Vladimir Poznyak

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.

Validation of the alcohol, smoking and substance involvement screening test (ASSIST)

AIM The concurrent, construct and discriminative validity of the World Health Organizations Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) were examined in a multi-site international study. PARTICIPANTS One thousand and 47 participants, recruited from drug treatment (n = 350) and primary health care (PHC) settings (n = 697), were administered a battery of instruments. MEASUREMENTS Measures included the ASSIST; the Addiction Severity Index-Lite (ASI-Lite); the Severity of Dependence Scale (SDS); the MINI International Neuropsychiatric Interview (MINI-Plus); the Rating of Injection Site Condition (RISC); the Drug Abuse Screening Test (DAST); the Alcohol Use Disorders Identification Test (AUDIT); the Revised Fagerstrom Tolerance Questionnaire (RTQ); and the Maudsley Addiction Profile (MAP). FINDINGS Concurrent validity was demonstrated by significant correlations between ASSIST scores and scores from the ASI-Lite (r = 0.76-0.88), SDS (r = 0.59), AUDIT (r = 0.82) and RTQ (r = 0.78); and significantly greater ASSIST scores for those with MINI-Plus diagnoses of abuse or dependence (P < 0.001). Construct validity was established by significant correlations between ASSIST scores and measures of risk factors for the development of drug and alcohol problems (r = 0.48-0.76). Discriminative validity was established by the capacity of the ASSIST to discriminate between substance use, abuse and dependence. Receiver operating characteristic (ROC) analysis was used to establish cut-off scores with suitable specificities (50-96%) and sensitivities (54-97%) for most substances. CONCLUSIONS The findings demonstrated that the ASSIST is a valid screening test for identifying psychoactive substance use in individuals who use a number of substances and have varying degrees of substance use.

Evidence-based guidelines for mental, neurological, and substance use disorders in low- and middle-income countries: summary of WHO recommendations.

Shekhar Saxena and colleagues summarize the recent WHO Mental Health Gap Action Programme (mhGAP) intervention guide that provides evidence-based management recommendations for mental, neurological, and substance use (MNS) disorders.

The association between alcohol use, alcohol use disorders and tuberculosis (TB). A systematic review.

BackgroundIn 2004, tuberculosis (TB) was responsible for 2.5% of global mortality (among men 3.1%; among women 1.8%) and 2.2% of global burden of disease (men 2.7%; women 1.7%). The present work portrays accumulated evidence on the association between alcohol consumption and TB with the aim to clarify the nature of the relationship.MethodsA systematic review of existing scientific data on the association between alcohol consumption and TB, and on studies relevant for clarification of causality was undertaken.ResultsThere is a strong association between heavy alcohol use/alcohol use disorders (AUD) and TB. A meta-analysis on the risk of TB for these factors yielded a pooled relative risk of 2.94 (95% CI: 1.89-4.59). Numerous studies show pathogenic impact of alcohol on the immune system causing susceptibility to TB among heavy drinkers. In addition, there are potential social pathways linking AUD and TB. Heavy alcohol use strongly influences both the incidence and the outcome of the disease and was found to be linked to altered pharmacokinetics of medicines used in treatment of TB, social marginalization and drift, higher rate of re-infection, higher rate of treatment defaults and development of drug-resistant forms of TB. Based on the available data, about 10% of the TB cases globally were estimated to be attributable to alcohol.ConclusionThe epidemiological and other evidence presented indicates that heavy alcohol use/AUD constitute a risk factor for incidence and re-infection of TB. Consequences for prevention and clinical interventions are discussed.

Contribution of six risk factors to achieving the 25×25 non-communicable disease mortality reduction target: a modelling study

BACKGROUND Countries have agreed to reduce premature mortality (defined as the probability of dying between the ages of 30 years and 70 years) from four main non-communicable diseases (NCDs)--cardiovascular diseases, chronic respiratory diseases, cancers, and diabetes--by 25% from 2010 levels by 2025 (referred to as 25×25 target). Targets for selected NCD risk factors have also been agreed on. We estimated the contribution of achieving six risk factor targets towards meeting the 25×25 mortality target. METHODS We estimated the impact of achieving the targets for six risk factors (tobacco and alcohol use, salt intake, obesity, and raised blood pressure and glucose) on NCD mortality between 2010 and 2025. Our methods accounted for multi-causality of NCDs and for the fact that when risk factor exposure increases or decreases, the harmful or beneficial effects on NCDs accumulate gradually. We used data for risk factor and mortality trends from systematic analyses of available country data. Relative risks for the effects of individual and multiple risks, and for change in risk after decreases or increases in exposure, were from re-analyses and meta-analyses of epidemiological studies. FINDINGS If risk factor targets are achieved, the probability of dying from the four main NCDs between the ages of 30 years and 70 years will decrease by 22% in men and by 19% in women between 2010 and 2025, compared with a decrease of 11% in men and 10% in women under the so-called business-as-usual trends (ie, projections based on current trends with no additional action). Achieving the risk factor targets will delay or prevent more than 37 million deaths (16 million in people aged 30-69 years and 21 million in people aged 70 years or older) from the main NCDs over these 15 years compared with a situation of rising or stagnating risk factor trends. Most of the benefits of achieving the risk factor targets, including 31 million of the delayed or prevented deaths, will be in low-income and middle-income countries, and will help to reduce the global inequality in premature NCD mortality. A more ambitious target on tobacco use (a 50% reduction) will almost reach the target in men (>24% reduction in the probability of death), and enhance the benefits to a 20% reduction in women. INTERPRETATION If the agreed risk factor targets are met, premature mortality from the four main NCDs will decrease to levels that are close to the 25×25 target, with most of these benefits seen in low-income and middle-income countries. On the basis of mortality benefits and feasibility, a more ambitious target than currently agreed should be adopted for tobacco use. FUNDING UK MRC.

A Randomized Controlled Trial of a Brief Intervention for Illicit Drugs Linked to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in clients recruited from primary health care settings in four countries

AIMS This study evaluated the effectiveness of a brief intervention (BI) for illicit drugs (cannabis, cocaine, amphetamine-type stimulants and opioids) linked to the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). The ASSIST screens for problem or risky use of 10 psychoactive substances, producing a score for each substance that falls into either a low-, moderate- or high-risk category. DESIGN Prospective, randomized controlled trial in which participants were either assigned to a 3-month waiting-list control condition or received brief motivational counselling lasting an average of 13.8 minutes for the drug receiving the highest ASSIST score. SETTING Primary health-care settings in four countries: Australia, Brazil, India and the United States. PARTICIPANTS A total of 731 males and females scoring within the moderate-risk range of the ASSIST for cannabis, cocaine, amphetamine-type stimulants or opioids. MEASUREMENTS ASSIST-specific substance involvement scores for cannabis, stimulants or opioids and ASSIST total illicit substance involvement score at baseline and 3 months post-randomization. FINDINGS Omnibus analyses indicated that those receiving the BI had significantly reduced scores for all measures, compared with control participants. Country-specific analyses showed that, with the exception of the site in the United States, BI participants had significantly lower ASSIST total illicit substance involvement scores at follow-up compared with the control participants. The sites in India and Brazil demonstrated a very strong brief intervention effect for cannabis scores (P < 0.005 for both sites), as did the sites in Australia (P < 0.005) and Brazil (P < 0.01) for stimulant scores and the Indian site for opioid scores (P < 0.01). CONCLUSIONS The Alcohol, Smoking and Substance Involvement Screening Test-linked brief intervention aimed at reducing illicit substance use and related risks is effective, at least in the short term, and the effect generalizes across countries.

Multicentre study of acute alcohol use and non-fatal injuries: data from the WHO collaborative study on alcohol and injuries

OBJECTIVES To study the risk of non-fatal injury at low levels and moderate levels of alcohol consumption as well as the differences in risk across modes of injury and differences among alcoholics. METHODS Data are from patients aged 18 years and older collected in 2001-02 by the WHO collaborative study on alcohol and injuries from 10 emergency departments around the world (n = 4320). We used a case-crossover method to compare the use of alcohol during the 6 hours prior to the injury with the use of alcohol during same day of the week in the previous week. FINDINGS The risk of injury increased with consumption of a single drink (odds ratio (OR) = 3.3; 95% confidence interval = 1.9-5.7), and there was a 10-fold increase for participants who had consumed six or more drinks during the previous 6 hours. Participants who had sustained intentional injuries were at a higher risk than participants who had sustained unintentional injuries. Patients who had no symptoms of alcohol dependence had a higher OR. CONCLUSION Since low levels of drinking were associated with an increased risk of sustaining a non-fatal injury, and patients who are not dependent on alcohol may be at higher risk of becoming injured, comprehensive strategies for reducing harm should be implemented for all drinkers seen in emergency departments.

Alcohol and infectious diseases : an overlooked causal linkage?

Alcohol has been identified as a major risk factor for chronic disease and injury [1]. However, no infectious disease has been included in the list of alcoholattributable disease categories, even though several such diseases have consistent associations with alcohol. In July 2008, 25 international experts from eight countries (Australia, Brazil, Canada, China, South Africa, Tanzania, Thailand and the United States) and various disciplines, together with representatives of the World Health Organization (WHO) and Joint United Nations Programme on Human Immunodeficiency Virus/ Acquired Immune Deficiency Syndrome (UNAIDS), met in Cape Town to review systematically evidence relating to the linkages between alcohol consumption and HIV disease and tuberculosis (TB) and examine potential causal impacts of alcohol use on both the incidence and course of these infectious diseases. The meeting was hosted by the South African Medical Research Council (MRC) and co-sponsored by the WHO. Over 4 days the participants reviewed data from published and unpublished studies, meta-analyses and other reviews that were prepared specifically for the meeting, as well as information on biological pathways in order to understand more clearly the linkages between alcohol and HIV and TB. Clear criteria were set out for causality to be met, based on common epidemiological standards [2,3]. After reviewing the evidence, there was general consensus that there was conclusive evidence of a causal linkage between heavy drinking patterns and/or alcohol use disorders (AUD) and the incidence of active TB, and that these exposure categories were also linked causally to worsening of the disease course for both TB and HIV. Participants, however, concluded that while alcohol usage was associated consistently with the prevalence [4] and incidence of HIV [5], further research was needed to substantiate causality. Heavy alcohol use and AUD have long been associated with active TB [6]. A recent meta-analysis [7] found a threefold increase risk of active TB for consumption of more than 40 g/day or AUD. The causal pathways between heavy consumption and incidence of active TB are both biological and social. Regarding the biological pathways, heavy use of alcohol has an impact on multiple organs and systems, including the weakening of the immune system [8], and thus facilitates the transition to active TB and worsens the disease course. These exposure patterns impact upon both the innate and the adaptive immune system overall, and via breaking immune barriers of specific organs such as the lungs. The second important causal pathway is via social–behavioural consequences of heavy alcohol use and/or alcohol dependence. TB is more prevalent in low-income, densely populated housing areas—settings often associated with high rates of AUD. Heavy use of alcohol has also been shown to disrupt drinkers from seeking medical attention and decrease their adherence to therapeutic schedules. As a result, treatment outcomes for heavy users of alcohol are worse, even after controlling for homelessness and unemployment [9]. Finally, heavy alcohol use has been linked to the development of multi-drug-resistant TB [10]. Similar causal pathways for TB were identified between alcohol use and worsening the course of the HIV disease. Again, compromised immunity and comorbid conditions, and the impact of heavy alcohol use on treatment adherence, including regular intake of medication, play a crucial role [11]. In addition, there are potential interactions with treatment medication for HIV, and also with treatment for common co-morbid conditions such as hepatitis C virus (HCV) infection [12]. Regarding a potential impact of alcohol on infection with HIV, it was concluded that ‘the relationship between alcohol use and risky sex is complex, [reflecting] multiple underlying causal and non-causal processes’ [13]. There is a need to answer a number of questions about the potential links, such as: ‘Do people with whom heavy drinkers have sex differ from the partners of people who do not drink heavily?’; ‘Are heavy drinkers more likely to have multiple concurrent partners than people who are not heavy drinkers?; and ‘Are condoms applied less correctly after heavy drinking than otherwise?’. This will require both a re-analysis of already available data as well as new, longitudinal studies to be carried out. In particular, there is a need for a large cohort study on the effects and potential interactions of various risk factors on HIV incidence in countries of high HIV prevalence, including an examination of the contribution of co-infections such as TB. Such research would also be crucial for developing interventions to reduce the risk of new infections. Establishing causality is only the first step. In the next step we need to identify effective interventions to reduce the burden of TB attributable to alcohol. Similarly, interventions to improve TB and HIV treatment outcomes via addressing harmful use of alcohol should be developed. Alcohol-related interventions have been shown to be EDITORIAL doi:10.1111/j.1360-0443.2008.02500.x

Mental Health and Substance Abuse

This article describes the reasons why countries need to develop services for mental and substance use disorders. It also outlines key recommendations for the organization and delivery of services and discusses a number of key variables – resources, paradigm, value system, and environment – in terms of how they shape mental health services. Finally the article highlights the need to move from a biomedical model to a public health model and the role that training, mental health policy, and legislation can play in order to deliver high-quality services that respect human rights.

Clinical assessment compared with breathalyser readings in the emergency room: concordance of ICD-10 Y90 and Y91 codes

Objectives: The purpose of this study was to analyse the validity of clinical assessment of alcohol intoxication (ICD-10 Y91) compared with estimated blood alcohol concentration (BAC) using a breath analyser (ICD-10 Y90) among patients in the emergency room (ER). Methods: Representative samples of ER patients reporting within six hours of injury (n = 4798) from 12 countries comprising the WHO Collaborative Study on Alcohol and Injuries were breath analysed and assessed blindly for alcohol intoxication at the time of ER admission. Data were analysed using Kendall’s Tau-B to measure concordance of clinical assessment and BAC, and meta analysis to determine heterogeneity of effect size. Results: Raw agreement between the two measures was 86% (Tau-B 0.68), but was lower among those reporting drinking in the six hours prior to injury (raw agreement 39%; Tau-B 0.32). No difference was found by gender or for timing of clinical assessment in relation to breath analysis. Patients positive for tolerance or dependence were more likely to be assessed as intoxicated at low levels of BAC. Estimates were homogeneous across countries only for females and for those negative for alcohol dependence. Conclusions: Clinical assessment is moderately concordant with level of BAC, but in those patients who have actually been drinking within the last six hours the concordance was much less, possibly because, in part, of a tendency on the part of clinicians to assign some level of intoxication to anyone who appeared to have been drinking.