The lack of a consistent framework for identifying unhealthy alcohol users has significant implications for patient management and disease burden assessment. Therefore, we propose the following framework in which unhealthy alcohol use comprises 2 distinct subpopulations: those at risk of experiencing alcohol-related consequences and those who have subthreshold problems associated with use. The former, termed “risky drinkers,” are defined by exceeding recommended guidelines for moderate drinking (⩽1 or 2 drinks per day for women and men, respectively). People with subthreshold problems associated with use, defined as exhibiting exactly 1 AUD symptom, would be classified as “problematic drinkers” within this proposed framework. These definitions would help bring the core elements of unhealthy alcohol use into focus, which in turn would help identify and provide management strategies sooner to those affected and reduce the overall burden of unhealthy alcohol use.

Mental health and economic stressors associated with high-risk drinking and increased alcohol consumption early in the COVID-19 pandemic in the United States

Physical distancing measures to curb COVID-19 transmission introduced mental health and economic stressors, possibly impacting problematic drinking. This cross-sectional study examines mental health and economic stressors early in the COVID-19 pandemic which may be associated with heavy alcohol use and increased alcohol use. We administered an online survey of U.S. adults via social media April 5 to May 5, 2020. High-risk drinking was defined by WHO risk drinking levels, a daily average of ≥4 drinks for men and ≥3 drinks for women. Participants reported retrospective assessments of increased alcohol use if their past-week alcohol consumption exceeded their past-year average weekly alcohol consumption. We used logistic regression to assess possible covariates of high-risk drinking and increased alcohol use. Among 2175 participants, 10% (n = 222) reported high-risk drinking, and 36% (n = 775) reported increased alcohol consumption. In multivariable analysis, high-risk drinking was significantly associated with household job loss (OR = 1.41, 95%CI = (1.06, 1.88)) and depressive symptoms (OR = 1.05, 95% CI = (1.02, 1.07)), and women had higher odds of high-risk drinking than men (OR = 2.37, 95% CI = (1.32, 4.69)). Previous mental health diagnosis was not significantly associated with high-risk drinking during the pandemic (OR = 1.31, 95% CI = (0.98, 1.76)) in univariable analysis. High-risk drinkers were almost six times as likely to report retrospective assessments of increased alcohol consumption, controlling for mental health and economic stressors (OR = 5.97, 95% CI = (4.35, 8.32)). Findings suggest a need for targeted interventions to address the complex mental health and economic stressors that may increase alcohol consumption and high-risk drinking during and after the pandemic.

The relationship of frequency of cocaine use to substance and psychiatric disorders in the U.S. general population

BACKGROUND

In clinical trials of pharmacotherapy for substance use, abstinence is the primary endpoint accepted by regulatory agencies. However, this endpoint could be overly restrictive, impeding efforts to identify effective medications for cocaine use disorder. To examine non-abstinent gradations in cocaine use as potential indicators of improvement, we investigated the relationship of frequency of cocaine use to clinical correlates in national survey data.

METHODS

Lifetime cocaine users (n = 2501) were interviewed in the National Epidemiological Survey on Alcohol and Related Conditions (NESARC) in 2001-2002 and re-interviewed in 2004-2005. Adjusted odds ratios (aORs) indicated associations between heaviest frequency of cocaine use and use of other substances, DSM-IV substance use disorders, psychiatric disorders, and change between 2001-2002 and 2004-2005. The reference category for all aORs was non-users.

RESULTS

Greater lifetime cocaine use frequency was associated with lifetime cocaine, alcohol, and cannabis dependence (aOR for a linear trend = 2.80, 1.22, 1.22, respectively) and past-year cocaine, alcohol, and cannabis dependence (aOR = 1.78, 1.13, 1.16, respectively). Greater lifetime cocaine use frequency was associated with past-year depressive, panic, and generalized anxiety disorders (aOR = 1.07, 1.09, 1.12, respectively). Among cocaine users in 2001-2002, compared to the reference group using less than monthly, use ≥1x/week and use 1-3 times a month was associated with cocaine use disorder in 2004-2005 (aOR = 2.13 and aOR = 1.67, respectively).

CONCLUSION

Gradations in risk for dependence on cocaine, other substances and psychiatric disorders by frequency of cocaine use indicates a promising direction for more sensitive outcome measures of treatment effects on cocaine outcomes than binary indicators (e.g., any use vs. none). Study results add to findings suggesting that non-abstinent measures might be useful indicators of treatment efficacy in clinical trials.

Trauma and Alcohol Use Among Transgender and Gender Diverse Women: An Examination of the Stress-Buffering Hypothesis of Social Support

Transgender and gender diverse (TGD) women (i.e., individuals who were assigned male at birth and identify as women or trans women) experience trauma at disproportionate rates compared to cisgender populations. While trauma is associated with increased alcohol use among TGD women, research regarding factors that are protective of this association is scant. The stress-buffering hypothesis of social support suggests that perceived social support, defined as the judgment that social network members will be helpful when individuals experience stress, may buffer and reduce the association between trauma symptoms and alcohol use. However, this relationship has not been examined among TGD women. We examined whether perceived social support moderates the association between trauma and alcohol use among 89 TGD women. Exploratory multiple regression analyses provided support for this hypothesis, insofar as trauma symptoms were related to alcohol use by individuals with low, relative to high levels of perceived social support. Exploratory analyses demonstrated that this finding was driven by perceived social support from friends and family. Our results are the first to suggest that social support reduces alcohol use among TGD women and add to the literature on their trauma and alcohol use.

Patterns of reduced use and abstinence in multi-site randomized controlled trials of pharmacotherapies for cocaine and methamphetamine use disorders

BACKGROUND

Many individuals with cocaine or methamphetamine use disorders who enter treatment do not achieve abstinence but reduce their use of the target drug. We aimed to compare change in pattern of drug use (i.e., achieving "abstinence", "reduced use" or no reduction in use) among participants in randomized controlled trials (RCTs) of treatment of cocaine and methamphetamine use disorder, irrespective of the type of treatment.

METHODS

The data were drawn from 10 multi-site pharmacotherapy RCTs of cocaine (n = 1,134) and methamphetamine (n = 555) use disorders. The outcome patterns and their sociodemographic and clinical correlates were compared in cocaine and methamphetamine RCTs, using multinomial logistic regression models. Analyses were adjusted for missing data, clustering within RCTs, socio-demographic and baseline clinical characteristics, and treatment arms.

RESULTS

Those in cocaine RCTs were more likely to experience reduced use compared to participants in methamphetamine RCTs (20.6% vs. 13.2%, respectively), but less likely to experience "abstinence" (7.6% vs. 20.3%; Chi-squared = 14.20, df = 2, P < 0.001). Differences in "abstinence" persisted after adjustment for baseline covariates. Association of sociodemographic and clinical correlates with outcomes differed in cocaine and methamphetamine RCTs.

CONCLUSION

A sizeable proportion of individuals in RCTs of pharmacological treatment for stimulant use disorder who do not attain "abstinence" nevertheless reduce their use. The outcome patterns of drug use are different for cocaine and methamphetamine use disorders and reliance on abstinence as the sole outcome may obscure these differences.

World Health Organization risk drinking levels as a treatment outcome measure in topiramate trials

BACKGROUND

Although abstinence has traditionally been considered the only suitable outcome for alcohol treatment, reduced drinking is also associated with improved functioning and medical and psychiatric outcomes. The World Health Organization (WHO) risk drinking levels (RDLs) have been shown to be valid outcome measures in treatment trials for alcohol use disorder (AUD).

METHODS

We conducted a secondary analysis of two 12-week, randomized controlled trials (RCTs), in which a total of 308 individuals with problematic alcohol use received topiramate or placebo treatment. We compared the utility of the WHO RDLs with other treatment outcomes, including self-reported measures of alcohol consumption, alcohol-related problems, and quality of life, and the biomarker gamma-glutamyltransferase.

RESULTS

Topiramate treatment was associated with small effect sizes for both a 1-level (d = 0.26) and a 2-level (d = 0.19) reduction in WHO RDL, effects that were not significant after correction for multiple comparisons. No heavy drinking days, one of the outcome measures recommended by the US Food and Drug Administration for alcohol medication registration trials, also exhibited a small effect (0.21), while an effect size for abstinence could not be calculated. There were medium effects of topiramate on continuous measures of percent heavy drinking days (d = 0.49) and alcohol-related problems (d = 0.41).

CONCLUSIONS

Topiramate is an efficacious pharmacotherapy for AUD. Although continuous measures of drinking and alcohol-related problems yielded larger effect sizes than the WHO RDLs, the latter nonetheless provide a categorical alternative for use in both clinical care and pharmacotherapy trials.

The World Health Organization Risk Drinking Levels Measure of Alcohol Consumption: Prevalence and Health Correlates in Nationally Representative Surveys of U.S. Adults, 2001-2002 and 2012-2013

OBJECTIVE

Little is known about change over time in the prevalence of World Health Organization (WHO) risk drinking levels (very high, high, moderate, low) and their association with health conditions, overall and by gender. The authors used two sets of nationally representative U.S. survey data to determine whether changes over time varied by gender and to examine whether health conditions related to alcohol were associated with WHO risk drinking level within each survey, and whether these associations differed by gender.

METHODS

Data on current drinkers from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC; N=26,655) and the 2012-2013 NESARC-III (N=25,659) were analyzed using logistic regression. Prevalence differences between surveys were estimated for each drinking level overall and by gender. Within each survey, prevalence differences by WHO risk drinking level were estimated for alcohol use disorder (AUD), drug use disorders, functional impairment, liver disease, and depressive and anxiety disorders.

RESULTS

In the 2012-2013 survey, the prevalences of moderate, high, and very high risk drinking were 5.9%, 3.2%, and 3.5%, respectively, representing significant increases from the prevalences in the 2001-2002 survey, which were 1.0%, 0.6%, and 0.9%, respectively. The increase for very high risk drinking among men (0.5%) was smaller than the increase among women (1.4%). Within both surveys, compared with low risk, health conditions were significantly associated with very high risk (range of prevalence differences, 2.2%-57.8%), high risk (2.6%-41.3%), and moderate risk (0.6%-29.8%) drinking. Associations were similar by gender, except that there were stronger effects for AUD in men and for functional impairment and depressive and anxiety disorders in women.

CONCLUSIONS

The increase in potentially problematic drinking levels among U.S. adults emphasizes the need for better prevention and treatment strategies. The study results support the validity of the WHO risk drinking levels, which show clinical utility as nonabstinent drinking reduction treatment goals. Such goals could engage more people in treatment, improving public health by decreasing personal and societal consequences of risk drinking.

The future of translational research on alcohol use disorder

In March 2019, a scientific meeting was held at the University of California, Los Angeles (UCLA) Luskin Center to discuss approaches to expedite the translation of neurobiological insights to advances in the treatment of alcohol use disorder (AUD). A guiding theme that emerged was that while translational research in AUD is clearly a challenge, it is also a field ripe with opportunities. Herein, we seek to summarize and disseminate the recommendations for the future of translational AUD research using four sections. First, we briefly review the current landscape of AUD treatment including the available evidence-based treatments and their uptake in clinical settings. Second, we discuss AUD treatment development efforts from a translational science viewpoint. We review current hurdles to treatment development as well as opportunities for mechanism-informed treatment. Third, we consider models of translational science and public health impact. Together, these critical insights serve as the bases for a series of recommendations and future directions. Towards the goal of improving clinical care and population health for AUD, scientists are tasked with bolstering the clinical applicability of their research findings so as to expedite the translation of knowledge into patient care.

Stability of Drinking Reductions and Long-term Functioning Among Patients with Alcohol Use Disorder

BACKGROUND

The World Health Organization (WHO) categorizes alcohol consumption according to grams consumed into low-, medium-, high-, and very-high-risk drinking levels (RDLs). Although abstinence has been considered the ideal outcome of alcohol treatment, reductions in WHO RDLs have been proposed as primary outcomes for alcohol use disorder (AUD) trials.

OBJECTIVE

The current study examines the stability of WHO RDL reductions and the association between RDL reductions and long-term functioning for up to 3 years following treatment.

DESIGN AND PARTICIPANTS

Secondary data analysis of patients with AUD enrolled in the COMBINE Study and Project MATCH, two multi-site, randomized AUD clinical trials, who were followed for up to 3 years post-treatment (COMBINE: n = 694; MATCH: n = 806).

MEASURES

Alcohol use was measured via calendar-based methods. We estimated all models in the total sample and among participants who did not achieve abstinence during treatment.

KEY RESULTS

One-level RDL reductions were achieved by 84% of patients at the end of treatment, with 84.9% of those individuals maintaining that reduction at a 3-year follow-up. Two-level RDL reductions were achieved by 68% of patients at the end of treatment, with 77.7% of those individuals maintaining that reduction at a 3-year follow-up. One- and two-level RDL reductions at the end of treatment were associated with significantly better mental health, quality of life (including physical quality of life), and fewer drinking consequences 3 years after treatment (p < 0.05), as compared to no change or increased drinking.

CONCLUSION

AUD patients can maintain WHO RDL reductions for up to 3 years after treatment. Patients who had WHO RDL reductions functioned significantly better than those who did not reduce their drinking. These findings are consistent with prior reports suggesting that drinking reductions, short of abstinence, yield meaningful improvements in patient health, well-being, and functioning.

[Pharmacotherapy of alcohol withdrawal: update and new developments]

Bislang sind nur wenige Medikamente zur pharmakologischen Rückfallprophylaxe der Alkoholabhängigkeit zugelassen. Neben dem in Deutschland nicht mehr vertriebenen Disulfiram sind es die Opioidantagonisten Naltrexon und Nalmefen sowie das vermutlich über glutamaterge Neurone wirkende Acamprosat. Baclofen und γ‑Hydroxybutyrat (GHB) sind in einzelnen Ländern zugelassen. Wirkstoffe wie z. B. Vareniclin, Gabapentin und Topiramat können für die Rückfallprophylaxe der Alkoholabhängigkeit von Interesse sein, jedoch ist bislang keine Zulassung erfolgt. Vor dem Hintergrund der zur Revision anstehenden S3-Leitlinie zur Diagnose und Behandlung alkoholbezogener Störungen wird der heutige Kenntnisstand zur Pharmakotherapie der Alkoholabhängigkeit dargestellt.

Are non-abstinent reductions in World Health Organization drinking risk level a valid treatment target for alcohol use disorders in adolescents with ADHD?

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Changes in WHO alcohol risk level are highly variable in youth treated for ADHD/SUD.

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Achieving > 2-level reduction in WHO risk is linked to improvements in functioning.

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Achieving > 2-level reduction in WHO risk is linked to decreased ADHD symptoms.

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> 2-level reduction in WHO risk may be a valid non-abstinent AUD outcome in youth with ADHD/SUD.

Introduction

Abstinence from drinking represents the primary treatment target for alcohol use disorders (AUD) in youth, but few adolescents who engage in problematic drinking seek treatment. A reduction in World Health Organization (WHO) drinking risk level has been established as valid and reliable non-abstinent treatment target for AUD in adults but remains unstudied in youth.

Methods

The present study used data from the NIDA-CTN-0028 trial to examine associations between reductions in WHO drinking risk level and changes in global functioning and attention-deficit hyperactivity disorder (ADHD) symptoms during treatment in a sample of adolescents (ages 13–18 years) with ADHD and comorbid substance use disorder (SUD) (n = 297, 61% with AUD) receiving a 16-week intervention that combined ADHD pharmacotherapy (OROS-methylphenidate vs. placebo) and drug-focused cognitive-behavioral therapy.

Results

Shifts in drinking risk level during treatment were highly variable in adolescents treated for ADHD/SUD, and influenced by AUD diagnostic status. In the total sample, 15% of participants had a 2-level or greater reduction in WHO drinking risk level, with 59% and 24% showing no change or an increase in risk-level during treatment respectively. Achieving at least a 2-level change in WHO drinking risk level during treatment was associated with greater reduction in ADHD symptoms and better functional outcomes.

Conclusions

These findings parallel the adult AUD literature and provide preliminary support for the use 2-level reductions in WHO risk levels for alcohol use as a clinically valid non-abstinent treatment outcome for youth with ADHD and comorbid AUD.

Evidence based models of care for the treatment of alcohol use disorder in primary health care settings: a systematic review

Background

Pharmacological and behavioural treatments for alcohol use disorders (AUDs) are effective but the uptake is limited. Primary care could be a key setting for identification and continuous care for AUD due to accessibility, low cost and acceptability to patients.

We aimed to synthesise the literature regarding differential models of care for the management of AUD in primary health care settings.

Methods

We conducted a systematic review of articles published worldwide (1998-present) using the following databases; Medline, PsycINFO, Cochrane database of systematic reviews, Cochrane Central Register of Controlled Trials and Embase. The Grey Matters Tool guided the grey literature search. We selected randomised controlled trials evaluating the effectiveness of a primary care model in the management of AUD. Two researchers independently assessed and then reached agreement on the included studies. We used the Cochrane risk of bias tool 2.0 for the critical appraisal.

Results

Eleven studies (4186 participants) were included. We categorised the studies into ‘lower’ versus ‘higher’ intensity given the varying intensity of clinical care evaluated across the studies. Significant differences in treatment uptake were reported by most studies. The uptake of AUD medication was reported in 5 out of 6 studies that offered AUD medication. Three studies reported a significantly higher uptake of AUD medication in the intervention group. A significant reduction in alcohol use was reported in two out of the five studies with lower intensity of care, and three out of six studies with higher intensity of care.

Conclusion

Our results suggest that models of care in primary care settings can increase treatment uptake (e.g. psychosocial and/or pharmacotherapy) although results for alcohol-related outcomes were mixed. More research is required to determine which specific patient groups are suitable for AUD treatment in primary health care settings and to identify which models and components are most effective.

Trial Registration

PROSPERO: CRD42019120293.

Mifepristone Decreases Chronic Voluntary Ethanol Consumption in Rhesus Macaques

The efficacy of short-term treatment with mifepristone (MIFE), a high-affinity, nonselective glucocorticoid receptor antagonist, to reduce ethanol drinking was tested in a rhesus macaque model. Stable individual daily ethanol intakes were established, ranging from 1.6 to 4.0 g/kg per day (n = 9 monkeys). After establishment of chronic ethanol intake, a MIFE dosing regimen that modeled a study of rodent drinking and human alcohol craving was evaluated. Three doses of MIFE (17, 30, and 56 mg/kg per day) were each administered for four consecutive days. Both 30 and 56 mg/kg decreased ethanol intake compared with baseline drinking levels without a change in water intake. The dose of 56 mg/kg per day of MIFE produced the largest reduction in ethanol self-administration, with the average intake at 57% of baseline intakes. Cortisol was elevated during MIFE dosing, and a mediation analysis revealed that the effect on ethanol drinking was fully mediated through cortisol. During a forced abstinence phase, access to 1.5 g/kg ethanol resulted in relapse in all drinkers and was not altered by treatment with 56 mg/kg MIFE. Overall, these results show that during active drinking MIFE is efficacious in reducing heavy alcohol intake in a monkey model, an effect that was related to MIFE-induced increase in cortisol. However, MIFE treatment did not eliminate ethanol drinking. Further, cessation of MIFE treatment resulted in a rapid return to baseline intakes, and MIFE was not effective in preventing a relapse during early abstinence. SIGNIFICANCE STATEMENT: Mifepristone reliably decreases average daily ethanol self-administration in a nonhuman primate model. This effect was mediated by cortisol, was most effective during open-access conditions, and did not prevent or reduce relapse drinking.

World Health Organization risk drinking level reductions are associated with improved functioning and are sustained among patients with mild, moderate and severe alcohol dependence in clinical trials in the United States and United Kingdom

AIMS

To examine whether World Health Organization (WHO) risk-level reductions in drinking were achievable, associated with improved functioning and maintained over time among patients at varying initial alcohol dependence severity levels. Design and setting Secondary data analysis of multi-site randomized clinical trials: the US Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (COMBINE) study and the UK Alcohol Treatment Trial (UKATT).

PARTICIPANTS

Individuals with alcohol dependence enrolled in COMBINE (n = 1383; 68.8% male) and seeking treatment for alcohol problems in UKATT (n = 742; 74.1% male). Interventions Naltrexone, acamprosate or placebo, and combined behavioral intervention or medication management in COMBINE. Social behavior network therapy or motivational enhancement therapy in UKATT.

MEASUREMENTS

WHO risk-level reductions were assessed via the calendar method. Alcohol dependence was measured by the Alcohol Dependence Scale, the Leeds Dependence Questionnaire and the Diagnostic and Statistical Manual of Mental Disorders. Measures of functioning included alcohol-related consequences (Drinker Inventory of Consequences and Alcohol Problems Questionnaire), mental health (Short Form Health Survey) and liver enzyme tests.

FINDINGS

One- and two-level reductions in WHO risk levels in the last month of treatment were maintained at the 1-year follow-up [adjusted odds ratio (OR), 95% confidence interval (CI) = one-level reduction in COMBINE: 3.51 (2.73, 4.29) and UKATT: 2.65 (2.32, 2.98)] and associated with fewer alcohol-related consequences [e.g. B, 95% CI = one-level reduction COMBINE: -26.22 (-30.62, -21.82)], better mental health [e.g. B, 95% CI = one-level reduction UKATT: 9.53 (7.36, 11.73)] and improvements in γ-glutamyltransferase [e.g. B, 95% CI = one-level reduction UKATT: -89.77 (-122.50, -57.04)] at the end of treatment, even among patients with severe alcohol dependence. Results were similar when abstainers were excluded. Conclusions Reductions in World Health Organization risk levels for alcohol consumption appear to be achievable, associated with better functioning and maintained over time in both the United States and the United Kingdom.

Reduction in World Health Organization Risk Drinking Levels and Cardiovascular Disease

BACKGROUND

Reductions in World Health Organization (WHO) risk drinking levels have recently been shown to lower the risk of multiple adverse health outcomes, but prior work has not examined reductions in WHO risk drinking levels in relation to cardiovascular disease (CVD), the leading cause of death for men and women in the United States and of global mortality. This study examined associations between reductions in WHO risk drinking levels and subsequent risk for CVD.

METHODS

In a US national survey, 1,058 very-high-risk and high-risk drinkers participated in Wave 1 interviews (2001 to 2002) and Wave 2 follow-ups (2004 to 2005). Self-reported CVD history that was communicated to the participant by a doctor or other healthcare professionals included arteriosclerosis, hypertension, angina, tachycardia, or myocardial infarction. We used logistic regression to estimate adjusted odds ratios (aOR) evaluating relationships between ≥2-level reductions in WHO risk drinking levels from Wave 1 to Wave 2 and the risk of Wave 2 CVD, controlling for baseline characteristics.

RESULTS

Reductions of ≥2 WHO risk drinking levels were associated with significantly lower odds of CVD in individuals who at Wave 1 were very-high-risk (aOR = 0.58 [0.41 to 0.80]) or high-risk drinkers (aOR = 0.81 [0.70 to 0.94]). Interaction terms showed that this relationship varied by age. Among individuals >40 years old at Wave 1, reductions of ≥2 WHO risk drinking levels were associated with significantly lower odds of CVD among very-high-risk drinkers (aOR = 0.42 [0.28 to 0.63]) but not high-risk drinkers (p = 0.50). Among individuals ≤40 years old at Wave 1, reductions of ≥2 WHO risk drinking levels were associated with significantly lower odds of CVD among high-risk drinkers (aOR = 0.50 [0.37 to 0.69]) but not very-high-risk drinkers (p = 0.27).

CONCLUSIONS

These results show that reductions in WHO risk drinking levels are associated with reduced CVD risk among very-high-risk and high-risk drinkers in the US general population, and provide further evidence that reducing high levels of drinking provides important benefit across multiple clinical domains.

The selective FKBP51 inhibitor SAFit2 reduces alcohol consumption and reinstatement of conditioned alcohol effects in mice

There is still no widely effective pharmacotherapy for alcohol addiction available in the clinic. FK506-binding protein 51 (FKBP51) is a negative regulator of the glucocorticoid receptor signaling pathway that regulates the stress-induced glucocorticoid feedback circuit. Here we asked whether selective inhibitors of FKBP51, exemplified by SAFit2, may serve as a new pharmacological strategy to reduce alcohol consumption and conditioned alcohol effects in a mouse model. We report that a relatively short treatment with SAFit2 (20 mg/kg, ip) reduces ongoing 16 vol% alcohol consumption when administered during free access to alcohol in a two-bottle free-choice test. SAFit2 was also able to reduce alcohol consumption when given during an abstinence period immediately before relapse. In contrast, SAFit2 did not affect alcohol consumption when given during a relapse period after repeated withdrawal from alcohol. SAFit2 (10 and 20 mg/kg, ip) showed no effects when used in an intermittent drinking schedule. When 20 vol% alcohol was only available every other day, SAFit2 had no effect on drinking, no matter whether given during a drinking episode or the day before. SAFit2 (2 and 20 mg/kg, ip) did not affect the expression of an alcohol-induced conditioned place preference (CPP). However, SAFit2 was able to inhibit alcohol-induced reinstatement of an extinguished CPP in a dose-dependent way. Altogether, these data may suggest pharmacological inhibition of FKBP51 as a viable strategy to reduce alcohol seeking and consumption.

Outcome in Relation to Drinking Goals in Alcohol-Dependent Individuals: A Follow-up Study 2.5 and 5 Years After Treatment Entry

AIMS

To evaluate the long-term treatment outcome (up to 5 years) with respect to different drinking goals of patients.

METHODS

Alcohol-dependent individuals (n = 349) were recruited from three alcohol treatment units. They were interviewed using the Addiction Severity Index (ASI). They were sub-grouped according to their goal at treatment entry: abstinence, low- risk drinking and no decided goal.

RESULTS

Patients with abstinence as a goal at treatment entry reported at 2.5 years follow-up a higher abstinence rate, a more pronounced reduction in alcohol consumption, reduction in total number of DSM-IV criteria, higher frequency of low-risk drinking and fewer diagnoses of alcohol dependence compared to the groups who had low risk drinking as a goal or no decided goal. This improvement remained basically unchanged in all three groups at 5 years follow-up, suggesting long-term stability after the treatment interventions.

CONCLUSIONS

The findings suggest that: (1) alcohol-dependent patients who have abstinence as their own drinking goal have a more favorable treatment outcome than those who have low-risk drinking as a goal or no decided goal. (2) Abstinence as a drinking goal should be considered for those who have a longer duration (for example more than 10 years) of their alcohol-related problems. (3) Patients who have no decided goal should be recommended abstinence as a drinking goal.

Quality Measures, All-Cause Mortality, and Health Care Use in a National Cohort of Veterans With Cirrhosis

Decompensated cirrhosis is associated with high morbidity and mortality. However, no standardized quality measures (QMs) have yet been adopted widely. The Veterans Affairs (VA) Advanced Liver Disease Technical Advisory Group recently developed a set of six internal QMs to guide quality improvement efforts in cirrhosis in the domains of access to care, hepatocellular carcinoma surveillance, variceal surveillance, quality of inpatient care for upper gastrointestinal bleeding, and cirrhosis-related rehospitalizations. We aimed to (1) quantify adherence to cirrhosis QMs and (2) determine whether adherence was associated with all-cause mortality and health care use within a large national cohort of veterans with cirrhosis. We performed a retrospective study using data from the Veterans Outcomes and Costs Asociated with Liver Disease cohort of 121,129 patients newly diagnosed with cirrhosis from January 1, 2008, to December 31, 2016, at 128 VA facilities. The mean follow-up time was 2.7 years (interquartile range, 1.1-5.1 years). Adherence to outpatient access to specialty care was 71%, variceal surveillance was 32%, and early postdischarge care was 54%. In adjusted analyses, outpatient access to specialty care (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.78-0.82), hepatocellular carcinoma surveillance (HR, 0.92; 95% CI, 0.90-0.95), variceal surveillance (HR, 0.93; 95% CI, 0.89-0.99), and early postdischarge care (HR, 0.57; 95% CI, 0.54-0.60) were associated with lower all-cause mortality. Readmissions after 30 days (HR, 1.53; 1.46-1.60) and 90 days (HR, 1.88; 95% CI, 1.54-1.70) were associated with higher all-cause mortality. Higher adherence to QMs was also associated with lower inpatient health care use. Conclusion: Five of the six proposed VA cirrhosis QMs were measurable using existing data sources, associated with mortality and health care use, and may be used to guide future quality improvement efforts in cirrhosis.

Prevention, screening, and treatment for heavy drinking and alcohol use disorder

Heavy drinking and alcohol use disorder are major public health problems. Practitioners not specialising in alcohol treatment are often unaware of the guidelines for preventing, identifying, and treating heavy drinking and alcohol use disorder. However, a consensus exists that clinically useful and valuable tools are available to address these issues. Here, we review existing information and developments from the past 5 years in these areas. We also include information on heavy drinking and alcohol use disorder among individuals with co-occurring psychiatric disorders, including drug use disorders. Areas covered include prevention; screening, brief intervention, and referral for treatment; evidence-based behavioural interventions; medication-assisted treatment; technology-based interventions (eHealth and mHealth); and population-level interventions. We also discuss the key topics for future research.

Clinical validation of reduction in cocaine frequency level as an endpoint in clinical trials for cocaine use disorder

BACKGROUND

Despite calls for non-abstinence endpoints in randomized clinical trials (RCTs) for cocaine use disorder, there is a lack of data validating non-abstinence endpoints. We conducted a clinical validation of reduction in cocaine frequency level as a non-abstinence endpoint in RCTs for cocaine use disorder (CUD).

METHODS

We utilized a pooled dataset (n = 716; 63.6 % male, 51.4 % non-Hispanic white) from seven RCTs for CUD. We specified three cocaine frequency levels at baseline and end of treatment (EOT): abstinence, low frequency (1-4 days/month), and high frequency (5+ days/month). Multiple regression analyses were conducted.

RESULTS

Among the sample, 38.3 % had at least a one-level reduction from baseline to EOT, whereas 61.7 % did not change/increased frequency level. At least a one-level reduction in cocaine frequency level from baseline to EOT versus no change/increase was significantly associated with better functioning up to one year following treatment on measures of cocaine use, as well as psychological, employment, legal, and other drug use problem severity domains of the Addiction Severity Index (ASI). We also conducted analyses only among those at the high frequency level at baseline and found those who reduced to low frequency use at EOT had similar outcomes at follow-up as those who reduced to abstinence.

CONCLUSIONS

At least a one-level reduction in cocaine frequency level from pretreatment to EOT can be a clinically meaningful endpoint given its relation to sustained clinical benefit up to one-year following treatment. These data parallel recent findings regarding reduction in drinking risk level among individuals with alcohol use disorder.

Reduction in non-abstinent World Health Organization (WHO) drinking risk levels and drug use disorders: 3-year follow-up results in the US general population

BACKGROUND

To provide information on the clinical relevance of a reduction in the World Health Organization (WHO) drinking risk categories, we examined their relationship to an important indicator of how individuals feel and function: drug use disorders (DUDs), i.e., those involving substances other than alcohol.

METHOD

Current drinkers in a U.S. national survey (n = 22,005) were interviewed in 2001-02 and re-interviewed 3 years later. WHO drinking risk levels and DSM-IV-defined DUD were assessed at both waves. The relationship of changes in WHO drinking risk levels to the presence of DUD were examined using adjusted odds ratios (aOR).

RESULTS

At Wave 1, 2.5% of respondents were WHO very-high-risk drinkers, and 2.5%, 4.8%, and 90.2% were high-risk, moderate-risk, and low-risk drinkers, respectively. Among Wave 1 very-high-risk drinkers, significantly lower odds of DUD at Wave 2 were predicted by reductions in WHO risk levels of one, two or three levels (aOR = 0.15, 0.01, 0.24, respectively; all p-values <.0001). Among participants who initially were drinking at lower risk levels, reductions in drinking or abstinence were generally associated with significantly lower odds of DUD, although the results were less consistent.

CONCLUSIONS

Among very-high-risk drinkers, reduction in the WHO drinking risk categories were associated with lower risk of a DUD. These results add to findings indicating that reductions in WHO drinking risk levels are a meaningful indicator of how individuals feel and function and could therefore serve as informative outcomes in alcohol clinical trials. WHO risk levels can also guide treatment goals and clinical recommendations on drinking reduction.

Maintenance of World Health Organization Risk Drinking Level Reductions and Posttreatment Functioning Following a Large Alcohol Use Disorder Clinical Trial

Background

Reductions in the World Health Organization (WHO) risk drinking levels have been proposed as an alternative primary outcome for alcohol clinical trials. Yet, little is known about whether reductions in WHO risk drinking levels can be maintained over time. The current study examined whether reductions in WHO risk drinking levels were maintained for up to 1 year following treatment, and whether reductions over time were associated with improvements in functioning.

Methods

Secondary data analysis of individuals with alcohol dependence (n = 1,226) enrolled in the COMBINE study, a multisite, randomized, placebo‐controlled clinical trial. Logistic regression was used to examine the maintenance of end‐of‐treatment WHO risk level reductions and WHO risk level reductions at the 1‐year follow‐up. Repeated‐measures mixed models were used to examine the association between WHO risk level reductions and functional outcomes over time.

Results

Achieving at least a 1‐ or 2‐level reduction in risk by the end of treatment was significantly associated with WHO risk level reductions at the 1‐year follow‐up assessment (p < 0.001). Among individuals who achieved at least a 1‐level reduction by the end of treatment, 85.5% reported at least a 1‐level reduction at the 1‐year follow‐up. Among individuals who achieved at least a 2‐level reduction by the end of treatment, 77.8% reported at least a 2‐level reduction at the 1‐year follow‐up. WHO risk level reductions were associated with significantly lower alcohol consumption, better physical health (p < 0.01), and fewer alcohol‐related consequences (p < 0.001) up to 1 year following treatment.

Conclusions

One‐ and 2‐level reductions in WHO risk levels during alcohol treatment were maintained after treatment and associated with better functioning over time. These findings support the use of the WHO risk level reductions as an outcome measure that reflects clinically significant improvement in how individuals seeking treatment for alcohol use disorder feel and function.

Reduction in non-abstinent WHO drinking risk levels and depression/anxiety disorders: 3-year follow-up results in the US general population

BACKGROUND

Non-abstinent drinking reductions that predict improvement in how individuals feel or function, such as the World Health Organization (WHO) drinking risk levels, may be useful outcomes in clinical trials for alcohol use disorders (AUD).

METHODS

Current drinkers in a U.S. national survey (n = 22,005) were interviewed in 2001-02 (Wave 1) and re-interviewed 3 years later (Wave 2). WHO drinking risk levels, a 4- level categorization system (very-high-risk, high-risk, moderate-risk, and low-risk drinkers) defined using estimated mean ethanol consumption (grams) per day in the prior 12 months, and DSM-IV depressive and anxiety disorders were assessed at both waves. Logistic regression was used to produce adjusted odds ratios (aOR) testing the associations of changes between Wave 1 and Wave 2 WHO risk levels to the presence or persistence of depression and/or anxiety disorder by each initial Wave 1 risk level.

RESULTS

Among Wave 1 very-high-risk drinkers, lower odds of depression and/or anxiety disorders at Wave 2 were predicted by reductions in WHO risk levels of one-, two- or three-levels (aOR = 0.42, 0.37, 0.67, p-values 0.04-<.0001), as was the persistence of depression and/or anxiety disorders among those with such disorders at Wave 1 (aOR = 0.37, 0.29, 0.51, p-values .03-<.0001). Results were less consistent for participants initially drinking at lower risk levels.

CONCLUSIONS

Among very-high-risk drinkers, reductions in the WHO drinking risk categories were associated with lower risk of depression and/or anxiety disorders. These results add to findings indicating reductions in WHO risk levels are a meaningful indicator of how individuals feel and function.

Drinking Risk Level Reductions Associated with Improvements in Physical Health and Quality of Life Among Individuals with Alcohol Use Disorder

BACKGROUND

Abstinence and no heavy drinking days are currently the only Food and Drug Administration-approved end points in clinical trials for alcohol use disorder (AUD). Many individuals who fail to meet these criteria may substantially reduce their drinking during treatment, and most individuals with AUD prefer drinking reduction goals. One- and two-level reductions in World Health Organization (WHO) drinking risk levels have been proposed as alternative end points that reflect reduced drinking and are associated with reductions in drinking consequences, improvements in mental health, and reduced risk of developing alcohol dependence. The current study examined the association between WHO drinking risk level reductions and improvements in physical health and quality of life in a sample of individuals with alcohol dependence.

METHODS

Secondary data analysis of individuals with alcohol dependence (n = 1,142) enrolled in the longitudinal, prospective COMBINE study, a multi site randomized placebo-controlled clinical trial, examining the association between reductions in WHO drinking risk levels and change in blood pressure, liver enzyme levels, and self-reported quality of life following treatment for alcohol dependence.

RESULTS

One- and two-level reductions in WHO drinking risk level during treatment were associated with significant reductions in systolic blood pressure (p < 0.001), improvements in liver enzyme levels (all p < 0.01), and significantly better quality of life (p < 0.001).

CONCLUSIONS

One- and two-level reductions in WHO drinking risk levels predicted significant improvements in markers of physical health and quality of life, suggesting that the WHO drinking risk level reduction could be a meaningful surrogate marker of improvements in how a person "feels and functions" following treatment for alcohol dependence. The WHO drinking risk levels could be useful in medical practice for identifying drinking reduction targets that correspond with clinically significant improvements in health and quality of life.