Journal Article Annotations
2017, 1st Quarter
Annotations by S. Alex Sidelnik, MD, and Diana Robinson, MD
The finding: Alcohol abuse was identified as a risk factor for atrial fibrillation, myocardial infarction, and congestive heart failure to a similar degree as other well-established risk factors. Additionally, alcohol abuse appeared to have larger effects on those without traditional risk factors such as smoking, hypertension, and diabetes.
Strengths and weaknesses: This is a large-scale longitudinal analysis of over 14 million California residents who received inpatient medical care, ambulatory surgery, and emergency care between 2005 and 2009. The authors identified patients with a diagnosis of alcohol abuse via physician coding and performed a multivariable adjusted analysis to assess risk of atrial fibrillation, myocardial infarction, and congestive heart failure in those with alcohol abuse. The study’s strengths are in its large sample size, robust statistical analysis, and comparison to well-established cardiac disease risk factors. As the study relies on physician coding, there are limitations in assessing the impact of quantity or severity of alcohol use on cardiac disease and potential bias towards identification of individuals with more severe alcohol use.
Relevance: As cardiovascular disease continues to be the leading cause of death in the United States, identifying modifiable risk factors is valuable in mitigating risk of future illness. The study shows that alcohol abuse exhibits similar amounts of risk for cardiac disease as other well-established risk factors. Clinicians may find the information valuable in attempting to mitigate the risk of cardiac disease in those with alcohol use disorders.
The finding: Substance use disorders, especially opioid use disorders, contribute to the disease burden among patients who have few barriers to access of medical or psychiatric care. Such disorders interfere, in significant ways, with the effectiveness of care in a primary care integrated system.
Strengths and weaknesses: This is a naturalistic study of treatment-seeking patients. Weaknesses include use of diagnoses assigned by provider resulting in possible under estimates of unrecognized substance use disorders. Patients with high-risk drug use without criteria for substance use disorder were excluded. Selection criteria limit conclusions to insured population with few barriers of access of care.
Relevance: Given the prevalence of substance use disorders in primary care practice, the identification and intervention for substance use disorders would appear to be a target for improving health status using the integrative care model. This study supports further investigations into specific interventions using this model within primary care medical homes.
The finding: For opioid naïve patients receiving a first prescription of opioids, the likelihood of chronic opioid use increased with each additional day of medication supplied starting with the third day. The sharpest increases in chronic use were after the fifth and thirty-first days on therapy, getting a second prescription/refill, 700 morphine milligram equivalents cumulative dose, and first prescriptions with 10- and 30-day supplies. Unexpectedly, patients who started a long-acting opioid followed by patients who started tramadol were at the highest probability of continued opioid use at 1 and 3 years.
Strengths and weaknesses: This is a retrospective analysis of a large database of insurance claims from 2006-2015. 1,294,247 patients met the inclusion criteria, including 33,548 (2.6%) who continued opioid therapy for ≥1 year. Limitations included 1) determining if the chronic opioid use was intentional versus outgrowth of acute use being unknown; 2) lack of documentation of pain characteristics including pain intensity, duration, or etiology; and 3) inability to capture prescriptions paid for out of pocket or obtained illegally.
Relevance: There is minimal literature available quantifying the transition from acute to chronic opioid use. This study’s evidence on risks for long-term might inform opioid prescribing, dispensing, and authorizing practices among prescribers, pharmacists, and those managing pharmacy benefits. The knowledge that the risk for chronic opioid use increases with each additional day supplied can help guide the duration of first prescription and the need for a refill, and guide the discussion with patients about the long-term risks of opioid use.