Debbie M. Cheng

Alcohol Consumption and HIV Disease Progression

Objective:To assess the relation between alcohol consumption and laboratory markers of HIV disease progression. Methods:We prospectively assessed CD4 cell counts, HIV RNA levels, and alcohol consumption for up to 7 years in 595 HIV-infected persons with alcohol problems recruited between 1997 and 2003. We investigated the relation of these markers of HIV disease progression to alcohol consumption using longitudinal regression models controlling for known prognostic factors, including adherence and depressive symptoms, and stratified by antiretroviral therapy (ART) use. Results:Among subjects who were not on ART, heavy alcohol consumption was associated with a lower CD4 cell count (adjusted mean decrease of 48.6 cells/μL compared with abstinence; P = 0.03) but not with higher log10 HIV RNA. Among subjects who were on ART, heavy alcohol consumption was not associated with a lower CD4 cell count or higher log10 HIV RNA. Conclusions:Heavy alcohol consumption has a negative impact on the CD4 cell count in HIV-infected persons not receiving ART. In addition to the known deleterious effects of alcohol on ART adherence, these findings suggest that avoiding heavy alcohol consumption in patients not on ART may have a beneficial effect on HIV disease progression.

Screening and brief intervention for drug use in primary care: the ASPIRE randomized clinical trial.

IMPORTANCE The United States has invested substantially in screening and brief intervention for illicit drug use and prescription drug misuse, based in part on evidence of efficacy for unhealthy alcohol use. However, it is not a recommended universal preventive service in primary care because of lack of evidence of efficacy. OBJECTIVE To test the efficacy of 2 brief counseling interventions for unhealthy drug use (any illicit drug use or prescription drug misuse)-a brief negotiated interview (BNI) and an adaptation of motivational interviewing (MOTIV)-compared with no brief intervention. DESIGN, SETTING, AND PARTICIPANTS This 3-group randomized trial took place at an urban hospital-based primary care internal medicine practice; 528 adult primary care patients with drug use (Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST] substance-specific scores of ≥4) were identified by screening between June 2009 and January 2012 in Boston, Massachusetts. INTERVENTIONS Two interventions were tested: the BNI is a 10- to 15-minute structured interview conducted by health educators; the MOTIV is a 30- to 45-minute intervention based on motivational interviewing with a 20- to 30-minute booster conducted by masters-level counselors. All study participants received a written list of substance use disorder treatment and mutual help resources. MAIN OUTCOMES AND MEASURES Primary outcome was number of days of use in the past 30 days of the self-identified main drug as determined by a validated calendar method at 6 months. Secondary outcomes included other self-reported measures of drug use, drug use according to hair testing, ASSIST scores (severity), drug use consequences, unsafe sex, mutual help meeting attendance, and health care utilization. RESULTS At baseline, 63% of participants reported their main drug was marijuana, 19% cocaine, and 17% opioids. At 6 months, 98% completed follow-up. Mean adjusted number of days using the main drug at 6 months was 12 for no brief intervention vs 11 for the BNI group (incidence rate ratio [IRR], 0.97; 95% CI, 0.77-1.22) and 12 for the MOTIV group (IRR, 1.05; 95% CI, 0.84-1.32; P = .81 for both comparisons vs no brief intervention). There were also no significant effects of BNI or MOTIV on any other outcome or in analyses stratified by main drug or drug use severity. CONCLUSIONS AND RELEVANCE Brief intervention did not have efficacy for decreasing unhealthy drug use in primary care patients identified by screening. These results do not support widespread implementation of illicit drug use and prescription drug misuse screening and brief intervention. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00876941.

Office-Based Management of Opioid Dependence with Buprenorphine: Clinical Practices and Barriers

BackgroundBuprenorphine is a safe, effective and underutilized treatment for opioid dependence that requires special credentialing, known as a waiver, to prescribe in the United States.ObjectiveTo describe buprenorphine clinical practices and barriers among office-based physicians.DesignCross-sectional survey.ParticipantsTwo hundred thirty-five office-based physicians waivered to prescribe buprenorphine in Massachusetts.MeasurementsQuestionnaires mailed to all waivered physicians in Massachusetts in October and November 2005 included questions on medical specialty, practice setting, clinical practices, and barriers to prescribing. Logistic regression analyses were used to identify factors associated with prescribing.ResultsPrescribers were 66% of respondents and prescribed to a median of ten patients. Clinical practices included mandatory counseling (79%), drug screening (82%), observed induction (57%), linkage to methadone maintenance (40%), and storing buprenorphine notes separate from other medical records (33%). Most non-prescribers (54%) reported they would prescribe if barriers were reduced. Being a primary care physician compared to a psychiatrist (AOR: 3.02; 95% CI: 1.48–6.18) and solo practice only compared to group practice (AOR: 3.01; 95% CI: 1.23–7.35) were associated with prescribing, while reporting low patient demand (AOR: 0.043, 95% CI: 0.009–0.21) and insufficient institutional support (AOR: 0.37; 95% CI: 0.15–0.89) were associated with not prescribing.ConclusionsCapacity for increased buprenorphine prescribing exists among physicians who have already obtained a waiver to prescribe. Increased efforts to link waivered physicians with opioid-dependent patients and initiatives to improve institutional support may mitigate barriers to buprenorphine treatment. Several guideline-driven practices have been widely adopted, such as adjunctive counseling and monitoring patients with drug screening.

Brief intervention for medical inpatients with unhealthy alcohol use: a randomized, controlled trial

Context Brief interventions reduce alcohol use in outpatients who drink unhealthy amounts but are not alcohol-dependent. Their effect in medical inpatients is unknown. Contribution The authors screened all adult medical inpatients at an urban teaching hospital and randomly assigned 341 risky drinkers to a 30-minute motivational counseling intervention followed gy treatment planning or to usual care. By 3 months, the same proportion of patients from both groups had received alcohol assistance, and both groups had reduced their drinking to the same degree. Cautions Three quarters of the participants met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria for alcohol dependence. Implications In this well-done study, brief intervention did not affect alcohol-related outcomes in persons who drank unhealthy amounts. The Editors Professional organizations recommend that clinicians screen their patients for unhealthy alcohol use (that is, the spectrum from drinking risky amounts to dependence) and conduct a brief intervention when indicated (1, 2). Despite this recommendation and the existence of brief, valid screening tools (35), patients with unhealthy alcohol use often are not identified and do not receive timely care. Although widely recommended, brief intervention has proven efficacy in decreasing alcohol consumption and related consequences only in unhealthy drinkers without alcohol dependence and in outpatient settings (6). Its efficacy among other populations (for example, persons with alcohol dependence) and in inpatient settings remains unclear (7). Evidence suggests, however, that medical inpatientsa group with a high prevalence of alcohol-related problemsmay benefit from brief intervention. Some studies have demonstrated the efficacy of brief intervention in settings similar to medical services in which alcohol-related problems are common and their related consequences are severe (8, 9). Further, brief interventions are well suited to medical services. Patients who otherwise might not seek care are accessible and have time for an intervention. Persons admitted because of an alcohol-related problem may recognize the link between drinking and hospitalization, thus providing a teachable moment (10). Also, busy staff might implement a brief intervention because of its brevity and flexibility. The unmet need for alcohol screening and intervention and opportunities for implementation underscore the importance of determining the efficacy of brief intervention in medical inpatients with unhealthy alcohol use. In addition, evaluating its effectiveness and practicality in real-world settings is critical to help clinicians make informed decisions when treating their patients (11). Therefore, we conducted a randomized, controlled trial to examine whether screening followed by brief intervention would improve alcohol-related outcomes in typical medical inpatients (that is, a racially diverse group with a range of unhealthy alcohol use, comorbid conditions, and readiness to change). We hypothesized that screening and brief intervention would lead to the following: receipt of alcohol assistance (for example, specialty treatment) among persons with alcohol dependence and, among all persons decreased alcohol consumption, alcohol-related problems, and health care utilization and improved readiness to change and health-related quality of life. Methods Patients As previously described, we recruited patients from the inpatient medical service of a large, urban teaching hospital (12). Trained research associates approached all patients who were age 18 years or older and whose physicians did not decline patient contact. Patients fluent in English or Spanish who gave verbal consent were asked to complete a screening interview to determine eligibility: currently (past month) drinking risky amounts (defined for eligibility as >14 standard drinks/wk or 5 drinks/occasion for men and >11 drinks/wk or 4 drinks/occasion for women and persons 66 years); 2 contacts to assist with follow-up; no plans to move from the area in the next year; and a Mini-Mental State Examination score of 21 or greater (13, 14). Research associates assessed demographic characteristics and administered the Alcohol Use Disorders Identification Test (AUDIT) (15) by interview. To better characterize current alcohol use, they assessed the average numbers of drinking-days per week and drinks consumed on a typical day, and the maximum number of drinks consumed per occasion (16, 17). For the first 7 months of the study, research associates asked these additional questions only to patients with an AUDIT score of 8 or greater (a recommended cutoff for screening) (18). For the remaining 22 months, research associates asked the additional questions to anyone who drank in the past 12 months to maximize identification of drinkers of risky amounts. Lastly, the research associates asked all patients who were drinking risky amounts to describe their readiness to change by using a visual analog scale ranging from 0 to 10 (19). Enrolled patients provided written informed consent and were compensated for each completed interview. The institutional review board at Boston University Medical Center approved this study. We secured additional privacy protection with a certificate of confidentiality from the National Institute on Alcohol Abuse and Alcoholism. Assessment at Enrollment Research associates interviewed patients before randomization to assess the characteristics shown in Table 1. One author reviewed the medical records to determine medical diagnoses (29). Diagnoses of alcohol use disorders were based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (30), and were determined with the Composite International Diagnostic Interview (CIDI) Alcohol Module (31, 32). Table 1. Characteristics at Enrollment of All Study Patients and of the Subgroup with Alcohol Dependence* Randomization and Intervention An off-site data management group generated assignments to control and intervention groups by using a permuted block (size 8) randomization procedure stratified by AUDIT score (<12 vs. 12) and provided us the assignments in sealed opaque envelopes. We used the AUDIT score to stratify because we could not score the CIDI before randomization. After each baseline assessment, research associates opened an envelope and informed the patient of his or her assignment. Patients in the control group received usual care (that is, they were told the screening results and that they could discuss their drinking with their physicians). Specialists were available by referral. Systematic alcohol screening and brief intervention were not routine at this hospital. We assigned patients in the intervention group to a 30-minute session of brief motivational counseling (19, 33) conducted by counseling and clinical psychology doctoral students whom we trained and supervised. Sessions were audiotaped and included feedback, an open discussion, and construction of a change plan (Appendix). Outcomes and Measurements The first primary outcome was self-reported receipt of alcohol assistance in the past 3 months by patients with CIDI-determined alcohol dependence. This outcome was measured at the 3-month follow-up visit with a standardized interview based on the Treatment Services Review (34) and Form 90 (35). Assistance included residential treatment, outpatient treatment (for example, specialty counseling or therapy), medications, employee assistance programs, or mutual-help groups (for example, Alcoholics Anonymous). The other primary outcome was the change in the number of mean drinks per day in the past 30 days from enrollment to 12 months among all patients. We determined consumption with the Timeline Follow-back method (36). Five secondary consumption outcomes (past 30 days) included changes from enrollment to 12 months in the numbers of heavy drinking episodes (5 drinks/occasion for men and 4 drinks/occasion for women and for persons 66 y) and days abstinent; and the proportions of patients drinking risky amounts (>14 drinks/wk or 5 drinks/occasion for men and >7 drinks/wk or 4 drinks/occasion for women and persons 66 y) (37), having 1 or more heavy drinking episodes, and abstaining for all 30 days. Other secondary outcomes included the changes at 12 months in readiness to change (Taking Steps scale on the Stages of Change Readiness and Treatment Eagerness Scale) (38), alcohol problems (total score on the Short Inventory of Problems) (39), physical and mental health-related quality of life (Physical and Mental Component Summary scale scores on the Short-Form Health Survey) (40), and emergency department visits and days of medical hospitalization (both determined by a standardized interview based on the Treatment Services Review and Form 90) (34, 35). Follow-up Procedures Research associates conducted follow-up visits, which included reassessment of most domains covered at enrollment, usually in person and at 3 and 12 months (10% and 13%, respectively, by telephone; similar by randomized group). They performed alcohol breath tests at in-person follow-up visits (41). Although they were involved in the randomization assignment, research associates were not involved in the intervention. Further, 64% of patients at 3-month follow-up and 85% of patients at 12-month follow-up were interviewed by a different research associate than at baseline. Statistical Analysis We analyzed all patients in the groups to which they were randomly assigned. Reported P values are 2-tailed and are considered statistically significant if they were less than 0.05. We analyzed data with SAS/STAT software, versions 8.2 and 9.1.3 (SAS Institute, Inc., Cary, North Carolina). To describe the study sample and to compare groups, we used the chi-square test, Fisher exact test, 2-sample t test, and Wilcoxon rank-sum test, as appropriate. For the primary analyses, we used logistic and linear

Health literacy, antiretroviral adherence, and HIV-RNA suppression: a longitudinal perspective.

BACKGROUND: Low health literacy has been associated with worse adherence to antiretroviral therapy (ART) and higher HIV-RNA levels, but these relationships have not been evaluated in longitudinal analyses. METHODS: We evaluated literacy using the Rapid Estimate of Adult Literacy in Medicine (REALM) (≤6th grade, 7th to 8th grade, ≥9th grade) in the HIV-Alcohol Longitudinal Cohort study of HIV-infected persons with a history of alcohol problems, conducted from 1997 to 2001. We tested HIV-RNA levels and administered a standardized questionnaire regarding demographics, substance use, receipt of ART, and adherence with ART, every 6 months for up to 7 occasions. Among the 235 subjects on ART, we investigated the relationship between literacy and 2 outcomes: 100% 3-day self-reported adherence and HIV-RNA suppression (<500 copies). RESULTS: Subjects’ literacy levels were the following: 14% ≤6th grade, 29% 7th to 8th grade, and 57% ≥9th grade. In 66% of the observations (478/725), subjects reported 100% 3-day adherence with ART. Of the 685 HIV-RNA assays from these subjects, 62% had <500 copies. In unadjusted analyses, subjects with the lowest literacy level (≤6th grade) had a higher odds of adherence (odds ratio [OR] 2.23, 95% confidence interval 1.15 to 4.30) and HIV-RNA suppression (OR 2.01, 95% confidence interval 1.03 to 3.90) compared with those with ≥9th grade literacy. This trend persisted but was no longer statistically significant in adjusted models of adherence (AOR 1.93, 95% confidence interval 0.86 to 4.31) and HIV-RNA suppression (AOR 1.70, 95% confidence interval 0.79 to 3.65). CONCLUSION: Contrary to our hypothesis, low literacy was not associated with a lower odds of adherence or virologic suppression in this longitudinal analysis of HIV-infected patients with a history of alcohol problems. Indeed, trends in these data suggest the possibility that low literacy may be associated with a higher odds of adherence and virologic suppression. These counterintuitive findings underscore the need to pursue a fuller understanding of the mechanisms by which literacy affects health outcomes.

Effect of local restaurant smoking regulations on progression to established smoking among youths

Background: While smoke-free restaurant laws are intended to protect the public from secondhand smoke exposure, they may also discourage smoking among adolescents. There is no evidence from longitudinal studies to test this hypothesis. Objective: To examine the effect of local restaurant smoking regulations on progression to established smoking among adolescents. Design, setting, and subjects: A cohort of 2623 Massachusetts youths, ages 12–17 years at baseline, was interviewed via random digit dial telephone survey in 2001–2002 and followed up two years later. A generalised estimating equations (GEE) logistic regression analysis was used and controlled for potential individual, household, and town level confounding factors. Main outcome measure: Progression to established smoking during the two year follow up period (defined as having smoked 100 or more cigarettes in one’s life). Results: Compared to youths living in towns with weak regulations, those living in towns with strong regulations (complete restaurant smoking bans) had less than half the odds of progression to established smoking (odds ratio (OR) 0.39, 95% confidence interval (CI) 0.24 to 0.66). The association was stronger for youths in towns with strong regulations in effect for two or more years (OR 0.11, 95% CI 0.03 to 0.37), although it was still present for those in towns with strong regulations in effect for less than two years (OR 0.55, 95% CI 0.33 to 0.90). No relationship was found between living in a town with a medium restaurant smoking regulation (restriction of smoking to enclosed, separately ventilated areas) and rates of progression to established smoking. Conclusions: Local restaurant smoking bans may be an effective intervention to prevent youth smoking.

A randomized controlled trial of an automated exercise coach for older adults.

To compare the efficacy of a computer‐based physical activity program (Embodied Conversational Agent—ECA) with that of a pedometer control condition in sedentary older adults.

Antihypertensive Therapy Increases Cerebral Blood Flow and Carotid Distensibility in Hypertensive Elderly Subjects

Many physicians are reluctant to lower blood pressure to recommended levels in elderly hypertensive patients because of concern about producing cerebral hypoperfusion. Because hypertension is associated with potentially reversible structural and functional alterations in the cerebral circulation that may improve with treatment, we investigated whether long-term pharmacological reduction of systolic blood pressure will improve, rather than worsen, cerebral blood flow and its regulation. Three groups of elderly subjects 65 years of age or older were studied prospectively: normotensive subjects (N=19), treated hypertensive subjects with systolic pressure <140 mm Hg (N=18), and uncontrolled hypertensive subjects with systolic pressure >160 mm Hg at entry into the study (N=14). We measured beat-to-beat blood flow velocity in the middle cerebral artery (transcranial Doppler ultrasonography), finger arterial pressure (photoplethysmography), and pulsatile distensibility of the carotid artery (duplex Doppler ultrasonography) at baseline and after 6 months of observation or antihypertensive therapy. After baseline hemodynamic measurements, uncontrolled hypertensive subjects underwent aggressive treatment with lisinopril with or without hydroclorothiazide or, if not tolerated, nifedipine or an angiotensin receptor blocker to bring their systolic pressure <140 mm Hg for 6 months. The other 2 groups were observed for 6 months. After 6 months of successful treatment, uncontrolled hypertensive subjects had significant increases in cerebral blood flow velocity and carotid distensibility that was not seen in the other groups. Treatment reduced cerebrovascular resistance and did not impair cerebral autoregulation. Therefore, judicious long-term treatment of systolic hypertension in otherwise healthy elderly subjects does not cause cerebral hypoperfusion.

Screening and Brief Intervention for Unhealthy Drug Use in Primary Care Settings: Randomized Clinical Trials Are Needed

The efficacy of screening and brief intervention (SBI) for drug use in primary care patients is largely unknown. Because of this lack of evidence, US professional organizations do not recommend it. Yet, a strong theoretical case can be made for drug SBI. Drug use is common and associated with numerous health consequences, patients usually do not seek help for drug abuse and dependence, and SBI has proven efficacy for unhealthy alcohol use. On the other hand, the diversity of drugs of abuse and the high prevalence of abuse and dependence among those who use them raise concerns that drug SBI may have limited or no efficacy. Federal efforts to disseminate SBI for drug use are underway, and reimbursement codes to compensate clinicians for these activities have been developed. However, the discrepancies between science and policy developments underscore the need for evidence-based research regarding the efficacy of SBI for drug use. This article discusses the rationale for drug SBI and existing research on its potential to improve drug-use outcomes and makes the argument that randomized controlled trials to determine its efficacy are urgently needed to bridge the gap between research, policy, and clinical practice.

Impact of health literacy on depressive symptoms and mental health-related: quality of life among adults with addiction.

AbstractBACKGROUND: Health literacy has been linked to health status in a variety of chronic diseases. However, evidence for a relationship between health literacy and mental health outcomes is sparse. OBJECTIVE: We hypothesized that low literacy would be associated with higher addiction severity, higher levels of depressive symptoms, and worse mental health functioning compared with those with higher literacy in adults with alcohol and drug dependence. METHODS: The association of literacy with multiple mental health outcomes was assessed using multivariable analyses. Measurement instruments included the Rapid Estimate of Adult Literacy in Medicine (REALM), the Center for Epidemiologic Studies-Depression (CES-D) scale, the Mental Component Summary scale of the Short Form Health Survey, and the Addiction Severity Index for drug and alcohol addiction. Subjects included 380 adults recruited during detoxification treatment and followed prospectively at 6-month intervals for 2 years. Based on the REALM, subjects were classified as having either low (≤8th grade) or higher (≥9th grade) literacy levels. RESULTS: In longitudinal analyses, low literacy was associated with more depressive symptoms. The adjusted mean difference in CES-D scores between low and high literacy levels was 4 (P <.01). Literacy was not significantly associated with mental health-related quality of life or addiction severity. CONCLUSIONS: In people with alcohol and drug dependence, low literacy is associated with worse depressive symptoms. The mechanisms underlying the relationship between literacy and mental health outcomes should be explored to inform future intervention efforts.