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Evaluating and Treating Alcohol Use in Older Adult Patients

Author/s: 
Frank, Chris, Molnar, Rummell, Sonja, Chan, Peter

Clinical question
How do I evaluate and treat alcohol use in older
adult patients?
Bottom line
Although older adults generally drink less alcohol than
their younger counterparts,1 the consequences of use
are more severe. Older adults are more susceptible to
alcohol-related toxicity due to physiologic changes.2
The health impacts of heavy alcohol intake include
increased risks of cardiovascular disease, stroke, liver
disease, cancer, and mortality.3 Acute and chronic
alcohol use contributes to geriatric syndromes, such as
cognitive impairment, falls, frailty, and malnutrition.4

Keywords 
alcohol use older adults cardiovascular disease

Alcohol-Related Liver Disease A Review

Author/s: 
Aleksander Krag, Frederik Aberg, Jessica Mellinger, Brian P. Lee, Mads Israelsen

Abstract
Importance: Alcohol-related liver disease (ALD) is the leading cause of liver-related morbidity and mortality, and the most common indication for liver transplant in Europe and the US. In the US, ALD-related mortality increased from 6.7 deaths per 100 000 people in 1999 to 12.5 deaths per 100 000 people in 2022.

Observations: ALD can develop with long-term daily alcohol consumption of more than 20 g per day for women (1.4 standard drinks/d) and more than 30 g per day for men (2.1 standard drinks/d), with 1 standard drink containing 14 g of ethanol, equivalent to approximately 12 oz of beer, 5 oz of wine, or 1.5 oz of distilled spirits. ALD encompasses reversible steatosis; steatohepatitis, which can cause alcohol-associated hepatitis; and fibrosis, which can cause cirrhosis, portal hypertension, hepatic decompensation, and hepatocellular carcinoma. Risk factors for ALD progression include increased quantity and duration of alcohol use, female sex, older age, obesity, type 2 diabetes, metabolic syndrome, smoking, viral hepatitis, and specific genetic variants. Most patients with ALD (90%) are asymptomatic or have nonspecific symptoms, such as fatigue. Alcohol-associated hepatitis often causes fever, anorexia, nausea, vomiting, abdominal pain, and jaundice. Individuals with decompensated cirrhosis typically have ascites, variceal bleeding, jaundice, and/or hepatic encephalopathy. Noninvasive liver fibrosis tests, such as the Fibrosis-4 score (which includes alanine transaminase, aspartate aminotransferase, platelet count, and age), and more specific second-line tests, including liver stiffness measurement (vibration-controlled transient elastography) and blood-based fibrosis markers such as the enhanced liver fibrosis test and N-terminal propeptide of type III collagen, provide early diagnosis of ALD and assess liver fibrosis severity, which is the strongest predictor of liver-related outcomes. Alcohol cessation interventions such as motivational enhancement therapy, cognitive behavioral therapy, and pharmacologic therapy (eg, baclofen, naltrexone) are recommended to prevent disease progression. Because alcohol consumption is often underreported, screening tools, such as the Alcohol Use Disorders Identification Test, and sensitive biomarkers of recent alcohol intake (eg, blood phosphatidylethanol) may improve clinical accuracy. Sustained abstinence from alcohol is the primary treatment for ALD. Among patients with alcohol-related cirrhosis, alcohol abstinence over a median follow-up of 36 months was associated with reduced risk of liver-related mortality (adjusted hazard ratio, 0.43 [95% CI, 0.26-0.70]) and all-cause mortality (adjusted hazard ratio, 0.45 [95% CI, 0.30-0.67]). Liver transplant evaluation should be considered for patients with severe alcohol-associated hepatitis or decompensated cirrhosis.

Conclusions and Relevance: People with chronic daily heavy alcohol consumption should be assessed for ALD with noninvasive testing. The primary treatment goal is alcohol cessation. Patients with severe alcohol-associated hepatitis or decompensated cirrhosis should be considered for liver transplant.

Keywords 
Alcohol-related liver disease ALD alcohol use

What Is Atrial Fibrillation?

Author/s: 
Rebecca Voelker

Atrial fibrillation is an abnormal heart rhythm that can cause stroke, heart failure, heart attack, chronic kidney disease, dementia, and death.

Atrial fibrillation is classified as paroxysmal (intermittent episodes lasting 7 days or less), persistent (lasting more than 7 days), long-standing persistent (lasting more than 1 year), or permanent.1

In the US, atrial fibrillation affects about 10.55 million people and is more common among men than women. Other risk factors include older age, smoking, high blood pressure, diabetes, heart disease, high alcohol consumption, sleep apnea, an overactive thyroid gland, and possibly genetic factors.

Keywords 
atrial fibrillation Cardiology Patient Information jama Patient Information Rhythm Disorders

Reported Risky Alcohol Use Among US Adults Prescribed 3 Classes of Chronic Alcohol–Interactive Medications

Author/s: 
Bernstein, Eden Y., Baggett, Travis P., Anderson, timothy S.

Alcohol-interactive medications pose increased risk of adverse events and death when used with alcohol.1 To our knowledge, the most recent study of alcohol use and alcohol-interactive medications included data through 2010.1 Mortality rates from alcohol and such medications have since increased.2,3 Therefore, we assessed contemporary patterns of risky alcohol use among adults taking high-risk alcohol-interactive medications.

Keywords 
alcohol drug interaction

Alcohol Use Disorder and Alcohol-Associated Liver Disease

Author/s: 
Ramissoon, R., Shah, V. H.

This article is part of a Festschrift commemorating the 50th anniversary of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Established in 1970, first as part of the National Institute of Mental Health and later as an independent institute of the National Institutes of Health, NIAAA today is the world’s largest funding agency for alcohol research. In addition to its own intramural research program, NIAAA supports the entire spectrum of innovative basic, translational, and clinical research to advance the diagnosis, prevention, and treatment of alcohol use disorder and alcohol-related problems. To celebrate the anniversary, NIAAA hosted a 2-day symposium, “Alcohol Across the Lifespan: 50 Years of Evidence-Based Diagnosis, Prevention, and Treatment Research,” devoted to key topics within the field of alcohol research. This article is based on Dr. Shah’s presentation at the event. NIAAA Director George F. Koob, Ph.D., serves as editor of the Festschrift.

Keywords 
alcoholism liver diseases alcoholism complications alcoholism diagnosis alcohol misuse

Looking Back, Looking Forward: Current Medications and Innovative Potential Medications to Treat Alcohol Use Disorder

Author/s: 
Mason, B. J.

This article is part of a Festschrift commemorating the 50th anniversary of the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Established in 1970, first as part of the National Institute of Mental Health and later as an independent institute of the National Institutes of Health, NIAAA today is the world's largest funding agency for alcohol research. In addition to its own intramural research program, NIAAA supports the entire spectrum of innovative basic, translational, and clinical research to advance the diagnosis, prevention, and treatment of alcohol use disorder and alcohol-related problems. To celebrate the anniversary, NIAAA hosted a 2-day symposium, "Alcohol Across the Lifespan: 50 Years of Evidence-Based Diagnosis, Prevention, and Treatment Research," devoted to key topics within the field of alcohol research. This article is based on Dr. Mason's presentation at the event. NIAAA Director George F. Koob, Ph.D., serves as editor of the Festschrift.

Keywords 
alcohol alcoholism National Institute on Alcohol Abuse and Alcoholism (U.S.) National Institutes of Health (U.S.) naltrexone

Unhealthy alcohol use in a 65-year-old man awaiting surgery

Author/s: 
Brothers, T. D., Kaulbach, J., Tran, A.

Three months before elective hip arthroplasty, a 65-yearold man with osteoarthritis presents to his family physician to discuss his alcohol consumption. His surgeon had expressed concern and advised him to speak to his family physician about decreasing his drinking before surgery. He reports drinking around 6 to 10 ounces of whiskey daily for the past 5 years. His alcohol intake increased gradually after retirement, and he now has cravings daily. He recently abstained from alcohol for 4 days while visiting family and developed irritability, tremor, nausea and headache. He has never had withdrawal seizures or delirium tremens, and he does not use any other substances. He is otherwise healthy, apart from hypertension that is controlled with perindopril. He is alarmed by his cravings, withdrawal symptoms and surgeon’s concerns, and is considering decreasing his alcohol use.

Perioperative alcohol cessation intervention for postoperative complications

Author/s: 
Egholm, Julie W., Pedersen, Bolette, Møller, Ann M., Adami, Johanna, Juhl, Carsten B., Tønnesen, Hanne

Background: Risky consumption of alcohol is a global problem. More than 3.3 million deaths annually are associated with risky use of alcohol, and global alcohol consumption continues to increase. People who have high alcohol consumption often require planned and emergency surgical procedures.Risky drinking is associated with increased postoperative complications such as infections, cardiopulmonary complications, and bleeding episodes. Alcohol causes disorders of the liver, pancreas, and nervous system. Stopping consumption of alcohol can normalize these organ systems to some degree and may reduce the occurrence of complications after surgery.This review was first published in 2012 and was updated in 2018.

Objectives: To assess the effects of perioperative alcohol cessation interventions on rates of postoperative complications and alcohol consumption.

Search methods: We searched the following databases up until 21 September 2018: Cochrane Central Register of Controlled Trials (CENTRAL), in the Cochrane Library; MEDLINE; Embase; CINAHL via EBSCOhost; and two trials registers. We scanned the reference lists and citations of included trials and any identified relevant systematic reviews for further references to additional trials. When necessary, we contacted trial authors to ask for additional information.

Selection criteria: We included all randomized controlled trials (RCTs) that evaluated the effects of perioperative alcohol cessation interventions on postoperative complications and alcohol consumption. We included participants with risky consumption of alcohol who were undergoing all types of elective or acute surgical procedures under general or regional anaesthesia or sedation, who were offered a perioperative alcohol cessation intervention or no intervention.We defined 'risky drinking' as alcohol consumption equivalent to more than 3 alcoholic units (AU)/d or 21 AU/week (with 1 AU containing 12 grams of ethanol) with or without symptoms of alcohol abuse or dependency. This corresponds to the amount of alcohol associated with increased postoperative complication rates in most clinical studies.

Data collection and analysis: We used guidance provided in the Cochrane Handbook for Systematic Reviews of Interventions. We presented main outcomes as dichotomous variables in a meta-analysis. When data were available, we conducted subgroup and sensitivity analyses to explore the risk of bias. Primary outcome measures were postoperative complications and in-hospital and 30-day mortality. Secondary outcomes were successful quitting at the end of the programme, postoperative alcohol use, and length of hospital stay. We assessed the quality of evidence using the GRADE approach.

Main results: We included in this updated review one new study (70 participants), resulting in a total of three RCTs (140 participants who drank 3 to 40 AU/d). All three studies were of moderate to good quality. All studies evaluated the effects of intensive alcohol cessation interventions, including pharmacological strategies for alcohol withdrawal symptoms, patient education, and relapse prophylaxis. We identified one ongoing study.Overall, 53 of the 122 participants from three studies who underwent surgery developed any type of postoperative complication that required treatment. Of 61 participants in the intervention groups, 20 had complications, compared with 33 of 61 participants in the control groups (risk ratio (RR) 0.62, 95% confidence interval (CI) 0.40 to 0.96). Results show differences between the three clinical studies regarding outcome measurement and intensity of the interventions. However, all alcohol cessation programmes were intensive and included pharmacological therapy. The overall quality of evidence for this outcome is moderate.In-hospital and 30-day postoperative mortality rates were low in the three studies. Researchers reported one death among 61 participants in the intervention groups, and three deaths among 61 participants in the control groups (RR 0.47, 95% CI 0.07 to 2.96). The quality of evidence for this outcome is low.Investigators describe more successful quitters at the end of the intervention programme than among controls. Forty-one out of 70 participants in the intervention groups successfully quit drinking compared with only five out of 70 participants in the control groups (RR 8.22, 95% CI 1.67 to 40.44). The quality of evidence for this outcome is moderate.All three studies reported postoperative alcohol consumption (grams of alcohol/week) at the end of the programme as median and range values; therefore it was not possible to estimate the mean and the standard deviation (SD). We performed no meta-analysis. All three studies reported length of stay, and none of these studies described a significant difference in length of stay. Data were insufficient for review authors to perform a meta-analysis. No studies reported on the prevalence of participants without risky drinking in the longer term.

Authors' conclusions: This systematic review assessed the efficacy of perioperative alcohol cessation interventions for postoperative complications and alcohol consumption. All three studies showed a significant reduction in the number of participants who quit drinking alcohol during the intervention period. Intensive alcohol cessation interventions offered for four to eight weeks to participants undergoing all types of surgical procedures to achieve complete alcohol cessation before surgery probably reduced the number of postoperative complications. Data were insufficient for review authors to assess their effects on postoperative mortality. No studies reported an effect on length of stay, and no studies addressed the prevalence of risky drinking in the longer term.Included studies were few and reported small sample sizes; therefore one should be careful about drawing firm conclusions based on these study results. All three studies were conducted in Denmark, and most participants were men. The included participants may represent a selective group, as they could have been more motivated and/or more interested in participating in clinical research or otherwise different, and effects may have been overestimated for both intervention and control groups in these studies. Trial results indicate that these studies are difficult to perform, that strong research competencies are necessary for future studies, and that further evaluation of perioperative alcohol cessation interventions in high-quality randomized controlled trials is needed. Once published and assessed, the one 'ongoing' study identified may alter the conclusions of this review.

Conflict of interest statement

Hanne Tønnesen has authored all three of the studies included in this review (Egholm 2017; Tønnesen 1999a; Tønnesen 2002).

Julie Weber Melchior Egholm, Johanna Adami, and Bolette Pedersen have authored one of the included studies (Egholm 2017).

Hanne Tønnesen is also the primary investigator for the ongoing study (NCT02188446).

Therefore, to avoid any potential bias, Carsten B Juhl extracted data and checked the interpretation against study reports and any available study registration details or protocols as an independent review author.

Interventions for Substance Use Disorders in Adolescents: A Systematic Review

Author/s: 
Steele, D.W., Becker, S.J., Danko, K.J., Balk, E.M., Saldanha, I.J., Adam, G.P., Bagley, S.M., Friedman, C., Spirito, A., Scott, K., Ntzani, E.E., Saeed, I., Smith, B., Popp J., Trikalinos, T.A.

Structured Abstract

Objectives. This systematic review (SR) synthesizes the literature on behavioral, pharmacologic, and combined interventions for adolescents ages 12 to 20 years with problematic substance use or substance use disorder. We included interventions designed to achieve abstinence, reduce use quantity and frequency, improve functional outcomes, and reduce substance-related harms.

Data sources. We conducted literature searches in MEDLINE, the Cochrane CENTRAL Trials Registry, Embase, CINAHL, and PsycINFO to identify primary studies meeting eligibility criteria through November 1, 2019.

Review methods. Studies were extracted into the Systematic Review Data Repository. We categorized interventions into seven primary intervention components: motivational interviewing (MI), family focused therapy (Fam), cognitive behavioral therapy (CBT), psychoeducation, contingency management (CM), peer group therapy, and intensive case management. We conducted meta-analyses of comparative studies and evaluated the strength of evidence (SoE). The PROSPERO protocol registration number is CRD42018115388.

Results. The literature search yielded 33,272 citations, of which 118 studies were included. Motivational interviewing reduced heavy alcohol use days by 0.7 days/month, alcohol use days by 1.2 days/month, and overall substance use problems by a standardized mean difference of 0.5, compared with treatment as usual. Brief MI did not reduce cannabis use days (net mean difference of 0). Across multiple intensive interventions, Fam was most effective, reducing alcohol use days by 3.5 days/month compared with treatment as usual. No intensive interventions reduced cannabis use days. Pharmacologic treatment of opioid use disorder led to a more than 4 times greater likelihood of abstinence with extended courses (2 to 3 months) of buprenorphine compared to short courses (14 to 28 days).

Conclusions. Brief interventions: MI reduces heavy alcohol use (low SoE), alcohol use days (moderate SoE), and substance use–related problems (low SoE) but does not reduce cannabis use days (moderate SoE). Nonbrief interventions: Fam may be most effective in reducing alcohol use (low SoE). More research is needed to identify other effective intensive behavioral interventions for alcohol use disorder. Intensive interventions did not appear to decrease cannabis use (low SoE). Some interventions (CBT, CBT+MI, and CBT+MI+CM) were associated with increased cannabis use (low SoE). Both MI and CBT reduce combined alcohol and other drug use (low SoE). Combined CBT+MI reduces illicit drug use (low SoE). Subgroup analyses of interest (male vs. female, racial and ethnic minorities, socioeconomic status, and family characteristics) were sparse, precluding conclusions regarding differential effects. Pharmacological interventions: longer courses of buprenorphine (2–3 months) are more effective than shorter courses (14–28 days) to reduce opioid use and achieve abstinence (low SoE). SRs in the college settings support use of brief interventions for students with any use, heavy or problematic use. More research is needed to identify the most effective combinations of behavioral and pharmacologic treatments for opioid, alcohol, and cannabis use disorders.

Citation

Suggested citation: Steele DW, Becker SJ, Danko KJ, Balk EM, Saldanha IJ, Adam GP, Bagley SM, Friedman C, Spirito A, Scott K, Ntzani EE, Saeed I, Smith B, Popp J, Trikalinos TA. Interventions for Substance Use Disorders in Adolescents: A Systematic Review. Comparative Effectiveness Review No. 225. (Prepared by the Brown Evidence-based Practice Center under Contract No. 290-2015-00002-I.) AHRQ Publication No. 20-EHC014. Rockville, MD: Agency for Healthcare Research and Quality. May 2020. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCCER225.

Keywords 
substance abuse
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