Alys Havard

Systematic review and meta-analyses of strategies targeting alcohol problems in emergency departments: interventions reduce alcohol-related injuries

AIMS To critique the methodological adequacy of evaluations of emergency department (ED)-based interventions for alcohol problems and to conduct a meta-analysis to examine the extent to which interventions in this setting are effective in reducing alcohol consumption and related harm. METHODS An electronic search of 11 databases and a manual search of reference lists were conducted to identify studies published in peer-review journals between January 1996 and July 2007 (inclusive). Studies evaluating the outcome of an intervention designed to reduce alcohol problems in patients presenting to the ED were eligible for inclusion. Methodological data were extracted using review criteria adapted from the both the Center for Disease Control (CDC) Guide to Community Preventive Services Data Collection Instrument and the Cochrane Effective Practice and Organization of Care Review Group Data Collection Checklist. Continuous outcomes were pooled using a fixed effect inverse variance approach while binary outcomes were pooled in a generic inverse variance meta-analysis. RESULTS Thirteen studies were identified for inclusion in the review. Methodological quality was found to be reasonable, with the exception of poor reporting of effect-size information and inconsistent selection of outcome measures. Meta-analyses revealed that interventions did not significantly reduce subsequent alcohol consumption, but were associated with approximately half the odds of experiencing an alcohol-related injury (odds ratio = 0.59, 95% confidence interval 0.42-0.84). CONCLUSIONS There are few evaluations of emergency department-based interventions for alcohol problems. Future evaluations should use consistent outcome measures and report effect sizes. The existing evidence suggests that interventions are effective in reducing subsequent alcohol-related injuries.

A systematic review of work-place interventions for alcohol-related problems

AIMS The aims of this study were to (1) gauge any improvement in methodological quality of work-place interventions addressing alcohol problems; and (2) to determine which interventions most effectively reduce work-place-related alcohol problems. METHODS A literature search was undertaken of the data bases, Ovid Medline, PsychINFO, Web of Science, Scopus, HSELINE, OSHLINE and NIOSHTIC-2 for papers published between January 1995 and September 2007 (inclusive). Search terms varied, depending on the database. Papers were included for analysis if they reported on interventions conducted at work-places with the aim of reducing alcohol problems. Methodological adequacy of the studies was assessed using a method derived from the Cochrane Collaboration guidelines. RESULTS Ten papers reporting on work-place alcohol interventions were located. Only four studies employed randomized controlled trials (RCT), but all these had methodological problems. Weaknesses in all studies related to representativeness of samples, consent and participation rates, blinding, post-test time-frames, contamination and reliability, and validity of measures used. All except one study reported statistically significant differences in measures such as reduced alcohol consumption, binge drinking and alcohol problems. CONCLUSIONS The literature review revealed few methodologically adequate studies of work-place alcohol interventions. Study designs, types of interventions, measures employed and types of work-places varied considerably, making comparison of results difficult. However, it appears from the evidence that brief interventions, interventions contained within health and life-style checks, psychosocial skills training and peer referral have potential to produce beneficial results.

Patterns of major depression and drug-related problems amongst heroin users across 36 months.

The study aimed to determine patterns of major depression (MD) across 36 months, and the relationship to outcomes for the treatment of heroin dependence. As part of a longitudinal cohort study, 429 heroin users were interviewed at 36 month follow-up. MD declined from 23.8% at baseline to 8.2% at 36 months. Females were more likely to have MD at both baseline (31.1 vs. 19.8) and 36 months (11.9 vs. 6.1%). Those with MD at baseline were significantly more likely to be diagnosed with MD at a follow-up interview (40.2 vs. 15.9%) and at 36 months (14.7 vs. 6.1%). Antidepressant use did not decrease across 36 months amongst either gender. Baseline MD was not related to treatment exposure across 36 months. There were large and significant declines in drug use and drug-related problems, and improvements in physical health with no group differences evident at 36 months. Despite improvements in global mental health, at both baseline and 36 months those with MD at baseline had significantly lower SF12 mental health scores. It was concluded that, with the exception of depression, the prognosis of depressed heroin users is not worse than that of non-depressed users.

Benzodiazepine use among heroin users: Baseline use, current use and clinical outcome

INTRODUCTION AND AIMS Benzodiazepine use is associated with elevated levels of harm. The current study aimed to ascertain the long-term nature of the relationship between benzodiazepine use and clinical profile among heroin users. DESIGN AND METHODS Longitudinal cohort, with follow-up at 3, 12, 24 and 36 months. Participants were 615 heroin users recruited for the Australian Treatment Outcome Study. RESULTS At baseline, current benzodiazepine users were more likely to be committing crime, had poorer psychological health and poorer physical health. Baseline benzodiazepine use was not associated with the likelihood across follow-up of heroin use (P = 0.44), committing crime (P = 0.17), poorer psychological health (P = 0.31) or poorer physical health (P = 0.48). Current benzodiazepine use was, however, associated with a greater likelihood of concurrent heroin use (OR 2.77), crime (OR 2.04), poorer psychological health (beta = -4.47) and poorer physical health (beta = -2.33). DISCUSSION AND CONCLUSIONS Clinicians should be aware that reductions in benzodiazepine use are associated with reductions in harm, and that baseline benzodiazepine status does not equate to poor long-term outcome.

The effectiveness of community-action in reducing risky alcohol consumption and harm: a cluster randomised controlled trial

In a cluster randomized controlled trial, Anthony Shakeshaft and colleagues measure the effectiveness of a multi-component community-based intervention for reducing alcohol-related harm.

Outcomes after detoxification for heroin dependence: findings from the Australian Treatment Outcome Study (ATOS)

As part of the Australian Treatment Outcome Study (ATOS), 177 (88%) heroin users entering detoxification (DTX) and 66 (83%) heroin users not in treatment (NT) were interviewed at baseline and 3 months to examine drug use, risk-taking, overdose, crime and psychopathology outcomes. The majority (76%) of the DTX group had entered additional treatment at 3 months, mainly further detoxification, and 54% were currently in treatment, mainly maintenance and residential rehabilitation. There were reductions in heroin use and other drug use in those entering detoxification. Forty-two per cent were abstinent at 3 months compared to 20% in the NT group. There were also reductions in crime among those entering DTX, and less marked reductions in the NT group. Psychopathology showed less change. Detoxification may, in some part, function as a gateway to further treatment and those entering DTX showed modest but significant improvements across drug use and crime at 3 months.

The Smoking MUMS (Maternal Use of Medications and Safety) Study: protocol for a population-based cohort study using linked administrative data

Introduction Approximately 14% of Australian women smoke during pregnancy. Although the risk of adverse outcomes is reduced by smoking cessation, less than 35% of Australian women quit smoking spontaneously during pregnancy. Evidence for the efficacy of bupropion, varenicline or nicotine replacement therapy as smoking cessation aids in the non-pregnant population suggest that pharmacotherapy for smoking cessation is worth exploring in women of childbearing age. Currently, little is known about the utilisation, effectiveness and safety of pharmacotherapies for smoking cessation during pregnancy; neither the extent to which they are used prior to pregnancy nor whether their use has changed in response to related policy reforms. The Smoking MUMS (Maternal Use of Medications and Safety) Study will explore these issues using linked person-level data for a population-based cohort of Australian mothers. Methods and analysis The cohort will be assembled by linking administrative health records for all women who gave birth in New South Wales or Western Australia since 2003 and their children, including records relating to childbirth, use of pharmaceuticals, hospital admissions, emergency department presentations and deaths. These longitudinal linked data will be used to identify utilisation of smoking cessation pharmacotherapies during and between pregnancies and to explore the associated smoking cessation rates and maternal and child health outcomes. Subgroup and temporal analyses will identify potential differences between population groups including indigenous mothers and social security recipients and track changes associated with policy reforms that have made alternative smoking cessation pharmacotherapies available. Ethics and dissemination Ethical approval has been obtained for this study. To enhance the translation of the projects findings into policy and practice, policy and clinical stakeholders will be engaged through a reference group and a policy forum will be held. Outputs from the project will include scientific papers and summary reports designed for policy audiences.

A systematic and methodological review of interventions for young people experiencing alcohol-related harm

AIMS This review identified published studies evaluating interventions delivered outside educational settings, designed for young people with existing alcohol use problems, or who participate in behaviour that places them at high risk of alcohol-related harm, critiqued their methodology and identified opportunities for new interventions. METHODS A systematic search of the peer-reviewed literature interrogated 10 electronic databases using specific search strings, limited to 2005-09. No additional studies were found by a librarian searching other collections and clearing-houses, or by hand-searching review paper reference lists. The 1697 articles identified were reviewed against criteria from the Dictionary for the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. RESULTS The methodological quality of existing studies is variable, and needs to be both more rigorous and more consistent. Particular problems include the lack of blinding outcome assessors, a reliance solely on self-report measures, highly variable consent and follow-up rates, infrequent use of intention-to-treat analyses and the absence of any economic or cost analyses. The range of interventions evaluated is currently limited to individually focused approaches, almost exclusively implemented in the United States. CONCLUSIONS There is a great need for more intervention trials for young people at high risk of experiencing alcohol-related harm that are both methodologically rigorous and have a broader community focus, to complement the psychological interventions that currently dominate the relevant literature. Such trials would improve outcomes for high-risk young people themselves and would improve the evidence base, both in their own right and by facilitating future meta-analyses.

The ageing heroin user: Career length, clinical profile and outcomes across 36 months

INTRODUCTION AND AIMS The study examined the relationships between length of career (LOC), clinical presentation and outcomes across 36 months among a cohort of 615 heroin users. DESIGN AND METHODS Longitudinal cohort study. RESULTS At baseline, each additional year of heroin use was associated with increased likelihood of: being male, exposure to treatment, having been imprisoned, daily injecting, lifetime and recent polydrug use, having overdosed, poorer physical health and reduced likelihood of heroin smoking. In contrast, LOC was not related to frequency of heroin use, current polydrug use, recent heroin overdose, recent imprisonment, recent criminality or psychopathology. There were also no associations between LOC and outcomes across 36 months in terms of treatment, drug use, crime, severe psychiatric disability or major depression. Longer LOC was associated across 36 months, however, with daily injecting, poorer physical health, severe physical disability and poorer mental health. DISCUSSION AND CONCLUSIONS The data point to the maintenance of heroin-related harms well into the third decade of use.

Randomized controlled trial of mailed personalized feedback for problem drinkers in the emergency department: the short-term impact.

BACKGROUND Evidence exists for the efficacy of emergency department (ED)-based brief alcohol interventions, but attempts to incorporate face-to-face interventions into routine ED practice have been hampered by time, financial, and attitudinal constraints. Mailed personalized feedback, which is likely to be more feasible, has been associated with reduced alcohol consumption in other settings, but its cost-effectiveness in the ED has not been examined. METHODS The intervention was evaluated with a randomized controlled trial of patients presenting to 5 rural EDs in New South Wales, Australia. Patients aged 14 years and older were screened using the Alcohol Use Disorders Identification Test, and those scoring 8 or more were randomly allocated to the intervention or control group. Participants in the intervention group received mailed personalized feedback regarding their alcohol consumption. The control group received no feedback. RESULTS Two hundred and forty-four (80%) participants were successfully followed up at 6 weeks. A significant effect of the mailed feedback was observed only in patients with an alcohol-involved ED presentation. Among this subgroup of participants, those in the intervention group consumed 12.2 fewer drinks per week than the control group after controlling for baseline consumption and other covariates (effect size d = 0.59). The intervention was associated with an average cost of Australian