Joan Colom

Treatment for alcohol dependence in Catalonia: health outcomes and stability of drinking patterns over 20 years in 850 patients.

AIMS The aim of this study was to evaluate long-term outcomes in alcohol-dependent patients following outpatient treatment and gender differences in drinking outcome and mortality. METHODS A 20-year longitudinal prospective study was done with interim analyses at 1, 5 and 10 years. Of the original sample of 850 patients, 767 (90%) were located 20 years later and 393 of these were interviewed. 273 (32%) patients died during the intervening period and 101 (12%) no longer wished to participate in the study. Drinking status was assigned based on the 12 months prior to the follow-up interview. RESULTS At the 20-year follow-up, 277 (32.6%) of the 393 patients for whom drinking status could be assigned were abstinent (defined never drinking or drinking on less than occasion per month and never more than four drinks/drinking occasion.), 29 (3.4%) were controlled drinkers and 87 (10.2%) were heavy drinkers. Controlled drinking was the least stable category, with 23% continuing from year 5 to year 10 in that category, and 10% continuing in that category from year 10 to year 20. Mortality was higher (39.1%) in those who had been categorized at year 5 as heavy drinkers compared to those who had been categorized as controlled drinkers or abstinent. Abstinent patients reported fewer alcohol-related problems and better psychosocial functioning than heavy drinkers. Women achieved higher abstinence rates (47.2% versus 29.0%, P = 0.005) and had lower mortality (22.4% versus 34.5%, P = 0.03) than men. CONCLUSIONS Over the long-term, abstinence is the most frequent and stable drinking outcome achieved and is associated with fewer problems and better psychosocial functioning. Controlled drinking is rarely achieved and sustained. Women appear to do better than men in the long term.

Implementing training and support, financial reimbursement, and referral to an internet-based brief advice program to improve the early identification of hazardous and harmful alcohol consumption in primary care (ODHIN) : study protocol for a cluster randomized factorial trial

BackgroundThe European level of alcohol consumption, and the subsequent burden of disease, is high compared to the rest of the world. While screening and brief interventions in primary healthcare are cost-effective, in most countries they have hardly been implemented in routine primary healthcare. In this study, we aim to examine the effectiveness and efficiency of three implementation interventions that have been chosen to address key barriers for improvement: training and support to address lack of knowledge and motivation in healthcare providers; financial reimbursement to compensate the time investment; and internet-based counselling to reduce workload for primary care providers.Methods/designIn a cluster randomized factorial trial, data from Catalan, English, Netherlands, Polish, and Swedish primary healthcare units will be collected on screening and brief advice rates for hazardous and harmful alcohol consumption. The three implementation strategies will be provided separately and in combination in a total of seven intervention groups and compared with a treatment as usual control group. Screening and brief intervention activities will be measured at baseline, during 12 weeks and after six months. Process measures include health professionals’ role security and therapeutic commitment of the participating providers (SAAPPQ questionnaire). A total of 120 primary healthcare units will be included, equally distributed over the five countries. Both intention to treat and per protocol analyses are planned to determine intervention effectiveness, using random coefficient regression modelling.DiscussionEffective interventions to implement screening and brief interventions for hazardous alcohol use are urgently required. This international multi-centre trial will provide evidence to guide decision makers.Trial registrationClinicalTrials.gov. Trial identifier: NCT01501552

El ISCA (Interrogatorio Sistematizado de Consumos Alcohólicos): un nuevo instrumento para la identificación prematura de bebedores de riesgo

Fundamento En el contexto del estudio de la Organizacion Mundial de la Salud (OMS) sobre alcohol y atencion primaria, se ha evidenciado la necesidad de desarrollar instrumentos estandarizados de identificacion temprana, que faciliten a los profesionales de atencion primaria los trabajos de cribado sistematico. El objetivo del presente estudio era desarrollar un nuevo instrumento estandarizado para registrar consumos alcoholicos y validar su utilidad para la deteccion de consumos de riesgo en el contexto de la atencion primaria. Sujetos y metodo El Interrogatorio Sistematizado de Consumos Alcoholicos (ISCA) se administro conjuntamente con el AUDIT, que sirvio de criterio externo, a un total de 255 pacientes que acudieron a consulta en 5 centros de atencion primaria. Resultados La correlacion entre las puntuaciones en las dos pruebas fue positiva y altamente significativa (r = 0,831; p 28 para los varones y > 17 para las mujeres) y atendiendo a los diferentes criterios externos utilizados, en los varones la sensibilidad del ISCA oscilo entre el 70 y el 81% y la especificidad entre el 82 y el 99%. En las mujeres los niveles de sensibilidad oscilaron entre el 46 y el 100% y los de especificidad entre el 97 y el 100%. Conclusiones El ISCA parece util en la deteccion de consumo de riesgo y es ademas sencillo de administrar por los equipos de atencion primaria, por lo que se puede utilizar indistinta o complementariamente al AUDIT.

Efficacy of opiate maintenance therapy and adjunctive interventions for opioid dependence with comorbid cocaine use disorders: a systematic review and meta-analysis of controlled clinical trials

Aims: To determine the efficacy of Opiate Maintenance Therapy (OMT) and adjunctive interventions for dual heroin and cocaine dependence by means of a meta-analysis. Method: We searched for and retrieved randomized controlled clinical trials. We used RevMan 5.0 with random effects modeling for statistical analysis and for comparisons of relative risk, effect sizes, and confidence intervals. Subsequent moderator variables and sensitivity analyses were performed. Results: Thirty-seven studies, which have enrolled 3,029 patients, have been included in this meta-analysis. High doses of OMT were more efficacious than lower ones in the achievement of sustained heroin abstinence (RR = 2.24 [1.54, 3.24], p < .0001) but had no effect on cocaine abstinence. At equivalent doses, methadone was more efficacious than buprenorphine on cocaine abstinence (RR = 1.63 [1.20, 2.22], p = .002) and also appeared to be superior on heroin abstinence (RR = 1.39 [1.00, 1.93], p = .05). Several pharmacological and psychological potentiation strategies have been investigated. An improvement on sustained cocaine abstinence was achieved with indirect dopaminergic agonists (RR = 1.44 [1.05, 1.98], p = .03) and with contingency management (CM) focusing on cocaine abstinence (RR = 3.11 [1.80, 5.35], p < .0001). Conclusions: Dual opioid and cocaine dependence can be effectively treated with OMT in combination with adjunctive interventions. Higher OMT doses are preferable to lower ones and methadone to buprenorphine. OMT can be enhanced with indirect dopaminergic drugs and with CM focusing on cocaine abstinence.

The research translation problem: alcohol screening and brief intervention in primary care - real world evidence supports theory.

Translational research projects based in England, New Zealand and Catalonia are described. In combination they provide real world evidence in support of the evolving discourse on translating the evidence on screening and brief intervention for problem use of alcohol so that it is acceptable and fit for routine practice. Acceptance and uptake was enhanced by encouraging primary health clinicians to use evidence-based screening and brief intervention processes which fit with the context in which they work and which build on the skills they already have and use in practice. Emerging general principles included: tailoring procedures to fit with local circumstances; breaking the process down into clinically acceptable steps and negotiating where there is flexibility. Key issues explored in each case study included how ‘screening’ is best conducted, what is a brief intervention best suited to which provider and which providers should run the process.

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.

Brief Interventions Implementation on Alcohol from the European Health Systems Perspective

Alcohol-related health problems are important public health issues and alcohol remains one of the leading risk factors of chronic health conditions. In addition, only a small proportion of those who need treatment access it, with figures ranging from 1 in 25 to 1 in 7. In this context, screening and brief interventions (SBI) have proven to be effective in reducing alcohol consumption and alcohol-related problems in primary health care (PHC) and are very cost effective, or even cost-saving, in PHC. Even if the widespread implementation of SBI has been prioritized and encouraged by the World Health Organization, in the global alcohol strategy, the evidence on long term and population-level effects is still weak. This review study will summarize the SBI programs implemented by six European countries with different socio-economic contexts. Similar components at health professional level but differences at organizational level, especially on the measures to support clinical practice, incentives, and monitoring systems developed were adopted. In Italy, cost-effectiveness analyses and Internet trials shed new light on limits and facilitators of renewed, evidence-based approaches to better deal with brief intervention in PHC. The majority of the efforts were aimed at overcoming individual barriers and promoting health professionals’ involvement. The population screened has been in general too low to be able to detect any population-level effect, with a negative impact on the acceptability of the program to all stakeholders. This paper will present a different point of view based on a strategic broadening of the implemented actions to real inter-sectoriality and a wider holistic approach. Effective alcohol policies should strive for quality provision of health services and the empowerment of the individuals in a health system approach.

Professional's Attitudes Do Not Influence Screening and Brief Interventions Rates for Hazardous and Harmful Drinkers: Results from ODHIN Study

AIMS To determine the relation between existing levels of alcohol screening and brief intervention rates in five European jurisdictions and role security and therapeutic commitment by the participating primary healthcare professionals. METHODS Health care professionals consisting of, 409 GPs, 282 nurses and 55 other staff including psychologists, social workers and nurse aids from 120 primary health care centres participated in a cross-sectional 4-week survey. The participants registered all screening and brief intervention activities as part of their normal routine. The participants also completed the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ), which measure role security and therapeutic commitment. RESULTS The only significant but small relationship was found between role security and screening rate in a multilevel logistic regression analysis adjusted for occupation of the provider, number of eligible patients and the random effects of jurisdictions and primary health care units (PHCU). No significant relationship was found between role security and brief intervention rate nor between therapeutic commitment and screening rate/brief intervention rate. The proportion of patients screened varied across jurisdictions between 2 and 10%. CONCLUSION The findings show that the studied factors (role security and therapeutic commitment) are not of great importance for alcohol screening and BI rates. Given the fact that screening and brief intervention implementation rate has not changed much in the last decade in spite of increased policy emphasis, training initiatives and more research being published, this raises a question about what else is needed to enhance implementation.

Tratamiento del alcoholismo y su impacto a largo plazo. Resultados a 10 años de un estudio longitudinal prospectivo de 850 pacientes

Fundamento y objetivo: El sindrome de dependencia alcoholica se define como una enfermedad cronica. A pesar de ello, son escasos los estudios prospectivos que analizan a largo plazo la influencia del tratamiento en el curso de la enfermedad, y en ningun caso incluyen bebedores procedentes de culturas vitivinicolas. Este estudio longitudinal prospectivo pretende analizar prospectivamente el curso de la enfermedad, asi como el impacto que en dicho curso tiene el tratamiento, en una muestra de bebedores espanoles. Pacientes y metodo: Se incluyo en el estudio a 850 pacientes entre 16 y 55 anos de edad que solicitaron tratamiento por su dependencia alcoholica en 1988-1989 en 8 centros de la Red de Atencion a las Drogodependencias de Cataluna (un 75,6% de los pacientes elegibles). Los pacientes debian cumplir criterios del DSM-III de dependencia alcoholica, tener domicilio estable y un familiar dispuesto a proporcionar informacion colateral. Se han realizado evaluaciones a los 0, 1, 5 y 10 anos de iniciado el tratamiento, y estan previstas nuevas evaluaciones a los 15 y 20 anos. Resultados: A los 10 anos, 131 pacientes (15,4%; intervalo de confianza [IC] del 95%, 13-18) habian fallecido, 656 (77,2%; IC del 95%, 75-80) estaban vivos y 63 (7,4%; IC del 95%, 5-9) no pudieron ser localizados; 54 pacientes (6,4%; IC del 95%, 5-8) rechazaron ser entrevistados. Se pudo evaluar el consumo en los ultimos 3 anos para 588 pacientes (70%; IC del 95%, 67-73), de los cuales 311 (37%; IC del 95%, 34-40) se mantuvieron abstinentes, 58 (7%; IC del 95%, 5-9) bebieron controladamente y 219 (26%; IC del 95%, 23-29) fueron bebedores continuos. La abstinencia se asocio a menores tasas de morbilidad, menor accidentalidad y menor uso de servicios de urgencias. Asimismo, los pacientes abstinentes presentaron menores niveles de estres psicosocial y un mejor funcionamiento global, especialmente en el ambito sociolaboral. Conclusiones: Estos resultados cuestionan la creencia popular de que los alcoholicos recaen inexorablemente. Los cambios producidos por el tratamiento persisten a lo largo del tiempo de forma estable, observandose una mejor evolucion en los pacientes abstinentes. Si bien el tratamiento resulta efectivo para un alto porcentaje de pacientes, se observa tambien en la muestra una mortalidad 4 y 6 veces superior a la esperada para los varones y las mujeres, respectivamente.

High Prevalence and Incidence of HIV and HCV Among New Injecting Drug Users With a Large Proportion of Migrants—Is Prevention Failing?

ABSTRACT Objectives: The aim of this study was to assess differences in the prevalence of HIV and HCV infection and associated risk factors between new (injecting for ≤5 years) and long-term injectors and to estimate HIV/HCV incidence among new injectors. Methods: Cross-sectional study among people who inject drugs (PWID) who attended harm reduction centers in Catalonia in 2010–11. Anonymous questionnaires and oral fluid samples were collected. Poisson regression models were applied to determine the association between HIV/HCV infection and risk factors. Results: Of the 761 participants, 21.4% were new injectors. New injectors were younger than long-term injectors (mean age = 31.6 vs. 37.8) and were more likely to be immigrants (59.0% vs. 33.4%). HIV and HCV prevalence was 20.6% and 59.4% among new injectors, and estimated HIV and HCV incidence 8.7 and 25.1 /100 person-years, respectively. Among new injectors, HIV infection was associated with homelessness (PR = 3.10) and reporting a previous sexually transmitted infection (PR = 1.79). Reporting front/backloading (PR = 1.33) and daily injection (PR = 1.35) were risk-factors for HCV infection. For long-term injectors, HIV risk factors were: having shared syringes (PR = 1.85), having injected cocaine (PR = 1.38), reporting front/backloading (PR = 1.30) and ever having been in prison (PR = 2.03). Conclusion: A large proportion of PWID in Catalonia are new injectors, a subgroup with a high level of both sexual and parenteral exposure and a high incidence rate of HIV/ HCV infections. It is important to improve early diagnosis of these infections among this group, in particular among migrants. To identify and address risk factors for homelessness PWID should be a priority.