Juergen Rehm

Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010

BACKGROUND We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) to estimate the burden of disease attributable to mental and substance use disorders in terms of disability-adjusted life years (DALYs), years of life lost to premature mortality (YLLs), and years lived with disability (YLDs). METHODS For each of the 20 mental and substance use disorders included in GBD 2010, we systematically reviewed epidemiological data and used a Bayesian meta-regression tool, DisMod-MR, to model prevalence by age, sex, country, region, and year. We obtained disability weights from representative community surveys and an internet-based survey to calculate YLDs. We calculated premature mortality as YLLs from cause of death estimates for 1980-2010 for 20 age groups, both sexes, and 187 countries. We derived DALYs from the sum of YLDs and YLLs. We adjusted burden estimates for comorbidity and present them with 95% uncertainty intervals. FINDINGS In 2010, mental and substance use disorders accounted for 183·9 million DALYs (95% UI 153·5 million-216·7 million), or 7·4% (6·2-8·6) of all DALYs worldwide. Such disorders accounted for 8·6 million YLLs (6·5 million-12·1 million; 0·5% [0·4-0·7] of all YLLs) and 175·3 million YLDs (144·5 million-207·8 million; 22·9% [18·6-27·2] of all YLDs). Mental and substance use disorders were the leading cause of YLDs worldwide. Depressive disorders accounted for 40·5% (31·7-49·2) of DALYs caused by mental and substance use disorders, with anxiety disorders accounting for 14·6% (11·2-18·4), illicit drug use disorders for 10·9% (8·9-13·2), alcohol use disorders for 9·6% (7·7-11·8), schizophrenia for 7·4% (5·0-9·8), bipolar disorder for 7·0% (4·4-10·3), pervasive developmental disorders for 4·2% (3·2-5·3), childhood behavioural disorders for 3·4% (2·2-4·7), and eating disorders for 1·2% (0·9-1·5). DALYs varied by age and sex, with the highest proportion of total DALYs occurring in people aged 10-29 years. The burden of mental and substance use disorders increased by 37·6% between 1990 and 2010, which for most disorders was driven by population growth and ageing. INTERPRETATION Despite the apparently small contribution of YLLs--with deaths in people with mental disorders coded to the physical cause of death and suicide coded to the category of injuries under self-harm--our findings show the striking and growing challenge that these disorders pose for health systems in developed and developing regions. In view of the magnitude of their contribution, improvement in population health is only possible if countries make the prevention and treatment of mental and substance use disorders a public health priority. FUNDING Queensland Department of Health, National Health and Medical Research Council of Australia, National Drug and Alcohol Research Centre-University of New South Wales, Bill & Melinda Gates Foundation, University of Toronto, Technische Universität, Ontario Ministry of Health and Long Term Care, and the US National Institute of Alcohol Abuse and Alcoholism.

THE RELATION BETWEEN DIFFERENT DIMENSIONS OF ALCOHOL CONSUMPTION AND BURDEN OF DISEASE - AN OVERVIEW

AIMS As part of a larger study to estimate the global burden of disease and injury attributable to alcohol: to evaluate the evidence for a causal impact of average volume of alcohol consumption and pattern of drinking on diseases and injuries; to quantify relationships identified as causal based on published meta-analyses; to separate the impact on mortality versus morbidity where possible; and to assess the impact of the quality of alcohol on burden of disease. METHODS Systematic literature reviews were used to identify alcohol-related diseases, birth complications and injuries using standard epidemiological criteria to determine causality. The extent of the risk relations was taken from meta-analyses. RESULTS Evidence of a causal impact of average volume of alcohol consumption was found for the following major diseases: tuberculosis, mouth, nasopharynx, other pharynx and oropharynx cancer, oesophageal cancer, colon and rectum cancer, liver cancer, female breast cancer, diabetes mellitus, alcohol use disorders, unipolar depressive disorders, epilepsy, hypertensive heart disease, ischaemic heart disease (IHD), ischaemic and haemorrhagic stroke, conduction disorders and other dysrhythmias, lower respiratory infections (pneumonia), cirrhosis of the liver, preterm birth complications and fetal alcohol syndrome. Dose-response relationships could be quantified for all disease categories except for depressive disorders, with the relative risk increasing with increased level of alcohol consumption for most diseases. Both average volume and drinking pattern were linked causally to IHD, fetal alcohol syndrome and unintentional and intentional injuries. For IHD, ischaemic stroke and diabetes mellitus beneficial effects were observed for patterns of light to moderate drinking without heavy drinking occasions (as defined by 60+ g pure alcohol per day). For several disease and injury categories, the effects were stronger on mortality compared to morbidity. There was insufficient evidence to establish whether quality of alcohol had a major impact on disease burden. CONCLUSIONS Overall, these findings indicate that alcohol impacts many disease outcomes causally, both chronic and acute, and injuries. In addition, a pattern of heavy episodic drinking increases risk for some disease and all injury outcomes. Future studies need to address a number of methodological issues, especially the differential role of average volume versus drinking pattern, in order to obtain more accurate risk estimates and to understand more clearly the nature of alcohol-disease relationships.

Modeling the impact of alcohol dependence on mortality burden and the effect of available treatment interventions in the European Union

Alcohol consumption is a major risk factor for the burden of disease, and Alcohol Dependence (AD) is the most important disorder attributable to this behavior. The objective of this study was to quantify mortality associated with AD and the potential impact of treatment. For the EU countries, for the age group 15-64 years, mortality attributable to alcohol consumption in general, to heavy drinking, and to AD were estimated based on the latest data on exposure and mortality. Potential effects of AD treatment were modeled based on Cochrane and other systematic reviews of the effectiveness of the best known and most effective interventions. In the EU 88.9% of men and 82.1% of women aged 15-64 years were current drinkers; and 15.3% of men and 3.4% of women in this age group were heavy drinkers. AD affected 5.4% of men and 1.5% of women. The net burden caused by alcohol consumption was 1 in 7 deaths in men and 1 in 13 deaths in women. The majority of this burden was due to heavy drinking (77%), and 71% of this burden was due to AD. Increasing treatment coverage for the most effective treatments to 40% of all people with AD was estimated to reduce alcohol-attributable mortality by 13% for men and 9% for women (annually 10,000 male and 1700 female deaths avoided). Increasing treatment rates for AD was identified as an important issue for future public health strategies to reduce alcohol-attributable harm and to complement the current focus of alcohol policy.

Epidemiology and alcohol policy in Europe

AIMS To describe three aspects of the epidemiology of alcohol-attributable deaths in Europe, dose, demography and place, and to illustrate how such knowledge can better be used to inform alcohol policy formulation and implementation. DESIGN epidemiological and population health modeling. SETTING Europe. PARTICIPANTS Based on country-specific aggregate statistics. MEASUREMENTS EXPOSURE country-specific adult per capita consumption triangulated with survey data; outcomes: mortality statistics. FINDINGS The absolute risk of dying from an alcohol-attributable disease and injury (accounting for a protective effect for ischaemic diseases) increases with increasing daily alcohol consumption beyond 10 g alcohol per day, the first data point. Over 2/3 of all alcohol-attributable deaths occurring amongst the 20-64 year old population of the European Union (minus Cyprus and Malta) occur in the 45-64 year olds. About 25% of the difference in life expectancy between western and eastern Europe for men aged 20-64 years in 2002 can be attributed to alcohol, largely, but not exclusively, as a result of differences in heavy episodic drinking patterns. CONCLUSIONS Any reduction in the dose of alcohol consumed, at least down to 10 g/day, will reduce the annual and lifetime risk of an alcohol-related death. There is a need for alcohol policy to focus on measures in reducing alcohol consumption, throughout middle age, with immediacy of impact. Policy should strive to reduce alcohol-related health inequalities, with the specific recommendations for policy depending on the cost-effectiveness of interventions related to the epidemiological profile of the country or region under consideration. Fortunately, there are evidence-based policy options that reduce the amount of alcohol consumed and many alcohol-related harms with immediate effect, that reduce the risk of an alcohol-related death in middle age, and that would help to close the health gap between eastern and western Europe.

Alcohol consumption as a risk factor for pneumonia: a systematic review and meta-analysis.

The aim of this study was to quantify the association between alcohol consumption and incidence of pneumonia and to examine possible pathways. This was done by a systematic review and meta-analyses on the dose-response relationship between alcohol consumption or alcohol-use disorders and the incidence of community-acquired pneumonia (CAP). The relative risk (RR) of CAP increased monotonically with increasing alcohol consumption. Individuals consuming 24, 60, and 120 g of pure alcohol daily demonstrated RRs for incident CAP of 1·12 (95% CI 1·02-1·23), 1·33 (95% CI 1·06-1·67) and 1·76 (95% CI 1·13-2·77), respectively, relative to non-drinkers. Clinically defined alcohol-use disorders were associated with an eightfold increased risk of CAP (RR 8·22, 95% CI 4·85-13·95). In conclusion, alcohol was found to be a risk factor for pneumonia with a clear statistical association, and a monotonic dose-response relationship.

Cocaine Use in Europe – A Multi-Centre Study

An increase in the use of cocaine and crack in several parts of Europe has raised the question whether this trend is similar to that of the USA in the 1980s. However, research in the field of cocaine use in Europe has been only sporadic. Therefore, a European multi-centre and multi-modal project was designed to study specific aspects of cocaine and crack use in Europe, in order to develop guidelines for public health strategies. Data on prevalence rates were analysed for the general population and for specific subgroups. Despite large differences between countries in the prevalence of cocaine use in the general population, most countries show an increase in the last few years. The highest rate with a lifetime prevalence of 5.2% was found for the United Kingdom, although with a plateau effect around the year 2000. With regard to specific subgroups, three groups seem to show a higher prevalence than the general population: (1) youth, especially in the party scene; (2) socially marginalized groups, such as homeless and prostitutes or those found in open drug scenes; (3) opiate-dependent patients in maintenance treatment who additionally use cocaine. Specific strategies need to be developed to address problematic cocaine use in these subgroups.

Cancer risk assessment of ethyl carbamate in alcoholic beverages from Brazil with special consideration to the spirits cachaça and tiquira

BackgroundEthyl carbamate (EC) is a multi-site carcinogen in experimental animals and probably carcinogenic to humans (IARC group 2A). Traces of EC below health-relevant ranges naturally occur in several fermented foods and beverages, while higher concentrations above 1 mg/l are regularly detected in only certain spirits derived from cyanogenic plants. In Brazil this concerns the sugarcane spirit cachaça and the manioc (cassava) spirit tiquira, which both regularly exceed the national EC limit of 0.15 mg/l. This study aims to estimate human exposure in Brazil and provide a quantitative risk assessment.MethodsThe human dietary intake of EC via alcoholic beverages was estimated based on WHO alcohol consumption data in combination with own surveys and literature data. This data comprises the EC contents of the different beverage groups cachaça, tiquira, other spirits, beer, wine, and unrecorded alcohol (as defined by the WHO; including alcohol which is not captured in routine government statistics nor taxed). The risk assessment was conducted using the margin of exposure (MOE) approach with benchmark doses obtained from dose-response modelling of animal experiments. Lifetime cancer risk was calculated using the T25 dose descriptor.ResultsConsidering differences between pot-still and column-still cachaça, its average EC content would be 0.38 mg/l. Tiquira contained a considerably higher average EC content of 2.34 mg/l. The whole population exposure from all alcoholic beverages was calculated to be around 100 to 200 ng/kg bw/day, with cachaça and unrecorded alcohol as the major contributing factors. The MOE was calculated to range between 400 and 2,466, with the lifetime cancer risk at approximately 3 cases in 10,000. An even higher risk may exist for binge-drinkers of cachaça and tiquira with MOEs of up to 80 and 15, respectively.ConclusionsAccording to our risk assessment, EC poses a significant cancer risk for the alcohol-drinking population in Brazil, in addition to that of alcohol alone. Model calculations show that the implementation of the 0.15 mg/l limit for cachaça would be beneficial, including an increase of the MOE by a factor between 3 to 6. The implementation of policy measures for tiquira and unrecorded alcohol also appears to be advisable.

Alcohol : No Ordinary Commodity – a summary of the second edition

This article summarizes the contents of Alcohol: No Ordinary Commodity (2nd edn). The first part of the book describes why alcohol is not an ordinary commodity, and reviews epidemiological data that establish alcohol as a major contributor to the global burden of disease, disability and death in high-, middle- and low-income countries. This section also documents how international beer and spirits production has been consolidated recently by a small number of global corporations that are expanding their operations in Eastern Europe, Asia, Africa and Latin America. In the second part of the book, the scientific evidence for strategies and interventions that can prevent or minimize alcohol-related harm is reviewed critically in seven key areas: pricing and taxation, regulating the physical availability of alcohol, modifying the drinking context, drink-driving countermeasures, restrictions on marketing, education and persuasion strategies, and treatment and early intervention services. Finally, the book addresses the policy-making process at the local, national and international levels and provides ratings of the effectiveness of strategies and interventions from a public health perspective. Overall, the strongest, most cost-effective strategies include taxation that increases prices, restrictions on the physical availability of alcohol, drink-driving countermeasures, brief interventions with at risk drinkers and treatment of drinkers with alcohol dependence.

Multiple viral hepatitis in injection drug users and associated risk factors

Background:  While infections due to hepatitis B virus (HBV) and hepatitis C virus (HCV) have been well‐studied in injection drug users (IDUs), hepatitis A virus (HAV) infection and coinfection with multiple hepatitis viruses have received less attention.

Gender differences in prevalence of substance use disorders among individuals with lifetime exposure to substances: results from a large representative sample.

BACKGROUND AND OBJECTIVES Research regarding substance use and substance use disorders (SUDs) shows significant gender differences in prevalence of substance use and dependence. Though lifetime exposure to substances is higher among males, previous reports have not regarded gender differences in prevalence of SUDs among individuals formerly exposed to substances. In addition, though substance abuse is particularly important when exploring gender differences, previous reports have largely focused on rates of transition to substance dependence alone. In this study, we explored gender differences in prevalence of SUDs among individuals with lifetime exposure to substances using a single diagnostic category (abuse or dependence). METHODS We analyzed 11 different categories of substances: heroin, cocaine, cannabis, nicotine, alcohol, hallucinogens, inhalants, sedatives, tranquilizers, opioids, and amphetamines. Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions (Wave 1, n = 43,093). The impact of gender on prevalence of SUDs among individuals with lifetime exposure to substances was assessed with odds ratios (ORs) using logistic regressions and adjusted for socio-demographic factors. RESULTS Our results show that among individuals with lifetime exposure to substances, males had a significantly higher prevalence of alcohol (OR = 2.95), sedatives (OR = 2.00), cannabis (OR = 1.93), tranquilizers (OR = 1.64), opioids (OR = 1.54), hallucinogens (OR = 1.31), and cocaine (OR = 1.26) use disorders compared with females. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Using a single broad diagnostic category highlights gender differences in the prevalence of SUDs among individuals with former exposure to substances. Specifically, the significant gender differences found for alcohol, sedatives, and cannabis use disorders may be important for tailoring preventive measures targeted at reducing rates of SUDs among males using these substances.