Journal Article Annotations
2017, 1st Quarter
Substance Use & Addictive Disorders
Annotations by S. Alex Sidelnik, MD, and Diana Robinson, MD
- Alcohol abuse and cardiac disease
- Alcohol, cannabis, and opioid use disorders, and disease burden in an integrated health care system
- Characteristics of initial prescription episodes and likelihood of long-term opioid use – United States, 2006-2015
PUBLICATION #1 — Substance Use & Addictive Disorders
Alcohol abuse and cardiac disease
Whitman IR, Agarwal V, Nah G, et al
J Am Coll Cardiol 2017; 69(1):13-24
Understanding the relationship between alcohol abuse, a common and theoretically modifiable condition, and the most common cause of death in the world, cardiovascular disease, may inform potential prevention strategies.
The study sought to investigate the associations among alcohol abuse and atrial fibrillation (AF), myocardial infarction (MI), and congestive heart failure (CHF).
Using the Healthcare Cost and Utilization Project database, we performed a longitudinal analysis of California residents ≥21 years of age who received ambulatory surgery, emergency, or inpatient medical care in California between 2005 and 2009. We determined the risk of an alcohol abuse diagnosis on incident AF, MI, and CHF. Patient characteristics modifying the associations and population-attributable risks were determined.
Among 14,727,591 patients, 268,084 (1.8%) had alcohol abuse. After multivariable adjustment, alcohol abuse was associated with an increased risk of incident AF (hazard ratio [HR]: 2.14; 95% confidence interval [CI]: 2.08 to 2.19; p < 0.0001), MI (HR: 1.45; 95% CI: 1.40 to 1.51; p < 0.0001), and CHF (HR: 2.34; 95% CI: 2.29 to 2.39; p < 0.0001). In interaction analyses, individuals without conventional risk factors for cardiovascular disease exhibited a disproportionately enhanced risk of each outcome. The population-attributable risk of alcohol abuse on each outcome was of similar magnitude to other well-recognized modifiable risk factors.
Alcohol abuse increased the risk of AF, MI, and CHF to a similar degree as other well-established risk factors. Those without traditional cardiovascular risk factors are disproportionately prone to these cardiac diseases in the setting of alcohol abuse. Thus, efforts to mitigate alcohol abuse might result in meaningful reductions of cardiovascular disease.
On PubMed: J Am Coll Cardiol 2017; 69(1):13-24
Annotation (Alex Sidelnik)
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.
PUBLICATION #2 — Substance Use & Addictive Disorders
Alcohol, cannabis, and opioid use disorders, and disease burden in an integrated health care system
Bahorik AL, Satre DD, Kline-Simon AH, Weisner CM, Campbell CI
J Addict Med 2017; 11(1):3-9
We examined prevalence of major medical conditions and extent of disease burden among patients with and without substance use disorders (SUDs) in an integrated health care system serving 3.8 million members.
Medical conditions and SUDs were extracted from electronic health records in 2010. Patients with SUDs (n = 45,461; alcohol, amphetamine, barbiturate, cocaine, hallucinogen, and opioid) and demographically matched patients without SUDs (n = 45,461) were compared on the prevalence of 19 major medical conditions. Disease burden was measured as a function of 10-year mortality risk using the Charlson Comorbidity Index. P-values were adjusted using Hochberg’s correction for multiple-inference testing within each medical condition category.
The most frequently diagnosed SUDs in 2010 were alcohol (57.6%), cannabis (14.9%), and opioid (12.9%). Patients with these SUDs had higher prevalence of major medical conditions than non-SUD patients (alcohol use disorders, 85.3% vs 55.3%; cannabis use disorders, 41.9% vs 23.0%; and opioid use disorders, 44.9% vs 26.1%; all P < 0.001). Patients with these SUDs also had higher disease burden than non-SUD patients; patients with opioid use disorders (M = 0.48; SE = 1.46) had particularly high disease burden (M = 0.23; SE = 0.09; P < 0.001).
Common SUDs, particularly opioid use disorders, are associated with substantial disease burden for privately insured individuals without significant impediments to care. This signals the need to explore the full impact SUDs have on the course and outcome of prevalent conditions and initiate enhanced service engagement strategies to improve disease burden.
On PubMed: J Addict Med 2017; 11(1):3-9
Annotation (Alex Sidelnik)
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.
PUBLICATION #3 — Substance Use & Addictive Disorders
Characteristics of initial prescription episodes and likelihood of long-term opioid use – United States, 2006-2015
Shah A, Hayes CJ, Martin BC
MMWR Morb Mortal Wkly Rep 2017; 66(10):265-269
Because long-term opioid use often begins with treatment of acute pain (1), in March 2016, the CDC Guideline for Prescribing Opioids for Chronic Pain included recommendations for the duration of opioid therapy for acute pain and the type of opioid to select when therapy is initiated (2). However, data quantifying the transition from acute to chronic opioid use are lacking. Patient records from the IMS Lifelink+ database were analyzed to characterize the first episode of opioid use among commercially insured, opioid-naïve, cancer-free adults and quantify the increase in probability of long-term use of opioids with each additional day supplied, day of therapy, or incremental increase in cumulative dose. The largest increments in probability of continued use were observed after the fifth and thirty-first days on therapy; the second prescription; 700 morphine milligram equivalents cumulative dose; and first prescriptions with 10- and 30-day supplies. By providing quantitative evidence on risk for long-term use based on initial prescribing characteristics, these findings might inform opioid prescribing practices.
On PubMed: MMWR Morb Mortal Wkly Rep 2017; 66(10):265-269
Annotation (Diana Robinson)
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.