Interactions between alcohol and other drugs

A Review of Bioinformatics Tools to Understand Acetaminophen-Alcohol Interaction

Background: Drug-ethanol interaction can result in hepatotoxicity. The liver is capable of metabolizing both acetaminophen and ethanol; however, severe acute or moderate chronic simultaneous exposure can cause cell and tissue damage. Therapeutic doses can become harmful if gene activity is altered via competition for metabolic pathways. Simultaneous intake of ethanol and acetaminophen results in overactive CYP2E1 and depletion of glutathione, leaving NAPQI to build up in the liver. NAPQI is a hepatotoxic substance typically neutralized by glutathione. Methods: Bioinformatics tools including PharmGKB, Chemical Annotation Retrieval Toolkit, Transcriptome Analysis Console 4.0 (TAC), wikipathways, STRING, and Ingenuity Pathway Analysis (IPA) were used to explore interactive metabolic pathways of ethanol-acetaminophen exposure as a proof of concept for assessing drug-drug or drug-alcohol interactions. Results: As the ethanol-acetaminophen comparison indicates, bioinformatics tools may be used to understand interactive pathways following exposure to ethanol and acetaminophen, with potential extrapolation to other drug-drug/drug-ethanol interactions. Conclusions: Direct interactive effects were not able to be confirmed through this bioinformatics study due to the lack of existing ethanol-acetaminophen simultaneous exposure data. This work suggests that a battery of software applications should be used to assess interactive effects.

1H NMR-based metabolomics reveals interactive effects between the carrier solvent methanol and a pharmaceutical mixture in an amphibian developmental bioassay with Limnodynastes peronii

Organic carrier solvents are used in aquatic toxicity testing to improve chemical solubility and facilitate the exploration of dose-response relationships. Both water- and solvent-control groups are normally included in these scenarios to ensure that the solvent itself has no effect on the test organism, but this fails to consider possible interactive effects between carrier solvents and contaminants of interest. We explored this topic by exposing Limnodynastes peronii tadpoles to a mixture of common water-soluble pharmaceuticals (diclofenac, metformin and valproic acid) in the presence and absence of the carrier solvent methanol, according to standard developmental bioassay methodology. Nuclear Magnetic Resonance (NMR) spectroscopy was applied as a platform for untargeted metabolomics, to compare broad sub-lethal hepatotoxicity in solvent- and solvent-free exposure scenarios. Considerable interactive effects were identified between the pharmaceutical mixture and a typical dose of methanol (0.003%). Specifically, pronounced differences were observed between the solvent- and solvent-free exposure groups for leucine, acetate, glutamine, citrate, glycogen, tyrosine, arginine, purine nucleotides and an unidentified metabolite at 6.53 ppm. Various other metabolites exhibited similar disparity related to the use of carrier solvent, but the interactions were non-significant. These results raise important questions about the use of carrier solvents for chemical exposures in aquatic ecotoxicology, and particularly for studies interested in sub-lethal mechanistic information and/or biomarker discovery.

Use of alcohol and drugs with addiction potential among older women and men in a population-based study. The Nord-Trøndelag Health Study 2006-2008 (HUNT3)

Background

Little is known about the consumption habits of older adults in Norway with respect to alcohol and the use of drugs with addiction potential, such as benzodiazepines, z-hypnotics and opioids, among regular drinkers. We studied the prevalence of self-reported consumption of alcohol on a regular basis in community-living older men and women (≥ 65 years). Furthermore, we investigated the prevalence of dispensed prescribed drugs with addiction potential in older men and women who were regular drinkers.

Methods

We used data from the Nord-Trøndelag Health Study 2006–2008 (HUNT3). Of 12,361 older adults in the HUNT3 study, 11,545 had answered the alcohol consumption item and were included in our study. Regular drinkers were defined as consuming alcohol one or more days a week. Data on dispensed drugs with addiction potential were drawn from the Norwegian Prescription Database. Addiction potential was defined as at least one prescription for benzodiazepines, z-hypnotics or opioids during one year for a minimum of two consecutive years.

Results

In total 28.2% of older Norwegian adults were regular drinkers. Men in the study were more likely to be regular drinkers than women. Drugs with addiction potential were used by 32.4% of participants, and were more commonly used by women. Nearly 12% of participants used benzodiazepines, 19% z-hypnotics and 12.4% opioids. Among regular drinkers, 29% used drugs with addiction potential, which was also more common among women. Adjusted for age, gender and living situation, use of z-hypnotics was associated with regular alcohol intake, while use of opioids was associated with no regular alcohol intake.

Conclusion

The prevalence of the use of drugs with addiction potential was high in a Norwegian population of older adults who reported regular consumption of alcohol. Strategies should be developed to reduce or prevent alcohol consumption among older adults who use drugs with addiction potential.

Concurrent use of alcohol interactive medications and alcohol in older adults: a systematic review of prevalence and associated adverse outcomes

BACKGROUND

Older adults are susceptible to adverse effects from the concurrent use of medications and alcohol. The aim of this study was to systematically review the prevalence of concurrent use of alcohol and alcohol-interactive (AI) medicines in older adults and associated adverse outcomes.

METHODS

A systematic search was performed using MEDLINE (PubMed), Embase, Scopus and Web of Science (January 1990 to June 2016), and hand searching references of retrieved articles. Observational studies reporting on the concurrent use of alcohol and AI medicines in the same or overlapping recall periods in older adults were included. Two independent reviewers verified that studies met the inclusion criteria, critically appraised included studies and extracted relevant data. A narrative synthesis is provided.

RESULTS

Twenty studies, all cross-sectional, were included. Nine studies classified a wide range of medicines as AI using different medication compendia, thus resulting in heterogeneity across studies. Three studies investigated any medication use and eight focused on psychotropic medications. Based on the quality assessment of included studies, the most reliable estimate of concurrent use in older adults ranges between 21 and 35%. The most reliable estimate of concurrent use of psychotropic medications and alcohol ranges between 7.4 and 7.75%. No study examined longitudinal associations with adverse outcomes. Three cross-sectional studies reported on falls with mixed findings, while one study reported on the association between moderate alcohol consumption and adverse drug reactions at hospital admission.

CONCLUSIONS

While there appears to be a high propensity for alcohol-medication interactions in older adults, there is a lack of consensus regarding what constitutes an AI medication. An explicit list of AI medications needs to be derived and validated prospectively to quantify the magnitude of risk posed by the concurrent use of alcohol for adverse outcomes in older adults. This will allow for risk stratification of older adults at the point of prescribing, and prioritise alcohol screening and brief alcohol interventions in high-risk groups.

1H NMR-based metabolomics reveals sub-lethal toxicity of a mixture of diabetic and lipid-regulating pharmaceuticals on amphibian larvae

Pharmaceuticals are widely used for the treatment of various physical and psychological ailments. Due to incomplete removal during sewage treatment many pharmaceuticals are frequently detected in aquatic waterways at trace concentrations. The diversity of pharmaceutical contaminants and potential for complex mixtures to occur makes it very difficult to predict the toxicity of these compounds on wildlife, and robust methods are therefore needed to explore sub-lethal effects. Metabolic syndrome is one of the most widespread health concerns currently facing the human population, and various drugs, including anti-diabetic medications and lipid- and cholesterol-lowering fibrates and statins, are widely prescribed as treatment. In this study, we exposed striped marsh frog (Limnodynastes peronii) tadpoles to a mixture of the drugs metformin, atorvastatin and bezafibrate at 0.5, 5, 50 and 500μg/L to explore possible effects on growth and development, energy reserves (triglycerides and cholesterol), and profiles of small polar metabolites extracted from hepatic tissues. It was hypothesised that exposure would result in a general reduction in energy reserves, and that this would subsequently correspond with reduced growth and development. Responses differed from expected outcomes based on the known mechanisms of these compounds in humans, with no changes to hepatic triglycerides or cholesterol and a general increase in mass and condition with increasing exposure concentration. Deviation from the expected response patterns may be explained by differences in the receptivity or uptake of the compounds in non-mammalian species. Proton nuclear magnetic resonance (¹H NMR) spectroscopy revealed evidence of broad metabolic dysregulation in exposed animals, and possible interaction between the solvent and mixture. Specifically, increased lactic acid and branched-chain amino acids were observed, with responses tending to follow a non-monotonic pattern. Overall, results demonstrate that a mixture of drugs commonly prescribed to treat human metabolic syndrome is capable of eliciting physiological and developmental effects on larval amphibians. Importantly, outcomes further suggest that it may not be possible to predict toxicological effects in non-target wildlife based on our knowledge of how these compounds act in humans.

Alcohol Consumption in Older Adults: A Comparison of Two Assessment Methods

Two methods of assessing alcohol consumption in older adults were compared. Participants (52 men, 82 women) recruited through random-digit-dial telephone contacts completed a survey that included a section on alcohol consumption. Within 1 month, participants completed a paper-and-pencil dietary intake questionnaire (EPAT) that included an alcohol consumption item. The two alcohol assessment measures were significantly correlated (r = –.75); however, 13% reported greater alcohol consumption on the EPAT, and only 1.5% reported higher consumption on the alcohol survey. Rates of agreement were lower among participants who drank more than the sample average (32% reported greater alcohol consumption on the dietary measure). Embedding questions within a more general dietary intake assessment may enhance selfreported alcohol consumption in older adults. Dietary measures such as the EPAT are practical for clinical use because they provide alcohol and nutritional information, areas that should be routinely assessed, and they are brief and easy to administer.

Anesthetic management for magnetic resonance imaging in a pediatric patient addicted to palm wine: An alcoholic beverage

The incidence of drug and alcohol abuse is on rise despite increasing awareness and education about health hazards related to it. Anesthesiologist may come across patients with alcohol abuse in elective as well as emergency situations. We report a rare case of excessive requirement of anesthetics in a pediatric patient of only six years for MRI, addicted to palm wine, an alcoholic beverage created from the sap of various species of palm tree.

Assessing the Usability of Web-Based Alcohol Education for Older Adults: A Feasibility Study

Background

Older adults can experience unfavorable health effects from drinking at relatively low consumption levels because of age-related physiological changes and alcohol’s potentially adverse interactions with declining health, increased medication-use and diminishing functional status. At the same time, alcohol use in older adults may be protective against heart disease, stroke, and other disorders associated with aging. We developed “A Toast to Health in Later Life! Wise Drinking as We Age,” a web-based educational intervention to teach older adults to balance drinking risks and benefits.

Objective

To examine the intervention’s feasibility in a sample of community-dwelling current drinkers ≥55 years of age and examine its effects on their quantity and frequency of alcohol use, adherence to standard drinking guidelines, and alcohol-related risks.

Methods

Participants were recruited in person, by mail and by telephone between September and October 2014 from a community-based social services organization serving Los Angeles County. Once enrolled, participants were randomly assigned to the intervention or to a control group. The conceptual frameworks for the intervention were the Health Belief Model, models of adult learning, and the US Department of Health and Human Services guidelines for designing easy-to-use websites. The intervention’s content focuses on the relationship between drinking and its effects on older adults’ medical conditions, use of medications, and ability to perform daily activities. It also addresses quantity and frequency of alcohol use, drinking and driving and binge drinking. The control group did not receive any special intervention. Data on alcohol use and risks for both groups came from the online version of the Alcohol-Related Problems Survey and were collected at baseline and four weeks later. Data on usability were collected online from the intervention group immediately after it completed its review of the website.

Results

The 49 intervention and 47 control participants did not differ at baseline in age, ethnicity, medication use, medical conditions, or alcohol use and both groups were mostly female, college-educated, and in good health. Of the intervention participants, 94% (46/49) had little or no difficulty using the website, with 67% (33/49) reporting that they will change the way they think about drinking because of their exposure to the education. At the 4-week follow-up, the intervention group reported drinking less (P=.02). No changes between groups were found in quantity and frequency, adherence to recommended guidelines, or risk status.

Conclusions

Community-dwelling older adults are receptive to online alcohol education. To be most effective, the education should be included as a component of a larger effort consisting of screening and counseling preferably in a health care setting.

Influence of the Alcohol Present in a Phytotherapic Tincture on Male Rat Lipid Profiles and Renal Function

This study evaluated the influence of the alcohol present in a formulation of the antiophidic phytotherapic tincture, Específico-Pessôa, on rat blood biochemical and hematological parameters, and on organ histology. Three groups of rats were treated orally for 10, 15, or 30 days; one group received the tincture, the other received alcohol alone, and the third was a control group. The results of this study indicated that cholesterol levels were significantly increased after 10 days in the alcohol and tincture groups, although these decreased after 30 days in the tincture group. Triglyceride levels were significantly reduced after 15 days in the tincture group and after 30 days in the alcohol and tincture groups. A higher creatinine level was observed in the alcohol and tincture groups after 15 and 30 days. The uric acid levels in these groups were reduced at 10 and 30 days, although this metabolite was elevated at 15 days in the alcohol group. Hydropic multifocal degeneration with lymphohistiocytic infiltration and some polymorphonuclear cells was observed in the livers of rats treated with either the tincture or alcohol. These data demonstrate the importance of considering the potential actions of the alcohol present in pharmaceutical formulations.

Potential for alcohol and drug interactions in older adults: evidence from the Irish longitudinal study on ageing

BACKGROUND

Older adults are susceptible to adverse effects from the concomitant use of prescription medications and alcohol. This study estimates the prevalence of exposure to alcohol interactive (AI) medications and concomitant alcohol use by therapeutic class in a large, nationally representative sample of older adults.

METHODS

Cross-sectional analysis of a population based sample of older Irish adults aged ≥60 years using data from The Irish Longitudinal Study on Ageing (TILDA) (N = 3,815). AI medications were identified using Stockley's Drug Interactions, the British National Formulary and the Irish Medicines Formulary. An in-home inventory of medications was used to characterise AI drug exposure by therapeutic class. Self-reported alcohol use was classified as non-drinker, light/moderate and heavy drinking. Comorbidities known to be exacerbated by alcohol were also recorded (diabetes mellitus, hypertension, peptic ulcer disease, liver disease, depression, gout or breast cancer), as well as sociodemographic and health factors.

RESULTS

Seventy-two per cent of participants were exposed to AI medications, with greatest exposure to cardiovascular and CNS agents. Overall, 60% of participants exposed to AI medications reported concomitant alcohol use, compared with 69.5% of non-AI exposed people (p < 0.001). Almost 28% of those reporting anti-histamine use were identified as heavy drinkers. Similarly almost one in five, combined heavy drinking with anti-coagulants/anti-platelets and cardiovascular agents, with 16% combining heavy drinking with CNS agents. Multinomial logistic regression showed that being male, younger, urban dwelling, with higher levels of education and a history of smoking, were associated with an increased risk for concomitant exposure to alcohol consumption (both light/moderate and heavier) and AI medications. Current smokers and people with increasing co-morbidities were also at greatest risk for heavy drinking in combination with AI medications.

CONCLUSIONS

The concurrent use of alcohol with AI medications, or with conditions known to be exacerbated by alcohol, is common among older Irish adults. Prescribers should be aware of potential interactions, and screen patients for alcohol use and provide warnings to minimize patient risk.

Wine, Food and Health

Wine has historically been associated with religious rights, used as a salubrious beverage, employed as a medication as well as a medicinal solvent, and consumed as a food accompaniment. It is the latter that is most intimately associated in the minds of most modern consumers. Despite this, there is little flavor commonality on which pairing could be based. The first section of the chapter examines this feature, and wine’s primary role as a palate cleanser and food condiment. The synergistic role of food and wine in suppressing each other’s least pleasant attributes is also explained. The final section deals with the latest evidence relating to the many beneficial health effects of moderate wine consumption, shortfalls in the data, headache induction, dental erosion, and conditions under which wine intake is contraindicated.

Alcohol and prescription drug safety in older adults

Background

The objectives of this study were to investigate older adults’ knowledge of prescription drug safety and interactions with alcohol, and to identify pharmacists’ willingness to disseminate prescription drug safety information to older adults.

Methods

The convenience sample consisted of 48 older adults aged 54–89 years who were recruited from a local pharmacy and who completed surveys addressing their alcohol consumption, understanding of alcohol and prescription drug interactions, and willingness to change habits regarding alcohol consumption and prescription drugs. To address pharmacist willingness, 90 pharmacists from local pharmacies volunteered and answered questions regarding their willingness to convey prescription drug safety information to older adults.

Results

Older adults reported low knowledge of alcohol and prescription drug safety, with women tending to be slightly more knowledgeable. More importantly, those who drank in the previous few months were less willing to talk to family and friends about how alcohol can have harmful interactions with prescription drugs, or to be an advocate for safe alcohol and prescription drug use than those who had not had a drink recently. Pharmacists reported that they were willing to convey prescription drug safety information to older adults via a variety of formats, including displaying or distributing a flyer, and directly administering a brief intervention.

Conclusion

In this study, older adults were found to have inadequate knowledge of prescription drug safety and interactions with alcohol, but pharmacists who regularly come in contact with older adults indicated that they were ready and willing to talk to older adults about prescription drug safety. Future research should focus on interventions whereby pharmacists disseminate prescription drug safety information to older adults in order to improve healthy prescription drug and alcohol behavior and reduce medical and health costs associated with interactions between alcohol and prescription drugs.

Alcohol and the older adult: a comprehensive review

Alcohol consumption in the older adult is of major concern with the advent of baby boomers coming into the over 65-age bracket. Alcohol consumption has been touted as beneficial for health, and while that may be accurate for moderate consumption in younger persons, there is considerable risk associated with increased alcohol intake in older adults. This increase is partially due to age-related physiological changes, existing diagnoses, number of comorbid conditions, and increased use of prescribed and/or over-the-counter medications, coupled with other concerns. This review addresses the current research regarding ethanol consumption in older adults and all-cause mortality as well as several conditions more frequently seen in the geriatric population. These conditions include vascular diseases, hypertension, type 2 diabetes, gastrointestinal disorders, hepatic disorders, dental and oro-facial problems, bone density decline, and falls and fractures. In addition, drug interactions and recent research into select vitamin and mineral considerations with increased alcohol intake in older persons are addressed. While recommendations for alcohol intake have not been specifically established for age ranges within the 65-year-and-older bracket, and practitioners do not routinely assess alcohol intake or ethanol related adverse events in this population, common sense approaches to monitoring will become increasingly important as the generation of "boomers" who believe that alcohol intake improves health comes of age.

Risks of combined alcohol/medication use in older adults

BACKGROUND

Many older adults (ie, those aged >65 years) drink alcohol and use medications that may be harmful when consumed together.

OBJECTIVE

This article reviews the literature on alcohol and medication interactions, with a focus on older adults.

METHODS

Relevant articles were identified through a search of MEDLINE and International Pharmaceutical Abstracts (1966-August 2006) for English-language articles. The following medical subject headings and key words were used: alcohol medication interactions, diseases worsened by alcohol use, and alcohol metabolism, absorption, and distribution. Additional articles were identified by a manual search of the reference lists of the identified articles, review articles, textbooks, and personal reference sources.

RESULTS

Many older adults drink alcohol and take medications that may interact negatively with alcohol. Some of these interactions are due to age-related changes in the absorption, distribution, and metabolism of alcohol an medications. Others are due to disulfiram-like reactions observed with some medications, exacerbation of therapeutic effects and adverse effects of medications when combined with alcohol, and alcohol's interference with the effectiveness of some medications.

CONCLUSIONS

Older adults who drink alcohol and who take medications are at risk for a variety of adverse consequences depending on the amount of alcohol and the type of medications consumed. It is important for clinicians to know how much alcohol their older patients are drinking to be able to effectively assess their risks and to counsel them about the safe use of alcohol and medications. Similarly, it is important for older adults to understand the potential risks of their combined alcohol and medication use to avoid the myriad of problems possible with unsafe use of these substances..

Declared and undeclared substance use among emergency department patients: a population-based study

AIMS

To estimate both self-reported and corrected prevalences of substance use in a population-based study of general hospital emergency department (ED) patients and predict undeclared use.

DESIGN

A state-wide cross-sectional, two-stage probability sample survey that incorporates toxicological screening.

SETTING

Seven Tennessee EDs in acute care, adult, civilian, non-psychiatric hospitals.

PARTICIPANTS

A total of 1502 Tennessee residents, 18 years of age and older, possessing intact cognition, able to give informed consent and not in police custody. Measurements Prevalence of self-reported current substance use by age, sex and type with correction for under-reporting based on toxicological screening. Covariates in the multivariate analysis of undeclared use were socio-demographics, ED visit circumstances, health-care coverage, prior health status and treatment history and tobacco addiction.

FINDINGS

Declared current use was highest for alcohol (females 26%, males 47%), marijuana (males 11%, females 6%) and benzodiazepines (females 10%, males 7%). After correction for under-reporting, overall use for any of the eight targeted substances rose from 44% to 56% for females and 61% to 69% for males. Largest absolute changes involved opioids, benzodiazepines, marijuana, amphetamines and/or methamphetamine, with little change for alcohol. Patients aged 65 years and older manifested excess undeclared use relative to patients aged 18-24 years, as did patients not reporting tobacco addiction or receiving substance abuse treatment.

CONCLUSION

Adjustment for under-reporting produced minimal change in the estimated prevalence of alcohol use. However, toxicological screening markedly increased estimates of other drug use, especially for the elderly, who may under-report medication use. Screening tests are useful tools for detecting undeclared substance use.

Community prevalence of alcohol use and concomitant use of medication--a source of possible risk in the elderly aged 75 and older?

AIMS

To explore alcohol use and concomitant use of prescription and over the counter (OTC) medicines in people aged 75 years or over.

DESIGN

Community-based randomized survey of home-dwelling elderly persons, Setting: the City of Kuopio, Finland.

PARTICIPANTS

Population-based random sample of 700 persons aged 75 years or over, of whom 601 participated (86%). Only home-dwellers (n = 523) were included in this study.

MEASUREMENTS

Alcohol use based on responses to questions concerning quantity and frequency, and CAGE questions. Use of prescription and non-prescription medicines. Mean corpuscular volume.

RESULTS

Of the participants, 44% used alcohol. Most alcohol drinkers used medications on a regular basis (86.9%) or as needed (87.8%), among them medicines known to have some potential interactions with alcohol. Elevated mean corpuscular volume was more widespread among alcohol drinkers than non drinkers.

CONCLUSION

Theoretical risks posed by alcohol use are not minimal in the older elderly, though the quantity of alcohol use is not considerable. Physicians and nurses should pay attention to chronic diseases and medications when counselling aged people about alcohol consumption. The question of clinical importance of alcohol-medication interactions needs to be studied further.

Older adults' health and changes in late-life drinking patterns

This study focused on the prospective associations between older adults' health-related problems and their late-life alcohol consumption and drinking problems. A sample of 1,291 late-middle-aged community residents (55-65 years old at baseline) participated in a survey of health and alcohol consumption, and was followed one year, four years, and 10 years later. Health-related problems increased and alcohol consumption and drinking problems declined over the 10-year interval. Medical conditions, physical symptoms, medication use, and acute health events predicted a higher likelihood of abstinence and less frequent and lower alcohol consumption. However, overall health burden predicted more subsequent drinking problems, even after controlling for alcohol consumption and a history of heavy drinking and increased drinking in response to stressors. Among older adults, increased health problems predict reduced alcohol consumption but more drinking problems. Older adults with several health problems who consume more alcohol are at elevated risk for drinking problems and should be targeted for brief interventions to help them curtail their drinking.

Ten-year patterns of alcohol consumption and drinking problems among older women and men

AIMS

This study focused on changes in 10-year patterns of alcohol consumption among older women and men, late-life and life history predictors of drinking problems, and gender differences in these predictors.

DESIGN, SETTING, PARTICIPANTS

A sample of late-middle-aged community residents (N = 1291) who had consumed alcohol in the past year or shortly before was surveyed at baseline and 1 year, 4 years and 10 years later.

MEASUREMENTS

At each contact point, participants completed an inventory that assessed their alcohol consumption, drinking problems and health-related and life context factors. Participants also provided information about their life history of drinking.

RESULTS

Over the 10 years, the proportion of individuals who consumed alcohol declined. Among individuals who continued to drink, women and men showed comparable declines in alcohol consumption, minor concomitants of alcohol consumption and drinking problems. In addition to the amount of alcohol consumption, smoking, friends' approval of drinking and avoidance coping consistently predicted late-life drinking problems. With respect to life history factors, heavy drinking, drinking problems and increased drinking in response to life events were related to a higher likelihood of late-life drinking problems; obtaining help from family members and friends and, among men, participation in Alcoholics Anonymous, were related to a lower likelihood of problems.

CONCLUSION

Older women and men show comparable declines in alcohol consumption and drinking problems. Specific late-life social context and coping variables, and life history indices, are risk factors for late-life drinking problems among both women and men.

Diagnosis and treatment of alcohol dependence in older alcoholics

Treatment of alcohol dependence among older alcoholic patients should be multidimensional to address as many potential relapse factors as possible. As the literature suggests, alcohol-related disorders often are under diagnosed and under treated. More efforts are needed to identify and improve diagnosis of these disorders in older alcoholic patients. For better outcomes, age-specific programs should be implemented. Furthermore, when treating elderly patients, basic therapeutic principles like respect for privacy and a respectful attitude should be adopted. Adequate medical, pharmacologic, and psychiatric treatment should be provided when appropriate. Medication to reduce cravings should be considered in patients without contraindications to its use. Participation in individual, group, and family therapy and attendance at self-help group meetings such as AA should be encouraged (Table 8). Despite the lack of empiric testing to validate these recommendations in an elderly population, clinical experience suggests that adherence to these recommendations will benefit elderly patients just as it has the general adult population. Research is necessary to explore the benefits of alcohol treatments in elderly patients. Until then, adherence to these recommendations should be the best available approach.

Assessing substance abuse treatment need: a statewide hospital emergency department study

STUDY OBJECTIVE

Health care providers in hospital emergency departments rarely take substance abuse histories or assess associated treatment need. This study compares documentation of psychoactive drug-related diagnoses for adult ED patients in medical records with treatment need assessed through self-report, toxicologic screening, and Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), criteria.

METHODS

A statewide, 2-stage, probability sample survey was conducted in 7 Tennessee general hospital EDs from June 1996 to January 1997. Main outcome measures were the prevalence of diagnosed substance abuse problems, positive bioassay results, denied use, and treatment need. Sensitivity and multivariate analyses were conducted by using varied case definitions of treatment need.

RESULTS

Thirty-one percent (95% confidence interval [CI] 27.3% to 34.7%) of screened ED patients (n=1,330) had positive test results for substance use. Their prevalence of denial of use in the 30 days before the survey ranged from 10% for alcohol (95% CI 5.7% to 14.3%) to 100% for phencyclidine. One percent of all ED patients (n=1,502) had a recorded diagnosis of substance abuse. By contrast, as many as 27% (95% CI 23.3% to 31.8%) were assessed as needing substance abuse treatment on the basis of a comprehensive case definition that accounted for denial and positive test results. A sensitivity analysis using other case definitions is also presented. For example, 4% (95% CI 2.8% to 5.3%) of patients met the very strict definition of DSM-IV current drug dependence only. Under the comprehensive case definition, TennCare patients (adjusted odds ratio [OR] 1.63; 95% CI 1.30 to 2.05) and Medicare patients (adjusted OR 2.50; 95% CI 1.34 to 4.65) showed excess treatment need relative to the privately insured. Excess need was also exhibited by patients reporting 1 or more prior ED visits in the past year (adjusted OR 1.62; 95% CI 1.13 to 2.31) and by patients taking 2 or more hours to reach the ED after the onset of injury or illness (adjusted OR 1.54; 95% CI 1.16 to 2.04). Treatment need was inversely associated with age. Irrespective of case definition, less than 10% of ED patients who needed substance abuse treatment were receiving such treatment.

CONCLUSION

EDs can be important venues for detecting persons in need of substance abuse treatment.

Drug & alcohol intervention for older women: a pilot study

Pretest and posttest information was gathered from 26 older women attending educational programs related to alcohol and drug use. The goals of the study were to determine current knowledge about alcohol and drugs among older women and to gather some initial information about the potential for alcohol and drug interactions and misuse. The intervention included a 60-minute presentation on the metabolism of alcohol and drugs in the aging body, the potential for alcohol-drug interactions, and a discussion of healthy lifestyles (e.g., diet, exercise). Older women, especially those who were moderate to heavy drinkers, were found to have many misconceptions about alcohol and drug use, but their knowledge improved dramatically after the brief educational intervention. This finding may suggest that most of the women had knowledge deficits rather than deeply entrenched attitudes about alcohol and drug use or alcohol dependence. Therefore, simple educational interventions may be very effective with this subset of women.

Informing older adults about non-hazardous, hazardous, and harmful alcohol use

Low levels of alcohol may be hazardous in the elderly, but available education focuses on younger, abusive, and dependent drinkers. A total of 209 older persons participated in various components of the development and evaluation of 'A Toast To Health In Later Life!' health promotion materials for the elderly. Patient focus groups, physicians, educators, and alcohol-use researchers contributed to all materials and measures. An education model for older adults guided the instructional format. Knowledge and self-efficacy scores increased significantly from pre- to post-test. Over 45% of persons in selected senior centers reviewed the materials without prompting by the study team. Older adults are willing to read extensively about the relationships among drinking, health, and medication use. Patient educators should include consumers in the design of health promotion materials and measures. Practitioners who rely on written educational materials for patient education and counseling should be provided with evidence of appropriateness, effectiveness, and feasibility.

The nurse's role in assessing alcohol use by older people

Nurses have the potential to carry out health promotion activity related to alcohol use in a range of settings where older people receive care. The majority of the literature on alcohol use in later life has focused on abuse, especially on the more common risk of drug-alcohol interactions. In order to work effectively with older people in health prevention and education, nurses need to be knowledgeable about older people's patterns of drinking, the effects of alcohol on medication and the current evidence on the harm and benefits of alcohol to health. In carrying out assessments, a skillful approach needs to be adopted in questioning older clients on what some might regard as a sensitive issue. Screening tools for the detection of alcohol abuse in the general adult population may not be valid for use with older clients. Tools specific to the detection of alcohol abuse by older people will be considered.

Gender and alcohol use: the roles of social support, chronic illness, and psychological well-being

Men and women differ in their use of alcohol, in their rates of chronic illnesses and psychological symptoms, and in the social support they receive. In this paper, we assess how the latter three factors are associated with alcohol use, and how these associations differ by gender. Respondents were 3,074 male and 3,947 female randomly selected Health Maintenance Organization members who responded to a mail survey in 1990. Hierarchical multiple regression analyses indicate that social support is associated with alcohol consumption in similar ways for both genders, yet the associations between some demographic, physical health/functioning, and psychological well-being measures are different for men and women. Men with fewer role limits due to physical health drank more, while women with better psychological well-being drank less. Poor psychological well-being may be a modifiable risk factor for increased alcohol use among women; practitioners should be alert for greater consumption among men with few functional limitations and good health.

Are older hazardous and harmful drinkers less likely to participate in health-related behaviors and practices as compared with nonhazardous drinkers?

OBJECTIVES

To describe the (1) prevalence of at-risk drinking and participation in health-related behaviors and practices and (2) associations of at-risk drinking with other health-related behaviors and practices among older persons completing a health-risk appraisal for the elderly (HRA-E).

DESIGN

Cross-sectional study using data from a self-administered, mailed survey sample.

SETTINGS

Persons from three organizations were surveyed: (1) the American Association of Retired Persons; and (2) a large medical group and (3) a community-based senior health center in southern California.

PARTICIPANTS

1,889 persons age 55 years and older.

MEASUREMENTS

The HRA-E included items on health characteristics, drinking behaviors (including amount of alcohol use and two alcoholism screening measures: the CAGE (Cut down, Annoyed, Guilty, Eye opener) and Short Michigan Alcoholism Screening Test-Geriatric version (SMAST-G), and participation in selected health-related behaviors and practices. Social drinkers were defined as those who drank fewer than 14 drinks weekly and screened negative on the CAGE (defined as two or more "no" responses) and SMAST-G. Hazardous drinkers drank fewer than 14 drinks weekly and screened negative. Harmful drinkers drank fewer than 14 drinks weekly and screened positive. Possible at-risk drinkers drank 14 or more drinks weekly and screened positive. Least squares regression models were used to assess the effects of hazardous, harmful, and possible at-risk drinking on each of the health-related practices and behaviors. We also conducted these analyses using three other definitions of social, possible at-risk, hazardous, and harmful drinking.

RESULTS

Of all respondents, 40% were social drinkers, 3% were harmful drinkers, 2% were hazardous drinkers, and 11% were possible at-risk drinkers. Hazardous, harmful, and possible at-risk drinkers commonly reported driving after drinking or being driven by someone who had been drinking (67%, 76%, and 64% respectively). Harmful and possible at-risk drinkers were more likely than social drinkers to smoke and were less likely to use seatbelts regularly. These findings were observed regardless of how the drinking groups were defined.

CONCLUSION

All groups of at-risk drinkers more commonly engaged in selected adverse health-related behaviors and practices than did social drinkers.

Alcohol use in late life: disability and comorbidity

Alcohol use by older adults is common, yet the risks and/or benefits of drinking, especially moderate drinking, are not well understood. Heavy drinking is a well-established factor in causing disability and excessive mortality among all age groups, including the elderly. However, literature is emerging that suggests that among elders with chronic medical and emotional health disorders, even modest alcohol consumption can lead to excessive disability and poorer perceived health. This article reviews the current literature on alcohol use and the relationship to common health problems in late life and suggests a model for examining the interaction of alcohol use and disability. Implications for intervention development are also discussed.

Alcohol and the health of aging men

Alcohol drinking, alcohol abuse, and alcoholism are more common among men than women at all ages. This article reviews the epidemiology and clinical effects of alcohol use in aging men. Alcoholism demands aggressive intervention when encountered in cognitively impaired people.

A new paradigm for alcohol use in older persons

BACKGROUND

Current paradigms for conceptualizing alcohol-related problems typically focus on persons who are abusing or dependent on alcohol. These paradigms may not apply to older drinkers whose alcohol use, regardless of consumption-level, can cause problems because of age-related changes in physiology and interactions with increased morbidity, medication use, and functional limitations.

OBJECTIVE

We convened an expert panel# to develop clinical indications of harmful, hazardous, and nonhazardous drinking in persons 65 years of age and older.

RESEARCH DESIGN AND SUBJECTS

Nine panelists with expertise in psychiatry, geriatrics, internal medicine, and alcohol research were provided with epidemiological data and a published explicit literature review of alcohol use in the elderly. The RAND/UCLA two-round panel method was used to develop the indications. After the second round, the authors wrote a draft statement that was circulated to the panelists whose comments were incorporated into a final document.

RESULTS

Panelists agreed on 215 scenarios in which older peoples' use of alcohol either alone or in the presence of chronic medical conditions, medication use, symptoms, smoking, and functional limitations are hazardous or harmful. Panelists' ratings of risk did not differ significantly between persons aged 65 to 74 years and those aged 75 years and older.

CONCLUSION

Alcohol use may be hazardous or harmful for older persons, particularly in conjunction with physical or emotional illnesses, medication use, functional limitations, smoking, and driving after drinking. When asking about alcohol use in older persons, clinicians need to be aware of these factors to assist in identifying and managing potential or actual alcohol-related problems.

Pharmacokinetic interactions between alcohol and other drugs

The frequent use of alcohol (ethanol) together with prescription drugs gives any described pharmacokinetic interaction significant clinical implications. The issue is both the effect of alcohol on the pharmacokinetics of various drugs and also the effect of those drugs on the pharmacokinetics of alcohol. This review discusses these pharmacokinetic interactions but also briefly describes some other effects of alcohol that are clinically relevant to drug prescribing. The use of several different study designs may be required before we can confidently state the presence or absence of any alcohol-drug interaction. Short term administration of alcohol in volunteers is the most common study design but studies of social drinking and prolonged moderate alcohol intake can be important in some situations. Community-based studies may illustrate the clinical relevance of any interaction. Alcohol can affect the pharmacokinetics of drugs by altering gastric emptying or liver metabolism (by inducing cytochrome P450 2E1). Drugs may affect the pharmacokinetics of alcohol by altering gastric emptying and inhibiting gastric alcohol dehydrogenase. The role of gastric alcohol dehydrogenase in the first-pass metabolism of alcohol is reviewed in this article and the arguments for and against any potential interaction between alcohol and H2 receptor antagonists are also discussed. The inhibition of the metabolism of acetaldehyde may cause disulfiram-like reactions. Pharmacodynamic interactions between alcohol and prescription drugs are common, particularly the additive sedative effects with benzodiazepines and also with some of the antihistamine drugs; other interactions may occur with tricyclic antidepressants. Alcohol intake may be a contributing factor to the disease state which is being treated and may complicate treatment because of various pathophysiological effects (e.g. impairment of gluconeogenesis and the risk of hypoglycaemia with oral hypoglycaemic agents). The combination of nonsteroidal anti-inflammatory drugs and alcohol intake increases the risk of gastrointestinal haemorrhage.

The Sonda Project: prevention, prediction, and psychological disorder

The Sonda Project began in Italy in 1985 and was created by Semeion Research Center of Sciences of Communication. It has been operating in approximately 30 Italian cities, ranging from large to small, since 1986. The aim of the Sonda Project is to undertake primary prevention measures at the level of personality organization disorder. Cognitive and communication disorders are, in the context of the Sonda Project, the common ground for many expressions of cultural disorders labeled drug addiction, alcoholism, violence, etc. From the point of view of the Sonda Project, measures aimed at combating drug-addiction and alcoholism are no more than superficial strategies incapable of dealing with the causes of self and hetero-destruction (of others). Such abuses are the most evident political symptoms. The methodological aim of the Sonda Project, therefore, consists in understanding, predicting, and acting upon the incubation disorder of human beings; a disorder which subsequently transforms itself into more or less recognizable symptoms. In order to attain its aim, the Sonda Project has made use of two instruments: 1) a series of Intelligent Computerized Observatories, able to predict, in each community, the typology of people who are more likely to exhibit forms of destructive suffering; 2) a local team able to use such advanced technology and able to utilize territorial activation techniques. These are designed to reinsert into the arena of the social game those people who are more "at risk" in terms of self and heterodestruction, and who are most exposed to psychological and sociological levels of relational "fatigue."