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O'Malley SS, Wu R, Mayne ST, Jatlow PI. Smoking cessation is followed by increases in serum bilirubin, an endogenous antioxidant associated with lower risk of lung cancer and cardiovascular disease. Nicotine Tob Res 2014; 16:1145-9. [PMID: 24812024 DOI: 10.1093/ntr/ntu067] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION Lower concentrations of serum bilirubin, an endogenous antioxidant, have been associated with risk of many smoking-related diseases, including lung cancer and cardiovascular disease, and current smokers are reported to have lower bilirubin levels than nonsmokers and past smokers. This study evaluates the effects of smoking cessation on bilirubin levels. METHODS In a secondary analysis of a 6-week placebo-controlled trial of naltrexone for smoking cessation, indirect and total bilirubin concentrations were evaluated at baseline and following smoking cessation. Individuals who were continuously abstinent for 6 weeks (n = 155) were compared to those who were not (n = 193). Participants reported smoking ≥ 20 cigarettes daily at baseline and received smoking cessation counseling, 21 mg nicotine patch daily, and either placebo or 1 of 3 doses of naltrexone (25, 50, or 100mg) for 6 weeks. Change in indirect and total bilirubin following the quit date was measured at Weeks 1, 4, and 6 compared to baseline. RESULTS Individuals who were continuously abstinent from smoking, independent of naltrexone condition, showed a significantly greater mean increase in indirect (~unconjugated) bilirubin (0.06 mg/dl, SD = 0.165) compared to those who did not (mean = 0.02, SD = 0.148, p = .015). Similar results were obtained for total bilirubin (p = .037). CONCLUSIONS Smoking cessation is followed by increases in bilirubin concentration that have been associated with lower risk of lung cancer and cardiovascular disease.
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Affiliation(s)
- Stephanie S O'Malley
- Department of Psychiatry, Yale School of Medicine, New Haven, CT; Yale Comprehensive Cancer Center, New Haven, CT;
| | - Ran Wu
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Susan T Mayne
- Yale Comprehensive Cancer Center, New Haven, CT; Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Peter I Jatlow
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT
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Hansson H, Rundberg J, Zetterlind U, Johnsson KO, Berglund M. Two-year outcome of an intervention program for university students who have parents with alcohol problems: a randomized controlled trial. Alcohol Clin Exp Res 2007; 31:1927-33. [PMID: 17908264 DOI: 10.1111/j.1530-0277.2007.00516.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Only a few intervention studies aiming to change high-risk drinking behavior have involved university students with heredity for alcohol problems. This study evaluated the effects after 2 years on drinking patterns and coping behavior of intervention programs for students with parents with alcohol problems. METHOD In total, 82 university students (57 women and 25 men, average age 25 years) with at least 1 parent with alcohol problems were included in the study. The students were randomly assigned to 1 of the 3 programs: (i) alcohol intervention program, (ii) coping intervention program, or (iii) combination program. All the 3 intervention programs were manual based and individually implemented during 2 2-hour sessions, 4 weeks apart. Before the participants were randomly assigned, all were subjected to an individual baseline assessment. This assessment contained both a face-to-face interview and 6 self-completion questionnaires: the Alcohol Use Disorders Identification Test, estimated Blood Alcohol Concentration, Short Index of Problems, the Symptom Checklist-90, Coping with Parents' Abuse Questionnaire, and The Interview Schedule for Social Interaction (ISSI). Follow-up interviews were conducted after 1 and 2 years, respectively. The results after 1 year have previously been reported. RESULTS All participants finished the baseline assessment, accepted and completed the intervention. Ninety-five percent of the students completed the 24-month follow-up assessment. Only the group receiving the combination program continued to improve their drinking pattern significantly (p < 0.05) from the 12-month follow-up to the 24-month follow-up. The improvements in this group were significantly better than in the other 2 groups. The group receiving only alcohol intervention remained at the level of improvement achieved at the 12-month follow-up. The improvements in coping behavior achieved at the 12-month follow-up remained at the 24-month follow-up for all the 3 groups, i.e., regardless of intervention program. CONCLUSION Positive effects of alcohol intervention between 1 and 2 years were found only in the combined intervention group, contrary to the 1-year results with effects of alcohol intervention with or without a combination with coping intervention.
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Affiliation(s)
- Helena Hansson
- Clinical Alcohol Research, Lund University, University Hospital MAS, Malmö, Sweden.
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Tate SR, Norman SB, McQuaid JR, Brown SA. Health problems of substance-dependent veterans with and those without trauma history. J Subst Abuse Treat 2007; 33:25-32. [PMID: 17588486 DOI: 10.1016/j.jsat.2006.11.006] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2006] [Revised: 11/17/2006] [Accepted: 11/24/2006] [Indexed: 11/29/2022]
Abstract
Substance use disorders (SUDs) and posttraumatic stress disorder (PTSD) are associated with an increased risk for health problems. We examined whether trauma history and PTSD were related to physical health in patients with an SUD. We compared health stressors, health service utilization, and self-rated health status in three groups of male veterans receiving SUD treatment: (1) no trauma exposure (SUD-only group), n = 55; (2) with PTSD (SUD-PTSD group), n = 32; and (3) trauma exposure without PTSD (SUD-trauma group), n = 34. The veterans were assessed quarterly for 1 year. Groups differed in their likelihood of experiencing chronic health stressors at all time points. The SUD-only group consistently had the lowest rates of chronic health stressors, the SUD-PTSD group had the highest rates, and the SUD-trauma group fell in between. In contrast, groups did not differ in rates of acute health problems. Chronic health stressors appear to be associated with trauma exposure and psychologic response to the trauma. Substance use disorder interventions may benefit from incorporation of primary care services.
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Affiliation(s)
- Susan R Tate
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA
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Tate SR, McQuaid JR, Brown SA. Characteristics of life stressors predictive of substance treatment outcomes. J Subst Abuse Treat 2005; 29:107-15. [PMID: 16135339 DOI: 10.1016/j.jsat.2005.05.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2004] [Revised: 03/05/2005] [Accepted: 05/06/2005] [Indexed: 11/27/2022]
Abstract
Most research and treatment focusing on the relationship between life stress and substance use have considered stress as a unitary construct despite the fact that stressors vary in terms of temporal characteristics (short-term vs. long-term) and domains (work, health). In contrast to most stressor domains, increasing evidence suggests that health stressors may reduce the risk of initiating substance use after treatment. We separately evaluated the effect of short-term stress events (discrete date of occurrence), long-term stressors (ongoing stressors lasting 2 weeks or longer), and health stressors on posttreatment alcohol and drug use. Veterans (N=195) were assessed while receiving addiction treatment and quarterly for 1 year. The odds of initiating posttreatment substance use were 2.5 times greater for participants experiencing severe (nonhealth) long-term stressors. In contrast, participants experiencing short-term health events or severe (nonhealth) short-term events were less likely to initiate posttreatment substance use (odds ratio=.28 and .44, respectively).
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Affiliation(s)
- Susan R Tate
- Department of Psychiatry, University of California, San Diego, and VA San Diego Healthcare System, San Diego, CA 92161, USA
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Korzec A, de Bruijn C, van Lambalgen M. The Bayesian Alcoholism Test had better diagnostic properties for confirming diagnosis of hazardous and harmful alcohol use. J Clin Epidemiol 2005; 58:1024-32. [PMID: 16168348 DOI: 10.1016/j.jclinepi.2005.02.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2004] [Revised: 01/10/2005] [Accepted: 02/14/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Conventional tests for alcoholism fail to confirm hazardous and harmful alcohol use (HHAU) accurately and objectively. We validated a Bayesian Alcoholism Test (BAT) for confirming the diagnosis of HHAU. STUDY DESIGN AND SETTING BAT is based on studies on the prevalence of HHAU and other diseases causing similar abnormalities, and on conditional probabilities of these disorders and associated biochemical markers and clinical signs. BAT was compared to carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) in treatment-seeking alcoholics, non-treatment-seeking heavy drinkers, and controls. Main outcome measures were test sensitivity and specificity, likelihood ratios, and receiver-operating characteristic (ROC) curves. RESULTS Comparing alcoholics and controls, sensitivity of BAT (94%) was significantly higher than CDT (63%) and GGT (73%). The area under the ROC curve for BAT (.989) was significantly higher than the area under the curve for CDT (.909) and area under the curve for GGT (.902). Using pooled data of all 182 subjects included in the study, the amount of drinking had a significant better correlation coefficient with BAT (.795) than with CDT (.657), and GGT (.604). CONCLUSION BAT has better diagnostic properties than CDT and GGT for confirming HHAU.
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Affiliation(s)
- Aleksander Korzec
- Sint Lucas Andreas Hospital, Postbus 9423, 1006 AE Amsterdam, The Netherlands.
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Abstract
Alcohol biomarkers such as carbohydrate-deficient transferrin (CDT) and gamma-glutamyltransferase (GGT) have significant potential for enhancing the quality of medical treatment in primary health care settings. Recent studies demonstrate that these laboratory tests can help the general practitioner in several ways. First, CDT and GGT can detect current heavy drinking in primary care patients with a fair degree of sensitivity (approximately 60% to 70%), with CDT being more specific (approximately 90%). When combined with self-report tests, they can provide a clinically useful alcohol screening battery. Second, elevated CDT and GGT levels have been correlated with specific alcohol-sensitive diseases (e.g., hypertension) and, as such, can serve as risk indicators for those diseases. Third, alcohol biomarkers have proven to be useful in monitoring the effectiveness of brief alcohol interventions with medical patients. Unfortunately, preliminary findings indicate that physicians have little knowledge of current biomarker research as applied to primary health care. Translational studies are needed on methods to facilitate knowledge and use of alcohol biomarkers by general practitioners.
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Affiliation(s)
- Peter M Miller
- Medical University of South Carolina, 67 President Street, P.O. Box 250861, Charleston, SC 29425, USA.
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Abstract
BACKGROUND Biomedical markers may provide additive objective information in screening and confirmation of acute or recent consumption, intoxication, relapse, heavy drinking, hazardous/harmful use/abuse and dependence and alcohol use related organ dysfunction (alcohol use-related disorders: AUDs). AIMS To review the use of biomarkers in clinical practice to detect AUDs. FINDINGS About one-fifth of the patients seen in clinical practice have AUDs, which offer a variety of treatment options if diagnosed. The diagnosis of AUDs relies on clinical and alcohol-related history, physical examination, questionnaires and laboratory values. No clinical available laboratory test [e.g. for acute abuse: alcohol in blood or breath; for chronic alcohol abuse: gamma-glutamyl transferase (GGT), mean corpuscular volume (MCV), carbohydrate-deficient transferrin (CDT)] is reliable enough on its own to support a diagnosis of alcohol dependence, harmful use or abuse. Sensitivities, specificities and the predictive values may vary considerably according to patient and control group characteristics (e.g. gender, age or related comorbidity). In patient groups with limited cooperation markers may be helpful when considering treatment options. CONCLUSIONS More research is needed to determine the value of markers (single or combined, with questionnaires) in the context of clinical decision-making algorithms in defined settings and with defined dichotomous outcome variables.
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Affiliation(s)
- Tim Neumann
- Department of Anesthesiology and Intensive Care Medicine, Universitaetsmedizin-Berlin Charité, Charité Campus Mitte Berlin, Germany
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Abstract
AIMS The blood tests used traditionally as markers of excessive drinking are the liver enzymes, gamma glutamyltransferase (GGT), aspartate aminotransferase (AST) and alanine aminotransferase (ALT), and the red blood cell volume (mean corpuscular volume: MCV). Here we review the nature of these markers' association with alcohol use, their practical application in detecting, assessing or monitoring drinking and increases in understanding of these markers in the past 10 years. DESIGN Articles were identified via Medline search and perusal of bibliographies. FINDINGS The conventional markers have imperfect sensitivity and specificity, but have an added clinical role in the detection of complications of drinking, and of comorbid conditions that may increase risk of drinking. GGT may in part be a marker of the oxidative stress associated with ethanol metabolism. Markers are more likely to be elevated in those aged more than 30 years and in regular drinkers with a longer drinking history. The markers may be useful in opportunistic case finding, in motivating patients to change drinking and in monitoring treatment response. Increased prevalence of obesity and hepatitis C must be considered in interpretation of liver enzyme results. The liver enzymes are prognostic indicators for several medical conditions and for mortality. CONCLUSIONS These conventional tests are widely available and relatively inexpensive. While having limited sensitivity and specificity in detection of excessive drinking, they also provide valuable data on complications of drinking, comorbid conditions that may be affected by drinking and, in some cases, prognosis.
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Latt NC, Jurd S, Houseman J, Wutzke SE. Naltrexone in alcohol dependence: a randomised controlled trial of effectiveness in a standard clinical setting. Med J Aust 2002; 176:530-4. [PMID: 12064984 DOI: 10.5694/j.1326-5377.2002.tb04550.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2001] [Accepted: 02/28/2002] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine whether naltrexone is beneficial in the treatment of alcohol dependence in the absence of obligatory psychosocial intervention. DESIGN Multicentre, randomised, double-blind, placebo-controlled trial. SETTING Hospital-based drug and alcohol clinics, 18 March 1998 - 22 October 1999. PATIENTS 107 patients (mean age, 45 years) fulfilling Diagnostic and statistical manual of mental disorders (4th edition) criteria for alcohol dependence. INTERVENTIONS Patients with alcohol dependence were randomly allocated to naltrexone (50 mg/day) or placebo for 12 weeks. They were medically assessed, reviewed and advised by one physician, and encouraged to strive for abstinence and attend counselling and/or Alcoholics Anonymous, but this was not obligatory. MAIN OUTCOME MEASURES Relapse rate; time to first relapse; side effects. RESULTS On an intention-to-treat basis, the Kaplan-Meier survival curve showed a clear advantage in relapse rates for naltrexone over placebo (log-rank test, chi(2)(1) = 4.15; P = 0.042). This treatment effect was most marked in the first 6 weeks of the trial. The median time to relapse was 90 days for naltrexone, compared with 42 days for placebo. In absolute numbers, 19 of 56 patients (33.9%) taking naltrexone relapsed, compared with 27 of 51 patients (52.9%) taking placebo (P = 0.047). Naltrexone was well tolerated. CONCLUSIONS Unlike previous studies, we have shown that naltrexone with adjunctive medical advice is effective in the treatment of alcohol dependence irrespective of whether it is accompanied by psychosocial interventions.
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Affiliation(s)
- Noeline C Latt
- Faculty of medicine, University of Sydney and Herbert Street Drug and Alcohol Clinic, Royal North Shore Hospital, St Leonards, NSW 2065, Australia.
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Wutzke SE, Conigrave KM, Saunders JB, Hall WD. The long-term effectiveness of brief interventions for unsafe alcohol consumption: a 10-year follow-up. Addiction 2002; 97:665-75. [PMID: 12084136 DOI: 10.1046/j.1360-0443.2002.00080.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIMS To examine the long-term impact of brief and early interventions for hazardous and harmful alcohol consumption. DESIGN A 9-month and 10-year follow-up of subjects recruited into a randomized controlled trial of a range of alcohol-related brief interventions. SETTING General practices, the outpatient or acute care services of a major city hospital, and a privately run health screening programmeme. PARTICIPANTS The cohort of 554 (non-dependent) hazardous and harmful drinkers recruited into the Australian arm of the Phase II World Health Organization collaborative project on identification and treatment of persons with harmful alcohol consumption. INTERVENTION The effectiveness of three forms of intervention, ranging from 5 to 60 minutes in duration, were compared with a no-treatment control condition. MEASUREMENTS Included drinking behaviour and biological markers of alcohol use. In addition, at 10 years subjects were asked about symptoms of diagnosable alcohol use disorders and their experience of alcohol-related psychological, social and physical harm. Mortality was also assessed. FINDINGS Results provide further evidence for the short-term effectiveness of alcohol-related brief interventions. In comparison to controls, subjects offered intervention: (1) report significantly lower consumption; and (2) less unsafe drinking at 9-month follow-up. The intensity of intervention was not related to the amount of change in drinking behaviour. Analysis at 10 years failed to find any differences in outcomes between intervention and control groups in median consumption, mean reduction in consumption from baseline to follow-up, mortality and ICD-10 diagnoses of alcohol dependence or harmful alcohol use. CONCLUSIONS This study failed to find evidence that brief advice and counselling without regular follow-up and reinforcement can sustain significant long-term reductions in drinking behaviour at 10-year follow-up.
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Affiliation(s)
- Sonia E Wutzke
- Faculty of Medicine, University of Sydney, Sydney, Australia.
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Kristenson H, Osterling A, Nilsson JA, Lindgärde F. Prevention of alcohol-related deaths in middle-aged heavy drinkers. Alcohol Clin Exp Res 2002; 26:478-84. [PMID: 11981123 DOI: 10.1111/j.1530-0277.2002.tb02564.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Alcohol as a cause of death in middle-aged patients is well-known from clinical studies. A similarly important correlation in the general population of urban middle-aged men is highly underestimated. Health screening investigations have shown that mortality related to alcohol is five times more common in nonparticipants than in participants. From the mid-70s, the Malmoe Screening and Intervention Study (MSIS) commenced screening investigations including a large number of residents of Malmoe. One goal was to find intervention programs for individuals in an early development of problem drinking, thereby preventing development of serious complications of endstage alcoholism. Herein, we report on the mortality of heavy drinkers (drinking more than 40 g alcohol/day) who were randomized to an intervention or control procedure and whose median survival was 13 years postentry into the MSIS. METHODS Health-screened men, aged 45-49 years at the initial screening examination and displaying serum gamma-glutamyltransferase (GT) in the top decentile of the GT distribution, were included. A total of 978 out of 11,257 participants met this criteria. A randomized intervention and control study was performed for four years and consisted of men (n = 667) who were born between 1927-1937 and who had two consecutive high GT values within 3 weeks along with heavy alcohol consumption. Half the individuals were informed of the test results and invited for further assessment by a senior physician (n = 365). The principles for brief intervention (DiClemente et al.,1991; Miller and Sanchez, 1993; National Institute of Alcohol Abuse and Alcoholism, 1999) were applied. The other half of the men (n = 302) were left with the information that they had a high GT value and were followed up with laboratory checkups every 2nd year. Mortality was followed up until 1991 and information on deaths was obtained from hospital and police records, necropsy reports, and death certificates. RESULTS Long-term follow-up of mortality for 10-16 years (median, 13 years) showed that 124 of the 978 men had died (12.7%). Autopsy was performed in 96.5% of the cases. In 59 men (48%), death was alcohol-related. In the intervention group (n = 365), 38 (10.4%) men were dead and in the control group (n = 302), 42 (13.9%) men had died. There was a statistically significant difference (p = 0.026), with advantage for treatment. Less alcohol-related deaths and deaths occurring later during follow-up were found in the intervention group compared with the control group. The difference between the groups in total mortality, coronary heart disease, and cancer death was not statistically significant. CONCLUSIONS These findings support previous results from the MSIS study indicating that long-term intervention in urban males with alcohol-induced GT increases may be beneficial in terms of survival.
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Affiliation(s)
- Hans Kristenson
- Department of Alcohol and Drug Diseases, University of Lund, Malmoe General Hospital, Sweden
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Wutzke SE, Shiell A, Gomel MK, Conigrave KM. Cost effectiveness of brief interventions for reducing alcohol consumption. Soc Sci Med 2001; 52:863-70. [PMID: 11234861 DOI: 10.1016/s0277-9536(00)00189-1] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The direct costs and health effects of a primary-care-based brief intervention for hazardous alcohol consumption were examined. The total cost of the intervention was calculated from costs associated with: marketing the intervention programme; providing training and support in the use of the intervention materials; physician time required for providing brief advice for 'at-risk' drinkers. The effect of the intervention on health outcomes was expressed in terms of number of life years saved by preventing alcohol-related deaths. This was derived by combining estimates of the impact of the programme if it were implemented nationally with available evidence on the health effects of excess alcohol consumption. Results are based on international trial evidence showing the physical resources required by the intervention and its effectiveness combined with Australian price data. The costs associated with screening and brief advice using the current intervention programme range from Aus$19.14 to Aus$21.50. The marginal costs per additional life year saved were below Aus$1873. The robustness of the model used is supported by an extensive sensitivity analysis. In comparison with existing health promotion strategies the costs and effects of the current intervention are highly encouraging.
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Affiliation(s)
- S E Wutzke
- Department of Psychological Medicine, University of Sydney, Australia.
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Conigrave KM, Burns FH, Reznik RB, Saunders JB. Problem drinking in emergency department patients: the scope for early intervention. Med J Aust 1991; 154:801-5. [PMID: 2041505 DOI: 10.5694/j.1326-5377.1991.tb121368.x] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the prevalence of previously undiagnosed problem drinking and thereby to assess the suitability of the emergency department for early intervention. DESIGN Three hundred and fifty ambulatory care patients were assessed by means of a structured interview schedule, physical examination and blood tests. Alcohol intake and presence of alcohol-related problems were recorded, along with history of past advice on drinking and self-perception of an alcohol problem. SETTING The ambulatory care section of the emergency department of Royal Prince Alfred Hospital, Sydney. PATIENTS Three hundred and fifty subjects, aged between 18 and 55 years, were sequentially selected over an 18-month period. RESULTS Forty-one per cent of subjects (95% confidence interval, 36%-46%), 50% of men and 26% of women, were classified as problem drinkers on the basis of hazardous or harmful levels of alcohol consumption, frequent drinking to intoxication, evidence of dependence, or experience of alcohol-related problems. Of these, 63% had not previously received advice on drinking from a health professional and only 28% perceived they had a problem. Of particular note was that 24% of men and 4% of women were drinking 12 or more drinks (120 g of alcohol or more) in a single session on a weekly or more frequent basis. CONCLUSIONS Many of the problem drinkers attending the emergency department have not previously received advice about their drinking from a health professional. The emergency department therefore offers considerable potential as a site for early detection and intervention in patients with hazardous and harmful alcohol use and related disorders.
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