Hugo López-Pelayo

A randomised controlled non-inferiority trial of primary care-based facilitated access to an alcohol reduction website (EFAR Spain): the study protocol

Introduction Early identification (EI) and brief interventions (BIs) for risky drinkers are effective tools in primary care. Lack of time in daily practice has been identified as one of the main barriers to implementation of BI. There is growing evidence that facilitated access by primary healthcare professionals (PHCPs) to a web-based BI can be a time-saving alternative to standard face-to-face BIs, but there is as yet no evidence about the effectiveness of this approach relative to conventional BI. The main aim of this study is to test non-inferiority of facilitation to a web-based BI for risky drinkers delivered by PHCP against face-to-face BI. Method and analysis A randomised controlled non-inferiority trial comparing both interventions will be performed in primary care health centres in Catalonia, Spain. Unselected adult patients attending participating centres will be given a leaflet inviting them to log on to a website to complete the Alcohol Use Disorders Identification Test (AUDIT-C) alcohol screening questionnaire. Participants with positive results will be requested online to complete a trial module including consent, baseline assessment and randomisation to either face-to-face BI by the practitioner or BI via the alcohol reduction website. Follow-up assessment of risky drinking will be undertaken online at 3 months and 1 year using the full AUDIT and D5-EQD5 scale. Proportions of risky drinkers in each group will be calculated and non-inferiority assessed against a specified margin of 10%. Assuming reduction of 30% of risky drinkers receiving standard intervention, 1000 patients will be required to give 90% power to reject the null hypothesis. Ethics and dissemination The protocol was approved by the Ethics Commmittee of IDIAP Jordi Gol i Gurina P14/028. The findings of the trial will be disseminated through peer-reviewed journals, national and international conference presentations. Trial registration number ClinicalTrials.gov NCT02082990.

Definitions of Risky and Problematic Cannabis Use: A Systematic Review

ABSTRACT Although cannabis is widely used, it remains unclear which consumption patterns are more likely to produce future consequences (risky/hazardous use) or current damage (problematic/harmful use). This unresolved issue contributes to cannabis public health implications. In order to facilitate further consensus, this review analyzes previously used definitions in the literature. Methods: This systematic review was performed following the PRISMA guidelines. Articles published before October 2015 in the Medline, Scopus–Elsevier, ISI-Web of Knowledge and Cochrane databases and fulfilling a-priori decided criteria were retrieved. Definitions in preselected websites of national and international organizations addressing drug problems were also included. Results: Definitions identified in articles (n = 46) and official websites (n = 3) widely varied from each other. Weekly cannabis use was mostly considered risky. Problematic cannabis use was mostly described with the Cannabis Abuse and Screening Test. Evidence-based definitions as well as information on quantities consumed, time-frames and special considerations for risky groups were very limited. Conclusions: Working on official definitions is highly necessary as criteria used remain incomplete, leading to increased confusion in the field. Recommendations to improve existing definitions are given.

Alcohol abstinence in patients surviving an episode of alcoholic hepatitis: Prediction and impact on long-term survival

Alcoholic hepatitis (AH) is the most severe form of alcoholic liver disease. Most studies have focused on short‐term prognosis, whereas factors associated with long‐term survival are largely unknown. The aims of our study were to (1) determine the impact of complete abstinence from alcohol on long‐term survival and (2) identify prognostic factors at admission capable of predicting abstinence during long‐term follow‐up in patients with AH. One hundred forty‐two patients with biopsy‐proven AH that survived the first episode were included. Demographic, psychiatric, and biochemical variables at admission and drinking status during follow‐up were obtained. Cox regression, logistic regression, and classification and regression trees (CART) analyses were used for statistical analysis. Overall mortality was 38% with a median follow‐up of 55 months. During follow‐up, complete abstinence was reported in 39% and was associated with better long‐term survival (hazard ratio, 0.53; P = 0.03). After adjustment for baseline prognostic scoring systems (Model for End‐Stage Liver Disease and age, bilirubin, international normalized ratio, creatinine scores), complete abstinence was independently associated with survival (P < 0.05). Age and lack of past alcoholism treatments were independently associated with complete abstinence (P < 0.001 and P = 0.02, respectively) during follow‐up. CART analysis generated a simple and practical algorithm based on the combination of past alcoholism treatments and age. Using CART analysis, we stratified 2 subgroups of patients with high (65%) and low (26%‐29%) rates of complete abstinence after an episode of AH. Conclusion: Complete abstinence after an episode of AH positively impacts long‐term survival. The combination of 2 variables easily obtained at admission might be useful to predict long‐term abstinence after an episode of AH. Strategies aimed at promoting alcohol abstinence in these patients are necessary. (Hepatology 2017;66:1842–1853)

Cannabinoid hyperemesis syndrome.

Recent articles published in CNS Neuroscience and Therapeutics reflect the increasing interest of the scientific community in the therapeutic properties of cannabis[1,2]. However, an aspect that is commonly overlooked is the potential medical side effects of cannabis use, among which severe hyperemesis is an uncommon condition. Cannabinoid hyperemesis syndrome (CHS) occurs in chronic, daily cannabis users and is characterized by cyclic vomiting and compulsive bathing behavior. This clinical manifestation is paradoxical, given the previously identified therapeutic role of cannabis as an antiemetic agent. We report a recent case of CHS associated with organic and psychiatric complications that was diagnosed at our center. A 36-year-old Hispanic woman attended the emergency department of a tertiary hospital presenting with second-degree burns on 20% of her body surface. These had been caused by repeated showers in excessively hot water. She also reported a history of frequent episodes of nausea and vomiting for the previous 24 months, which after several inconclusive assessments had been attributed to anxiety. She denied any medical or surgical history, except diagnosis of gastritis in 2011, treated with omeprazole. She had visited the emergency department on several occasions during the previous 5 years referring anxiety and abdominal pain associated with vomiting and compulsive hot showers which the patient had claimed were aimed at relieving anxiety symptoms, and which were considered to be part of an obsessive–compulsive disorder (OCD). She had been treated with antidepressant and anxiolytic drugs without clear improvement. She admitted to smoking marijuana daily for at least 5 years, while she denied the use of any other illicit substances. The patient was admitted for evaluation and was administered acid-suppressive medications, antiemetics, rehydration, and topical treatment. The patient’s laboratory data at admission were normal, except for hypokalemia and a positive urinary drug screen for cannabis, while the physical examination yielded no additional information. During the length of the patient’s hospital admission, she continued to take hot showers numerous times each day. Taking into account the patient’s clinical presentation and her history of regular cannabis use, she was diagnosed with CHS. The patient was informed of the diagnosis, and of the need to cease her marijuana use. On further questioning, the patient confirmed persistent, daily marijuana use over the past 5 years. Following liaison with her psychiatrist, she was referred to a drug treatment center to address her cannabis use disorder, while her OCD diagnosis was withdrawn and her medication modified. Six months later, she had succeeded in giving up cannabis use entirely, she had not suffered any further episodes of nausea or vomiting, and she showered once daily with mild warm water.

Risky Drinkers Underestimate their Own Alcohol Consumption

Risky Drinkers Underestimate their Own Alcohol Consumption Antoni Gual*, José Ángel Arbesú, José Zarco, María de las Mercedes Balcells-Oliveró, Hugo López-Pelayo, Laia Miquel, and Julio Bobes Grup de Recerca en Addiccions Clínic, Hospital Clínic de Barcelona, IDIBAPS, Universitat de Barcelona, Red de Trastornos adictivos (RETICS), Barcelona, Spain, Médico de Familia, Coordinador Área de Neurociencias de Semergen, Centro de Salud de la Eria, Oviedo, Spain, Médico de Familia, Coordinador Grupo de Intervención en Drogas semFYC, CS Ibiza, SERMAS, Spain, and Área de Psiquiatría, Universidad de Oviedo, Centro de Investigación Biomédica en Red área de Salud Mental (CIBERSAM), Oviedo, Spain

Implementing referral to an electronic alcohol brief advice website in primary healthcare: results from the ODHIN implementation trial

Objectives The objective of the present study was to explore whether the possibility of offering facilitated access to an alcohol electronic brief intervention (eBI) instead of delivering brief face-to-face advice increased the proportion of consulting adults who were screened and given brief advice. Design The study was a 12-week implementation study. Sixty primary healthcare units (PHCUs) in 5 jurisdictions (Catalonia, England, the Netherlands, Poland and Sweden) were asked to screen adults who attended the PHCU for risky drinking. Setting A total of 120 primary healthcare centres from 5 jurisdictions in Europe. Participants 746 individual providers (general practitioners, nurses or other professionals) participated in the study. Primary outcome Change in the proportion of patients screened and referred to eBI comparing a baseline 4-week preimplementation period with a 12-week implementation period. Results The possibility of referring patients to the eBI was not found to be associated with any increase in the proportion of patients screened. However, it was associated with an increase in the proportion of screen-positive patients receiving brief advice from 70% to 80% for the screen-positive sample as a whole (p<0.05), mainly driven by a significant increase in brief intervention rates in England from 87% to 96% (p<0.01). The study indicated that staff displayed a low level of engagement in this new technology. Staff continued to offer face-to-face advice to a larger proportion of patients (54%) than referral to eBI (38%). In addition, low engagement was seen among the referred patients; on average, 18% of the patients logged on to the website with a mean log-on rate across the different countries between 0.58% and 36.95%. Conclusions Referral to eBI takes nearly as much time as brief oral advice and might require more introduction and training before staff are comfortable with referring to eBI. Trial registration number NCT01501552; Post-results.

The Standard Joint Unit

OBJECTIVE Reliable data on cannabis quantities is required to improve assessment of cannabis consumption for epidemiological analysis and clinical assessment, consequently a Standard Joint Unit (SJU) based on quantity of 9-Tetrahydrocannabinol (9-THC) has been established. METHODOLOGY Naturalistic study of a convenience sample recruited from February 2015-June 2016 in universities, leisure spaces, mental health services and cannabis clubs in Barcelona. Adults, reporting cannabis use in the last 60 days, without cognitive impairment or language barriers, answered a questionnaire on cannabis use and were asked to donate a joint to further determine their 9-THC and Cannabidiol (CBD) content. RESULTS 492 participants donated 315 valid joints. Donators were on average 29 years old, mostly men (77%), single (75%), with at least secondary studies (73%) and in active employment (63%). Marijuana joints (N=232) contained a median of 6.56mg of 9-THC (Interquartile range-IQR=10,22) and 0.02mg of CBD (IQR=0.02); hashish joints (N=83) a median of 7.94mg of 9-THC (IQR=10,61) and 3.24mg of CBD (IQR=3.21). Participants rolled 4 joints per gram of cannabis and paid 5€ per gram (median values). CONCLUSION Consistent 9-THC-content in joints lead to a SJU of 7mg of 9-THC, the integer number closest to the median values shared by both cannabis types. Independently if marijuana or hashish, 1 SJU = 1 joint = 0.25 g of cannabis = 7 mg of 9-THC. For CBD, only hashish SJU contained relevant levels. Similarly to the Standard Drink Unit for alcohol, the SJU is useful for clinical, epidemiological and research purposes.

Effectiveness of a Specialized Brief Intervention for At‐risk Drinkers in an Emergency Department: Short‐term Results of a Randomized Controlled Trial

BACKGROUND Screening, Brief Intervention, and Referral to Treatment (SBIRT) programs have been developed, evaluated, and shown to be effective, particularly in primary care and general practice. Nevertheless, effectiveness of SBIRT in emergency departments (EDs) has not been clearly established. OBJECTIVE We aimed to evaluate the feasibility and efficacy of an SBIRT program conducted by highly specialized professionals in the ED of a tertiary hospital. METHODS We conducted a randomized controlled trial to study the feasibility and efficacy of an SBIRT program conducted by alcohol specialists for at-risk drinkers presenting to the ED, measured with the three-item version of the Alcohol Use Disorder Identification Test (AUDIT-C). Patients were randomized to two groups, with the control group receiving two leaflets-one regarding alcohol use and the other giving information about the study protocol. The intervention group received the same leaflets as well as a brief motivational intervention on alcohol use and, where appropriate, a referral to specialized treatment. The primary outcomes were the proportion of at-risk alcohol use measured by AUDIT-C scale and the proportion of patients attending specialized treatment at 1.5 months. RESULTS Of 3,027 patients presenting to the ED, 2,044 (67%) were potentially eligible to participate, 247 (12%) screened positive for at-risk drinking, and 200 agreed to participate. Seventy-two percent of the participating sample were men, and the mean (±SD) age was 43 (±16.7) years. Follow-up rates were 76.5%. At 1.5 months, the intervention group showed greater reductions in alcohol consumption and fewer patients continuing with at-risk alcohol use (27.8% vs. 48.1%; p = 0.01). The SBIRT program also increased the probability of attending specialized treatment, compared to the control condition (23% vs. 9.8%, p = 0.0119) CONCLUSION: The SBIRT program in the ED was found to be feasible and effective in identifying at-risk drinkers, reducing at-risk alcohol use, and increasing treatment for alcohol problems.

Barriers to implement screening for alcohol consumption in Spanish hypertensive patients

Background Alcohol intake and hypertension (HT) are interrelated public health problems with cost-effective interventions at the primary care level that, to date, are poorly implemented. Objective This study aims to explore the barriers to implementing alcohol interventions for people with HT in primary care. Methods As part of the project BASIS (Baseline Alcohol Screening and Intervention Survey), an internet survey from five European countries was developed to determine the role of alcohol in the management of HT in primary care practice. The survey contained 28 core items and 7 country-specific items. We present answers from Spanish general practitioners (GPs), who were reached through the main professional and scientific societies via e-mail and asked to take the online survey. Results In total, 867 GPs answered the survey (65.1% women, 70.4% > 30 years old). As indicated by the Alcohol Use Disorders Identification Test-C scores, 12.4% of GPs who responded were risky drinkers (21.3% of men versus 7.1% of women). GPs reported considering alcohol relatively unimportant in HT treatment, as well as a difficult condition to deal with. The three main barriers to implement screening for alcohol consumption in HT patients were the lack of time (50.0%), considering alcohol unimportant for HT (28.4%) and stigma (16.5%). Conclusions GPs did not consider alcohol consumption a relevant factor for HT and, additionally, found it difficult to deal with alcohol problems. Some of the barriers for alcohol screening could be overcome through structural changes in the health system, such as empowering GPs to treat alcohol use disorders (rather than a single focus on implementing preventive strategies) by enhancing training in alcohol diagnosis and treatment.

Quantitative Criteria to Screen for Cannabis Use Disorder

Introduction: The Standard Joint Unit (1 SJU = 7 mg of 9-Tetrahydrocannabinol) simplifies the exploration of risky patterns of cannabis use. This study proposes a preliminary quantitative cutoff criterion to screen for cannabis use disorder (CUD). Methodology: Socio-demographical data and information on cannabis quantities, frequency of use, and risk for CUD (measured with the Cannabis Abuse Screening Test (CAST) of cannabis users recruited in Barcelona (from February 2015 to June 2016) were collected. CAST scores were categorized into low, moderate, and high risk for CUD, based on the SJU consumed and frequency. Receiver operating characteristic (ROC) analysis related daily SJU with CUD. Results: Participants (n = 473) were on average 29 years old (SD = 10), men (77.1%), and single (74.6%). With an average of 4 joints per smoking day, 82.5% consumed cannabis almost every day. Risk for CUD (9.40% low, 23.72% moderate, 66.88% high) increased significantly with more frequency and quantities consumed. The ROC analyses suggest 1.2 SJU per day as a cutoff criterion to screen for at least moderate risk for CUD (sensitivity 69.4%, specificity 63.6%). Conclusion: Frequency and quantity should be considered when exploring cannabis risks. A 1 SJU per day is proposed as a preliminary quantitative-based criterion to screen users with at least a moderate risk for CUD.