Adverse physical effects of alcohol misuse

Reviewing the burden of comorbidity in patients receiving specialist in-patient treatment for drug and alcohol problems

AIMS AND METHOD

To compare and contrast the burden of comorbidity in a population receiving in-patient treatment for substance misuse with that of a cohort admitted to the same unit 4 years previously. The Charlson Comorbidity Index (CCI) was used to quantify patients' comorbidity and predict 10-year survival.

RESULTS

There was a marked reduction in predicted 10-year survival: in 2014, 22% of patients had a predicted 98% chance of 10-year survival, whereas only 2% in the 2018 cohort had a predicted 98% chance. Additionally, in 2014 only 9% of patients had a <20% 10-year predicted survival chance, whereas 28% in 2018 had a predicted 10-year survival chance of <20%. In this time, funding for services was cut by 23% and the 12-bed unit was reduced to 8 beds. This resulted in an increase in the average waiting time from 30 to 65 days. In 2018, more patients were admitted for alcohol detoxification, rising from 79% to 93% of admissions. Chronic respiratory disease remains the most prominent comorbidity; however, there is also an increase in the percentage of patients with liver disease.

CLINICAL IMPLICATIONS

In-patient substance misuse units are known to serve individuals with complex illnesses. With service funding cuts, subsequent bed reductions and increased waiting times, this complexity is increasing, with a considerably higher burden of comorbidity. The consequential increased mortality risk highlights the ongoing need for adequate community and in-patient services with integrated care of mental and physical health alongside social work.

Alcohol dependence and physical comorbidity: Increased prevalence but reduced relevance of individual comorbidities for hospital-based mortality during a 12.5-year observation period in general hospital admissions in urban North-West England

Purpose:

Alcohol dependence (AD) is associated with an increase in physical comorbidities. The effects of these diseases on general hospital-based mortality are unclear. Consequently, we conducted a mortality study in which we investigated if the burden of physical comorbidities and their relevance on general hospital-based mortality differs between individuals with and without AD during a 12.5-year observation period in general hospital admissions.

Methods:

During 1 January 2000 and 30 June 2012, 23,371 individuals with AD were admitted at least once to seven General Manchester Hospitals. Their physical comorbidities with a prevalence ≥ 1% were compared to those of 233,710 randomly selected hospital controls, group-matched for age and gender (regardless of primary admission diagnosis or specialized treatments). Physical comorbidities that increased the risk of hospital-based mortality (but not outside of the hospital) during the observation period were identified using multiple logistic regression analyses.

Results:

Hospital-based mortality rates were 20.4% in the AD sample and 8.3% in the control sample. Individuals with AD compared to controls had a higher burden of physical comorbidities, i.e. alcoholic liver and pancreatic diseases, diseases of the conducting airways, neurological and circulatory diseases, diseases of the upper gastrointestinal tract, renal diseases, cellulitis, iron deficiency anemia, fracture neck of femur, and peripheral vascular disease. In contrast, coronary heart related diseases, risk factors of cardiovascular disease, diverticular disease and cataracts were less frequent in individuals with AD than in controls. Thirty-two individual physical comorbidities contributed to the prediction of hospital-based mortality in univariate analyses in the AD sample; alcoholic liver disease (33.7%), hypertension (16.9%), chronic obstructive pulmonary disease (14.1%), and pneumonia (13.3%) were the most frequent diagnoses in deceased individuals with AD. Multiple forward logistic regression analysis, accounting for possible associations of diseases, identified twenty-three physical comorbidities contributing to hospital-based mortality in individuals with AD. However, all these comorbidities had an equal or even lower impact on hospital-based mortality than in the comparison sample.

Conclusion:

The excess of in-hospital deaths in general hospitals in individuals with AD is due to an increase of multiple physical comorbidities, even though individual diseases have an equal or even reduced impact on general hospital-based mortality in individuals with AD compared to controls.

Substance misuse in later life: challenges for primary care: a review of policy and evidence

BACKGROUND

Substance misuse in older people represents a growing clinical and public health problem within primary care.

AIM

The aim of article is to explore policy and research evidence for informing best practice in the assessment, treatment effectiveness, treatment implementation and approaches to recovery for older people with substance misuse in primary care.

METHODS

Relevant search terms were used to examine the databases MEDLINE, EMBASE, CINAHL and PsychINFO up to January 2016.

RESULTS

An age-sensitive approach is required to overcome barriers to assessment. Training is essential for developing relevant knowledge, skills and attitudes. Clinical audit be used to develop care pathways, particularly for older people with dual diagnosis. There is also a need to develop closer links between primary care and the secondary care specialties, as well as added value in working with carers and voluntary agencies.

DISCUSSION

Further research is needed to inform more effective approaches to treatment. Adequate funding for workforce development and quality improvement in service development are also essential to improve health outcomes and quality of life in older people with substance misuse.

COMPARATIVE CHARACTERISTIC OF «ALCOHOL DEPRESSION» IN PERSONS WHO PARTICIPATED IN COMBAT OPERATIONS (COMBATANS) AND AFFECTED BY RADIATION CATASTROP

The relevance of work is conditioned by the considerable prevalence of depressive disorders and alcohol abuseamong people who participated in combat operations (combatants) and affected by a radiation emergency, whichneeds to be optimized for providing them with a comprehensive social, psychological-psychiatric, medication andsomato-neurological help on the basis of a biopsychosocial paradigm.The objective of the study was to increase the level of medical care to combatants of the Antiterrorist Operation /Joint Forces Operation (ATO/JFO) and person affected by the catastrophe at the Chornobyl NPP (ChNPP) with depres-sion associated with alcohol abuse through theoretical substantiation, development and implementation in theinstitutions of public health and other agencies involved of new principles and algorithms for diagnosis, treatmentand prevention.The object and methods of the study were 160 ATO/JFO combatants from the age of 22 to 56 years old (M ± SD:(41.5 ± 16.5) years) with alcohol and depressive disorders the main group. The comparison groups included 81Chornobyl catastrophe clean-up workers (liquidators) with post-traumatic stress disorder and comorbid chroniccerebrovascular pathology, as well as other contingents affected by the Chornobyl catastrophe. Clinical-anamnestic,socio-demographic, clinical psychopathological, psychodiagnostic, neurophysiological and neuroimaging methodswere used. Somato-neurological clinical examinations and laboratory tests have been applied. The analysis of thedata was performed using MS Excel spreadsheets and statistical package Statistica 10.0 (StatSoft) with the Studentt-criterion, paired t-test, criterion χ2, and Fisher exact test.The study design of the main group consisted of 5 stages: 1) screening; 2) inclusion; 3) randomization; 4) treat-ment and 5) catamnestic (follow-up) observation.Results. In the main group the distribution of depressive syndromes was revealed as follows: depressive-hypochon-dric - in 68 (42.5 %) patients; 2) asthenic-depressive - in 33 (20,6 %); 3) anxiety-depressive - in 31 (19.4 %); 4)depressive-dysphoric - in 14 (8.8 %); 5) apathetic-depressive - in 7 (4,35 %); and 6) simple depressive - in7 (4,35%). The combatants after participation in the ATO/JFO had personality deformation and irritative changes of thebrain bioelectric activity, thickening of the intima-media complex and venous dyshaemia in the basal veins ofRosenthal. In liquidators there is an excess of depressive disorders, the frequency and severity of which increase inproportion to the radiation dose. These disorders are characterized by progressive course, personality changes withpsychosomatic pre-disposition, comorbidity with cerebrovascular pathology, neurocognitive deficits and high fre-quency (24 %) of secondary alcohol abuse. The relationship between depressive disorders and alcohol dependencein the examined patients is diverse. Their variants differ in certain clinical manifestations and to a large extentdetermine the differential diagnosis and differentiated approaches to treatment, prevention and medical and socialrehabilitationConclusions. The comorbidity of depressive disorders with the abuse of alcohol by combatants and person affectedby the catastrophe at the ChNPP is gaining an increasing significance first of all because of the increased risk of suicidal behavior. The proposed diagnostic complex and differentiated approaches to treatment, prevention and med-ical and social rehabilitation may increase the level of medical care for the ATO /JFO combatants and the Chernobylcatastrophe survivors with depression associated with alcohol abuse.

The relationship between different dimensions of alcohol use and the burden of disease-an update

BACKGROUND AND AIMS

Alcohol use is a major contributor to injuries, mortality and the burden of disease. This review updates knowledge on risk relations between dimensions of alcohol use and health outcomes to be used in global and national Comparative Risk Assessments (CRAs).

METHODS

Systematic review of reviews and meta-analyses on alcohol consumption and health outcomes attributable to alcohol use. For dimensions of exposure: volume of alcohol use, blood alcohol concentration and patterns of drinking, in particular heavy drinking occasions were studied. For liver cirrhosis, quality of alcohol was additionally considered. For all outcomes (mortality and/or morbidity): cause of death and disease/injury categories based on International Classification of Diseases (ICD) codes used in global CRAs; harm to others.

RESULTS

In total, 255 reviews and meta-analyses were identified. Alcohol use was found to be linked causally to many disease and injury categories, with more than 40 ICD-10 three-digit categories being fully attributable to alcohol. Most partially attributable disease categories showed monotonic relationships with volume of alcohol use: the more alcohol consumed, the higher the risk of disease or death. Exceptions were ischaemic diseases and diabetes, with curvilinear relationships, and with beneficial effects of light to moderate drinking in people without heavy irregular drinking occasions. Biological pathways suggest an impact of heavy drinking occasions on additional diseases; however, the lack of medical epidemiological studies measuring this dimension of alcohol use precluded an in-depth analysis. For injuries, except suicide, blood alcohol concentration was the most important dimension of alcohol use. Alcohol use caused marked harm to others, which has not yet been researched sufficiently.

CONCLUSIONS

Research since 2010 confirms the importance of alcohol use as a risk factor for disease and injuries; for some health outcomes, more than one dimension of use needs to be considered. Epidemiological studies should include measurement of heavy drinking occasions in line with biological knowledge.

Selective serotonin reuptake inhibitors increase sympathetic activity under heavy alcohol exposure in rat models

AIMS

Self-medication with alcohol while being treated with antidepressants is a common problem in patients with depression. Both alcohol consumption and antidepressant administration can induce changes in the cardiac autonomic responses as indicated by heart rate variability (HRV). In this study, we examined cardiac autonomic responses induced by acute heavy alcohol exposure after SSRIs (selective serotonin reuptake inhibitors) medications.

MAIN METHODS

Rats were randomly divided into 3 groups, the alcohol administrated (Alc group), paroxetine administrated (SSRI group), and the SSRI+Alc group. Serum samples were collected to measure blood alcohol concentration (BAC). Physiological and cardiac autonomic responses including mean arterial pressure (MAP), heart rate (HR), and HRV were also compared among groups.

KEY FINDINGS

The SSRI group exhibited higher values of HRV and HF (high frequency) than did the Alc and SSRI+Alc groups after alcohol administration. In contrast to the Alc group, the SSRI+Alc group had significantly lower MAP than Alc group, and higher HR, standard deviation of NN-intervals (SDNN), SDNN to MRR ratio (CVNN), square root of the mean squared differences of the successive NN-intervals (RMSSD) and HF values after alcohol administration.

SIGNIFICANCE

Our results indicate that SSRIs increased sympathetic activity and alcohol reduced it in rats. The present study represents an attractive area for further research.

Associations of Alcohol Consumption and Chronic Diseases With Sleep Apnea Among US Adults

BACKGROUND

Sleep apnea (SA) is a common sleep disorder among US adults. Associations of SA with alcohol consumption and some chronic diseases have been inconsistent.

OBJECTIVES

This study aimed to estimate prevalence of SA and examine its associations with potential factors including alcohol consumption, asthma, diabetes, and hypertension.

PATIENTS AND METHODS

This was a cross-sectional study on 823 adults with SA and 38,638 controls from the 2011 National Survey on Drug Use and Health Data. Weighted univariate and multiple logistic regression analyses were used to examine the associations of SA with the potential factors.

RESULTS

The prevalence of SA was higher in males (4.01%) than in females (2.61%), while the prevalence increased with age (0.86%, 3.50%, and 4.47% for age groups of 18-25, 26-64, and ≥ 65, respectively). Univariate analysis revealed that all factors except for income and education were associated with SA (P < 0.05). In multivariable analyses, participants who were current and past alcohol consumers had significantly higher odds of having SA (OR = 1.52, 95% CI = 1.03-2.23; OR = 1.65, 95% CI = 1.09-2.49, respectively) than non-alcohol drinker. Furthermore, asthma (OR = 2.77, 95% CI = 2.04-3.75), diabetes (OR = 2.89, 95% CI = 2.19-3.83), and hypertension (OR = 2.42, 95% CI = 1.91-3.07) were significantly associated with SA.

CONCLUSIONS

Age, alcohol consumption, asthma, diabetes, and hypertension, were positively associated with SA. More efforts should be directed to promoting screening for SA and finding possible treatments for SA among these vulnerable groups.

How Alcohol Kills: Alcohol-Attributable and Alcohol-Associated Deaths in a Medical Examiner Population

Forensic pathologists frequently encounter the myriad effects of acute and chronic ethanolism and the many ways that alcohol contributes to sudden natural and unnatural deaths. Alcohol may act as risk factor for sudden death or directly participate as a cause of sudden death through its acute and chronic toxic effects. This retrospective descriptive study examines the causes and manner of deaths potentially attributable to alcohol and the results of postmortem toxicology testing for ethanol in unnatural deaths and alcohol-attributable natural deaths over a five-year period in a large medical examiner's office. Ethanol was detected in all types of unnatural deaths as well as alcohol-attributable natural deaths due to the complications of chronic ethanol abuse with a wide range of overlapping concentrations. Of the unnatural deaths involving individuals with a detectable ethanol concentration, 61% were accidents, 25% suicides, and 14% were homicides; ethanol was detected in 40.2% of accidents, 42.0% of suicides, and 53.1% of homicides. Ethanol was also detected in 41% of deaths due to chronic alcoholism. For the unnatural deaths involving intoxicated individuals and deaths due to chronic alcoholism, the deaths were certified as a wide variety of causes. In general, the results are similar to those in the existing literature. Forensic pathologists need to be well-versed in interpreting postmortem ethanol concentrations and determining the role of acute and/or chronic ethanolism in sudden deaths.

Holiday season for a healthy heart

The term "holiday heart" is defined as an acute cardiac arrhythmia or conduction disturbance associated with heavy alcohol intake in individuals with no known heart disease, but in whom heart rhythm is restored to normal with abstinence of alcohol. This article provides a brief overview of the literature on this topic, discusses causes of increased cardiac events during the holiday season, describes a patient profile and the effect on patients' health as well as on their families, and provides suggestions to decrease the risk of holiday heart during the festive season.

The relation between different dimensions of alcohol consumption and burden of disease: an overview

AIMS

As part of a larger study to estimate the global burden of disease and injury attributable to alcohol: to evaluate the evidence for a causal impact of average volume of alcohol consumption and pattern of drinking on diseases and injuries; to quantify relationships identified as causal based on published meta-analyses; to separate the impact on mortality versus morbidity where possible; and to assess the impact of the quality of alcohol on burden of disease.

METHODS

Systematic literature reviews were used to identify alcohol-related diseases, birth complications and injuries using standard epidemiological criteria to determine causality. The extent of the risk relations was taken from meta-analyses.

RESULTS

Evidence of a causal impact of average volume of alcohol consumption was found for the following major diseases: tuberculosis, mouth, nasopharynx, other pharynx and oropharynx cancer, oesophageal cancer, colon and rectum cancer, liver cancer, female breast cancer, diabetes mellitus, alcohol use disorders, unipolar depressive disorders, epilepsy, hypertensive heart disease, ischaemic heart disease (IHD), ischaemic and haemorrhagic stroke, conduction disorders and other dysrhythmias, lower respiratory infections (pneumonia), cirrhosis of the liver, preterm birth complications and fetal alcohol syndrome. Dose-response relationships could be quantified for all disease categories except for depressive disorders, with the relative risk increasing with increased level of alcohol consumption for most diseases. Both average volume and drinking pattern were linked causally to IHD, fetal alcohol syndrome and unintentional and intentional injuries. For IHD, ischaemic stroke and diabetes mellitus beneficial effects were observed for patterns of light to moderate drinking without heavy drinking occasions (as defined by 60+ g pure alcohol per day). For several disease and injury categories, the effects were stronger on mortality compared to morbidity. There was insufficient evidence to establish whether quality of alcohol had a major impact on disease burden.

CONCLUSIONS

Overall, these findings indicate that alcohol impacts many disease outcomes causally, both chronic and acute, and injuries. In addition, a pattern of heavy episodic drinking increases risk for some disease and all injury outcomes. Future studies need to address a number of methodological issues, especially the differential role of average volume versus drinking pattern, in order to obtain more accurate risk estimates and to understand more clearly the nature of alcohol-disease relationships.

Alcohol consumption, unprovoked seizures, and epilepsy: a systematic review and meta-analysis

PURPOSE

The purpose of this research was to analyze and quantify the association between alcohol consumption and epilepsy as an independent disease, in part operationalized by the occurrence of unprovoked seizures, as well as to examine causality.

METHODS

Systematic review, meta-analysis.

RESULTS

A strong and consistent association between alcohol consumption and epilepsy/unprovoked seizures was found with an overall relative risk (RR) of 2.19 [95% confidence interval (CI) 1.83-2.63]. There was a dose-response relationship between the amount of alcohol consumed daily and the probability of the onset of epilepsy. Individuals consuming an average of four, six, and eight drinks daily had RRs of 1.81 (95% CI 1.59-2.07), 2.44 (95% CI 2.00-2.97), and 3.27 (95% CI 2.52-4.26), respectively, compared to nondrinkers. Several pathogenic mechanisms for the development of epilepsy in alcohol users were identified. Most of the relevant studies found that a high percentage of alcohol users with epilepsy would qualify for the criteria of alcohol dependence. Data were inconclusive regarding a threshold for the effect of alcohol, but most studies suggest that the effect may only hold for heavy drinking (four and more drinks daily).

DISCUSSION

The relationship between alcohol consumption and epilepsy and unprovoked seizures was quantified and several pathogenic mechanisms were suggested, although none of them has been proven to be the unique causative pathway for epilepsy. Certain limitations underlying this study require further research to clarify the outstanding statistical issues and pathogenesis of epilepsy in heavy drinkers.

Management of alcohol use disorders

Welcome to the third module in our Continuing Professional Development Section (CPD). CPD is now a key element in the clinical activity of all health professionals and a cornerstone of good clinical governance throughout mental health services. This section of the Irish Journal of Psychological Medicine will provide CPD modules dedicated to key topics in mental health care. In order to assist learning and self-assessment, multiple choice questions will be provided at the end of each module.

This module and its multiple choice questions are available online on the website of the Irish Journal of Psychological Medicine (www.ijpm.org). The CPD policy of the College of Psychiatry of Ireland indicates that psychiatrists who participate in suitable online learning which fits the criteria for CPD may claim CPD points under the Personal CPD category (up to a maximum of 5 points per year).

We are confident that this CPD Section of the Irish Journal of Psychological Medicine will prove to be a valuable resource for consultant psychiatrists, psychiatric trainees and all journal readers. We welcome feedback from readers and, especially, any suggestions for topics to be covered in future CPD modules. Suggestions should be emailed to: psychological@medmedia.ie