Using “Heavy Drinking Days” to Measure Treatment Effectiveness

Newswise, May 12, 2016 — One of the challenges in evaluating the effectiveness of alcohol treatment is determining what constitutes a “good” outcome or meaningful improvement. While abstinence at the end of treatment is clearly a good outcome, a focus on abstinence ignores the benefits of patients reducing their drinking to less problematic levels so that they can function better and incur fewer social costs.

This study estimates the relationship between drinking practices at the end of a treatment program and subsequent health-care costs, with an emphasis on heavy and non-heavy drinking levels.

Researchers used data from the COMBINE trial, which randomized 1,383 adult participants with alcohol dependence to nine different combinations of medications and psychosocial interventions.

For this study, the authors examined heavy drinking days (HDDs) – defined as five or more drinks for men, four or more for women – and non-heavy drinking days (non-HDDs) during the last 30 days of COMBINE treatment for 748 patients (524 men, 224 women) enrolled in the COMBINE Economic Study. Total costs were treated as a function of drinking indicators.

Results indicate that having HDDs at the end of treatment is associated with higher costs.

For example, patients with HDDs had 66.3 percent higher health-care costs than those who were abstinent, and having more than two HDDs was associated with the highest costs (76.1%). Furthermore, patients who had only HDDs at the end of treatment had worse subsequent outcomes than those who had both non-HDDs and HDDs.

These findings offer a new context for evaluating treatment outcomes and provide new information on the association of drinking with adverse consequences.

Patients Abusing Drugs and Alcohol Are Self-Medicating Chronic Pain

 Newswise, May 12, 2016--With opioid addiction and prescription drug abuse considered one of the biggest public health threats of our time in the U.S., many are asking why so many Americans are struggling with addiction to illegal drugs and prescription medications. New research suggests that chronic pain may be part of the answer.

In a study that appears in the May issue of the Journal of General Internal Medicine, researchers at Boston University School of Medicine and Boston Medical Center have found that the majority of patients misusing drugs and alcohol have chronic pain and many are using these substances to "self-medicate" their pain.

According to the researchers, many illegal drugs such as marijuana and heroin have pain-relieving properties.

The researchers screened approximately 25,000 patients in primary care for illegal drug use and misuse of prescription medications.

Among these patients, 589 who screened positive for substance use were asked questions about chronic pain and their substance use. Substance use was defined as use of illegal drugs (heroin, marijuana, cocaine, etc.), use of prescription drugs in ways other than prescribed or high risk alcohol use.

They found that 87 percent of those who screened positive for illegal drug use, misuse of prescription drugs or heavy alcohol use suffered from chronic pain.

Half of these patients graded the pain as severe. In the subgroup that was using illegal drugs, 51 percent reported using one or more drug specifically to alleviate physical pain.

In those using prescription drugs without a prescription or using more than prescribed, 81 percent identified self-medication of pain as the reason for misuse. With regard to high risk alcohol use, the majority (79 percent) did so to manage pain.

"While the association between chronic pain and drug addiction has been observed in prior studies, this study goes one step further to quantify how many of these patients are using these substances specifically to treat chronic pain.

“It also measures the prevalence of chronic pain in patients who screen positive for illegal drug use and prescription drug abuse," explained corresponding author Daniel Alford, MD, MPH, associate professor of medicine and assistant dean of Continuing Medical Education and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program at BUSM. He is also the director of BMC's Clinical Addiction Research and Education Unit.

The results of this study suggest that counseling focused only on informing patients about the negative consequences of drug and alcohol use may miss a key aspect of why people are using these substances.

"Pain should be treated as part of the long-term strategy for recovery. If drugs are being used to self-medicate pain, patients may be reluctant to decrease, stop, or remain abstinent if their pain symptoms are not adequately managed with other treatments including non-medication-based treatments," added Alford.

###

This research was part of the ASPIRE study, which was funded by the National Institute on Drug Abuse (RO1 DA025068) and the Massachusetts Department of Public Health both of which received funding from the Center for Substance Abuse Treatment (TI018311). Other support included the National Center for Research Resources (UL1RR025771).

Smoking and Schizophrenia: Understanding and Breaking the Cycle of Addiction

Newswise, April 21, 2016– Smoking addiction in schizophrenia can be explained by significantly increased activation of the ventro-medial prefrontal cortex (vmPFC), a region involved in the brain reward system.

These new data, the result of a study by researchers at the Institut universitaire en santé mentale de Montréal (CIUSSS EST, Montreal) and the University of Montreal confirms the tendency to smoke and low smoking cessation rates of people with schizophrenia.

“Smoking is a real problem for people with schizophrenia,” said Stéphane Potvin, a researcher at the Institut universitaire en santé mentale de Montréal and lead author of the study.

"Their health and life expectancy are often undermined by this addiction, whose brain mechanisms were until now largely unknown," said the associate professor at the University of Montreal’s Faculty of Medicine.

Essentially, the research team observed greater neuronal activation of a specific region of the brain (vmPFC) in schizophrenia smokers compared with healthy subjects when presented with appetitive cigarette images.

At the behavioural level, the researchers also found that schizophrenia smokers had more depressive symptoms than did participants in the control group.

“These observations suggest that smoking has a greater rewarding effect in schizophrenia smokers. This corroborates the hypothesis already formulated of their increased vulnerability to this addiction but also demonstrates the great difficulty for them when it comes to quitting smoking," said Potvin.

The prevalence of smoking in people with schizophrenia is high, and cessation rates are low. Schizophrenia smokers are twelve more times likely to die from heart disease related to smoking than are those who do not smoke.

“It is necessary to explore avenues that will help people in their efforts to free themselves from smoking,” said Potvin. “

That is why we want to continue our research into whether this activation of the ventro-medial prefrontal cortex (vmPFC) is caused by the disease itself or by the effects of antipsychotics,” concluded the researcher.

Simultaneous Cocaine, Alcohol Use Linked to Suicide Risk

Photo By Psychonaught - Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9818612

Newswise, April 14, 2016--In a general sense, medical studies support the popular intuition -- a staple of movies and literature -- that suicidal behavior and substance misuse are linked. But the relationship between the two is not so simple.

A new study of hundreds of suicidal emergency department (ED) patients from around the U.S. found that the significance of the link varied with age, gender and race. Across the board, however, the use of cocaine and alcohol together was a red flag.

"One unexpected finding was that, when examined independently, alcohol use had no significant association and cocaine use had a borderline significant association," wrote authors of the study in the journal Crisis.

"However, reporting both alcohol misuse and cocaine use was significantly associated with a future suicide attempt."

Led by Sarah Arias, assistant professor (research) of psychiatry and human behavior in the Alpert Medical School of Brown University, the team examined 874 men and women who presented at one of eight emergency departments around the country between 2010 and 2012.

The patients were participants in the Emergency Department Safety Assessment and Follow-up Evaluation study, led by the University of Massachusetts Medical School. Individuals included in the analysis received standard care and either reported a recent suicide attempt or were actively engaged in suicidal thoughts at the time of the initial ED visit.

In another arm of the study, not included in this analysis, patients received an experimental intervention. Researchers gathered demographic and substance use information from the participants and then followed them for a full year afterward.

The key outcome in Arias' new study was whether people attempted suicide in the year following the ED visit. Of the 874 people, 195 people did at least once.

What Arias, who is also a research psychologist at Butler Hospital, and her colleagues found was that although people in the study reported misusing many different substances, including marijuana, prescription painkillers, tranquilizers and stimulants, only cocaine and alcohol appeared to have a significant association with suicide risk.

Of the entire study population, 298 misused alcohol, 72 were using cocaine and 41 were using both. Specifically, of those using both, the chance of attempting suicide again was 2.4 times greater than among people in the study who were not.

They also found that substance misuse was less likely an indicator of suicide risk among whites and women. Older people, meanwhile, were more likely to have an association between substance misuse and suicide.

Women are not less likely to be suicidal, the researchers note. In fact, they were more likely than men to have reported prior attempts. But the data showed that substance abuse was less likely to be involved among women.

"These disparate findings emphasize the complex interaction of sex, substance use, and suicide attempts," Arias and her co-authors wrote. "They also suggest women may be differentially at risk depending on whether they report substance use or past suicide attempts."

The study does not say anything about whether substance abuse causes suicidal behavior because it only reports observations of associations.

But Arias said she hopes the data will advance the understanding of how misuse of particular substances, among particular patients, may affect their risk of suicide.

"It's not a clear-cut, straightforward association," Arias said. "Even though substance use is often touted as a very strong predictor of suicidal intentions and behaviors, when we look at individual substances we're seeing that there's not that consistency in the future association with behavior."

Figuring out the specific cases where substance misuse is predictive could help save lives.

"We're on our way to trying to identify factors that can be used to better assess and identify people who are at risk for suicide, and ultimately I think this is a step in the right direction to get a better picture," she said.

"Patients who have potentially comorbid alcohol and cocaine use may be at a higher risk. Findings like these can be useful for informing suicide risk assessment."

###

In addition to Arias, the study's other authors are Orianne Dumas, Ashley Sullivan, Edwin Boudreaux, Ivan Miller and Carlos Camargo Jr. The research was funded by the National Institute of Mental Health (grant: U01MH088278).

Parkinson’s Disease Medications Increase Risk of Compulsive Gambling, Shopping and Binge Eating in Some Patients

Newswise, April 7, 2016 – Drugs commonly prescribed to treat Parkinson’s disease have been linked to impulse control disorders such as pathological gambling, compulsive buying, hypersexuality and binge eating in some patients, according to a review article by neurologists at Loyola Medicine and Loyola University Chicago Stritch School of Medicine.

These disorders can have disastrous personal, professional and financial consequences if not recognized or treated, according to the article in the journal Expert Review of Neurotherapeutics. Authors of the paper include José Biller, MD, and first author Adolfo Ramirez-Zamora, MD, who completed a residency in neurology at Loyola.

The paper details the latest findings for treating impulse control disorders (ICDs) in Parkinson’s disease patients, including adjusting medications, deep brain stimulation and a counseling technique called cognitive behavioral therapy.

One large, previous national study found that approximately 14 percent of Parkinson’s disease patients experience at least one ICD. The disorders are more common in men.

Men are more likely to display hypersexuality and pathological gambling, while women are more likely to exhibit compulsive eating and buying. Potentially catastrophic consequences include financial ruin, divorce and loss of employment.

Patients often lack insight and underestimate the presence and severity of ICDs and related conditions, the authors write. ICDs are probably more prevalent in Parkinson’s disease patients than previously reported.

The primary risk factor for ICDs is the use of a class of Parkinson’s disease medications called dopamine agonists, which help control tremors and other Parkinson’s symptoms.

These drugs include pramipexole (Mirapex®) and ropinirole (Requip®). Other risk factors include younger age, smoking, alcohol abuse and personality traits such as impulsivity, obsessive-compulsive disorder, depression and anxiety.

Management of ICDs is particularly difficult and no treatment guidelines for ICDs in Parkinson’s patients are available. Treatment should be individualized, and careful selection of specific interventions is critical. Treatments that have been considered include switching, reducing or discontinuing Parkinson’s medications.

But this can be challenging. Patients often are reluctant to change medications because they do not want their tremors to get worse. Patients also can experience withdrawal symptoms when taken off dopamine agonists, including anxiety, panic attacks, depression, irritability and fatigue.

The authors discuss alternative treatment strategies for Parkinson’s disease and medications that may help control ICDs, such as antidepressants, atypical antipsychotics and antiepileptic drugs.

Other potential nondrug treatments include cognitive behavioral therapy and a “brain pacemaker” called deep brain stimulation. The authors provide a much-needed, practical and detailed review of the factors important making management decisions

Families also play a critical role. Spouses and other family members should be warned that Parkinson’s medications can cause ICDs. Families should report to the patient’s physician any “unexplained absences, changes in routine behaviors, irritability, hiding evidence of the impulse control disorders and monetary consequences,” the authors write. Helpful non-pharmacological approaches include limiting access to bank accounts, credit cards and the internet.

Dr. Biller is chair of the department of neurology of Loyola University Chicago Stritch School of Medicine. Dr Ramirez-Zamora, a former resident in Loyola’s department of neurology, is now at Albany Medical College and serves as the Phyllis E. Duke Endowed Chair in Movement Disorders. Other co-authors are Lucy Gee of Albany Medical College and James Boyd, MD, of the University of Vermont College of Medicine.

Their article is titled, “Treatment of impulse control disorders in Parkinson’s disease: Practical considerations and future directions.”

In-Car Breathalyzers for DUI Offenders Curb Drunk-Driving Deaths by 15 Percent

So-Called “Ignition Interlocks” Save Lives with Similar Success as Airbag Laws, Penn Study Says

Newswise, March 18, 2016 —  State laws that require drivers who’ve been convicted of drunk driving to pass a breathalyzer-type test before starting their cars saved an estimated 915 lives between 2007 and 2013, according to a study published in the American Journal of Public Health by researchers at the Perelman School of Medicine at the University of Pennsylvania.

The findings represent a 15 percent reduction in drunk driving-related deaths compared to states without legislation requiring DUI offenders to use “mandatory ignition interlock.”

The research, led by Elinore J. Kaufman, MD, a student in Penn’s Health Policy master’s degree program and a resident at New York-Presbyterian Weill Cornell Medical College, used National Highway Traffic Safety Administration data to compare alcohol-related crash deaths in the 18 states that required ignition interlocks for all those convicted of DUI as of 2013 with the number of alcohol-related crash deaths in states without mandatory interlocks.

States with mandatory interlock laws saw a 0.8 decrease in deaths for every 100,000 people each year – which is comparable to lives shown to have been saved from mandatory airbag laws and the 21-year minimum legal drinking age combined (0.9 and 0.2 lives saved per 100,000 people, respectively).

Car crashes involving alcohol make up 30 percent of vehicular fatalities, resulting in 11,000 deaths each year. The National Highway Traffic and Safety Administration estimates that for each of the million drunk driving convictions each year, there are 88 previous instances of drunk driving.

“These laws are proven feasible and effective, and they are low hanging fruit for the remaining half of states, including Pennsylvania, that don’t have this protection in place yet,” Kaufman said.

Following increasing support for interlock laws in other states, Pennsylvania’s House of Representative’s Transportation Committee is considering legislation – SB 290 – that would require first-time DUI offenders with a blood-alcohol content of .10 or higher to install these devices.

“Our findings show that by preventing intoxicated drivers from starting their vehicles, these ignition interlock laws can directly prevent drunk driving and save lives,” Kaufman said. “We are encouraged by growing public and governmental support for expansion of interlock programs and innovative ways to use this technology to prevent more lives lost resulting from drunk driving.”

Previous research on mandatory interlock laws focused on recidivism rates, but the new Penn study serves as the first national analysis of the impact of a universal interlock requirement on alcohol-involved crash deaths.

“Although crashes and crash fatalities decline, we’re not seeing a significant reduction in those involving alcohol,” said the study’s senior author, Douglas J. Wiebe, PhD, an associate professor of epidemiology in the department of Biostatistics and Epidemiology and a senior scholar in the Center for Clinical Epidemiology and Biostatistics.

“We’re encouraged by the increasing number of states enacting mandatory interlock laws since 2013 and hope these findings advance public health conversations aimed at saving more lives.”

The researchers note that the variation in state ignition interlock laws and enforcement of those laws further illustrates the importance of taking a comprehensive approach to ensuring driving safety.

While mandatory minimum drinking age and interlock laws have shown progress in curbing drunk-driving incidence, the authors call for further steps, including new strategies to encourage alternative forms of transportation and changing “alcohol culture” and social behaviors to reduce binge drinking.

The Medical Minute: The Path From Prescription Pain Killers to Addiction

Newswise, March 9, 2016 — Abuse of prescription pain killers has become an epidemic in the United States, according to the Centers for Disease Control and Prevention (CDC). Even more concerning is that those going through withdrawal may turn to heroin as an inexpensive, easy-to-access substitute.

 

Dr. Vitaly Gordin, division chief of chronic pain management in the Department of Anesthesiology at Penn State Hershey Medical Center said it’s because heroin is an opiate analgesic, just like drugs such as oxycodone and tramadol, which are frequently prescribed for pain control.

The problem is not with patients who use the medicines to relieve short-term acute pain, like the kind after surgery. 

“The vast majority of them will very easily get off these medications as their condition improves and pain is decreasing,” he said.

Nor does it lie with those who have chronic conditions that require them to be on high doses of narcotic painkillers for long periods of time: “There are a lot of very legitimate patients who are receiving these medicines in a chronic setting who are not abusing them.”

The challenge comes when someone is taken off the medication after using a high dose for a length of time.

“Because of this declared epidemic, many primary care physicians, specialists and surgeons are taking these patients off the narcotics,” Gordin said. “But if they don’t have an exit strategy and get referred for alternate treatment, addictions counseling or rehabilitation, they can become desperate as they go through withdrawal.”

Without a renewing prescription for narcotics, the patients may turn to heroin.

Unlike with prescription painkillers, which are regulated by the Food and Drug Administration, it’s hard to verify exactly what is in the heroin you buy from a dealer.

“Several years ago there was a string of deaths of addicts who bought heroin laced with a potent painkiller called fentanyl,” Gordin said. “Because it’s all an underground, illegal business, you don’t know exactly what you’re getting.”

Many of the 20,000 deaths that occur each year from abuse of prescription pain killers happen when the narcotics are combined with another substance such as benzodiazepine or alcohol, which creates a dangerous – if not deadly – mix.

Gordin said patients with a history of drug abuse, untreated psychiatric conditions or pre-adolescent abuse of any kind are much more likely to develop addictions.

“In my 17 years working here, I have never seen as many inpatients on heroin as I have in the past six to 12 months,” he said. “Those who have abused heroin are getting into car accidents or involved in violent crimes because of being on the drug or trying to obtain it. I think it’s directly related.”

Gordin also said it is important that society begin to de-stigmatize addiction as a character flaw. “We need to understand it is a disease with psycho-social components and we need to have resources available to both prescribing physicians and patients who need drug rehabilitation.”

The Medical Minute is a weekly health news feature produced by Penn State Milton S. Hershey Medical Center. Articles feature the expertise of Penn State Hershey faculty physicians and staff, and are designed to offer timely, relevant health information of interest to a broad audience.