Journal Article Annotations
2018, 1st Quarter
Annotations by Thomas Penders, MS, MD, FACLP; S. Alex Sidelnik, MD; and Diana Robinson, MD
Type of study: Randomized controlled prospective trial
The finding: Among subjects meeting criteria for alcohol use disorders (AUD) who had co-occurring tobacco use disorders (TUD) use of varenicline was associated with both increased abstinence rates for smoking and decreased measures of drinking behaviour in actively drinking individuals with alcohol use disorders when compared to placebo.
Strength and weaknesses: This study adds to evidence for use of varenicline to treat tobacco use disorder is individuals with tobacco use and alcohol use disorder. The treatment effect was of moderate size. Objective measures of smoking cessation were used to verify the tobacco outcomes.
Primary outcomes reached statistical significant though the study was small 33 patients randomized to the treatment (16) and placebo groups (17). Fewer than half of subjects identified as candidates agreed to enter the study limiting generalizability to the entire papulation group of those with AUD and TUD)
Relevance: Rates of smoking are elevated among patients with alcohol use disorders. Smokers with alcohol use disorders are less likely to quit smoking. Among smokers with alcohol use disorders who become abstinent of alcohol, ongoing smoking increases risk of relapse to alcohol use. Both tobacco use and alcohol use are risk factors for a variety of serious medical conditions. Consultation psychiatrists often confront patient in both inpatient and outpatient settings to assist with evaluation and intervention in these two addictive disorders.
Type of study: Cohort study
The finding: Alcohol use disorders are as a major risk factor for all types of dementia with a significant association in early-onset dementia. Additionally, alcohol use disorders are observed to be the strongest modifiable risk factor for onset of dementia.
Strength and weaknesses: This study is a large retrospective cohort study of patients admitted to French Hospitals from 2008 to 2013 with a primary exposure of alcohol use disorder and main outcome dementia. Association of alcohol use and dementia along with other risk factors for dementia were analysed using a multivariate Cox models. The strengths of the study include a large sample size, significant observed effect (hazard ratio >3.3 for alcohol and all dementia), and robust sensitivity analyses. Limitations of the study include potential for upcoding bias in hospital coding, limitations in properly identifying alcohol use disorders and dementia in hospital discharge coding, and overpowering for statistical differences.
Relevance: The findings from the study suggest that alcohol use disorders may contribute to a substantial burden of risk in the development of dementia. Heavy drinking should be considered a major modifiable risk factor in development of dementia.
Type of study: Retrospective cohort study
The finding: This retrospective cohort study queried a large American insurance database (Aetna) to examine the association between opioid prescription refills after surgery and misuse in an opioid naïve population. Interestingly, whereas other studies that focused on chronic opioid users saw high rates of misuse with doses >100 MME/day, this study found a stronger association with misuse in opioid naïve patients receiving longer durations of prescriptions/more refills. The authors found that misuse increased an adjusted 44% for every refill fulfilled and 20% increase every week of prescription. The rate of opioid misuse (0.6% of patients or 183 per 100,000 person years) was consistent with other studies. The authors suggest future research in population based and clinical studies to examine if treating post-operative pain in opioid naïve patients with moderate-high opioid dosages for shorter durations as opposed to lower opioid dosages for longer durations may reduce the risk of misuse
Strength and weaknesses: Strengths include the large sample size (568,613 patients received postoperative opioids) over an 8 year period. The study design included clearly described sensitivity analysis to reduce the risk of unobserved confounding variables. They also included a clear description of determining the morphine milligram equivalent (MME) dosage for each opioid prescription.
Weaknesses included limited generalizability due to the inclusion criteria of commercially insured adults in the United States, so they did not include large populations with Medicaid, Medicare, and veterans. Also, the definition of opioid naïve was those patients that received 7 days or less of opioids in the 60 days prior to surgery which may have missed those receiving prescribed opioids outside of this window or through non-prescription sources which are a frequent source of initial opioid use. Finally, due to the nature of the study relying on the quality of the information in the database, they were unable to exclude those with undocumented pre-surgical misuse or opioid usage.
Relevance: C-L psychiatrists frequently evaluate patients with suspected opioid misuse/use disorders in the inpatient and outpatient settings. On the inpatient service, a clear hospital discharge plan for opioid tapering and discontinuation with attention to the duration and number of refills is essential to reduce opioid misuse. In the outpatient setting, when evaluating postoperative patients it is important to consider additional risk factors for developing an opioid use disorder such as the number of opioid refills and duration of opioid prescription. For both settings it is important to gain additional collateral information through the review of Prescription Monitoring Program databases when possible.