Cannabis use frequency and pain interference among people with HIV

Cannabis is often used by people with HIV (PWH) for pain, yet study results are inconsistent regarding whether and how it affects pain. This study examines whether greater cannabis use frequency is associated with lower pain interference and whether cannabis use modifies the association of pain severity and pain interference among 134 PWH with substance dependence or a lifetime history of injection drug use. Multi-variable linear regression models examined the association between past 30-day cannabis use frequency and pain interference. Additional models evaluated whether cannabis use modified the association between pain severity and pain interference. Cannabis use frequency was not significantly associated with pain interference. However, in a model with interaction between cannabis use frequency and pain severity, greater cannabis use frequency attenuated the strength of the association between pain severity and pain interference (p = 0.049). The adjusted mean difference (AMD) in pain interference was +1.13, + 0.81, and +0.05 points for each 1-point increase in pain severity for those with no cannabis use, 15 days of use, and daily use, respectively. These findings suggest that attenuating the impact of pain severity on pain-related functional impairment is a potential mechanism for a beneficial role of cannabis for PWH.

Medication for addiction treatment and acute care utilization in HIV-positive adults with substance use disorders

Medication for addiction treatment (MAT) could reduce acute care utilization in HIV-positive individuals with substance use disorders. The study objective was to determine if HIV-positive people with substance use disorders treated with MAT report less acute care utilization than those not receiving MAT. We assessed the association between MAT and acute care utilization among HIV-positive individuals with alcohol or opioid use disorder. Acute care utilization 6 months later was defined as any past 3-month self-reported (1) emergency department (ED) visit and (2) hospitalization. Of 153 participants, 88% had alcohol use disorder, 41% had opioid use disorder, and 48 (31%) were treated with MAT. Fifty-five (36%) participants had an ED visit and 38 (25%) participants had a hospitalization. MAT was not associated with an ED visit (AOR 1.12, 95% CI 0.46-2.75) or hospitalization (AOR 1.09, 95% CI 0.39-3.04). MAT was not associated with acute care utilization. These results highlight the need to increase MAT prescribing in HIV-positive individuals with substance use disorders, and to address the many factors that influence acute care utilization.

Readiness-to-change as a moderator of a web-based brief intervention for marijuana among students identified by health center screening

INTRODUCTION

Electronic screening and brief intervention has been identified as a low cost strategy to address marijuana use among students, however there is little known about who may be most responsive to this intervention approach. This study examined whether readiness-to-change moderated the influence of a web-based intervention on frequency of use at 3-month outcomes.

METHODS

One-hundred twenty-three students who smoked marijuana at least monthly were identified by screening in a student health center. Baseline and 3-month outcome assessments were conducted on-line. Participants were randomly assigned to either eCHECKUP TO GO-marijuana or a control condition after completing marijuana measures and the Readiness-to-Change Questionnaire (RTCQ). Negative binomial regression analyses were conducted to examine whether the effect of the intervention on marijuana use at 3-month outcomes was moderated by the Action and Problem Recognition dimensions of the RTCQ, adjusting for baseline use.

RESULTS

Analyses showed a significant Intervention × Action interaction. Probing of interaction effects showed that among those with high scores on the Action scale participants in the intervention group reported significantly fewer days of use than those in the control condition at follow-up (IRR=0.53, 95%CI: 0.94, 2.08). The Problem Recognition dimension did not moderate the influence of the intervention on outcomes.

CONCLUSION

These results suggest that this eSBI may bolster change efforts among students who have begun taking steps toward changing their marijuana use.

Factors associated with discontinuation of antiretroviral therapy in HIV-infected patients with alcohol problems

Although mortality rates among HIV-infected populations have declined with the advent of combination antiretroviral therapy (ART), patients with substance use disorders have benefited less from these therapies. While adherence to ART has been well studied, less is known about factors associated with discontinuation of ART. The aim of this study is to investigate predictors of discontinuation of ART in HIV-infected patients with alcohol problems, focusing on their substance use and depressive symptoms. The study cohort (n=266) was prospectively assessed with biannual standardised interviews between 2001 and 2005. Four predictor variables (cocaine, heroin, heavy alcohol use and substantial depressive symptoms) were assessed six months prior to the outcome (ART discontinuation). Longitudinal logistic regression models examined the association between predictor variables and ART discontinuation adjusting for age, gender, race/ethnicity, homelessness, CD4, HIV RNA and HIV Symptom Index. Subjects were 77% male; 43% black; 22% homeless; 45% used cocaine; 20% used heroin; 29% had heavy alcohol use; and 40% had substantial depressive symptoms. Discontinuation occurred in 135 (17%) of the observations (n=743). In bivariate analyses, cocaine use, heroin use and depressive symptoms were significantly associated with ART discontinuation but heavy alcohol use was not. In the multivariable model, substantial depressive symptoms (adjusted odds ratio (AOR)=1.66; 95% confidence interval (CI): 1.04, 2.65) but not cocaine (AOR=1.28; 95%CI: 0.76, 2.16) or heroin use (AOR=1.27 95%CI: 0.66, 2.44), remained significantly associated with ART discontinuation. Among HIV-infected adults with alcohol problems, depressive symptoms, but not substance use, predicted subsequent ART discontinuation. Recognition and treatment of depressive symptoms in this population may result in better maintenance of ART and its associated clinical benefits.

Association of alcohol consumption with HIV sex- and drug-risk behaviors among drug users

The relationship between alcohol use and HIV transmission is well recognized but not fully understood. In particular, the role of alcohol abuse as a mediator of HIV risk behavior among drug users is not well documented. We hypothesized that alcohol use in drug users will result in greater HIV risk-taking behavior. Participants were 354 drug users, of whom 105 were recent injection drug users. Multiple regression models were used to characterize whether measures of sexual and injection drug use HIV risk behavior were related to alcohol consumption, controlling for other potentially associated factors. We found that sexual HIV risk-taking behavior is associated with increased alcohol consumption among women (p = 0.02), with women having more risky sexual behavior than males. However, contrary to our hypothesis, there was no significant association of alcohol consumption with risky injection drug behavior. Addressing alcohol problems among drug users, particularly women, may be an important opportunity to reduce HIV sexual risk behavior among this high-risk population.

Validation of the screening strategy in the NIAAA "Physicians' Guide to Helping Patients with Alcohol Problems"

OBJECTIVE

This study was undertaken to determine the diagnostic test characteristics of the alcohol screening strategy recommended in the National Institute on Alcoholism and Alcohol Abuse (NIAAA) "Physicians' Guide to Helping Patients with Alcohol Problems."

METHOD

A research interview was performed on patients who presented to one urban emergency department (N = 395; 61% women). It asked three alcohol consumption questions, the CAGE questionnaire, and about past alcohol problems. The NIAAA-recommended screen was considered positive for alcohol consumption in excess of 14 drinks per week or 4 drinks per occasion for men, or 7 drinks per week or 3 drinks per occasion for women, or a CAGE score of 1 or greater. A sample of patients (n = 250) received the Composite International Diagnostic Interview substance abuse module, a gold standard interview, to determine lifetime or prior 12-month alcohol abuse or dependence; results were adjusted for verification bias.

RESULTS

The prevalence of lifetime:alcohol abuse or dependence was 13%, for which the NIAAA strategy was 81% sensitive and 80% specific. The prevalence of alcohol abuse or dependence in the prior 12 months was 10%, for which the strategy was 83% sensitive and 84% specific. Its positive likelihood ratio exceeded that of the CAGE, augmented CAGE or consumption questions alone, and its negative likelihood ratio was the lowest.

CONCLUSIONS

The screening strategy combining alcohol consumption and CAGE questions recommended in the NIAAA "Physicians' Guide" is valid, and has superior test characteristics compared to the CAGE alone, in this predominantly black (86%) emergency department population. Its brevity and simple interpretation recommend wider dissemination of the NIAAA "Physicians' Guide," although future research should examine its test characteristics in other clinical settings and with other populations.

Screening and intervention for illicit drug abuse: a national survey of primary care physicians and psychiatrists

BACKGROUND

Illicit drug abuse causes much morbidity and mortality, yet little is known about physicians' screening and intervention practices regarding illicit drug abuse.

METHODS

We mailed a survey to a national sample of 2000 practicing general internists, family physicians, obstetricians and gynecologists, and psychiatrists to assess their screening and intervention practices for illicit drug abuse.

RESULTS

Of 1082 respondents (adjusted response rate, 57%), 68% reported that they regularly ask new outpatients about drug use. For diagnosed illicit drug abuse, 55% reported that they routinely offer formal treatment referral, but 15% reported that they do not intervene. In multivariate logistic regression models, more optimal screening and intervention practices were associated with psychiatry specialty, confidence in obtaining the history of drug use, optimism about the effectiveness of therapy, less concern that patients will object, and fewer perceived time constraints.

CONCLUSIONS

Most physicians reported that they ask patients about illicit drug use, but a substantial minority inadequately intervene in diagnosed drug abuse. Initiatives to promote physician involvement in illicit drug abuse should include strategies to increase physicians' confidence in managing drug problems, engender optimism about the benefits of treatment, dispel concerns about patients' sensitivity regarding substance use, and address perceived time limitations.

Benefits of linking primary medical care and substance abuse services: patient, provider, and societal perspectives

Individuals with alcohol and drug use problems may receive health care from medical, mental health, and substance abuse providers, or a combination of all three. Systems of care are often distinct and separate, and substantial opportunities for benefit to patient, provider, and payer are missed. In this article, we outline (1) the possible benefits of linking primary care, mental health, and substance abuse services from the perspective of the major stakeholders-medical and mental health providers, addiction clinicians, patients, and society-and (2) reasons for suboptimal linkage and opportunities for improving linkage within the current health care system. We also review published models of linked medical and substance abuse services. Given the potential benefits of creating tangible systems in which primary care, mental health, and substance abuse services are meaningfully linked, efforts to implement, examine, and measure the real impact should be a high priority.

Improving alcoholism treatment across the spectrum of services

This article represents the proceedings of a symposium at the 2000 RSA Meeting in Denver, Colorado. The chair was Michael E. Hilton. The presentations were (1) The effects of brief advice and motivational enhancement on alcohol use and related variables in primary care, by Stephen A. Maisto, Joseph Conigliaro, Melissa McNiel, Kevin Kraemer, Mary E. Kelley, and Rosemarie Conigliaro; (2) Enhanced linkage of alcohol dependent persons to primary medical care: A randomized controlled trial of a multidisciplinary health evaluation in a detoxification unit, by Jeffrey H. Samet, Mary Jo Larson, Jacqueline Savetsky, Michael Winter, Lisa M. Sullivan, and Richard Saitz; (3) Cost-effectiveness of day hospital versus traditional alcohol and drug outpatient treatment in a health maintenance organization: Randomized and self-selected samples, by Constance Weisner, Jennifer Mertens, Sujaya Parthasarathy, Charles Moore, Enid Hunkeler, Teh-Wei Hu, and Joe Selby; and (4) Case monitoring for alcoholics: One year clinical and health cost effects, by Robert L. Stout, William Zywiak, Amy Rubin, William Zwick, Mary Jo Larson, and Don Shepard.

The impact of leaving against medical advice on hospital resource utilization

OBJECTIVE

To assess the effect of hospital discharge against medical advice (AMA) on the interpretation of charges and length of stay attributable to alcoholism.

DESIGN

Retrospective cohort. Three analytic strategies assessed the effect of having an alcohol-related diagnosis (ARD) on risk-adjusted utilization in multivariate regressions. Strategy 1 did not adjust for leaving AMA, strategy 2 adjusted for leaving AMA, and strategy 3 restricted the sample by excluding AMA discharges.

SETTING

Acute care hospitals.

PATIENTS

We studied 23,198 pneumonia hospitalizations in a statewide administrative database.

MEASUREMENTS AND MAIN RESULTS

Among these admissions, 3.6% had an ARD, and 1.2% left AMA. In strategy 1 an ARD accounted for a $1,293 increase in risk-adjusted charges for a hospitalization compared with cases without an ARD ( p =.012). ARD-attributable increases of $1,659 ( p =.002) and $1,664 ( p =. 002) in strategies 2 and 3 respectively, represent significant 28% and 29% increases compared with strategy 1. Similarly, using strategy 1 an ARD accounted for a 0.6-day increase in risk-adjusted length of stay over cases without an ARD ( p =.188). An increase of 1 day was seen using both strategies 2 and 3 ( p =.044 and p =.027, respectively), representing significant 67% increases attributable to ARDs compared with strategy 1.

CONCLUSIONS

Discharge AMA affects the interpretation of the relation between alcoholism and utilization. The ARD-attributable utilization was greater when analyses adjusted for or excluded AMA cases. Not accounting for leaving AMA resulted in an underestimation of the impact of alcoholism on resource utilization.

Screening and intervention for alcohol problems. A national survey of primary care physicians and psychiatrists

OBJECTIVE

To describe adult primary care physicians' and psychiatrists' approach to alcohol screening and treatment, and to identify correlates of more optimal practices.

DESIGN

Cross-sectional mailed survey.

PARTICIPANTS

A national systematic sample of 2,000 physicians practicing general internal medicine, family medicine, obstetrics-gynecology, and psychiatry.

MEASUREMENTS

Self-reported frequency of screening new outpatients, and treatment recommendations in patients with diagnosed alcohol problems, on 5-point Likert-type scales.

MAIN RESULTS

Of the 853 respondent physicians (adjusted response rate, 57%), 88% usually or always ask new outpatients about alcohol use. When evaluating patients who drink, 47% regularly inquire about maximum amounts on an occasion, and 13% use formal alcohol screening tools. Only 82% routinely offer intervention to diagnosed problem drinkers. Psychiatrists had the most optimal practices; more consistent screening and intervention was also associated with greater confidence in alcohol history taking, familiarity with expert guidelines, and less concern that patients will object.

CONCLUSIONS

Most primary care physicians and psychiatrists ask patients about alcohol use, but fewer use recommended screening protocols or offer formal treatment. A substantial minority of physicians miss the opportunity to intervene in alcohol problems. Efforts to improve physicians' screening and intervention for alcohol problems should address their confidence in their skills, familiarity with expert recommendations, and beliefs that patients object to their involvement

Successful teaching in evidence-based medicine

OBJECTIVES

Several published articles have described the importance of exposing medical trainees to the 'new paradigm' of evidence-based medicine (EBM). Recognizing this, we sought to develop and objectively evaluate a mini-course in EBM for third-year medical students.

DESIGN

We developed a mini-course consisting of four sessions in which students learn to derive sequentially focused questions, search MEDLINE, review articles critically and apply information from the literature to specific clinical questions. To evaluate the teaching intervention, we performed a controlled educational study. Students at the intervention site (n=34) attended the EBM mini-course, while students at the control site (n=26) received more 'traditional' didactic teaching on various clinical topics. Intervention and control students were surveyed immediately before and after the mini-course to assess changes in reading and literature searching skills, as well as a tendency to use the literature to answer clinical questions.

SETTING

Boston University School of Medicine.

SUBJECTS

Third-year medical students.

RESULTS

The intervention was associated with significant changes in students' self-assessed skills and attitudes. MEDLINE and critical appraisal skills increased significantly in the intervention group relative to the control group (significance of between group differences: P=0.002 for MEDLINE and P=0.0002 for critical appraisal), as did students' tendency to use MEDLINE and original research articles to solve clinical problems (significance of between group differences: P=0.002 and P=0.0008, respectively).

CONCLUSIONS

We conclude that this brief teaching intervention in EBM has had a positive impact on student skills and attitudes at our medical school. We believe that the key elements of this intervention are (1) active student involvement, (2), clinical relevance of exercises and (3) integrated teaching targeting each of the component skills of EBM.

The value of acupuncture detoxification programs in a substance abuse treatment system

Our purpose is to compare baseline characteristics and detoxification readmission rates of clients treated at outpatient acupuncture programs and at short-term residential programs, two options available to persons seeking substance abuse detoxification. This was a retrospective cohort study using data on clients discharged from publicly funded detoxification programs in Boston between January 1993 and September 1994. Multivariate models were used to examine the effect on 6-month detoxification readmission rates of treatment at residential detoxification programs (used by 6,907 clients) versus at outpatient acupuncture programs (used by 1,104 clients) after adjusting for baseline differences. Acupuncture clients were less likely to be readmitted for detoxification within 6 months (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.53-0.95). Similar results were found when the analysis was performed on a subsample of clients that were relatively similar in terms of baseline characteristics (OR 0.61, 95% CI 0.39-0.94). We determined that acupuncture detoxification programs are a useful component of a substance abuse treatment system.

Managing alcohol withdrawal in the elderly

The alcohol withdrawal syndrome is common in elderly individuals who are alcohol dependent and who decrease or stop their alcohol intake. While there have been few clinical studies to directly support or refute the hypothesis that withdrawal symptom severity, delirium and seizures increase with advancing age, several observational studies suggest that adverse functional and cognitive complications during alcohol withdrawal do occur more frequently in elderly patients. Most elderly patients with alcohol withdrawal symptoms should be considered for admission to an inpatient setting for supportive care and management. However, elderly patients with adequate social support and without significant withdrawal symptoms at presentation, comorbid illness or past history of complicated withdrawal may be suitable for outpatient management. Although over 100 drugs have been described for alcohol withdrawal treatment, there have been no studies assessing the efficacy of these drugs specifically in elderly patients. Studies in younger patients support benzodiazepines as the most efficacious therapy for reducing withdrawal symptoms and the incidence of delirium and seizure. While short-acting benzodiazepines, such as oxazepam and lorazepam, may be appropriate for elderly patients given the risk for excessive sedation from long-acting benzodiazepines, they may be less effective in preventing seizures and more prone to produce discontinuation symptoms if not tapered properly. To ensure appropriate benzodiazepine treatment, dose and frequency should be individualised with frequent monitoring, and based on validated alcohol withdrawal severity measures. Selected patients who have a history of severe or complicated withdrawal symptoms may benefit from a fixed schedule of benzodiazepine provided that medication is held for sedation. beta-Blockers, clonidine, carbamazepine and haloperidol may be used as adjunctive agents to treat symptoms not controlled by benzodiazepines. Lastly, the age of the patient should not deter clinicians from helping the patient achieve successful alcohol treatment and rehabilitation.

Evidence-based medicine and the real world: understanding the controversy

Controversy has surrounded the 'paradigm' of evidence-based medicine since its introduction in 1992 as a new approach to the teaching and practice of medicine. Here, we address two questions: (1) is evidence-based medicine a good thing?; and (2) why has so much controversy arisen? In addressing these questions, we propose that the discussion surrounding evidence-based medicine should no longer be about whether the application of evidence in clinical practice is a good thing, because it obviously is. Instead, the debate ought to focus on the more difficult question of how to enhance its acceptability among busy clinicians practising in the 'real world'. For the future, we optimistically anticipate an enhanced adoption of evidence-based medicine, as clinicians will become increasingly capable of efficiently accessing existing and forthcoming evidence resources.

Alcohol abuse and dependence in Latinos living in the United States: validation of the CAGE (4M) questions

BACKGROUND

Brief alcoholism screening questionnaires have not been adequately studied in the rapidly growing Latino population living in the United States.

OBJECTIVE

To assess (1) the prevalence of alcoholism and (2) the performance of 2 alcohol screening instruments in Latinos.

SUBJECTS AND METHODS

We performed a cross-sectional interview study in an urban teaching hospital-based primary care practice. Consecutive self-identified Latino subjects provided informed consent. All subjects were interviewed in English or Spanish using 2 alcoholism screening tools, the CAGE (or the Spanish version, the 4M), and the Alcohol Use Disorders Identification Test, and a criterion standard for the diagnosis of alcohol abuse and dependence, the Composite International Diagnostic Interview.

RESULTS

Of 210 subjects interviewed, 36% had a lifetime diagnosis of alcohol abuse or dependence by the criterion standard. Thirty-one percent were currently drinking hazardous amounts of alcohol. A CAGE (4M) score of 1 or more was 92% sensitive and 74% specific, and a score of 2 or more was 80% sensitive and 93% specific for a lifetime diagnosis of alcohol abuse or dependency. CAGE (4M) scores of 0, 2, 3, and 4 were associated with likelihood ratios (0.1, 4.8, 18.5, and 36.8, respectively) that resulted in substantial changes from pretest (36%) to posttest probability (to 6%, 73%, 91%, and 95%, respectively) of a diagnosis of alcohol abuse or dependency. At the standard cutoff point, the Alcohol Use Disorders Identification Test detected only 51% of subjects with alcohol disorders.

CONCLUSIONS

In Latinos in primary care settings, alcohol abuse and dependence are common and the CAGE (4M) is a brief, valid, screening tool for detecting alcohol use disorders.

Management of adults recovering from alcohol or other drug problems: relapse prevention in primary care

Patients recovering from substance use disorders are commonly seen in the primary care setting, and relapse is a serious long-term problem for these patients. Extrapolating from therapeutic strategies effective in specialty addiction treatment settings, this article outlines a practical approach to relapse prevention in the primary care setting. Working within a supportive patient-physician relationship, the primary care physician can help recovering patients decrease their susceptibility to relapse, recognize and manage high-risk situations, and use available self-help, pharmacological, and specialty resources. Drawing on the therapeutic relationship and skills they already possess, primary care physicians can have an important, productive, and satisfying role in the long-term management of patients in recovery from alcohol or other drug problems.

Introduction to alcohol withdrawal

Heavy drinkers who suddenly decrease their alcohol consumption or abstain completely may experience alcohol withdrawal (AW). Signs and symptoms of AW can include, among others, mild to moderate tremors, irritability, anxiety, or agitation. The most severe manifestations of withdrawal include delirium tremens, hallucinations, and seizures. These manifestations result from alcohol-induced imbalances in the brain chemistry that cause excessive neuronal activity if the alcohol is withheld. Management of AW includes thorough assessment of the severity of the patient's symptoms and of any complicating conditions as well as treatment of the withdrawal symptoms with pharmacological and nonpharmacological approaches. Treatment can occur in both inpatient and outpatient settings. Recognition and treatment of withdrawal can represent a first step in the patient's recovery process.

Physician unawareness of serious substance abuse

PURPOSE

To describe and assess the prevalence of perceived physician unawareness of serious substance abuse.

PATIENTS AND METHODS

We report an observational study with validation of multivariable results of data collected by interview from persons presenting for addictions treatment in the public system who reported having a physician.

RESULTS

Of 3,253 patients interviewed, 87% (2,843) responded to the question about having a physician. Of 1,440 patients who stated that they had physicians, 45% (651) reported that the physician who cared for them was unaware of their substance abuse. In multivariable logistic regressions adjusting for sociodemographics, health status, and substance abuse histories, the following patient characteristics were found to be independently associated with physician unawareness of substance abuse and were confirmed in a validation analysis (OR = Odds Ratio, CI = 95% Confidence Interval); no prior episodic medical illness (OR = 1.98, CI = 1.35-2.92), no health insurance (OR = 1.89, CI = 1.33-2.70), no prior mental health treatment (OR = 1.75, CI = 1.06-2.88), no chronic medical illness (OR = 1.69, CI = 1.18-2.40), no prior substance abuse treatment (OR 1.64, CI 1.17-2.31), and no prior detoxification (OR = 1.54, CI = 1.14-2.22).

CONCLUSIONS

Forty-five percent of patients with substance abuse serious enough to prompt a presentation for treatment stated that the physician who cared for them was unaware of their substance abuse. Patients without health insurance, a history of medical illness, or prior substance abuse or mental health treatment were more likely to have reported physician unawareness. Even among substance abusing patients requesting addiction treatment, many perceive that their physicians do not recognize their substance abuse.

The impact of alcohol-related diagnoses on pneumonia outcomes

BACKGROUND

There is controversy regarding the role of alcoholism as a prognostic factor in hospitalized patients with pneumonia.

OBJECTIVE

To assess the impact of alcohol abuse on hospitalization charges, length of hospital stay, intensive care unit use, and in-hospital mortality.

METHODS

We studied a cohort of all adults hospitalized in 1992 in Massachusetts with a principal diagnosis of pneumonia, and all Massachusetts residents hospitalized for pneumonia in 6 bordering states.

RESULTS

For the 23,198 pneumonia cases the mean total hospitalization charges were $9925, mean length of hospital stay was 9.6 days, 12% of the cases had intensive care unit stays, and 10% of the cases died during the hospitalization. In bivariate analyses, pneumonia cases with alcohol-related diagnoses had higher charges (mean, $11,232 vs $9877, P = .07), had shorter length of hospital stay (9.2 vs 9.6 days, P = .02), were more likely to experience an intensive care unit stay (19% vs 12%, P < .001), and had lower in-hospital mortality (6.0% vs 10.2%, P < .001). Multivariable analyses adjusting for comorbidity, pneumonia etiology, and demographics revealed that for pneumonia cases with alcohol-related diagnoses, risk-adjusted hospital charges were $1293 higher (adjusted mean, $11,179 vs $9888, P < .001), length of hospital stay was 0.6 days longer (10.1 vs 9.5 days, P = .001), intensive care unit use was higher (18% vs 12%; adjusted odds ratio, 1.63; 95% confidence interval, 1.33-1.98), and mortality was no different (10% with or without an alcohol-related diagnosis).

CONCLUSIONS

Having an alcohol-related diagnosis is associated with more use of intensive care, longer inpatient stays, and higher hospital charges. To understand resource utilization in cases of pneumonia, alcohol abuse is a comorbid factor that must be considered.

Pharmacotherapies for alcohol abuse. Withdrawal and treatment

Pharmacologic management of alcoholism is only one part of the management of both alcohol dependence and withdrawal, which also includes the provision of a calm, quiet environment; reassurance; ongoing reassessment; attention to fluid and electrolyte disorders; treatment of coexisting addictions and common medical, surgical, and psychiatric comorbidities; and referral for ongoing psychosocial and medical treatment. For further discussion of these topics, the reader is referred to previously published sources. A survey of alcoholism treatment programs revealed that although benzodiazepines were the most commonly used drugs, standardized monitoring of patients' withdrawal severity was not common practice, and a significant minority of clinicians were using a variety of other drugs, some not known to prevent or treat the complications of withdrawal. Treatment should be based on the available evidence (Working Group on Pharmacological Management of Alcohol Withdrawal: American Society of Addiction Medicine Committee on Practice Guidelines: Pharmacological management of alcohol withdrawal: An evidence-based practice guideline. Unpublished draft, 1997). Patients with significant symptoms, patients with complications such as seizures or delirium tremens, and patients at higher risk for complications of alcohol withdrawal should receive benzodiazepines, particularly chlordiazepoxide, diazepam, or lorazepam, because of their safety and documented efficacy in preventing and treating the most serious complications of alcohol withdrawal. These drugs may be dosed on a fixed schedule for a predetermined number of doses on a tapering schedule over several days, or they may be administered by front-loading. An alternative approach for selected patients without seizures or acute comorbidity is symptom-triggered therapy, which individualizes treatment and decreases the duration and dose of medication administration. With either of the regimens, patients should have their withdrawal severity monitored until symptoms are resolving. Once withdrawal from alcohol is safely completed, the focus should turn to helping to prevent relapse. Disulfiram may be useful in highly motivated subsets of patients and when compliance-enhancing strategies are used. Naltrexone is useful in the broader population of patients entering treatment for alcohol dependence. These pharmacologic interventions should be given in the context of ongoing psychosocial support. There is substantial evidence that pharmacologic management of alcohol abuse and dependence is effective. As would be predicted from alcohol's myriad cellular effects, no panacea exists for alcoholism. For alcohol withdrawal, however, although treatment regimens have only recently been refined, evidence for effective treatment of symptoms and prevention of complications with benzodiazepines has been available for decades. Within the last decade, effective treatments, including naltrexone, have been shown to reduce alcohol intake in alcohol-dependent persons. Given the prevalence and cost of alcohol-related problems, all effective therapies (including pharmacologic treatments) should be considered to treat alcohol abuse and dependence.

Alcohol withdrawal: a nationwide survey of inpatient treatment practices

OBJECTIVE

To describe current practices employed in the inpatient treatment for alcohol withdrawal.

DESIGN

Survey.

SETTING

Inpatient alcoholism treatment programs in the United States.

PARTICIPANTS

Medical directors of 176 (69%) of 257 eligible programs randomly selected from a national listing.

RESULTS

The medical directors estimated that of all inpatients treated for alcohol withdrawal at the programs, 68% received one of the following medications. Benzodiazepines, including the long-acting chlordiazepoxide (33%) and diazepam (16%), and less frequently the short-acting oxazepam (7%) and lorazepam (4%), were the most commonly used agents. Barbiturates (11%), phenytoin (10%), clonidine (7%), beta-blockers (3%), carbamazepine (1%), and antipsychotics (1%) were less frequently given. Drug was most often given on a fixed dosing schedule with additional medication "as needed" (52% of the programs). Only 31% of the programs routinely used a standardized withdrawal severity scale to monitor patients. Mean duration of sedative treatment was three days; inpatient treatment, four days. Use of fixed-schedule regimens was associated with longer sedative treatment (mean four vs three days, p < 0.01). Northeast census region location and psychiatrist program director were significantly associated with longer sedative and inpatient treatment duration.

CONCLUSIONS

The most commonly reported regimen for alcohol withdrawal included three days of long-acting benzodiazepines on a fixed schedule with additional medication "as needed." Standardized monitoring of the severity of withdrawal was not common practice. The directors reported using a variety of other regimens, some not known to prevent the major complications of withdrawal. Although geographic location and director specialty were significantly associated with treatment duration, much of the variation in treatment for alcohol withdrawal remains unexplained.

Adolescents' preferences regarding human immunodeficiency virus (HIV)-related physician counseling and HIV testing

OBJECTIVE

To assess adolescents' preferences regarding human immunodeficiency virus (HIV)-related physician counseling and HIV testing.

DESIGN

Anonymous, self-report survey.

SETTING

Metropolitan Boston public schools.

PARTICIPANTS

Students in 9th and 12th grade from 10 schools.

RESULTS

Of the 845 students (99%) who completed the survey, 53% were female, 50% seniors, and 76% white. Although 86% had regular physicians, only 27% reported ever discussing HIV with a physician. The majority wanted a physician to give them information about sexually transmitted diseases (82%), condoms (73%), sex (70%), safe sex (80%), and HIV (85%). Most wanted physicians to ask about personal experiences with sexually transmitted diseases (64%), condoms (59%), safe sex (67%), and HIV (72%). Seniors, students with female physicians, and students who had previously discussed sex with physicians were significantly more likely to want physicians to ask personal questions about HIV-related risk behaviors. Most, however, felt uncomfortable initiating a discussion about safe sex (59%), condoms (67%), sex (69%), and homosexuality (78%). More students preferred to speak with physicians (36%) than with family members (16%) or teachers (2%) about their personal risk of acquiring HIV, although 32% preferred to speak with friends. More preferred to be tested for HIV by someone who did not know them (40%) than by someone who did (32%). When asked about specific testing sites, 25% preferred a place that does only HIV testing, and 22% preferred their regular physicians' offices.

CONCLUSIONS

Adolescents want physicians to give them information and to ask personal questions about HIV and HIV-related risk behaviors, and they prefer that the physicians initiate the discussion. Although they have no clear preference for testing sites, many teenagers prefer to be tested by someone who does not know them.

Recognition and management of occult alcohol withdrawal

Many patients experience withdrawal because an acute illness has interrupted their usual alcohol intake. Medical and psychiatric complications of alcoholism may also coexist with withdrawal. Several findings predict the likelihood of seizures of delirium tremens and thus are useful in making initial treatment decisions.

Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial

OBJECTIVE

To assess the effect of an individualized treatment regimen on the intensity and duration of medication treatment for alcohol withdrawal.

DESIGN

A randomized double-blind, controlled trial.

SETTING

An inpatient detoxification unit in a Veterans Affairs medical center.

PATIENTS

One hundred one patients admitted for the treatment of alcohol withdrawal who could give informed consent and had no history of seizures or medication use that might alter the clinical course of withdrawal.

INTERVENTION

Patients were randomized to either a standard course of chlordiazepoxide four times daily with additional medication as needed (fixed-schedule therapy) or to a treatment regimen that provided chlordiazepoxide only in response to the development of the signs and symptoms of alcohol withdrawal (symptom-triggered therapy). The need for administration of "as-needed" medication was determined using a validated measure of the severity of alcohol withdrawal.

MAIN OUTCOME MEASURES

Duration of medication treatment and total chlordiazepoxide administered.

RESULTS

The median duration of treatment in the symptom-triggered group was 9 hours, compared with 68 hours in the fixed-schedule group (P < .001). The symptom-triggered group received 100 mg of chlordiazepoxide, and the fixed-schedule group received 425 mg (P < .001). There were no significant differences in the severity of withdrawal during treatment or in the incidence of seizures or delirium tremens.

CONCLUSIONS

Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal.