TABLE OF CONTENTS , Other Drugs, and Health: INTERVENTIONS & ASSESSMENTS T A B L E O F Lack of EfficacyC O N of T a E 3-Medication N T S Treatment Protocol for Current Evidence Dependence, 1 JANUARY–FEBRUARY 2012 Retention in Opioid Agonist Treatment after Prison Release Re- duces Re-incarceration, 1

Adding N-Acetylcysteine to INTERVENTIONS & ASSESSMENTS Glucocorticoids May Improve Outcomes in Patients with Severe Alcoholic Hepatitis, 2 Lack of Efficacy of a 3-Medication Treatment Protocol for Methamphetamine Dependence People Receiving Buprenorphine and Methadone Are More Likely to Be The PROMETA™ protocol, which includes − proportion of methamphetamine- Responsible for Traffic Crashes, 3 the benzodiazepine antagonist flumazenil, negative urine tests (50%, 40%, and Recent Notable Developments in the GABA-agonist , and the H 1- 30% versus 50%, 50%, and 40%, Pharmacotherapies, 3 histamine antagonist hydroxyzine, is un- respectively); proven for the treatment of methampheta- − mean methamphetamine craving HEALTH OUTCOMES mine dependence. In this double-blind trial, score (2.8, 3.1, and 2.2 versus 2.9, Modest Marijuana Exposure Does Not researchers randomized 120 patients with 2.9, and 2.4, respectively); or Adversely Affect Pulmonary Function, methamphetamine abuse or dependence − percentage with 3 consecutive but High Cumulative Exposure Does, to the PROMETA protocol (intravenous negative urine tests (36% and 39% 4 flumazenil 2 mg on days 1, 2, 3, 22, and 23; versus 46% and 51% at days 40 and Wine-specific Mortality Benefits oral gabapentin titrated to 1200 mg per 108, respectively). Disappear When Studied day by day 4 and continued to day 40; and • Mild, moderate, and severe adverse Appropriately, 4 oral hydroxyzine 50 mg prior to flumazenil events were reported by 73%, 23%, infusion and as take-home medication Thirty Years of Observational Studies and 4% of the experimental group and through day 10) or to placebo (active hy- of Alcohol’s Cardioprotective Effects: 59%, 40%, and 1% of the placebo Uncertainty Remains, 5 droxyzine only). Each group received 14 group, respectively. Lifestyle and Environmental Factors, weekly sessions of cognitive behavioral Including Tobacco and Alcohol Use, therapy. Outcomes were methampheta- Comments: The PROMETA protocol has and Risk of Cancer, 5 mine and other drug use documented by been promoted and used as a treatment for urine testing, self-reported methampheta- methamphetamine dependence despite lack HIV AND HCV mine craving, treatment retention, and of a strong scientific rationale and proven

Baclofen: New Hope for Alcohol adverse events. efficacy. This randomized placebo- Abstinence in Patients with Alcohol- controlled trial found no benefit of the and HCV-related Cirrhosis? 5 • Fifty percent of the experimental group PROMETA protocol over placebo for

Needle and Syringe Provision and and 70% of the placebo group re- treatment of methamphetamine abuse or Opioid Agonist Treatment May mained in the study through the medi- dependence. It raises serious questions Reduce the Spread of HCV in People cation phase (day 40). Only 30% of the about the use of the PROMETA protocol with Injection Drug Use, 6 for methamphetamine dependence. experimental group and 43% of the Mental-Health and Substance Use placebo group remained until the end Kevin L. Kraemer, MD, MSc

Disorders Impact the Development of of the study (day 108). References: Ling W, Shoptaw S, Hillhouse M, AIDS-defining Illness and Death in • HIV-infected Veterans, 6 During follow-up at days 23, 40, and et al. Double-blind placebo-controlled 108, the experimental and placebo evaluation of the PROMETA™ protocol for Political Engagement Is Associated groups did not differ significantly with methamphetamine dependence. Addiction. with Reduced HIV Risk Behaviors, 7 regard to: 2012;107(2):361–369. JOURNAL ALERT Retention in Opioid Agonist Treatment after Prison Release Reduces Drug and Alcohol Review Publishes Special Issue on Low-Risk Drinking Re-incarceration Guidelines, 7 Opioid agonist treatment (OAT) in prison recruited in 1996–1997 for a randomized RESOURCE ALERT and after release might influence the risk of controlled trial of OAT in prison in New re-incarceration. This prospective cohort South Wales, Australia. Participants were NIAAA Releases Free Simplified study linked data on OAT and incarceration followed through 2006. Screening Guide to Identify Underage Drinking, 8 among 375 men with heroin use originally (continued on page 2)

Alcohol, Other Drugs, and Health: Current Evidence is a project of the Boston Medical Center produced in cooperation with the Boston University Schools of Medicine and Public Health. Initially supported by a grant from the National Institute on Alcohol Abuse and Alcoholism, the newsletter is currently supported by grant no. R25-DA013582 from the National Institute on Drug Abuse (NIDA). The content is solely the responsibility of the authors and does not necessarily represent the official views of NIDA or the National Institutes of Health.

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Editorial Board Retention in OAT after Prison Release (continued from page 1)

Editor • During 9+ years of observation, 331 tions have shown that initiating OAT Richard Saitz, MD, MPH, FASAM, FACP participants engaged in OAT 1081 prior to release maximizes post-release Professor of Medicine & Epidemiology times, with a median of 2 episodes treatment retention, the current study Boston University Schools of Medicine & Public per participant (mean length of suggests active linkage to ongoing Health engagement, 156 days); 58% started treatment is an essential component.

OAT in prison. Continuing or initiating OAT during Co-Editor • Ninety percent of participants were incarceration is necessary but not David A. Fiellin, MD re-incarcerated after the first sufficient to optimize post-release Professor of Medicine and Public Health outcomes among opioid-dependent Yale University School of Medicine incarceration. inmates; correctional systems and • Engagement in OAT at the time of treatment providers must also provide Associate Editors release had no effect on re- transitional assistance to ensure that incarceration. former inmates reach OAT programs Nicolas Bertholet, MD, MSc • Alcohol Treatment Center Post-release retention in OAT was after release. Clinical Epidemiology Center associated with a one-fifth reduction Peter D. Friedmann, MD, MPH Lausanne University Hospital in the number of re-incarcerations. R. Curtis Ellison, MD Reference: Larney S, Toson B, Burns L, Professor of Medicine & Public Health Comments: This study affirms that et al. Effect of prison-based opioid Boston University School of Medicine retention in OAT following release is substitution treatment and post-release Peter D. Friedmann, MD, MPH associated with reduced re-incarceration retention in treatment on risk of re- Professor of Medicine & Community Health among former prisoners with opioid incarceration. Addiction. 2012;107 Warren Alpert Medical School of Brown University dependence. Although other investiga- (2):372–380.

Kevin L. Kraemer, MD, MSc Associate Professor of Medicine and Health Policy & Adding N-Acetylcysteine to Glucocorticoids May Improve Outcomes in Management Patients with Severe Alcoholic Hepatitis University of Pittsburgh Schools of Medicine & Public

Health This randomized controlled trial con- PRED- 95% OUT- PRED HR Hillary Kunins, MD, MPH, MS ducted in 11 French university hospitals COME NAC CI Associate Clinical Professor of Medicine and sought to determine whether N- 1-month 0.14 - 24% 8% 0.58 Psychiatry & Behavioral Sciences acetylcysteine [NAC], an antioxidant used mortality 0.76 Albert Einstein College of Medicine to treat acetaminophen-induced hepatitis, 3-month 0.33† 34% 22% 0.33 Darius A. Rastegar, MD further reduced mortality in patients mortality - 1.04 6-month 0.37 - Assistant Professor of Medicine treated with prednisolone for severe al- 38% 27% 0.62 mortality 1.06 Johns Hopkins School of Medicine coholic hepatitis. Subjects (N=174) were †As reported in the paper. Jeffrey H. Samet, MD, MA, MPH age 18 or older; had consumed, on aver- Professor of Medicine & Social & Behavioral Sciences age, >50 g alcohol per day in the past 3 • Adverse events were no higher in Boston University Schools of Medicine & Public months; had a Maddrey’s discriminant the PRED-NAC arm, and 2 major Health function* of 32 or more; and had liver adverse events (hepatorenal syn- Jeanette M. Tetrault, MD histologic findings consistent with alco- drome and infection) were signifi- Assistant Professor of Internal Medicine holic hepatitis. The long list of exclusion cantly lower. Yale University School of Medicine criteria included other possible causes of

Judith Tsui, MD, MPH liver disease (e.g., hepatitis B or C), HIV Comments: Although this study failed to Assistant Professor of Medicine infection, and “serious cardiac, respira- show significantly reduced mortality at 6 Section of General Internal Medicine tory or neurologic disease.” All patients months (the primary endpoint), a signifi- Boston Medical Center received oral prednisolone for 28 days, Boston University School of Medicine cant short-term benefit was seen in the while 85 also received intravenous NAC PRED-NAC arm with no serious ad- Alexander Y. Walley, MD, MSc on days 1–5. verse events. The failure may simply Assistant Professor of Medicine have been due to lack of sufficient Section of General Internal Medicine • Boston Medical Center Mortality rates and hazard ratios (HR) power. It is also possible that longer Boston University School of Medicine for patients in the prednisolone-only term outcomes would be better with Medical Director, Narcotic Addiction Clinic (PRED) and prednisolone plus NAC longer courses of NAC treatment. Boston Public Health Commission (PRED-NAC) arms are shown in the Darius A. Rastegar, MD table. Managing Editor Reference: Nguyen-Khac E, Thevenot T,

Donna M. Vaillancourt *Calculated as 4.6 × [patient’s prothrombin time - Piquet MA, et al. Glucocorticoids plus N- Boston Medical Center control prothrombin time (in seconds)] + serum acetylcysteine in severe alcoholic hepatitis. bilirubin level (mg/dL). N Engl J Med. 2011;365(19):1781–1789.

Alcohol, Other Drugs, and Health: Current Evidence, January–February 2012

P A G E 3

People Receiving Buprenorphine and Methadone Are More Likely to Be Responsible for Traffic Crashes

Opioid agonist treatment (OAT) among opioid-dependent Comments: Past studies have suggested there is no increase patients does not result in substantial driving impairment in in motor-vehicle accidents among drivers receiving OAT. driving simulation studies. The association between road Although OAT patients may not be involved in more traffic crashes and OAT has not been studied since bupre- crashes, when they are involved, this study suggests that norphine became available. This French study of 72,685 car, they are more likely to be responsible. But, we do not bicycle, and scooter drivers involved in traffic accidents be- know if the increased risk is because of OAT, because such tween 2005 and 2008 investigated the association between persons tend to be riskier drivers, or if there is some other risk of being responsible for a crash and having a prescrip- reason. Furthermore, we do not know how these risks tion for buprenorphine or methadone on the day of the stack up against the risk among patients with opioid addic- crash. Responsibility was determined by police crash re- tion who are not receiving OAT. In any case, when discuss- ports matched with a national crash database and linked to ing driving risk with patients, it seems reasonable to reas- national pharmacy data. sure them that driving is not impaired under experimental conditions, while at the same time recognizing that, under • In analyses adjusted for age, gender, road/vehicle con- real-world conditions, such patients may be more likely to ditions, and prescriptions for other medications known be responsible for a traffic crash. to impair driving ability, drivers who were prescribed Tae Woo Park, MD* & Alexander Y. Walley, MD, MSc buprenorphine or methadone had a 2-fold risk of being responsible for a road traffic crash compared with Reference: Corsenac P, Lagarde E, Gadegbeku B, et al. Road those who were not (odds ratio [OR], 2.02). traffic crashes and prescribed methadone and buprenor- • The 0.3% of drivers who were prescribed buprenor- phine: A French registry-based case-control study. Drug Al- phine or methadone were more likely to be men, to cohol Depend. November 18, 2011 [Epub ahead of print]. be younger, and to have been prescribed other medi- doi:10.1016/j.drugalcdep.2011.10.022.

cations that impair driving ability (such as anxiolytics) *Contributing Editorial Intern, Clinical Addiction Research and Education than the 99.7% who were not. (CARE) Unit, Boston University School of Medicine, Boston, MA.

Recent Notable Developments in Addiction Pharmacotherapies

Several recent studies have potentially important implica- Comments: Despite being early reports and, therefore, in- tions for practice: conclusive, the 2 studies among stimulant-dependent pa- tients are important, because pharmacological interven- • In one small randomized trial, 60 methamphetamine- tions targeting this group have not been particularly suc- dependent men who have sex with men were assigned cessful. These results hold some promise if they can be to mirtazepine or placebo, both added to counseling. replicated. Trazodone is often recommended for insomnia Although medication adherence was modest, metham- in patients with substance dependence because it has little phetamine-positive urine tests were half as frequent addiction risk, but the study in methadone-maintained pa- among men in the mirtazepine group, who also re- tients suggests that it may not work. Thus, the search for ported fewer risky sexual behaviors than those in the safe and efficacious alternatives should continue. placebo group. Richard Saitz MD, MPH

References: Colfax GN, Santos G-M, Das M, et al. Mirta- • In another small randomized trial (N=37), people with zapine to reduce methamphetamine use: a randomized dependence were assigned to varenicline or controlled trial. Arch Gen Psychiatry. 2011;68(11):1168– placebo. All participants received counseling. Those on 1175. varenicline were twice as likely to have negative urine tests for cocaine, and they also reported less reward Plebani JG, Lynch KG, Yu Q, et al. Results of an initial from cocaine use. clinical trial of varenicline for the treatment of cocaine de- pendence. Drug Alcohol Depend. 2012;121(1):163–166.

• In a larger (N=137) randomized placebo-controlled Stein MD, Kurth ME, Sharkey KM, et al. Trazodone for trial, trazodone had no effect on sleep or drug use sleep disturbance during methadone maintenance: a dou- among methadone-maintained opioid-dependent pa- ble-blind, placebo-controlled trial. Drug Alcohol Depend. tients with sleep complaints. 2012;120(1):65–73.

Alcohol, Other Drugs, and Health: Current Evidence, January–February 2012

P A G E 4 HEALTH OUTCOMES

Modest Marijuana Exposure Does Not Adversely Affect Pulmonary Function, but High Cumulative Exposure Does

Previous investigations have not shown a consistent impact − at >10 joint-years, there was a nonsignificant decline of marijuana smoking on pulmonary function. Investigators in FEV1. conducted a longitudinal analysis of 5016 adults* enrolled in − at >20 episodes of marijuana use per month, the the CARDIA † study to assess the impact of marijuana ex- decline in FEV1 was significant. posure on pulmonary function (FEV1 and FVC). Marijuana exposure was assessed at 6 follow-up exams, permitting Comments: The longitudinal study design and analysis of calculation of “joint-years” (where 365 joints=1 joint-year) linearity allowed the investigators to elucidate the complex and tobacco pack-years. Fifty-six percent of participants impact of marijuana on pulmonary function. The positive (n=2807) attended the 20-year follow-up examination with- effect of marijuana smoking on FVC (hypothesized to be a out differential attrition by marijuana use. “stretching and training” effect) dominated marijuana’s im- pact on pulmonary function at lower exposures, whereas its • In adjusted analyses, the association between marijuana negative effect on FEV1 seemed to dominate at higher ex- use and pulmonary function was nonlinear: posures. The authors note that estimating the impact of heavy marijuana use is imprecise in this sample because of − at low lifetime exposure, marijuana use was associ- the low number of heavy users and few non-tobacco users ated with increased FEV1 and FVC. among the heaviest marijuana users. Nevertheless, this − at >7 joint-years, the positive association shown study may help define thresholds for riskier marijuana use, between marijuana use and pulmonary function similar to those defined for alcohol. leveled off. Hillary Kunins, MD, MPH, MS

*Black/non-Hispanic and white/non-Hispanic men and women aged 18–30 Reference: Pletcher MJ, Vittinghoff E, Kalhan R, et al. Asso- years and healthy at enrollment in 1985. ciation between marijuana exposure and pulmonary func- †CARDIA=Coronary Artery Risk Development in Young Adults. tion over 20 years. JAMA. 2012;307(2):173–181.

Wine-specific Mortality Benefits Disappear When Studied Appropriately

Some have suggested that wine might be more beneficial to Comments: If there is a mortality benefit from drinking, health than other types of alcoholic beverages because of these results suggest beverage type doesn’t matter. But, compounds in wine besides alcohol. To test this hypothe- as is very common in studies examining the potential sis, investigators studied 802 past-month abstainers and benefits of drinking, this study tested associations be- drinkers of low-risk (“moderate”) amounts (1 to <3 [14 g] tween typical alcohol consumption during 1 month and drinks per day) age 55–65 years at enrollment. They as- mortality over 20 years without updating consumption. It sessed mortality over 20 years. also compared drinkers with those who had stopped drinking—a group well known to be less healthy (“sick • The mortality rate was 69% for abstainers, 50% for quitters”). “Moderate” drinkers are well known to be low-wine-consumption drinkers (

health factors, and health behaviors. Reference: Holahan CJ, Schutte KK, Brennan PL, et al. Wine

*Adjusted for age, gender, income and education, medical diagnoses, consumption and 20-year mortality among late-life moder- smoking, and physical activity. ate drinkers. J Stud Alcohol Drugs. 2012;73(1):80–88.

Alcohol, Other Drugs, and Health: Current Evidence, January–February 2012

P A G E 5 Thirty Years of Observational Studies of Alcohol’s Cardioprotective Effects: Uncertainty Remains This meta-analysis combined 44 observational studies from of heterogeneity means it is very difficult for clinicians to 1980–2010 that reported a relative risk for ischemic heart make inferences about individual patients. Some people disease (IHD) in relation to average alcohol intake. benefit from low-level drinking while others are harmed, and we cannot differentiate these groups. Furthermore, • The well-known J-shaped curve was confirmed (i.e., meta-analysis of even a large number of studies does not compared with abstainers, IHD risk is lower in people eliminate the possibility that residual confounding could ex- with low-level alcohol consumption but rises with in- plain the findings (e.g., IHD was reduced because of better creasing consumption). risk-factor profiles among those who drink low-level • The maximum cardioprotective effects for mortality amounts). Although advising patients about lower risk occurred between 32–63 g alcohol* per day for men drinking limits is the current standard of practice, consider- and between 11–31 g per day for women. able uncertainty remains about what constitutes a safe level of consumption, and for whom. • The effects were heterogeneous, even at low levels of Peter D. Friedmann, MD, MPH intake.

Comments: Although this study reaffirms the population- Reference: Roerecke M, Rehm J. The cardioprotective asso- level association between low-level alcohol intake and re- ciation of average alcohol consumption and ischaemic heart duced cardiovascular morbidity and mortality, the high level disease: a systematic review and meta-analysis. Addiction. January 9, 2012 [Epub ahead of print]. doi: 10.1111/j.1360- *One standard drink averaged to 12 g pure alcohol in this study. 0443.2012.03780.x.

Lifestyle and Environmental Factors, Including Tobacco and Alcohol Use, and Risk of Cancer Researchers estimated the fraction of cancers occurring in Comments: In this well-done analysis, smoking had, by far, the UK in 2010 that could be attributed to exposure to 14 the largest effect on cancer risk, while 4 percent of all lifestyle and environmental risk factors: tobacco; alcohol; cancer cases were attributable to alcohol intake diet (meat, fruit, vegetable, fiber, and salt consumption); (compared with abstaining). Although the use in this overweight; lack of exercise; occupation; infection; radiation analysis of abstinence as the optimal level of alcohol (ionizing and solar); hormone use; and breastfeeding. consumption related to cancer risk may be reasonable, it would not be the case for cardiovascular diseases or total • Exposure to less-than-optimum levels of the 14 risk mortality. Furthermore, the analysis did not examine factors was responsible for 45.3% of cancers in men levels of alcohol use, an important point since alcohol- and 40.1% of cancers in women (a total of about related cancer risk may relate to consumption amounts. 134,000 cases). The effects related to diet may have been overestimated as well, as the values used in this analysis were much • Of the lifestyle factors studied, tobacco smoking had greater than those seen in most studies. Nevertheless, the the largest effect on the risk of cancer, responsible for results do highlight the importance of targeting certain 19.4% of all new cases. behaviors to reduce cancer risk. • In men, deficient intake of fruits and vegetables (6.1%), R. Curtis Ellison, MD occupational exposures (4.9%), and alcohol consump- tion (4.6%) had the next largest effects on risk. Reference: Parkin DM, Boyd L, Walker LC. The fraction • In women, overweight and obesity (due to the asso- of cancer attributable to lifestyle and environmental ciation with breast cancer) (6.9%) and infectious-agent factors in the UK in 2010. Br J Cancer. 2011;105(Suppl exposure (3.7%) had the next largest effects on risk. 2):S77–S81.

HIV AND HCV

Baclofen: New Hope for Alcohol Abstinence in Patients with Alcohol- and HCV-related Cirrhosis?

Alcohol use and hepatitis-C virus (HCV) infection, either abstinence is recommended. Baclofen, a GABA B receptor alone or in combination, account for two-thirds of all liver agonist, is a potential therapeutic agent for alcohol disease in the Western world. Because alcohol dependence. This post-hoc analysis of a positive clinical consumption accelerates HCV-related liver fibrosis, no safe trial of baclofen for the treatment of alcohol dependence in level of drinking exists in patients with HCV, and total (continued on page 6)

Alcohol, Other Drugs, and Health: Current Evidence, January–February 2012

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Baclofen and Abstinence in Patients with Alcohol- and HCV-related Cirrhosis (continued from page 5) patients with cirrhosis explored whether the safety and Comments: In this post-hoc subgroup analysis of data from a efficacy of baclofen was also evident in a subgroup of larger randomized controlled trial, baclofen shows promise patients with HCV. Of 84 patients enrolled in the main trial, for improving alcohol abstinence among alcohol-dependent 24 had alcohol dependence, HCV infection, and cirrhosis. HCV-infected patients with cirrhosis. But at least 1 other Of these, 12 patients received baclofen (10 mg orally 3 study has found no efficacy for baclofen for alcohol- times per day) and 12 received placebo for 12 weeks. dependent patients with cirrhosis (www.bu.edu/aodhealth/ issues/issue_sept10/saitz_garbutt.html). None-theless, if • Ten patients receiving baclofen, compared with 3 these results are replicated in larger clinical trials, baclofen receiving placebo, achieved total alcohol abstinence would be a welcome pharmacotherapy for those with (p=0.01). cirrhosis and HCV infection. Jeanette M. Tetrault, MD • In the baclofen group, compared with placebo, albumin

values increased, and a trend toward reduction in Reference: Leggio L, Ferrulli A, Zambon A, et al. Baclofen international normalized ratio (INR) levels was promotes alcohol abstinence in alcohol dependent cirrhotic demonstrated. patients with hepatitis C virus (HCV) infection. Addict • No patients discontinued baclofen due to side effects. Behav. 2012;37(4):561–564.

Needle and Syringe Provision and Opioid Agonist Treatment May Reduce the Spread of HCV in People with Injection Drug Use

Injection drug use (IDU) is the primary route of HCV • Participants engaged in high NSP had 52% lower odds transmission. Interventions that impact injection drug use of new HCV infection (AOR, 0.48). behaviors, such as needle and syringe provision (NSP) and • The combined effect of the interventions was stronger opioid agonist treatment (OAT), may decrease the spread than each alone (AOR, 0.21). of HCV. However, there is little direct evidence linking such interventions to reductions in HCV incidence. This Comments: This meta-analysis suggests that NSP and OAT meta-analysis pooled data from 6 studies to assess whether may reduce the incidence of HCV. Limitations include the NSP* (alone or in combination) and OAT were associated design of the studies (i.e., observational versus randomized with reduced incidence of HCV. Studies were included if controlled trials) and moderate heterogeneity among they were published in the UK after 2000, if they studies included for OAT. These results support those of a contained individual-level data on NSP and/or OAT, and if prior meta-analysis (http://www.bu.edu/aodhealth/issues/ they measured newly acquired cases HCV infection. Six issue_sept11/tetrault_hagan.html) that found evidence obser-vational studies were identified: 4 were cross- supporting the effectiveness of needle exchange and OAT sectional studies, and 2 were cohort studies. as components of interventions to reduce HCV seroconversion in people with IDU. • Participants receiving OAT had 59% lower odds of new Judith Tsui, MD, MPH HCV infection (adjusted odds ratio [AOR], 0.41). Reference: Turner KM, Hutchinson S, Vickerman P, et al. The impact of needle and syringe provision and opiate *Needle and syringe provision (NSP) was defined as "high" or "low" ("high" indicating 1 or more sterile needles were obtained from a provider for substitution therapy on the incidence of HCV in injecting each injection reported). drug users. Addiction. 2011;106(11):1978-1988.

Mental-Health and Substance Use Disorders Impact the Development of AIDS-defining Illness and Death in HIV-infected Veterans

More than 60% of all HIV-infected veterans have at least 1 27,574 HIV-infected veterans who initiated combined mental-health or substance use disorder. Although antiretroviral treatment (cART) between 2000–2006. Sixty- depression is associated with medication nonadherence, nine percent of the sample had at least 1 mental-health or poor HIV outcomes, and mortality, the effect of other substance use disorder. mental-health or substance use disorders is unclear. In this retrospective cohort study, the authors analyzed data from • After adjusting for age, race, baseline CD4 cell count, the Veterans Health Administration HIV Clinical Case baseline comorbidity, cART adherence, and health-care Registry to assess the impact of mental-health and substance utilization, use disorders on HIV disease progression and death among (continued on page 7)

Alcohol, Other Drugs, and Health: Current Evidence, January–February 2012

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Mental Health, SUD, and AIDS-defining Illness in HIV-infected Veterans (continued from page 6)

− schizophrenia (hazard ratio [HR], 1.40), bipolar adequate cART therapy, specific mental-health and disorder (HR, 1.32), and substance use disorders substance use disorders impact both the development of (HR, 1.23) were associated with all-cause mortality, AIDS-defining illness and all-cause mortality. Lack of while anxiety disorders were inversely associated association between depressive disorders and the primary with all-cause mortality (HR, 0.80). outcomes is notable, and attempts to replicate this finding − depressive disorders were not associated with all- should be made in further studies. cause mortality. Jeanette M. Tetrault, MD − only substance use disorders were associated with development of AIDS-defining illness (HR, 1.19). Reference: Nurutdinova D, Chrusciel T, Zeringue A, et al. Mental health disorders and the risk of AIDS-defining illness Comments: Although this study was limited by reliance on and death in HIV-infected veterans. AIDS. 2012;26(2):229– administrative data, the findings suggest that, despite 234.

Political Engagement Is Associated with Reduced HIV Risk Behaviors

This study sought to determine whether civic and political less likely to share injection equipment, and those who engagement was associated with reduced HIV risk behaviors paid attention to politics were less likely to use in people with injection drug use (IDU). Subjects (N=162) shooting galleries. were recruited from 6 methadone maintenance programs in • On multivariable analysis, after adjusting for age, New York City and nearby New Jersey. All subjects were of gender, educational level, and homelessness, sharing Puerto Rican origin and reported current use of heroin or injection equipment was significantly less likely among cocaine and IDU in the past 30 days. Subjects were asked those who identified with a political party, and using a about their injection risk behaviors and political engagement shooting gallery was less likely among those who paid (i.e., being registered to vote, identifying as part of an more attention to politics. organized political party, and paying attention to politics as measured on a Likert scale). Comments: Although the results are not impressive, one would expect persons who are politically engaged to be • In the past 30 days, 38% had shared injection equip- more mindful of the impact of their behaviors on others. ment, and 15% had used “shooting galleries” (location Therefore, it is not surprising that individuals with higher where people gather to inject illegal drugs). levels of political engagement were less likely to engage in HIV risk behaviors. It would be interesting to see if political • In terms of political engagement, 63% reported being engagement can be increased among people with IDU, and registered to vote, 62% identified with a political party, if this engagement can be used to reduce HIV (and other and 30% reported paying a “fair amount” or “a lot” of health) risk behaviors. attention to politics. Darius A. Rastegar, MD • On bivariable analysis, higher levels of political engagement were significantly associated with reduced Reference: Mino M, Deren S, Kang SY, et al. Associations HIV risk behaviors on 3 measures: those registered to between political/civic participation and HIV drug injection vote and those identifying with a political party were risk. Am J Drug Alcohol Abuse. 2011;37(6):520–524.

JOURNAL ALERT

Drug and Alcohol Review Publishes Special Issue on Low-Risk Drinking Guidelines

Drug and Alcohol Review (DAR), the journal of the Austral- • Constructing and responding to low-risk drinking asian Professional Society on Alcohol and other Drugs guidelines. (APSAD), is releasing a special issue exploring the evidence • A relative-risk approach to estimating hazardous con- and controversies related to low-risk drinking guidelines. sumption. Although the print issue is not scheduled for release until • March 2012, many of the articles are available for early view Evaluating the validity of alternative drinking guidelines. on the DAR website. Topics include: (continued on page 8)

Alcohol, Other Drugs, and Health: Current Evidence, January–February 2012

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DAR: Special Issue on Drinking Guidelines (continued from page 7) Visit • • Differences in drinking guidelines Awareness of drinking guidelines www.aodhealth.org across countries. in the general public. • • to view the newsletter online, “Acceptable” risk during preg- Marketing responsible drinking: sign up for a free subscription, and nancy. Competing voices and interests. access additional features including • Drinking and youth: Is there a “low Visit the DAR homepage at http:// downloadable training risk” drinking level? presentations, free CME credits, • onlinelibrary.wiley.com/doi/10.1111/ The place of reported cardiopro- dar.2012.31.issue-1/issuetoc to access and much more! tective effects in shaping drinking articles on these and other guideline- guidelines. related topics. The major journals regularly re- viewed for the newsletter include:

Addiction RESOURCE ALERT Addiction Science & Clinical Practice Addictive Behaviors AIDS NIAAA Releases Free Simplified Screening Guide to Identify Underage Alcohol Drinking Alcohol & Alcoholism Alcoologie et Addictologie Alcoholism: Clinical & Experimental Research The National Institute on Alcohol haviors, and it often goes undetected. American Journal of Drug & Alcohol Abuse Abuse and Alcoholism (NIAAA) has This new tool was designed to allow American Journal of Epidemiology released a new 2-question screening busy practitioners who manage the American Journal of Medicine American Journal of Preventive Medicine tool to help clinicians identify children health and well-being of children and American Journal of Psychiatry and teenagers at risk for alcohol- adolescents to conduct fast, effective American Journal of Public Health related problems. The screening tool is alcohol screens and brief interven- American Journal on an integral part of Alcohol Screening and tions.” Annals of Internal Medicine Archives of General Psychiatry Brief Intervention for Youth: A Practi- Archives of Internal Medicine tioner’s Guide, a free downloadable pub- In addition to the 2-question screen, British Medical Journal lication produced by NIAAA (in col- the guide presents the first youth alco- Drug & Alcohol Dependence laboration with the American Academy hol risk estimator chart, which com- Epidemiology European Addiction Research of Pediatrics, clinical researchers, and bines information about a patient’s age European Journal of Public Health health-care practitioners) to help clini- and drinking frequency to give a clini- European Psychiatry cians overcome time constraints and cian a broad indication of the patient’s Gastroenterology other barriers to youth alcohol screen- chances for having alcohol-related Hepatology ing. problems. Journal of Addiction Medicine Journal of Addictive Diseases Journal of AIDS “We know that alcohol is, by far, the The complete guide is available for Journal of Behavioral Health Services & Research drug of choice among youth,” said download on the NIAAA website at Journal of General Internal Medicine NIAAA acting director Kenneth R. http://pubs.niaaa.nih.gov/publications/ Journal of Hepatology Journal of Infectious Diseases Warren, PhD. “Underage drinking is Practitioner/YouthGuide/ Journal of Studies on Alcohol also a marker for other unhealthy be- YouthGuide.pdf. Journal of Substance Abuse Treatment Journal of the American Medical Association Journal of Viral Hepatitis Lancet Visit www.aodhealth.org to download: New England Journal of Medicine Preventive Medicine Psychiatric Services Helping Patients Who Drink Too Much Substance Abuse Substance Use & Misuse A free multimedia training curriculum on screening and brief intervention Many others periodically reviewed (see www.aodhealth.org). for unhealthy alcohol use

• Learn skills for addressing unhealthy alcohol use (e.g. screen- Contact Information: ing, assessment, brief intervention, and referral) in primary care Alcohol, Other Drugs, and Health: settings. Includes a free PowerPoint slide presentation, trainer Current Evidence notes, case-based training videos, and related curricula on Boston University School of health disparities/cultural competence and pharmacotherapy. Medicine/Boston Medical Center 801 Massachusetts Ave., 2nd floor Boston, MA 02118 www.mdalcoholtraining.org

Continuing Medical Education (CME) Accreditation Statements Sponsored by Boston University School of Medicine

This activity has been planned and implemented in accordance with the Essential Areas Peter D. Friedmann, MD, MPH and Policies of the Accreditation Council for Continuing Medical Education (ACCME) Professor of Medicine and Community Health through the joint sponsorship of Boston University School of Medicine and Boston Warren Alpert Medical School of Brown University Medical Center. Boston University School of Medicine is accredited by the ACCME to Faculty member has served as a consultant for Clinical Tools, Inc., is a member of the provide continuing medical education for physicians (Course Code I.ACT1201). Bos- speakers bureau for Reckitt Benckiser Pharmaceuticals, and is a stockholder in ton University School of Medicine designates this enduring material for a maximum of Alkermes, Inc. Faculty member does not discuss unlabeled/investigational uses of a 1.25 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commen- commercial product. surate with the extent of their participation in the activity.. Kevin L. Kraemer, MD, MSc Target Audience Associate Professor of Medicine and Health Policy and Management The target audience is generalist clinicians, many of whom have received limited train- University of Pittsburgh Schools of Medicine and Public Health ing on detecting and treating substance abuse. Faculty member has nothing to disclose in regards to commercial support and does not discuss unlabeled/investigational uses of a commercial product.

Educational Needs Addressed Hillary Kunins, MD, MPH, MS Primary-care clinicians often miss the diagnosis of alcohol or drug problems and can- Associate Clinical Professor of Medicine and not stay abreast of the current substance-abuse literature in the context of a busy Psychiatry & Behavioral Sciences practice. Because of the effects of alcohol and drugs on adherence to care plans and Albert Einstein College of Medicine physician-patient relationships, patients with alcohol or drug problems may receive Faculty member is a stockholder in Pfizer, and her daughter is a stockholder in Abbott suboptimal treatment for other conditions. Further, physicians sometimes perceive Laboratories, Johnson & Johnson, and Medtronic, Inc. Faculty member does not dis- alcohol or drug dependence as less treatable than other medical conditions, and thus cuss unlabeled/investigational uses of a commercial product. delegate responsibilities for screening and intervention to others. At the root of the screening and treatment gap is the inadequate provision of substance-abuse education Darius A. Rastegar, MD in medical schools and mental-health fields. The newsletter addresses this not only by Assistant Professor of Medicine research dissemination but by providing free downloadable teaching tools for use by Johns Hopkins School of Medicine educators. Faculty member has nothing to disclose in regards to commercial support and does not discuss unlabeled/investigational uses of a commercial product. Educational Objectives At the conclusion of this program, participants will be able to state the latest research Jeffrey H. Samet, MD, MA, MPH findings on alcohol, illicit drugs, and health; incorporate the latest research findings on Professor of Medicine and Social and Behavioral Sciences alcohol, illicit drugs, and health into their clinical practices, when appropriate; and Boston University Schools of Medicine and Public Health recognize the importance of addressing alcohol and drug problems in primary care Faculty member has nothing to disclose in regards to commercial support and does settings. In sum, the purpose of the newsletter is to raise the status of alcohol and not discuss unlabeled/investigational uses of a commercial product. drug problems in both academic and clinical culture to promote evidence-based screening and treatment and ultimately improve patient care. Jeanette M. Tetrault, MD Assistant Professor of Internal Medicine Yale University School of Medicine Disclosure Statement Faculty member has nothing to disclose in regards to commercial support and does Boston University School of Medicine asks all individuals involved in the development not discuss unlabeled/investigational uses of a commercial product. and presentation of Continuing Medical Education/Continuing Education (CME/CE) activities to disclose all relationships with commercial interests. This information is Alexander Y. Walley, MD, MSc disclosed to activity participants. Boston University School of Medicine has procedures Assistant Professor of Medicine to resolve apparent conflicts of interest. In addition, faculty members are asked to Boston University School of Medicine disclose when any unapproved use of pharmaceuticals and devices is being discussed. Faculty member has nothing to disclose in regards to commercial support and does not discuss unlabeled/investigational uses of a commercial product. Course Faculty Richard Saitz, MD, MPH, FASAM, FACP Donna Vaillancourt Course Director Managing Editor Professor of Medicine and Epidemiology Alcohol, Other Drugs, and Health: Current Evidence Boston University Schools of Medicine and Public Health Boston Medical Center Faculty member has nothing to disclose in regards to commercial support and does Ms. Vaillancourt has nothing to disclose in regards to commercial support. not discuss unlabeled/investigational uses of a commercial product. Jody Walker, MS David A. Fiellin, MD Boston University School of Medicine Professor of Medicine CME Program Manager Yale University School of Medicine Ms. Walker has nothing to disclose in regards to commercial support.

Faculty member has nothing to disclose in regards to commercial support and does Disclaimer not discuss unlabeled/investigational uses of a commercial product. THESE MATERIALS AND ALL OTHER MATERIALS PROVIDED IN CONJUNC- TION WITH CONTINUING MEDICAL EDUCATION ACTIVITIES ARE IN- Nicolas Bertholet, MD, MSc TENDED SOLELY FOR PURPOSES OF SUPPLEMENTING CONTINUING MEDI- Department of Medicine and Public Health CAL EDUCATION PROGRAMS FOR QUALIFIED HEALTH CARE PROFESSION- Lausanne University, Switzerland ALS. ANYONE USING THE MATERIALS ASSUMES FULL RESPONSIBILITY AND Faculty member has nothing to disclose in regards to commercial support and does ALL RISK FOR THEIR APPROPRIATE USE. TRUSTEES OF BOSTON UNIVERSITY not discuss unlabeled/investigational uses of a commercial product. MAKES NO WARRANTIES OR REPRESENTATIONS WHATSOEVER REGARD- ING THE ACCURACY, COMPLETENESS, CURRENTNESS, NONINFRINGEMENT, R. Curtis Ellison, MD MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE OF THE MATE- Professor of Medicine and Public Health RIALS. IN NO EVENT WILL TRUSTEES OF BOSTON UNIVERSITY BE LIABLE TO Boston University School of Medicine ANYONE FOR ANY DECISION MADE OR ACTION TAKEN IN RELIANCE ON Faculty member is the Director of the Institute on Lifestyle and Health, which receives THE MATERIALS. IN NO EVENT SHOULD THE INFORMATION IN THE MATERI- various donations from individuals and companies in the alcohol beverage industry, ALS BE USED AS A SUBSTITUTE FOR PROFESSIONAL CARE. given as "unrestricted educational gifts." Funds are not given for specific research projects and donors have no prior information on, or input into, the surveillance being Date of original release: February 1, 2012. carried out or critiques published by the Institute or the Section. Faculty member Date of expiration: January 31, 2012. does not discuss unlabeled/investigational uses of a commercial product. CME Course Code I.ACT1201.