Alcohol use disorders in primary care: do gender-specific differences exist?

Reducing women's alcohol use: a brief intervention pilot study at a primary health care service in Brazil

This study assesses the feasibility of a brief intervention among women with hazardous alcohol use at a primary health care service in Brazil. A two-arm randomized pilot study was carried out from July 2017 to January 2018 with 44 women aged 18 years or older with hazardous alcohol use. The intervention group completed a brief intervention in a single session lasting 20 to 30 minutes. The control group received five minutes of brief advice. Alcohol use was assessed by the Alcohol Use Disorders Identification Test (AUDIT), and the frequency and quantity of alcohol consumed in the previous month were assessed at baseline and the first and third months of follow-up in both groups. The AUDIT score was decreased in both groups at baseline (intervention group 12.89, control group 10.64), the 1st month (intervention group 12.78 p = .9; control group 7.9 p = .01) and the 3rd month (intervention group 10.11 p = .13; control group 7.09 p < .01). The intervention group continued using alcohol after the brief intervention, although the quantity of alcohol consumed was reduced compared with that at baseline (p < .01). Finally, the brief intervention delivered in a primary health care service in Brazil showed the potential to reduce women's pattern of alcohol consumption.

Copattern of depression and alcohol use in medical care patients: cross-sectional study in Germany

OBJECTIVE

To predict depressive symptom severity and presence of major depression along the full alcohol use continuum.

DESIGN

Cross-sectional study.

SETTING

Ambulatory practices and general hospitals from three sites in Germany.

PARTICIPANTS

Consecutive patients aged 18-64 years were proactively approached for an anonymous health screening (participation rate=87%, N=12 828). Four continuous alcohol use measures were derived from an expanded Alcohol Use Disorder Identification Test (AUDIT): alcohol consumption in grams per day and occasion, excessive consumption in days per months and the AUDIT sum score. Depressive symptoms were assessed for the worst 2-week period in the last 12 months using the Patient Health Questionnaire (PHQ-8). Negative binomial and logistic regression analyses were used to predict depressive symptom severity (PHQ-8 sum score) and presence of major depression (PHQ-8 sum score≥10) by the alcohol use measures.

RESULTS

Analyses revealed that depressive symptom severity and presence of major depression were significantly predicted by all alcohol use measures after controlling for sociodemographics and health behaviours (p<0.05). The relationships were curvilinear: lowest depressive symptom severity and odds of major depression were found for alcohol consumptions of 1.1 g/day, 10.5 g/occasion, 1 excessive consumption day/month, and those with an AUDIT score of 2. Higher depressive symptom severity and odds of major depression were found for both abstinence from and higher levels of alcohol consumption. Interaction analyses revealed steeper risk increases in women and younger individuals for most alcohol use measures.

CONCLUSION

Findings indicate that alcohol use and depression in medical care patients are associated in a curvilinear manner and that moderation by gender and age is present.

Guidelines of the Brazilian Association of Studies on Alcohol and Other Drugs (ABEAD) for diagnosis and treatment of psychiatric comorbidity with alcohol and other substance and dependence

In recent years, several studies have been focused on the comorbidity of psychiatric disorders with alcohol and other substance dependence. In this context, the Brazilian Association of Studies on Alcohol and Other Drugs initiated a project to establish Brazilian Guidelines. The aim of this study was to review diagnostic and therapeutic criteria for the most prevalent psychiatric comorbidities. Randomized clinical trials, epidemiological studies, animal testing and other forms of research are reviewed herein. The main psychiatric comorbidities are investigated and data published in the literature are reviewed, based on guidelines adopted by other countries. Epidemiological aspects, diagnostic criteria, integrated treatment and the organization of specialized service, as well as details regarding psychotherapy and pharmacological treatment are discussed. The guidelines of the Brazilian Association of Studies on Alcohol and Other Drugs reinforce the importance of adequate diagnosis and treatment regarding alcoholic and drug dependent patients suffering of comorbid psychiatric disorders.

An Exploration of Responses to Drug Conditioned Stimuli during Treatment for Substance Dependence

Although it is well established that drug conditioned stimuli produce a variety of conditioned responses, it is not known whether such stimuli can also reinforce an arbitrary operant response and thus serve as conditioned reinforcers. Volunteers (n = 39) recruited from a residential treatment center for substance dependence were tested on a task in which presses on computer keys activated images of drugs/drug paraphernalia on a progressive ratio schedule of reinforcement. They also completed a personalized craving questionnaire and a personalized Implicit Association Test. A significant bias in responding was found for images of preferred drugs/route of drug administration. Craving, however, was low and the images generated negative evaluative reactions. Two additional studies were performed to ascertain the generalizability of the effects to a different population of drug-using individuals (i.e., students who drink) and to incentive stimuli of a different nature (i.e., sexual). The additional studies partially replicated and extended the central findings of the main study. Therefore, although these data should be considered preliminary in light of small group sizes, it is concluded that cue specificity and availability of the unconditioned stimuli (drugs and sex) plays a role in modulating responding maintained by conditioned reinforcers.

Does gender matter? A vignette study of general practitioners' management skills in handling patients with alcohol-related problems

AIMS

The aims of this study were to analyse the perceptions of female and male primary care physicians (PCPs) of alcohol problems in male and female patients, their recommendations to reduce or abstain from alcohol, their referrals to treatment and their views of safe levels of drinking for male and female patients. These factors were related to the physicians' own alcohol consumption.

METHODS

A slightly adjusted version of the WHO Collaborative Study Questionnaire for General Practitioners was posted to all PCPs (n = 132) in the district of Skaraborg, Sweden, of whom 68 PCPs responded. In the questionnaire, the PCPs' perceptions of two patient vignettes were analysed.

RESULTS

Both the gender of the patients in the vignettes and of the PCPs influenced the advice and the referrals that the patients received: 83% of male excessive drinkers and 47% of female excessive drinkers were recommended to cut down on drinking. In 50% of cases, the male excessive drinker was not referred, compared with 25% for the female excessive drinker. This was statistically significant only for excessive drinkers. The odds ratio for referral to any treatment was 0.33 (CI = 0.12-0.93) for the male excessive drinker compared with the female excessive drinker. The male PCP referred the excessive drinker less often to any treatment than did the female PCP, odds ratio 0.26 (CI = 0.08-0.90). The upper limit of alcohol consumption before the PCPs would advise the patient to cut down was significantly higher for PCPs with the AUDIT-C score >or= 3. The limit was 146 g/week for male patients and 103 g/week for female patients. Corresponding figures for PCP with the AUDIT-C score <or= 2 were 89 and 68 g/week.

CONCLUSION

Male patients were less likely to be advised to stop drinking altogether than female patients and were less likely to be referred, according to this vignette study. Taking into account that male patients have a higher prevalence of alcohol problems, this may be of considerable importance for men's health outcomes. Implications of these findings are the need to increase awareness of male excessive drinking and that gendered perceptions might bias alcohol management recommendations.

Barriers and facilitators for alcohol treatment for women: are there more or less for rural women?

Among women at-risk for problems drinking, treatment seeking can be hindered by a complex array of issues such as a lack of transportation, social stigma, denial, fear of losing children, and reluctance of primary care physicians to refer women. This study describes the barriers/facilitators and need for treatment among a community sample of rural and urban women at-risk drinkers. Data for this study were assembled from the baseline sample of individuals who participated in a large probability sample of rural and urban at-risk drinkers (N = 733) from six Southern states: Alabama, Arkansas, Georgia, Louisiana, Mississippi, and Tennessee. Men and women differed on perceived barriers/facilitators and need for alcohol treatment. Women differed from men on measures of treatment affordability, accessibility, acceptability and report of social support, illness severity, comorbidities, and demographic characteristics. Rural women differed from urban women on measures of treatment affordability and accessibility and report of illness severity and comorbidities.

Early onset alcohol dependence with high density of family history is not "male limited"

OBJECTIVE

Based on classical adoption studies, early onset type II alcoholism was originally described as "male limited." We examined the possible expression of this subtype in present day alcohol-dependent women. Detailed systematic assessment was obtained from 200 treatment-seeking alcohol-dependent women and 189 healthy population controls. Women fulfilling type II alcoholism criteria had higher alcoholism severity as measured by The Alcohol Use Disorders Identification Test and markedly higher use of illicit drugs. Both alcoholism subtypes scored higher than normal on anxiety and impulsivity traits, but type II women scored markedly higher on aggression subscales than either of the other groups. Importantly, density of family history was markedly higher in type II women, suggesting a higher heritability. Despite its original description as male limited, early onset alcoholism with high density of family history is likely to be a valid construct in women. Its recognition has important implications for diagnosis, treatment, and research.

Breast pumping and lactational state exert differential effects on ethanol pharmacokinetics

Prior research revealed that breast stimulation altered the way the lactating body handles alcohol. Its effects depended upon when it occurred relative to drinking. The goal of the present study was to determine whether breast pumping works independently of the physiological and metabolic changes that accompany lactation. To this end, we tested 12 women when they were exclusively breastfeeding 3-5-month-old infants and then again several months after lactation had ceased. Subjects were randomly assigned to one of two groups that differed in the timing of breast pumping relative to drinking a 0.4g/kg dose of alcohol: one group breast pumped 0.6h after drinking (pumped after group) and the other pumped 1h before drinking (pumped before group). For each reproductive stage, subjects were tested on 2 separate days, consuming a standardized meal 1 h before drinking during 1 test day and remaining fasted during the other. Breath alcohol concentrations (BrAC) and temperature readings were obtained before and at fixed intervals after drinking. Pumping before drinking significantly decreased BrAC during both reproductive stages, whereas pumping after drinking resulted in different BrAC time curves during lactation when compared with after lactation. That is, levels were significantly lower during the descending phase of the time curve during than after lactation. The interactions between pumping and reproductive stage were most apparent during fed condition. Furthermore, women were more sensitive to hypothermic effects of both fasting and drinking alcohol during lactation. These findings add to the growing literature that lactating women metabolize alcohol differently, in part, due to the frequent breast stimulation during breastfeeding and the pronounced physiological changes that accompany one of the most energetically costly mammalian activities.

Nicotinic receptor ligands reduce ethanol intake by high alcohol-drinking HAD-2 rats

Neuronal nicotinic acetylcholine receptors (nAChRs) are implicated in the reinforcing effects of many drugs of abuse, including ethanol. The present study examined the efficacy of cytisine, a nAChR partial agonist, and lobeline, a putative nAChR antagonist, on the maintenance of ethanol drinking by HAD-2 rats. Adult male HAD-2 rats were given access to ethanol (15 and 30%, with ad libitum access to water and food) 22 h/day for 12 weeks, beginning at 60 days of age, after which cytisine (0.0, 0.5, and 1.5 mg/kg) was tested for 3 consecutive days. The rats were given an 18-day washout period and were then tested with lobeline (0.0, 1.0, and 5.0 mg/kg) for 3 consecutive days. Ethanol intake was measured at 1, 4, and 22 h postinjection. Rats were injected intraperitoneally just before lights out (1200 h). There was a significant main effect of cytisine treatment on the second test day, with the 1.5 mg/kg dose significantly reducing ethanol intake at the 1- and 4-h time-points, relative to saline, and the 0.5 mg/kg dose inducing a significant reduction at the 4-h time-point. Conversely, lobeline treatment resulted in significant main effects of treatment for all three time-points within each test day, with the 5.0 mg/kg dose significantly reducing ethanol intake, relative to saline, at each time-point within each test day. These findings provide further evidence that activity at the nAChR influences ethanol intake and is a promising target for pharmacotherapy development for the treatment of alcohol dependence and relapse.

Lactational state modifies alcohol pharmacokinetics in women

BACKGROUND

Given the physiological adaptations of the digestive system during lactation, the present study tested the hypothesis that lactation alters alcohol pharmacokinetics.

METHODS

Lactating women who were exclusively breastfeeding a 2- to 5-month-old infant and 2 control groups of nonlactating women were studied. The first control group consisted of women who were exclusively formula-feeding similarly aged infants, whereas the other consisted of women who had never given birth. A within-subjects design study was conducted such that women drank a 0.4 g/kg dose of alcohol following a 12-hour overnight fast during one test session (fasted condition) or 60 minutes after consuming a standard breakfast during the other (fed condition). Blood alcohol concentration (BAC) levels and mood states were obtained at fixed intervals before and after alcohol consumption.

RESULTS

Under both conditions, the resultant BAC levels at each time point were significantly lower and the area under the blood alcohol time curve were significantly smaller in lactating women when compared with the 2 groups of nonlactating women. That such changes were due to lactation per se and not due to recent parturient events was suggested by the finding that alcohol pharmacokinetics of nonlactating mothers, who were tested at a similar time postpartum, were no different from women who had never given birth. Despite lower BAC levels in lactating mothers, there were no significant differences among the 3 groups of women in the stimulant effects of alcohol. However, lactating women did differ in the sedative effects of alcohol when compared with nulliparous but not formula-feeding mothers. That is, both groups of parous women felt sedated for shorter periods of time when compared with nulliparous women.

CONCLUSIONS

The systemic availability of alcohol was diminished during lactation. However, the reduced availability of alcohol in lactating women did not result in corresponding changes in the subjective effects of alcohol.

Alcohol use and misuse in urban Mexican men and women: an epidemiologic perspective

Consumption patterns and misuse of alcohol were examined in adults sampled from three cities in Mexico (n=1933). The sample was divided into groups of persons who abstained from alcohol, drank but endorsed no misuse, or drank and endorsed at least some misuse of alcohol. Half of the entire sample was categorized as drinkers (12 or more drinks in lifetime). Mexican men drank more per occasion and reported more problems with alcohol rather than did Mexican women. Low socioeconomic resources, not being married, and female gender were related to whether Mexicans abstained from alcohol rather than drank without misuse. Lifetime posttraumatic stress disorder (PTSD) or depression increased the likelihood of misusing alcohol versus drinking without misuse, as did greater amount of drinks consumed per occasion and male gender. Younger age and not being married were also related to misuse, although this was true mostly for women. The number of traumatic experiences in childhood and lower socioeconomic resources also predicted misuse, although mostly for men. Specific traumatic experiences and their relationship to alcohol use and misuse were also examined.

The alcohol-preferring P rat and animal models of excessive alcohol drinking

The alcohol-preferring, P, rat was developed by selective breeding to study ethanol drinking behavior and its consequences. Characterization of this line indicates the P rat meets all of the criteria put forth for a valid animal model of alcoholism, and displays, relative to their alcohol-non-preferring, NP, counterparts, a number of phenotypic traits associated with alcohol abuse and alcoholism. Behaviorally, compared with NP rats, P rats are less sensitive to the sedative and aversive effects of ethanol and more sensitive to the stimulatory effects of ethanol. Neurochemically, research with the P line indicates the endogenous dopaminergic, serotonergic, GABAergic, opiodergic, and peptidergic systems may be involved in a predisposition for alcohol abuse and alcoholism. Paralleling the clinical literature, genetically selected P rats display levels of ethanol intake during adolescence comparable to that seen during adulthood. Binge drinking has been associated with an increased risk for health and other problems associated with ethanol abuse. A model of binge-like drinking during the dark cycle indicates that P rats will consume 6 g/kg/day of ethanol in as little as three 1-hour access periods/day, which approximates the 24-hour intake of P rats with free-choice access to a single concentration of ethanol. The alcohol deprivation effect (ADE) is a transient increase in ethanol intake above baseline values upon re-exposure to ethanol access after an extended period of deprivation. The ADE has been proposed to be an animal model of relapse behavior, with the adult P rat displaying a robust ADE after prolonged abstinence. Overall, these findings indicate that the P rat can be effectively used in models assessing alcohol-preference, a genetic predisposition for alcohol abuse and/or alcoholism, and excessive drinking using protocols of binge-like or relapse-like drinking.

Gender and use of substance abuse treatment services

Women are more likely than men to face multiple barriers to accessing substance abuse treatment and are less likely to seek treatment. Women also tend to seek care in mental health or primary care settings rather than in specialized treatment programs, which may contribute to poorer treatment outcomes. When gender differences in treatment outcomes are reported, however, women tend to fare better than men. Limited research suggests that gender-specific treatment is no more effective than mixed-gender treatment, though certain women may only seek treatment in women-only programs. Future health services research should consider or develop methods for (1) improving care for women who seek help in primary care or mental health settings, (2) increasing the referral of women to specialized addiction treatment, (3) identifying subgroups of women and men who would benefit from gender-specific interventions, and (4) addressing gender-specific risk factors for reduced treatment initiation, continuation, and treatment outcomes.

Gender Differences in the Performance of a Computerized Version of the Alcohol Use Disorders Identification Test in Subcritically Injured Patients Who Are Admitted to the Emergency Department

OBJECTIVE

The Alcohol Use Disorder Identification Test (AUDIT) has been recommended as a screening tool to detect patients who are appropriate candidates for brief, preventive alcohol interventions. Lower AUDIT cutoff scores have been proposed for women; however, the appropriate value remains unknown. The primary purpose of this study was to determine the optimal AUDIT cutpoint for detecting alcohol problems in subcritically injured male and female patients who are treated in the emergency department (ED). An additional purpose of the study was to determine whether computerized screening for alcohol problems is feasible in this setting.

METHODS

The study was performed in the ED of a large, urban university teaching hospital. During an 8-month period, 1205 male and 722 female injured patients were screened using an interactive computerized lifestyle assessment that included the AUDIT as an embedded component. World Health Organization criteria were used to define alcohol dependence and harmful drinking. World Health Organization criteria for excessive consumption were used to define high-risk drinking. The ability of the AUDIT to classify appropriately male and female patients as having one of these three conditions was the primary outcome measure.

RESULTS

Criteria for any alcohol use disorder were present in 17.5% of men and 6.8% of women. The overall accuracy of the AUDIT was good to excellent. At a specificity >0.80, sensitivity was 0.75 for men using a cutoff of 8 points and 0.84 for women using a cutoff of 5 points. Eighty-five percent of patients completed computerized screening without the need for additional help.

CONCLUSIONS

Different AUDIT scoring thresholds for men and women are required to achieve comparable sensitivity and specificity when using the AUDIT to screen injured patients in the ED. Computerized AUDIT administration is feasible and may help to overcome time limitations that may compromise screening in this busy clinical environment.

Multicenter Validation Study of the %CDT TIA Kit in Alcohol Abuse and Alcohol Dependence

BACKGROUND

Carbohydrate-deficient transferrin (CDT) and gamma-glutamyl transferase (GGT) are used as biomarkers of alcohol misuse. The aim of this study was to evaluate, in terms of sensitivity and specificity, the performance of the new Bio-Rad %CDT TIA kit and GGT assay for identifying alcohol abuse and alcohol dependence (according to the DSM-IV criteria).

METHODS

An open multicenter study (30 centers) over 3 months, including patient groups of "abusers," "dependents," and controls, was conducted in France.

RESULTS

In alcohol abuse, the sensitivity of GGT was 0.56, and that of CDT was 0.80; in alcohol dependence, the sensitivity of GGT was 0.86, and that of CDT was 0.91. The specificity of GGT was 0.77, and that of CDT was 0.83. The association of GGT with CDT increased sensitivity for alcohol abuse to 0.90 and for alcohol dependence to 0.99, but it appreciably decreased specificity (0.63).

CONCLUSIONS

%CDT is the better screening marker for alcohol abuse and dependence, but GGT is still a useful marker for the detection of alcohol dependence. As an assay method, the second-generation Bio-Rad %CDT immunoassay can be recommended for routine CDT measurement.

The use of biological laboratory markers in the diagnosis of alcohol misuse: an evidence-based approach

BACKGROUND

A large number of patients seen in clinical practice have an underlying alcohol problem. There is a pressing need for accurate methods to diagnose alcohol over-consumption objectively. Our aim was to determine how best to use biological markers to objectify alcohol problems in patients with clinical suspicion of alcohol misuse.

METHODS

A 6-month longitudinal multicenter trial was conducted, using four study groups (alcohol abusers, alcohol-dependents, healthy controls and consulting controls). CDT, GGT and MCV were measured. Statistical analyses used a computer learning system that created classification systems displayed in decision trees.

RESULTS

In 379 subjects the marker that best discriminated those with alcohol problems from controls was CDT. GGT then helped to differentiate between alcohol abuse and alcohol dependence in cases of high CDT. MCV, age and gender provided no extra information.

DISCUSSION

We recommend CDT as a first-line biological marker to confirm or disprove suspected alcohol misuse. High CDT plus GGT above normal points to alcohol dependence, while high CDT plus GGT below normal is evidence of alcohol abuse.