Addiction Rehab: Managed Alcohol as a Harm Reduction Intervention for Alcohol Addiction in Populations at High Risk for Substance Abuse.
Managed alcohol as a harm reduction intervention for alcohol addiction in populations at high risk for substance abuse.
Filed under: Addiction Rehab
Cochrane Database Syst Rev. 2012; 12: CD006747
Muckle W, Muckle J, Welch V, Tugwell P
Managed alcohol programmes (MAP) are a harm reduction strategy used to minimise the personal harm and adverse societal effects that alcohol dependence can lead to by providing an alternative to zero-tolerance approaches that incorporate drinking goals (abstinence or moderation) that are compatible with the needs of the individual, and promoting access to services by offering low-threshold alternatives. This enables clients to gain access to services despite continued alcohol consumption and works to help the patient understand the risks involved in their behaviour and make decisions about their own treatment goals.To assess the effectiveness of MAP treatment regimens (serving limited quantities of alcohol daily to alcoholics) on their own or as compared to moderate drinking (self-controlled drinking), screening and brief intervention using a harm reduction approach, traditional abstinence-based interventions (12 step programmes) and no intervention.We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL and PsycINFO up to March 2012. This search was expanded by handsearching of high-yield journals and conference proceedings that had not already been handsearched on behalf of The Cochrane Collaboration, searching reference lists of all papers and relevant reviews identified, references to ongoing and recently completed clinical trials in the National Research Register and IFPMA Clinical Trials Database (which contains ClinicalTrials.gov, Centerwatch, Current Controlled Trials and ClinicalStudyResults.gov, and Osservatorio Nazionale sulla Sperimentazione Clinica dei Medicinali). Trials registers, grey literature and reference lists were also searched. Individuals, organisations and experts in the field were contacted.Randomised control trials (RCT), controlled clinical trials (CCT), interrupted time series (ITS) studies, and control before and after (CBA) studies involving vulnerable people aged 18 years or older who were at high risk for alcohol abuse attending MAP, defined as a structured programme that provided clients with controlled amounts of alcohol on a daily schedule, comparing no treatment, moderate drinking, brief intervention or 12-step variants.All study citations were collated into a single database. Two review author independently screened titles and abstracts and selected references potentially relevant to the review. Differences between selection lists were resolved by discussion. Two review authors independently evaluated whether studies should be included or excluded according to the eligibility criteria. In the event of a disagreement, a third author was consulted.No studies were included in the review. This systematic review was intended to assess the effectiveness of a brief MAP on the reduction of incidence of harmful behaviour; however, no evidence was available to make this comparison; 22 articles were considered possibly relevant and all were excluded. Most articles were excluded because they failed to compare or consider managed alcohol as the experimental or control intervention, as well as one study (Baker 2010), which was also excluded because study participants were under 18 years of age. No study reviewed offered an intervention that was compared with managed alcohol or considered it as the intervention of interest, providing insufficient evidence to address the objectives of the review. Four studies (Aalto 2001; Baker 2010; Bertholet 2005; Tracy 2007) considered alcohol reduction as an outcome of interest, while four engaged interventions in a shelter setting or targeted vulnerable people (Baker 2010; Bradford 2005; Lapham 1993; McGlynn 1993); only one study (Kidd 2011) offered a qualitative assessment of a participant being admitted to MAP, but offered no analysis of the programme itself. These results accurately reflect the use of MAPs in current practice as existing programmes are ongoing only in a small number of sample pilot projects that target individuals with severe alcohol dependence or who consume non-beverage alcohol.The lack of evidence does not allow for a conclusion regarding the efficacy of MAP on their own, or as compared to brief intervention, moderate drinking, no intervention or 12-step variants. It is the review authors’ opinion that it is likely to be the objective of MAPs that reduce their reportability and use in current practice, rather than a failure to provide an intervention that reduces the effects of alcohol dependence. Aiming to reduce harmful or antisocial behaviour in vulnerable individuals through the regulation of daily alcohol intake, rather than reducing harmful alcohol intake over time, provides considerable difficulty in developing measures of success from self-reported data (low treatment thresholds), monitoring long-term efficacy or establishing causal links between programme admission and a reduction in targeted behaviours, owing to the fact that prolonged participation in the programme is likely to indicate a willingness in the individual to change their behaviour patterns. More effort is needed to develop reporting measures, as well as methodologies, which address these specific challenges.
HubMed – addiction
Biomedical risk assessment as an aid for smoking cessation.
Filed under: Addiction Rehab
Cochrane Database Syst Rev. 2012; 12: CD004705
Bize R, Burnand B, Mueller Y, Rège-Walther M, Camain JY, Cornuz J
A possible strategy for increasing smoking cessation rates could be to provide smokers who have contact with healthcare systems with feedback on the biomedical or potential future effects of smoking, e.g. measurement of exhaled carbon monoxide (CO), lung function, or genetic susceptibility to lung cancer.To determine the efficacy of biomedical risk assessment provided in addition to various levels of counselling, as a contributing aid to smoking cessation.For the most recent update, we searched the Cochrane Collaboration Tobacco Addiction Group Specialized Register in July 2012 for studies added since the last update in 2009.Inclusion criteria were: a randomized controlled trial design; subjects participating in smoking cessation interventions; interventions based on a biomedical test to increase motivation to quit; control groups receiving all other components of intervention; an outcome of smoking cessation rate at least six months after the start of the intervention.Two assessors independently conducted data extraction on each paper, with disagreements resolved by consensus. Results were expressed as a relative risk (RR) for smoking cessation with 95% confidence intervals (CI). Where appropriate, a pooled effect was estimated using a Mantel-Haenszel fixed-effect method.We included 15 trials using a variety of biomedical tests. Two pairs of trials had sufficiently similar recruitment, setting and interventions to calculate a pooled effect; there was no evidence that carbon monoxide (CO) measurement in primary care (RR 1.06, 95% CI 0.85 to 1.32) or spirometry in primary care (RR 1.18, 95% CI 0.77 to 1.81) increased cessation rates. We did not pool the other 11 trials due to the presence of substantial clinical heterogeneity. Of the remaining 11 trials, two trials detected statistically significant benefits: one trial in primary care detected a significant benefit of lung age feedback after spirometry (RR 2.12, 95% CI 1.24 to 3.62) and one trial that used ultrasonography of carotid and femoral arteries and photographs of plaques detected a benefit (RR 2.77, 95% CI 1.04 to 7.41) but enrolled a population of light smokers and was judged to be at unclear risk of bias in two domains. Nine further trials did not detect significant effects. One of these tested CO feedback alone and CO combined with genetic susceptibility as two different interventions; none of the three possible comparisons detected significant effects. One trial used CO measurement, one used ultrasonography of carotid arteries and two tested for genetic markers. The four remaining trials used a combination of CO and spirometry feedback in different settings.There is little evidence about the effects of most types of biomedical tests for risk assessment on smoking cessation. Of the fifteen included studies, only two detected a significant effect of the intervention. Spirometry combined with an interpretation of the results in terms of ‘lung age’ had a significant effect in a single good quality trial but the evidence is not optimal. A trial of carotid plaque screening using ultrasound also detected a significant effect, but a second larger study of a similar feedback mechanism did not detect evidence of an effect. Only two pairs of studies were similar enough in terms of recruitment, setting, and intervention to allow meta-analyses; neither of these found evidence of an effect. Mixed quality evidence does not support the hypothesis that other types of biomedical risk assessment increase smoking cessation in comparison to standard treatment. There is insufficient evidence with which to evaluate the hypothesis that multiple types of assessment are more effective than single forms of assessment.
HubMed – addiction
Buprenorphine prescribing practices and exposures reported to a poison center – utah, 2002-2011.
Filed under: Addiction Rehab
MMWR Morb Mortal Wkly Rep. 2012 Dec 14; 61: 997-1001
Buprenorphine is an effective medication for the treatment of opioid dependence. Its use has increased in the United States as a result of the Drug Addiction Treatment Act of 2000, which allowed physicians to prescribe certain medications as part of office-based treatment for opioid addiction. In France, widespread use of medication-assisted therapy, primarily buprenorphine treatment, was associated with an 80% decrease in overdose deaths from heroin or cocaine from 465 in 1996 to 89 in 2003. With the expanded use of buprenorphine, an increase in exposures among children and adults has been reported in the United States. These exposures (including unintentional and intentional, therapeutic and nontherapeutic) have resulted in adverse effects and, in a small number of cases, death. To assess statewide increases in buprenorphine use and the number of reported exposures, the Utah Department of Health analyzed data from the Utah Controlled Substance Database (CSD) and the Utah Poison Control Center (PCC). The results of that analysis indicated a statewide increase in the annual number of patients prescribed buprenorphine from 22 in 2002 to 9,793 in 2011, and a concurrent increase in the annual number of prescribers writing buprenorphine prescriptions from 16 to 1,088. Over the same period, the number of exposures to buprenorphine reported annually to the PCC increased from six to 81. However, comparison of the ratios of buprenorphine exposures to patients and prescribers in 2002 with data for 2011 indicated substantial decreases from 6/22 for patients and 6/16 for prescribers in 2002 to 81/9,793 for patients and 81/1,088 for prescribers in 2011. Three of the total 462 buprenorphine exposures reported during 2002-2011 in Utah, in a teen and two adults, were associated with fatal outcomes. Increased buprenorphine prescribing in Utah during 2002-2011 likely represents expanded access to critically needed opioid addiction treatment; however, safeguards should be in place to prevent adverse effects. Prescribers and pharmacists are encouraged to counsel patients carefully regarding the safe use, storage, and disposal of buprenorphine.
HubMed – addiction
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