Selection and self-selection: how to determine the real impact of alcohol on health-care utilization and costs?
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Alcohol Drinking↗
Biomedical subjects
Jürgen Rehm
Publications and source records attributed to Jürgen Rehm.
J-shape or linear relationship between alcohol consumption and depression: does it matter?
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Alcohol Drinking↗
Multi-level analysis of alcohol-related injury among emergency department patients: a cross-national study.
AIM: The aim of this analysis was to examine the average rate and variation of alcohol-related injury across emergency department (ED) studies, the effect of usual drinking on likelihood of alcohol-related injury, whether cross-study variation in rate of alcohol-related injury can be explained by between-study difference in usual consumption and whether social-cultural contextual variables help explain cross-study variations, after between-study difference in usual consumption has been controlled. DESIGN: Data were merged from the Emergency Room Collaborative Alcohol Analysis Project (ERCAAP) and the WHO Collaborative Study on Alcohol and Injuries, together representing 28 studies in 16 countries, and include 8423 (drinking) injury patients who arrived in the ED within 6 hours after injury. Alcohol-related injury was based, separately, on a positive blood alcohol concentration (BAC) and self-reported drinking within 6 hours prior to injury. A multi-level design and hierarchical generalized linear models were used for analysis in which patients were nested within studies. FINDINGS: Overall prevalence of alcohol-related injury was 24% and 29% for positive BAC and self-report, respectively. At the patient level, log-transformed alcohol consumption in the last 12 months was a significant predictor of alcohol-related injury. At the study level significant variation in rates of alcohol-related injury was observed; studies with higher overall average consumption reported a higher rate of alcohol-related injury. When volume was controlled, societies with higher detrimental drinking pattern and higher legal level for intoxication while driving were more likely to have an increased rate of alcohol-related injury. CONCLUSIONS: Alcohol-related injury varies across EDs and countries. While it is associated with an individual's usual alcohol consumption, it is also affected by a number of societal drinking characteristics including the aggregate volume of consumption, overall drinking pattern and legislative policies to control drinking and related harms.
Adolescent↗
Eyes wide shut?--A conceptual and empirical critique of methadone maintenance treatment.
BACKGROUND: Methadone maintenance treatment (MMT) has been the 'gold standard' pharmacotherapy treatment for illicit opioid dependence for over 30 years. It has been widely evaluated, and is generally claimed to be 'effective'. METHODS: The objective of this paper is to review the rationale of MMT as an intervention for a biomedical disorder with primary social objectives as well as the methodological quality and evidence of MMT outcome research. Data sources included opioid dependence treatment practice, review and outcome research literature (1965-2001) in the form of peer-reviewed articles, books, monographs and reports that are preeminently cited and reviewed international studies on MMT. RESULTS/DATA SYNTHESIS: Rigorous and appropriate evaluation (i.e., RCTs, intent-to-treat, patient-centered) methods in MMT evaluations are rare. Evidence of MMT's effectiveness on primary treatment objectives is mixed and appears to be largely partial and short-term. Positive outcomes may be the result of selection effects of compliant patients and loss in proportion when more rigorous standards of analysis are applied. CONCLUSIONS: The quality of existing MMT research, and evidence for its general effectiveness are limited. Key concepts of self-medication and psychiatric comorbidity are largely ignored in MMT treatment and research frameworks, although they may serve to explain MMT's limited treatment success. Emerging new opioid pharmacotherapies require the fundamental review of the existing MMT paradigm as well as the application of rigorous and appropriate evaluation methods for future treatment.
Comorbidity↗
Comorbid depression among untreated illicit opiate users: results from a multisite Canadian study.
OBJECTIVES: This study aimed to describe patterns of major depression (MDD) in a cohort of untreated illicit opiate users recruited from 5 Canadian urban centres, identify sociodemographic characteristics of opiate users that predict MDD, and determine whether opiate users suffering from depression exhibit different drug use patterns than do participants without depression. METHOD: Baseline data were collected from 679 untreated opiate users in Vancouver, Edmonton, Toronto, Montreal, and Quebec City. Using the Composite International Diagnostic Interview Short Form for Major Depression, we assessed sociodemographics, drug use, health status, health service use, and depression. We examined depression rates across study sites; logistic regression analyses predicted MDD from demographic information and city. Chi-square analyses were used to compare injection drug use and cocaine or crack use among participants with and without depression. RESULTS: Almost one-half (49.3%) of the sample met the cut-off score for MDD. Being female, white, and living outside Vancouver independently predicted MDD. Opiate users suffering from depression were more likely than users without depression to share injection equipment and paraphernalia and were also more likely to use cocaine (Ps < 0.05). CONCLUSIONS: Comorbid depression is common among untreated opiate users across Canada; targeted interventions are needed for this population.
Adult↗
Determinants of overdose incidents among illicit opioid users in 5 Canadian cities.
BACKGROUND: Drug overdose is a major cause of death and illness among illicit drug users. Previous research has indicated that most illicit drug users experience nonfatal overdoses and has suggested a variety of factors that are associated with risk of overdose. In this study, we examined the occurrence of and the factors associated with nonfatal overdoses within a Canadian sample of illicit opioid users not enrolled in treatment at the time of study recruitment. METHODS: Interviewers used a standard questionnaire to collect data on sociodemographic characteristics, drug use, health and health care, experience in the criminal justice system and treatment for drug problems; they also performed standard assessments for mental health and infectious disease. The association between overdose and sociodemographic and drug-use factors was examined with chi(2) and t test analyses; marginally significant variables were examined with logistic regression to determine independent effects. RESULTS: A total of 679 subjects were interviewed; 651 provided answers sufficient for this analysis. One hundred and twelve (17.2%) of the 651 respondents reported an overdose episode in the previous 6 months. In the logistic regression analysis (after adjustment for sociodemographic factors), homelessness, noninjection use of hydromorphone in the past 30 days and involvement in drug treatment in the past 12 months were predictors of overdose (p < 0.05). INTERPRETATION: Overdose poses a considerable health risk for illicit opioid users. We found that a diverse set of factors was associated with overdose episodes. Prevention efforts will likely be more effective if they can be directed to specific causal factors.
Adult↗
Problems with the graduated frequency approach to measuring alcohol consumption: results from a pilot study in Toronto, Canada.
AIMS: To evaluate advantages and disadvantages of the graduated frequency (GF) approach, which asks about the frequency of alcohol consumption at mutually exclusive quantity levels (i.e. 12 or more drinks, at least eight drinks but less than 12, etc.). METHODS: Telephone survey of 464 adults aged 18 and older in Toronto, Canada, using random digit dialing and computer-assisted telephone interviewing. RESULTS: Respondents reported higher frequency and volume of drinking on the GF compared to overall and beverage-specific quantity-frequency type measures; however, at least 16% of GF responses included double counting on their frequency estimates using the GF. When these cases were excluded or corrected, differences between the GF and quantity-frequency measures mostly disappeared. The GF was superior to quantity-frequency measures for identifying heavy episodic drinkers. However, the GF had little advantage over the weekly recall method except for identifying very infrequent (i.e. less often than twice a month) heavy drinkers. CONCLUSIONS: Because the GF has a high rate of response errors in terms of measuring frequency of alcohol consumption, other combinations of measures, including alternate measures of heavy episodic drinking should be considered.
Adolescent↗
Injection drug use and the hepatitis C virus: considerations for a targeted treatment approach--the case study of Canada.
Infection with the hepatitis C virus (HCV) is a major public health burden in Canada and globally. The literature shows that injection drug use is currently the primary transmission route for HCV, and that a majority of injection drug users (IDUs) are currently infected with HCV in Canada. This article first reviews the burden of HCV within IDU populations and the transmission risks and the treatment implications specific to IDUs. Traditionally, IDUs have been excluded from HCV treatment unless abstaining from illicit drug use. However, recent research suggests that categorical exclusion is not medically necessary. A series of key questions about the feasibility of offering HCV treatment to IDUs in the specific Canadian context are considered, including concerns related to the motivation of treatment for IDUs, treatment delivery, treatment side effects, HCV reinfection, and the social environment. The article concludes that treatment of HCV-infected illicit drug users is both feasible and may be necessary to reduce transmission and adverse outcomes in this high-risk population.
Canada↗
Age, period and cohort influences on beer, wine and spirits consumption trends in the US National Alcohol Surveys.
AIMS: To estimate the separate influences of age, period and cohort on the consumption of beer wine and spirits in the United States. DESIGN: Linear age-period-cohort models controlling for demographic change with extensive specification testing. Setting US general population 1979-2000. MEASUREMENTS: Monthly average of past-year consumption of beer, wine and spirits in five National Alcohol Surveys. Findings The strongest cohort effects are found for spirits; cohorts born before 1940 are found to have significantly higher consumption than those born after 1946, with especially high spirits consumption for men in the pre-1930s cohorts. Significant cohort effects are also found for beer with elevated consumption in the 1946-65 cohorts for men but in the pre-1940 cohorts for women. Significant negative effects of age are found for beer and spirits consumption, although not for wine. Significant period effects are found for men's beer and wine consumption and for women's spirits consumption. Increased educational attainment in the population over time is associated with reduced beer consumption and increased wine consumption. CONCLUSIONS: Changing cohort demographics are found to have significant effects on beverage-specific consumption, indicating the importance of controlling for these effects in the evaluation of alcohol policy effectiveness and the potential for substantial improvement in the forecasting of future beverage-specific consumption trends, alcohol dependence treatment demand and morbidity and mortality outcomes.
Adult↗
Dosage regimes in the prescription of heroin and other narcotics to chronic opioid addicts in Switzerland--Swiss national cohort study.
AIMS: Within the guidelines of the research programme on medical prescription of narcotics for opioid addicts (PROVE), heroin, morphine, and methadone were prescribed to heavily opioid addicted individuals in Switzerland since 1994. This contribution analyses the course of dose levels during the treatment period. DESIGN: Naturalistic description of consumed dosages per day and month. SETTING AND PARTICIPANTS: The study describes the dosages prescribed to all individuals who began outpatient treatment in the PROVE programme in Switzerland between 1994 and 1996. MEASUREMENTS: Consumed amount of narcotics per day and the course of dosage of injectable heroin in different treatment regimes. FINDINGS: Heroin was the most frequently prescribed narcotic. Of all consumption days, heroin had been applied in 77% as injection and in 9% in a smokeable form. The mean daily dosage was 474 mg for intravenous application and 993 mg for the smokeable form. Second most frequent was the prescription of oral methadone, in most cases in combination with heroin. The mean amount of daily consumption of oral methadone was 53 mg. There were dosage differences between treatment regimes. During the course of treatment the mean dosage for injectable heroin per day decreased significantly and, depending on the treatment regime, almost linearly. CONCLUSIONS: The significance of heroin dosages in heroin-assisted therapy for treatment outcome should be further explored, especially in the light of the markedly higher dosages in Switzerland compared to the UK. During the treatment period, dosages did not increase but generally decreased, indicating no further increase in tolerance.
Administration, Oral↗
Cocaine use in Europe - a multi-centre study: patterns of use in different groups.
AIM: The study investigates patterns of cocaine powder and crack cocaine use of different groups in nine European cities. DESIGN, SETTING, PARTICIPANTS: Multi-centre cross-sectional study conducted in Barcelona, Budapest, Dublin, Hamburg, London, Paris, Rome, Vienna, and Zurich. Data were collected by structured face-to-face interviews. The sample comprises 1,855 cocaine users out of three subgroups: 632 cocaine users in addiction treatment, mainly maintenance treatment; 615 socially marginalized cocaine users not in treatment, and 608 socially integrated cocaine users not in treatment. MEASUREMENTS: Use of cocaine powder, crack cocaine and other substances in the last 30 days, routes of administration, and lifetime use of cocaine powder and crack cocaine. FINDINGS: The marginalized group showed the highest intensity of cocaine use, the highest intensity of heroin use and of multiple substance use. 95% of the integrated group snorted cocaine powder, while in the two other groups, injecting was quite prevalent, but with huge differences between the cities. 96% of all participants had used at least one other substance in addition to cocaine in the last 30 days. CONCLUSIONS: The use of cocaine powder and crack cocaine varies widely between different groups and between cities. Nonetheless, multiple substance use is the predominating pattern of cocaine use, and the different routes of administration have to be taken into account.
Adolescent↗
Decreased taxation, spirits consumption and alcohol-related problems in Switzerland.
OBJECTIVE: The spirits market in Switzerland was reformed in 1999 in accordance with the World Trade Organization agreement. The resulting tax reform and increased competition have resulted in markedly reduced prices for foreign spirits, and a previous study showed that spirits consumption increased significantly after the tax reform. The present study examined whether alcohol-related problems also increased at follow-up and if they did, whether the increase was the result of increased spirits consumption. Further correlates of alcohol-related problems were also explored. METHOD: Data were obtained from a longitudinal study on changes in alcohol consumption in Switzerland. The baseline survey was conducted 3 months before the tax reform, and the follow-up was conducted 28 months after the tax reform. A randomly selected sample of 4,007 residents aged 15 years or older participated in the baseline survey, and 73% of this sample participated in the follow-up survey. Alcohol consumption was measured on the basis of a graduated frequency, and alcohol-related problems were measured by items taken from the Alcohol Use Disorder Identification Test (AUDIT). RESULTS: Findings indicate that alcohol-related problems increased significantly at follow-up. The significance disappeared, however, after controlling for spirits consumption, indicating that the increase of alcohol-related problems at follow-up was mainly mediated through increased consumption of spirits. The multiple regression models showed that spirits, beer and wine consumption, gender, Age*Spirits Consumption interaction, region, smoking status, heavy-drinking frequency and average number of drinks were significant correlates of alcohol-related problems. CONCLUSIONS: Alcohol-related problems increased at the follow-up, particularly among younger age groups who consumed more spirits. Prevention programs on alcohol-related problems should target young people.
Adolescent↗
Reducing the global burden of hazardous alcohol use: a comparative cost-effectiveness analysis.
OBJECTIVE: Intervention strategies are available for reducing the high global burden of hazardous alcohol use as a risk factor for disease, but little is known about their potential costs and effects at a population level. This study set out to estimate these costs and effects. METHOD: Analyses were carried out for 12 epidemiological World Health Organization subregions of the world. A population model was used to estimate the impact of evidence-based personal and nonpersonal interventions--including brief physician advice, taxation, roadside random breath testing, restricted sales access and advertising bans. Costs were measured in international dollars (I$); population-level intervention effects were gauged in terms of disability-adjusted life years (DALYs) averted. Average and incremental cost-effectiveness ratios (CERs) were computed. RESULTS: The most costly interventions to implement are brief advice in primary care and roadside breath testing of drivers. In populations with a high prevalence of heavy drinkers (more than 5%, such as Europe and North America), the most effective and cost-effective intervention was taxation (more than 500 DALYs averted per 1 million population; CER < I$500 per DALY averted). In populations with a lower prevalence of heavy drinking, however, taxation is estimated to be less cost effective overall than other, more targeted strategies, such as brief physician advice, roadside breath testing and advertising bans. CONCLUSIONS: The most efficient public health response to the burden of alcohol use depends on the prevalence of hazardous alcohol use, which is related to overall per capita consumption. Population-wide measures, such as taxation, are expected to represent the most cost-effective response in populations with moderate or high levels of drinking, whereas more targeted strategies are indicated in populations with lower rates of hazardous alcohol use.
Adolescent↗
Predicting the outcome of eating disorders using structural equation modeling.
OBJECTIVE: There is a need for models that predict accurately the course of mental disorders. METHOD: Eating-disordered female inpatients were assessed longitudinally at the beginning of treatment (t1), at the end of treatment (t2), at 2 or 3-year follow-up (t3), and at 6-year follow-up (t4). The sample consisted of 196 women with bulimia nervosa (BN) purging type, 103 women with anorexia nervosa (AN), and 68 women with binge eating disorder (BED; N=367). Confirmatory factor analysis and path analysis were used to predict the women's status at 6-year follow-up. RESULTS: The results for BN and BED show that the specific eating disorder pathology was influenced mainly by specific eating disorder pathology at earlier time points and not by non-eating-specific (general) psychopathology. Similarly, general psychopathology was influenced mainly by general psychopathology at earlier time points. For AN patients, both categories of psychopathology (eating specific and general) were relevant for the 6-year outcome. The potential impact of 14 factors on the level of pathology was estimated (a) at baseline (at the beginning of treatment), (b) during the course of illness (baseline controlled), and (c) on the 6-year outcome of eating disorders (baseline and course controlled). Although there were many correlations between potential factors and baseline pathology, there was only a limited number of significant correlations with the 6-year outcome. This effect was mediated largely by the level of general psychopathology. DISCUSSION: The models for outcome prediction based on structural equation modeling techniques were very similar for BN and BED. For both BN and BED, there were almost entirely separate predictions for the specific eating disorder on the one hand and non-eating-related (general) psychopathology on the other hand. This was true to a lesser degree for AN. CONCLUSIONS: The use of refined path analytic methods in follow-up studies on larger general populations will be helpful to increase our understanding of the course of illness of psychiatric disorders.
Adolescent↗
Screening for antisocial personality disorder in drug users--a qualitative exploratory study on feasibility.
Knowledge about co-occurring personality disorders in drug users is important for planning therapy and prevention. The objective of this study was to assess whether the SCID-II (Structured Clinical Interview for DSM-III-R) Screen for antisocial personality disorder was feasible and acceptable in a population of opioid users. A qualitative study on veridicality and emotional quality in responses to SCID-II Screen was carried out by personal interview in a multifunctional addiction centre. The subjects were 10 outpatient participants (six female, four male) in methadone substitution treatment. The SCID-II Screen triggered a high level of emotions. Some questions were mainly interpreted from a victim's perspective, even though the intention was the perpetrator's view. Questions were seen as sex-biased. Provision of support to deal with potential emotional problems should be supplied. Potential revision should be considered to include the female perspective in the screen.
Adult↗
Alcohol consumption and total mortality/morbidity-definitions and methodological implications.
Two main types of studies of alcohol consumption and total mortality/morbidity are distinguished, namely: individual level studies and aggregate level studies. Alcohol consumption is usually characterized in terms of volume or average volume of consumption. More recently, patterns of drinking, especially heavy drinking occasions, have been introduced. On the individual level, the definition of mortality is trivial (death) and morbidity is either defined by hospitalization or by subjective definitions. On the aggregate level, mortality is defined either in death rates or in years of life lost, and morbidity as hospitalization rates or years of life lost to disability. Disability Adjusted Life Years (DALYs) combine mortality and morbidity into a summary measure of health. Individual level studies clearly should be given preference in assessing the relationship between alcohol and outcomes, as long as the assessment of alcohol consumption is state-of-the-art and the sample includes all relevant drinking patterns, plus if there is adequate control for confounding and adequate statistical analysis.
Alcohol Drinking↗
How stable is the risk curve between alcohol and all-cause mortality and what factors influence the shape? A precision-weighted hierarchical meta-analysis.
OBJECTIVE: To determine the influence of six determining variables on the shape of the risk curve between alcohol and all-cause mortality. METHODS DATA: Based on a systematic search with clear inclusion criteria, all articles on alcohol and all-cause mortality until 2000 were included. STATISTICAL METHODS: Precision-weighted pooling of relative risks (RRs); precision-weighted hierarchical analysis. VARIABLES: For pooling: RRs for different categories of average volume of drinking, lifetime abstainers and ex-drinkers. For hierarchical analysis: on first level: consumption in grams of pure alcohol per day; on second level: length of follow-up time in months; per capita consumption; average age, proportion of abstainers, average volume of drinking, and variability of average volume of drinking at baseline. OUTCOMES MEASURES: RR of former and current drinkers for all-cause mortality compared to abstainers. RESULTS: The main hypotheses could be confirmed for males: Ex-drinkers had a higher mortality risk than lifetime abstainers; the higher and the more diverse the average volume of alcohol consumption, the wider the dip of the curve; the older the persons at baseline, the more pronounced the protective effect; and the longer the follow-up time, the less pronounced the protective effect. Except for average volume of drinking effects for females went in the same direction but with one exception did not reach significance. CONCLUSIONS: There are systematic influences on the shape of the risk curve between alcohol and all-cause mortality. The overall beneficial effect of light to moderate drinking remained under all scenarios, indicating a high validity of the overall shape despite the heterogeneity between studies.
Age Distribution↗
Changes in alcohol consumption following a reduction in the price of spirits: a natural experiment in Switzerland.
AIMS: To discover what changes in alcohol consumption had occurred in subgroups defined by age, sex, volume of drinking and drinking occasions, following a reduction in the price of spirits in Switzerland in July 1999. DESIGN: Quasi-experimental. Longitudinal general-population survey with baseline 3 months before and follow-up 3 months after price change. PARTICIPANTS: Probabilistic telephone sample of 1347 individuals with at least monthly consumption on average in the previous 6 months at both interviews. The response rate at baseline was 74,8% and the attrition rate from baseline to follow-up 20.2%. MEASUREMENTS: Alcohol consumption was assessed by means of a beverage-specific graduated-frequency measure. High volume of drinking was defined as 40 + g/day for men and 20 + g/day for women. Binge drinking was defined as six + drinks on an occasion for men and four + drinks for women. FINDINGS: Spirits consumption increased significantly (by 28.6%) in the total sample, and specifically in young males and in individuals who were low-volume drinkers at baseline. Consumption of alcohol overall, or of wine or beer, did not change significantly. No indication of effects of substitution was found. CONCLUSIONS: Spirits consumption showed price-responsiveness in the early postintervention period. This finding is of particular interest, as (a) the increase in spirits consumption took place at a time of generally declining consumption of alcohol in Switzerland; and (b) in contrast to the findings of most studies, the intervention, namely price reduction, increased availability.
Adolescent↗