Alcohol, Other Drugs, and Health: TABLE OF TABLECONTENTS OF CONTENTS Current Evidence

JAN-MAR 2008 INTERVENTIONS & ASSESSMENTS

Topiramate Reduces Drinking in Adults With Alcohol Dependence, 1 InterventionsAlcohol and Health and Assessments Outcomes

Methadone Maintenance Plus Syringe Exchange Reduces HIV and HCV Topiramate Reduces Drinking in Adults With Alcohol Dependence Incidence, 1 Topiramate may decrease alcohol con- differences between the topiramate sumption among people with alcohol de- and placebo groups were even Extended-Release Naltrexone Works Particularly Well for Abstinent pendence by reducing the release of dopa- greater. Patients With Dependence, 2 mine. To determine topiramate’s efficacy • With both analytic approaches, topi- for reducing drinking, researchers ran- ramate recipients achieved ≥28 days Prevalence of Adolescent Substance domized 371 patients with alcohol de- of both continuous abstinence and Use Identified by Screening in Primary pendence from 17 sites across the U.S. to continuous nonheavy drinking faster Care, 3 receive topiramate (up to 300 mg per day) than placebo recipients did. Melatonin, Benzodiazepines, and or placebo for 14 weeks. Only subjects Sleep Quality Among Patients Receiv- without comorbid conditions (e.g., other Comments: Topiramate is a promising ing Methadone, 3 substance use, depression) who wanted to treatment for alcohol dependence. Both quit or reduce drinking were eligible to analytic approaches suggest that broaden- Inpatient Medical Care Plus Substance enroll. All subjects received weekly, man- ing the use of topiramate to treat alcohol Use Treatment Improves Health Ser- vices Utilization, 4 ual-guided adherence enhancement coun- dependence among adults who want to seling. reduce their drinking is warranted. How- Do Patient Characteristics Moderate ever, because this randomized controlled Naltrexone’s Effects on Drinking?, 4 • In analyses that considered all drop- trial had strict eligibility criteria to ensure outs as having relapsed to baseline that safety and efficacy could be measured,

measures, topiramate recipients had the generalizability of these findings to HEALTH OUTCOMES greater reductions in the percentage patients with comorbid illnesses, such as of drinking days (from a mean of 82% other substance disorders or psychiatric to 44% compared with 82% to 52% disease, may be limited. Prescription Opioid Use and Diver- for placebo recipients) and in liver Julia H. Arnsten, MD, MPH sion, 5 enzymes. They also had greater in- creases in abstinent days (from a Reference: Johnson BA, et al. Topiramate Impact of Substance Use on Adher- ence to HIV Medications, 5 mean of 10% to 38% compared with for treating alcohol dependence: a ran- 9% to 29% for placebo recipients). domized controlled trial. JAMA. 2007;298 Combining Healthy Behaviors, Includ- • In analyses that considered dropouts (14):1641–1651. ing Moderate Drinking, Reduces MI as missing rather than as relapses, the in Women, 6

Characteristics of Adolescents Who Use Cannabis But Not Tobacco, 6 Methadone Maintenance Plus Syringe Exchange Reduces HIV and HCV Incidence Racial Differences in Alcohol Treat- Sharing syringe and other injection equip- for HIV or HCV. ment Received and in Treatment Com- pleted, 6 ment places injection drug users (IDUs) at risk for bloodborne infections like HIV and • Over 20 years of follow-up, neither Moderate Drinking May Improve Fast- HCV. Participation in syringe exchange methadone maintenance alone nor ing Glucose in People With Diabetes, 7 programs plus receipt of methadone main- needle exchange alone was signifi- tenance may reduce the likelihood of cantly associated with HIV or HCV

these infections, although few studies have seroincidence. JOURNAL ALERT examined this possibility. Therefore, re- • However, daily methadone mainte- Issues of Substance Abuse Dedicated searchers in Amsterdam assessed the ef- nance of ≥60 mg plus no drug injec- to Screening and Brief Intervention, 8 fects of the combination of these strate- tion or injection only with exchanged gies among 714 injection drug users at risk (continued on page 2)

Alcohol, Other Drugs, and Health: Current Evidence is a project of the Boston Medical Center, supported by the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism, and produced in cooperation with the Boston University Schools of Medicine and Public Health.

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Methadone Maintenance (continued on from page 1) PAGE 2

needles (all in the past 6 recent outbreaks of HIV and HCV Editorial Board months) significantly reduced among IDUs, these findings are also both HIV and HCV seroinci- applicable to communities in the dence (adjusted incidence rate United States that lack adequate ac- Editor ratios 0.43 and 0.36, respec- cess to opioid treatment programs tively, when compared with and/or syringe exchange. Richard Saitz, MD, MPH, FASAM, FACP no methadone maintenance Peter D. Friedmann, MD, MPH Professor of Medicine & Epidemiology Boston University Schools of Medicine & Public Health and drug injection without exchanging needles). Reference: Van Den Berg C, et al. Full participation in harm reduction Co-Editor Comments: This study provides pro- programmes is associated with David A. Fiellin, MD spective evidence that a long-term, decreased risk for human Associate Professor of Medicine comprehensive public strategy to re- immunodeficiency virus and hepatitis Yale University School of Medicine duce bloodborne infections among C virus: evidence from the IDUs must include both syringe ex- Amsterdam Cohort Studies among change and opioid agonist therapy at drug users. Addiction. 2007;102 Associate Editors effective dose levels. Although most (9):1454–1462. Julia H. Arnsten, MD, MPH relevant to policy in countries with Associate Professor of Medicine, Epidemiology, & Psychiatry Albert Einstein College of Medicine Extended-Release Naltrexone Works Particularly Well for Abstinent Patients With Dependence R. Curtis Ellison, MD Many patients with alcohol dependence versus 7.2); Professor of Medicine & Public Health do not receive the full benefits of treat- • decreased days with heavy Boston University School of Medicine ment because they do not adhere to it. drinking (median days per In part to address issues with adher- month, 0.2 versus 2.9). Peter D. Friedmann, MD, MPH ence, extended-release naltrexone, Associate Professor of Medicine & Community Health which is released over a month after Smaller benefits, which were not Warren Alpert Medical School of Brown University one injection, was developed. always statistically significant, were

found among the 28 subjects treated Marc N. Gourevitch, MD, MPH In the pivotal randomized, placebo- with 190 mg of naltrexone. Dr. Adolph & Margaret Berger Professor of Medicine controlled trial that showed the effi- New York University School of Medicine cacy of naltrexone combined with psy- Comments: Requiring abstinence chosocial therapy, subjects with ≥7 Kevin L. Kraemer, MD, MSc before starting treatment for alcohol days of abstinence benefited the most Associate Professor of Medicine & Health Policy & dependence can be a barrier to care. Management from the drug. However, achieving 7 But at least in this industry- University of Pittsburgh Schools of Medicine & Public days of abstinence before treatment is sponsored secondary analysis of a Health difficult. Therefore, researchers as- small subgroup of subjects, those sessed naltrexone’s efficacy, in that who achieved 4 days of abstinence Jeffrey H. Samet, MD, MA, MPH same clinical trial, among the subgroup before entering treatment re- Professor of Medicine & Social & Behavioral Sciences of 82 subjects with ≥4 days of absti- sponded well to extended-release Boston University Schools of Medicine & Public Health nence. naltrexone. Unfortunately, this and other medications with proven effi- Alexander Y. Walley, MD, MSc In that subgroup, 380 mg of naltrexone cacy (e.g., acamprosate, oral naltrex- Instructor of Medicine in 28 subjects versus placebo in 28 one, and disulfiram) remain underuti- Boston University School of Medicine subjects lized in the treatment of alcohol de- pendence. • increased the time to first drink Richard Saitz, MD, MPH Managing Editor (median days, 41 versus 12); Rosanne T. Guerriero, MPH • increased continuous abstinence Reference: O’Malley SS, et al. Efficacy Boston Medical Center over 6 months (32% versus 11%); of extended-release naltrexone in • increased time to first heavy drink- alcohol-dependent patients who are ing (>180 versus 20 days); abstinent before treatment. J Clin • decreased days with any drinking Psychopharm. 2007;27(5):507–512. (median days per month, 0.7

Alcohol, Other Drugs, and Health: Current Evidence, Jan-Mar 2008

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Prevalence of Adolescent Substance Use Identified by Screening in Primary Care

Screening for alcohol and drug use among adolescents is • The prevalence of positive screens was lower at well- advocated by the American Medical Association and others. child visits (11%) than at sick visits (23%). However, the prevalence of adolescent substance use prob- • Statistical modeling estimated that 22% of the adoles- lems and disorders identified with an accepted screening cents had nonproblematic use, 11% had problematic instrument is not known. use (>1 substance-related problem during the past year but no diagnosis of abuse or dependence), 7% Using the validated CRAFFT* instrument, researchers had abuse, and 3% had dependence. screened 2133 12- to 18-year olds (representing a 93% par- ticipation rate) from a network of various New England Comments: The prevalence of substance use problems primary care practices. Researchers determined the preva- among adolescents, as determined with a validated tool in lence of positive screening results (2 or more positive re- primary care settings, is high. Therefore, identifying and sponses, which is highly correlated with having a substance- implementing efficacious approaches to address these related diagnosis and needing treatment) in the overall sam- problems is essential. ple, by visit type (e.g., well-child care, sick visit), and by prac- Jeffrey H. Samet, MD, MA, MPH tice site (urban hospital-based clinics, health maintenance organizations, rural family-medicine practices, and school- *Car Relax Alone Forget Friends Trouble (the main words based health centers). in 5 separate questions about alcohol and drug use)

• Overall, 44% of subjects reported any lifetime use of Reference: Knight JR, et al. Prevalence of positive alcohol or other drugs. substance abuse screen results among adolescent primary • Fifteen percent screened positive on the CRAFFT, with care patients. Arch Pediatr Adolesc Med. 2007;161 the highest prevalence of positive screens in school- (11):1035–1041. based clinics (30%) and rural family practices (24%).

Melatonin, Benzodiazepines, and Sleep Quality Among Patients Receiving Methadone

Both benzodiazepine abuse and sleep disorders are common Comments: This small trial has several findings relevant to worldwide among patients receiving methadone mainte- the vexing problems of sleep disturbance and benzodi- nance. This double-blind trial evaluated the effectiveness of azepine abuse among patients receiving methadone. Most melatonin in reducing sleep problems among 80 patients of the improvement in sleep quality was attributable to who were receiving methadone maintenance and abusing stopping benzodiazepines, a finding clinicians may choose benzodiazepines. These patients were recruited into a ben- to highlight when discussing benzodiazepine use with their zodiazepine withdrawal program where they each received sleep-disturbed patients who receive methadone. Al- melatonin (5 mg per day) for 6 weeks, nothing for 1 week though melatonin did not improve benzodiazepine discon- (washout week), and placebo for 6 weeks. tinuation overall, it improved sleep quality among patients who could not stop benzodiazepines and lengthened the • Overall, subjects reported higher subjective sleep qual- time to relapse among those who did stop. If replicated, ity, regardless of treatment arm, at 6 weeks. these findings will support melatonin’s possible use for • About one-third of subjects had stopped using benzodi- sleep problems among patients who receive methadone azepines (as identified by urine toxicology) by 6 weeks. maintenance and use anxiolytics, and as an adjunct to de- Sleep quality among these subjects was not affected by crease relapse to benzodiazepines. melatonin but was significantly better than sleep quality Peter D. Friedmann, MD, MPH among subjects who continued benzodiazepines. • Of subjects who continued using benzodiazepines at 6 weeks, sleep quality significantly improved with mela- Reference: Peles E, et al. Melatonin for perceived sleep tonin versus placebo. disturbances associated with benzodiazepine withdrawal • Over approximately 21 months, 63 patients stopped among patients in methadone maintenance treatment: a using benzodiazepines, although all but 4 relapsed. Time double-blind randomized clinical trial. Addiction. 2007;102 to benzodiazepine relapse was significantly longer (12):1947–1953. among subjects who received melatonin (125 days) ver- sus placebo (42 days) in the first 6 weeks.

Alcohol, Other Drugs, and Health: Current Evidence, Jan-Mar 2008

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Inpatient Medical Care Plus Substance Use Treatment Improves Health Services Utilization

During hospitalization for substance use-related medical • Patients who were assigned to but did not complete conditions (e.g., abscess, endocarditis), the underlying sub- the DH program demonstrated no post-discharge im- stance use is rarely addressed. Further, post-discharge re- provements in health service utilization. ferral for substance use treatment often goes uncompleted. Consequently, frequent re-admission and deterioration in Comments: Completing a program that integrated sub- health status are common. stance use care with hospital-based medical treatment for substance use-related conditions was associated with post- In an attempt to break this cycle, researchers evaluated the discharge improvements in health services utilization. Study impact of a special 12-bed unit on an inpatient day hospital limitations included nonrandom assignment of subjects and (DH) that addressed patients’ medical and substance use restriction of utilization data to nearby health facilities. treatment needs. Patients were assigned to DH (n=63) or Other models that bridge inpatient care for substance use- usual care (n=327) based on the availability of beds. related conditions with effective outpatient treatment should be developed and evaluated. These models should • Forty-nine percent of patients assigned to DH com- be cost-effective and tailored to patients most likely to pleted the 2-week program. benefit from such services. • In the 6 months following discharge, these DH com- Marc N. Gourevitch, MD, MPH pleters were less likely than patients who received usual care to have ≥3 emergency department visits Reference: O’Toole TP, et al. The effect of integrated medi- (adjusted odds ratio [AOR], 0.3) and were more likely cal-substance abuse treatment during an acute illness on to have ≥1 ambulatory care visit (AOR, 4.1). Hospital subsequent health services utilization. Med Care. 2007;45 admissions did not differ significantly between the (11):1110–1115. groups.

Do Patient Characteristics Moderate Naltrexone’s Effects on Drinking?

Moderators of naltrexone’s effects on drinking are not well • lower mean percent of heavy drinking days among understood. To address this, researchers randomized 180 subjects with the D4 dopamine receptor polymor- heavy drinkers* who were not seeking alcohol treatment phism DRD4-L to receive 3 weeks of daily naltrexone (50 mg) or placebo. Subjects kept a real-time electronic diary about their drink- Comments: The effect of naltrexone on drinking in this ing at specific times during the day. study was small and limited to mean percentage of drinking days. The study identified several moderators of naltrex- Sixty-three percent of subjects had alcohol dependence. one’s effects on drinking and several subjective measures, Overall, naltrexone was associated with a significantly but each moderator interacted with naltrexone on only lower mean percentage of drinking days (57% for the one, often intermediary, outcome. Although the nontreat- naltrexone group versus 65% for the placebo group). How- ment-seeking population and data collection with real-time ever, naltrexone was not associated with other drinking electronic diaries are strengths of this study, further work outcomes (drinks per day, drinks per drinking day, heavy is needed to identify which patients will have the best re- drinking days) or subjective outcomes (e.g., drinking urge, sponse to naltrexone. stimulation, sedation). Kevin L. Kraemer, MD, MSc

In analyses that assessed possible moderators, naltrexone *Drank on ≥4 days per week and heavily (>6 drinks for men, >4 was associated with the following: for women) on ≥2 days per week over the prior month

• reduced stimulation from drinking among women Reference: Tidey JW, et al. Moderators of naltrexone’s • lower urge to drink among subjects with earlier age of effects on drinking, urge, and alcohol effects in non- alcoholism onset treatment-seeking heavy drinkers in the natural • longer time between drinks among subjects with a environment. Alcohol Clin Exp Res. 2008;32(1):1–9. family history of alcohol problems

Alcohol, Other Drugs, and Health: Current Evidence, Jan-Mar 2008

PAGE 5 Health Outcomes

Prescription Opioid Use and Diversion

Prescription opioid analgesics are the most commonly When they obtained prescription opioids for abused prescription medication. Further, these drugs are euphoria, they usually did so from dealers. more frequently abused than heroin. Researchers in this study interviewed 586 drug users in New York City to Comments: This study helps to illuminate an emergent, determine patterns of prescription opioid use, misuse, and fairly American, drug abuse pattern—abuse and de- and sales (diversion). pendence on prescription opioids. Many individuals used these medications to avoid opioid withdrawal or to treat • Seventy-two percent of subjects used methadone, pain, an informative finding. Also, patients were less and 65% sold it. likely to use these physician-obtained medications for • Methadone was used and sold by more individuals euphoria than for other indications, which is notable and than was OxyContin, Vicodin, or Percocet. most likely reflects a high level of opioid tolerance. Fi- • Fifty-eight percent of prescription drug users ob- nally, many of these patients were interacting with physi- tained prescription opioids for pain, withdrawal, or cians, suggesting that physicians should show caution euphoria (which they used and/or sold) from doc- when prescribing opioids and should consider offering tors; 42% obtained them from dealers. office-based treatment (e.g., buprenorphine) or referral • Of subjects who reported using Oxycontin they to specialty treatment (e.g., methadone) when indicated. obtained from physicians, 83% reported having used David A. Fiellin, MD the drug primarily for pain; 50% used it primarily to prevent opioid withdrawal symptoms, and 38% used Reference: Davis WR, et al. Prescription opioid use, mis- it primarily for euphoria. use, and diversion among street drug users in New York • Prescription drug users were less likely to obtain City. Drug Alcohol Depend. 2008;92(1–3):267–276. prescription opioids for euphoria than for pain.

Impact of Substance Use on Adherence to HIV Medications

High levels of adherence to highly active antiretroviral jects with no use (adjusted odds ratio, 0.6; P=0.05); therapy (HAART) are associated with improved out- • lower in subjects with current use than in subjects comes for patients with HIV. Through interviews with with no use, regardless of receipt of substance use 659 patients with HIV, researchers in this study assessed treatment. whether illicit substance use and receiving substance use treatment influence adherence to HAART. Comments: This study demonstrates the potential ad- verse impact of illicit drug use on adherence to HIV Forty-two percent of the patients had used illicit drugs in medications. It also indicates the importance of ongoing the past 6 months (current use); 30% had used illicit substance use treatment for people with past substance drugs but not in the past 6 months (former use), and use. The study is limited because it did not evaluate 28% had never used illicit drugs. biologic outcomes (e.g., CD4 cell count or HIV viral load) or the impact of alcohol separately from the im- Adherence was pact of illicit substance use in multivariate analyses. Nonetheless, these findings support the importance of • significantly less common among subjects with cur- engaging patients with HIV and substance use (current rent use (60%) than among subjects with former or former) in substance use treatment. (68%) or no (77%) use; David A. Fiellin, MD • similar between subjects with former use who had received recent substance use treatment and sub- Reference: Hicks PL, et al. The impact of illicit drug use jects with no use; and substance abuse treatment on adherence to • lower in subjects with former use who had not re- HAART. AIDS Care. 2007;19(9):1134–1140. ceived recent substance use treatment than in sub-

Alcohol, Other Drugs, and Health: Current Evidence, Jan-Mar 2008

PAGE 6 Combining Healthy Behaviors, Including Moderate Drinking, Reduces MI in Women Certain behaviors can reduce the risk of myocardial infarc- • alcohol consumption, not smoking, and tion (MI) in women. However, little data are available on physical activity (RR, 0.1) the magnitude of the risk reduction from a combination of • alcohol consumption, not smoking, physical these behaviors. activity, and a waist-to-hip ratio <0.85 (RR, 0.08) Researchers in Sweden assessed the benefit of following a • Most MIs were attributable to the lack of these healthy diet plus drinking about ≥0.5 alcoholic drinks per healthy behaviors. day, not smoking, having a waist-hip ratio <0.85, and being physically active among 24,444 postmenopausal women Comments: In a recent study by Mukamal et al (http:// without cancer, cardiovascular disease, or diabetes at base- www.bu.edu/aodhealth/issues/issue_jan07/ line. A healthy diet included a high intake of vegetables, ellison_mukamal.htm), men with healthy lifestyles who fruit, whole grains, fish, and legumes; being physically active drank alcohol had a greater reduction in MI risk than did involved at least 40 minutes of daily walking or bicycling men with healthy lifestyles who did not drink. The present and 1 hour of weekly exercise. study shows a similar finding among women: it supports the notion that combining a Mediterranean-type diet and • During 6.2 years of follow-up, 308 cases of primary MI other healthy lifestyle factors, including low alcohol intake, occurred. may substantially reduce the risk of myocardial infarction • In adjusted analyses, each of the assessed health behav- in women. iors was inversely and independently associated with R. Curtis Ellison, MD the risk of MI, although results for physical activity were not significant. *Compared with women without any healthy lifestyle behaviors • The risk of MI was significantly lower among women with a healthy diet* plus the following: Reference: Akesson A, et al. Combined effect of low-risk dietary and lifestyle behaviors in primary prevention of • alcohol consumption (relative risk [RR] 0.5) myocardial infarction in women. Arch Intern Med. 2007;167 • alcohol consumption and not smoking (RR, (19):2122–2127.

0.2)

Characteristics of Adolescents Who Use Cannabis But Not Tobacco Cannabis is associated with tobacco use and has been de- get drunk ≥3 times in the last month (AOR, 4.5), and scribed as a “gateway” drug. But, whether adolescents who use other illegal drugs in last month (AOR, 2.3); use cannabis only differ from those who use both cannabis • less likely to report a good relationship with their and tobacco is unclear. To explore these possible differ- parents (AOR, 0.6). ences, researchers assessed social and academic perform- ance among a nationally representative sample of 5263 Comments: Unexpectedly, this cross-sectional study found Swiss adolescents who either used cannabis only, cannabis that adolescents who smoked cannabis only were more and tobacco, or neither. likely than adolescents who never used cannabis or to- bacco to be engaged in sports, in an academic track, and Subjects who used cannabis only, compared with subjects to report good peer relationships. At the same time, can- who used both cannabis and tobacco, were nabis only users were more likely to be truant, to get drunk, and to use other drugs. Prospective longitudinal • more likely to practice sports (adjusted odds ratio analyses are needed to determine whether cannabis use is [AOR], 2.4), be on an academic track (AOR, 2.6), and a cause or effect of these outcomes and how the interac- get good grades (AOR, 1.6); tion between tobacco and cannabis smoking influences • less likely in the past month to use cannabis ≥10 times adolescent development. [AOR, 0.3] and get drunk ≥3 times [AOR, 0.6]). Alexander Y. Walley, MD, MSc

Subjects who used cannabis only, compared with subjects Reference: Suris JC, et al. Some go without a cigarette: who never used cannabis or tobacco, were characteristics of cannabis users who have never smoked tobacco. Arch Pediatr Adolesc Med. 2007;161(11):1042– • more likely to practice sports (AOR, 1.4), be on an 1047. academic track (AOR, 1.4), and report good peer rela- tionships (AOR, 1.6) as well as be truant (AOR, 2.3),

Alcohol, Other Drugs, and Health: Current Evidence, Jan-Mar 2008

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Racial Differences in Treatment Received and in Treatment Completed

Racial and ethnic minorities may be less likely than others tion rates would improve for African Americans and to complete treatment for alcohol dependence. In this resolve for Hispanics. study, researchers assessed whether racial/ethnic differ- ences in type of treatment received (outpatient or resi- Comments: This study showed that completion rates for dential) could explain differences in treatment completion outpatient and residential alcohol treatment were low rates. They analyzed the discharge data of 10,591 patients among all racial/ethnic groups but lowest among African (4141 African Americans, 3120 Hispanics, and 3330 Americans. Even if African Americans had an equal prob- whites) treated in the publicly funded programs of a large, ability as whites of entering residential treatment, they urban county in California. would still be less likely to complete treatment. This study is unable to determine whether racial and ethnic minori- • The rate for completing outpatient treatment was ties should be steered to residential alcohol treatment. lowest among African Americans (18%), followed by But, it does underscore the need to improve the reten- whites (27%) and Hispanics (30%). The rate of com- tion and completion rates of patients with alcohol de- pleting residential treatment was also lowest among pendence, especially African Americans, enrolled in pub- African Americans (31%), followed by Hispanics licly funded alcohol treatment programs. (43%) and whites (46%). Kevin L. Kraemer, MD, MSc • In analyses adjusted for potential confounders, Afri- can Americans (odds ratio [OR], 1.9) and Hispanics Reference: Bluthenthal RN, et al. Are racial disparities in (OR, 2.1) were more likely than whites to enter out- alcohol treatment completion associated with racial differ- patient (versus residential) treatment. ences in treatment modality entry? Comparison of outpa- • Further analyses indicated that if minority patients in tient treatment and residential treatment in Los Angeles outpatient care had the same probability of receiving County, 1998 to 2000. Alcohol Clin Exp Res. 2007;31 residential treatment as did white patients with oth- (11):1920–1926. erwise similar characteristics, the disparity in comple-

Moderate Drinking May Improve Fasting Glucose in People with Diabetes

Data on the association between moderate drinking and Comments: In this study, patients with diabetes who had glycemic control are conflicting. To clarify this association, abstained for a week but started consuming about a glass researchers in Israel conducted a randomized trial of 109 of wine per day had a rather marked improvement in subjects with type 2 diabetes who had not consumed >1 their fasting blood glucose levels. Those with more se- drink in the past week. Subjects, aged 41 to 74 years, vere disease (i.e., higher baseline levels of hemoglobin were given either about 1 glass of wine or nonalcoholic A1c) showed the largest effect from alcohol, a finding beer (control) daily with dinner. Each subject received supported from many observational studies. Since sub- dietary counseling, was instructed to consume a specific jects were followed for only 3 months, long-term effects amount of calories, completed food diaries and question- cannot be estimated from this study. naires, and underwent blood testing. R. Curtis Ellison, MD

Results for the 91 patients who completed the 3-month trial include the following: Reference: Shai I, et al. Glycemic effects of moderate alcohol intake among patients with type 2 diabetes: a • Fasting blood glucose decreased in the alcohol group multi-center, randomized clinical intervention trial. (from 140 to 118 mg/dl) but not in the control group. Diabetes Care. 2007;30(12):3011–3016. • In the alcohol group, decreases were greatest among patients with higher levels of hemoglobin A1c at base- line. • Postprandial glucose levels did not significantly differ between the groups. • No notable adverse effects were reported.

Alcohol, Other Drugs, and Health: Current Evidence, Jan-Mar 2008

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Issues of Substance Abuse Dedicated to Screening and BI Visit www.aodhealth.org Two recent issues of Substance intervention approaches in col- to view the newsletter online, Abuse—the journal published by The lege students to sign up for a free subscription, and Association for Medical Education and • Measuring performance of BI in to access additional features including Research in Substance Abuse—focused the VA downloadable PowerPoint on alcohol and drug screening and brief presentations, free CME credits, intervention (BI). Topics explored in- Comments: These special issues are and much more! clude the following: timely given the large federal efforts to actively disseminate screening and • The history of screening and brief brief intervention throughout the intervention U.S. The research suggests that al- The major journals regularly reviewed for the • Screening and BI as a public health though screening and brief interven- newsletter include the following: approach to managing substance tion is now a mature clinical practice, many questions ranging from efficacy Addiction abuse Addictive Behaviors • Methodological issues in screening to implementation in different set- AIDS and BI research tings remain. Alcohol Alcohol & Alcoholism • Communication during BIs Richard Saitz, MD, MPH Rosanne T. Guerriero, MPH Alcoholism: Clinical & Experimental Research • Quality issues in alcohol screening American Journal of Drug & Alcohol Abuse

• Cost-effectiveness and cost-benefit American Journal of Epidemiology References: Substance Abuse. 2007;28 of screening and BI American Journal of Medicine (3). Alcohol/Drug Screening and American Journal of Preventive Medicine • Training to improve emergency Brief Intervention: Advances in Evi- American Journal of Psychiatry doctors’ skills in screening and BI American Journal of Public Health dence-Based Practice. Part I.; Sub- American Journal on Addictions • BI and multiple risk factors in pri- stance Abuse. 2007;28(4). Alcohol/ Annals of Internal Medicine mary care Drug Screening and Brief Interven- Archives of General Psychiatry • Adolescents’ preferences for sub- tion: Advances in Evidence-Based Archives of Internal Medicine stance abuse screening in primary Practice. Part II. British Medical Journal care practice Drug & Alcohol Dependence Epidemiology • Alternatives to person-delivered Journal of Addiction Medicine Journal of Addictive Diseases Journal of AIDS Journal of Behavioral Health Services & Research Journal of General Internal Medicine Journal of Studies on Alcohol Visit our companion site www.mdalcoholtraining.org Journal of Substance Abuse Treatment Journal of the American Medical Association to view... Lancet New England Journal of Medicine Preventive Medicine Psychiatric Services Substance Abuse Substance Use & Misuse Helping Patients Who Drink Too Much Many others periodically reviewed (see www..aodhealth.org)

A free online curriculum for screening and brief intervention for unhealthy alcohol use Contact Information: Alcohol, Other Drugs, and Health: Current Evidence Boston University School of Medicine/Boston Medical Center 91 East Concord Street, Suite 200 Boston, MA 02118 [email protected]

Alcohol, Other Drugs, and Health: Current Evidence, Jan-Mar 2008