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Cannabis is often used by people with HIV (PWH) for pain, yet study results are inconsistent regarding whether and how it affects pain. This study examines whether greater cannabis use frequency is associated with lower pain interference and whether cannabis use modifies the association of pain severity and pain interference among 134 PWH with substance dependence or a lifetime history of injection drug use. Multi-variable linear regression models examined the association between past 30-day cannabis use frequency and pain interference. Additional models evaluated whether cannabis use modified the association between pain severity and pain interference. Cannabis use frequency was not significantly associated with pain interference. However, in a model with interaction between cannabis use frequency and pain severity, greater cannabis use frequency attenuated the strength of the association between pain severity and pain interference (p = 0.049). The adjusted mean difference (AMD) in pain interference was +1.13, + 0.81, and +0.05 points for each 1-point increase in pain severity for those with no cannabis use, 15 days of use, and daily use, respectively. These findings suggest that attenuating the impact of pain severity on pain-related functional impairment is a potential mechanism for a beneficial role of cannabis for PWH. [ABSTRACT FROM AUTHOR]

Medication for addiction treatment (MAT) could reduce acute care utilization in HIV-positive individuals with substance use disorders. The study objective was to determine if HIV-positive people with substance use disorders treated with MAT report less acute care utilization than those not receiving MAT. We assessed the association between MAT and acute care utilization among HIV-positive individuals with alcohol or opioid use disorder. Acute care utilization 6 months later was defined as any past 3-month self-reported (1) emergency department (ED) visit and (2) hospitalization. Of 153 participants, 88% had alcohol use disorder, 41% had opioid use disorder, and 48 (31%) were treated with MAT. Fifty-five (36%) participants had an ED visit and 38 (25%) participants had a hospitalization. MAT was not associated with an ED visit (AOR 1.12, 95% CI 0.46–2.75) or hospitalization (AOR 1.09, 95% CI 0.39–3.04). MAT was not associated with acute care utilization. These results highlight the need to increase MAT prescribing in HIV-positive individuals with substance use disorders, and to address the many factors that influence acute care utilization. [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of an individualized treatment regimen on the intensity and duration of medication treatment for alcohol withdrawal.Design: A randomized double-blind, controlled trial.Setting: An inpatient detoxification unit in a Veterans Affairs medical center.Patients: One hundred one patients admitted for the treatment of alcohol withdrawal who could give informed consent and had no history of seizures or medication use that might alter the clinical course of withdrawal.Intervention: Patients were randomized to either a standard course of chlordiazepoxide four times daily with additional medication as needed (fixed-schedule therapy) or to a treatment regimen that provided chlordiazepoxide only in response to the development of the signs and symptoms of alcohol withdrawal (symptom-triggered therapy). The need for administration of "as-needed" medication was determined using a validated measure of the severity of alcohol withdrawal.Main Outcome Measures: Duration of medication treatment and total chlordiazepoxide administered.Results: The median duration of treatment in the symptom-triggered group was 9 hours, compared with 68 hours in the fixed-schedule group (P < .001). The symptom-triggered group received 100 mg of chlordiazepoxide, and the fixed-schedule group received 425 mg (P < .001). There were no significant differences in the severity of withdrawal during treatment or in the incidence of seizures or delirium tremens.Conclusions: Symptom-triggered therapy individualizes treatment, decreases both treatment duration and the amount of benzodiazepine used, and is as efficacious as standard fixed-schedule therapy for alcohol withdrawal. [ABSTRACT FROM AUTHOR]

Patients recovering from substance use disorders are commonly seen in the primary care setting, and relapse is a serious long-term problem for these patients. Extrapolating from therapeutic strategies effective in specialty addiction treatment settings, this article outlines a practical approach to relapse prevention in the primary care setting. Working within a supportive patient-physician relationship, the primary care physician can help recovering patients decrease their susceptibility to relapse, recognize and manage high-risk situations, and use available self-help, pharmacological, and specialty resources. Drawing on the therapeutic relationship and skills they already possess, primary care physicians can have an important, productive, and satisfying role in the long-term management of patients in recovery from alcohol or other drug problems. [ABSTRACT FROM AUTHOR]

Although mortality rates among HIV-infected populations have declined with the advent of combination antiretroviral therapy (ART), patients with substance use disorders have benefited less from these therapies. While adherence to ART has been well studied, less is known about factors associated with discontinuation of ART. The aim of this study is to investigate predictors of discontinuation of ART in HIV-infected patients with alcohol problems, focusing on their substance use and depressive symptoms. The study cohort (n=266) was prospectively assessed with biannual standardised interviews between 2001 and 2005. Four predictor variables (cocaine, heroin, heavy alcohol use and substantial depressive symptoms) were assessed six months prior to the outcome (ART discontinuation). Longitudinal logistic regression models examined the association between predictor variables and ART discontinuation adjusting for age, gender, race/ethnicity, homelessness, CD4, HIV RNA and HIV Symptom Index. Subjects were 77% male; 43% black; 22% homeless; 45% used cocaine; 20% used heroin; 29% had heavy alcohol use; and 40% had substantial depressive symptoms. Discontinuation occurred in 135 (17%) of the observations (n=743). In bivariate analyses, cocaine use, heroin use and depressive symptoms were significantly associated with ART discontinuation but heavy alcohol use was not. In the multivariable model, substantial depressive symptoms (adjusted odds ratio (AOR)=1.66; 95% confidence interval (CI): 1.04, 2.65) but not cocaine (AOR=1.28; 95%CI: 0.76, 2.16) or heroin use (AOR=1.27 95%CI: 0.66, 2.44), remained significantly associated with ART discontinuation. Among HIV-infected adults with alcohol problems, depressive symptoms, but not substance use, predicted subsequent ART discontinuation. Recognition and treatment of depressive symptoms in this population may result in better maintenance of ART and its associated clinical benefits. [ABSTRACT FROM AUTHOR]

Human immunodeficiency virus (HIV) risk behaviors are prevalent in persons with addictions. OBJECTIVES: To assess whether exposure to primary medical care is associated with decreases in HIV risk behaviors. DESIGN: Prospective 2-year cohort of 298 adults with addictions. OUTCOMES: Sex and drug-related HIV risk behaviors, measured by the Risk Assessment Battery. PREDICTORS: Cumulative number of primary care visits (0, 1, > or = 2). Associations were tested using regression models for correlated data. RESULTS: In women, receipt of primary care was associated with less sex risk behavior (mean decrease 2.1, p < or = 0.1). Among women and men, > or = 2 primary care visits was associated with lower odds of any drug risk behavior (OR = 0.37, p = 0.03). CONCLUSIONS: Exposure to primary care can impact HIV risk behavior favorably among adults with addictions. [ABSTRACT FROM AUTHOR]

Background: The efficacy of brief intervention in reducing alcohol consumption is well established for selected outpatients but not for medical inpatients.Objective: To determine whether brief intervention improves alcohol outcomes in medical inpatients who were identified by screening as having unhealthy alcohol use.Design: Randomized, controlled trial.Setting: Medical service of an urban hospital.Patients: 341 medical inpatients who were drinking risky amounts of alcohol (defined for eligibility as >14 drinks/wk or > or =5 drinks/occasion for men and >11 drinks/wk or > or =4 drinks/occasion for women and persons > or =66 y); 77% had alcohol dependence as determined by the Composite International Diagnostic Interview Alcohol Module.Intervention: A 30-minute session of motivational counseling given by trained counselors during a patient's hospitalization (n = 172) versus usual care (n = 169).Measurements: Self-reported primary outcomes were receipt of alcohol assistance (for example, alcohol disorders specialty treatment) by 3 months in dependent drinkers and change in the mean number of drinks per day from enrollment to 12 months in all patients.Results: The intervention was not significantly associated with receipt of alcohol assistance by 3 months among alcohol-dependent patients (adjusted proportions receiving assistance, 49% for the intervention group and 44% for the control group; intervention-control difference, 5% [95% CI, -8% to 19%]) or with drinks per day at 12 months among all patients (adjusted mean decreases, 1.5 for patients who received the intervention and 3.1 for patients who received usual care; adjusted mean group difference, -1.5 [CI, -3.7 to 0.6]). There was no significant interaction between the intervention and alcohol dependence in statistical models predicting drinks per day (P = 0.24).Limitations: Baseline imbalances existed between randomized groups. Patients who received usual care were assessed and advised that they could discuss their drinking with their physicians.Conclusions: Brief intervention is insufficient for linking medical inpatients with treatment for alcohol dependence and for changing alcohol consumption. Medical inpatients with unhealthy alcohol use require more extensive, tailored alcohol interventions. [ABSTRACT FROM AUTHOR]

Little is known about how well methadone programs address smoking cessation. We describe the frequency of smoking cessation counseling, and factors affecting its provision in methadone programs. We conducted a cross-sectional survey of methadone patients and their counselors. Of 575 patients, 76% were eligible smokers. Although only 48% of patients reported receiving smoking cessation counseling within the previous six months, 97% of counselors reported providing it (p < 0.0001). Time with one counselor was significantly associated with patient report of receiving smoking cessation counseling (OR 1.19 [95% CI 1.04-1.36]). Although addiction counseling is required in methadone programs, nicotine addiction is addressed less than half the time. Methadone programs should prioritize the provision of effective smoking cessation and facilitate continuity of patient-counselor relationships. [ABSTRACT FROM AUTHOR]

We evaluated the feasibility of establishing a multidisciplinary Health Evaluation and Linkage to Primary care (HELP) clinic at an urban residential detoxification unit. Patients received a clinical evaluation and facilitated linkage to primary medical care including personalized referral, reminders, and appointment rescheduling. Of 235 adults reporting alcohol, cocaine or heroin as first or second drug of choice and without a primary care physician, 178 (76%) received a full HELP clinic evaluation, 35 (15%) some clinic components, and 7 (3%) only a primary care appointment. Of those with a full evaluation, 28% received pneumococcal vaccination, and most received health behavior counseling. Over the subsequent 2 years, 131 (60%) of the 220 patients whom had any contact with the HELP clinic had at least one primary care visit. A multidisciplinary health clinic to evaluate patients during detoxification is feasible and can link patients with substance dependence to primary medical care. [ABSTRACT FROM AUTHOR]

Background: Screening and intervention for alcohol problems can reduce drinking and its consequences but are often not implemented.Objective: To test whether providing physicians with patients' alcohol screening results and simple individualized recommendations would affect the likelihood of a physician's having a discussion with patients about alcohol during a primary care visit and would affect subsequent alcohol use.Design: Cluster randomized, controlled trial.Setting: Urban academic primary care practice.Participants: 41 faculty and resident primary care physicians and 312 patients with hazardous drinking.Interventions: Providing physicians with alcohol screening results (CAGE questionnaire responses, alcohol consumption, and readiness to change) and recommendations for their patients at a visit.Measurements: Patient self-report of discussions about alcohol use immediately after the physician visit and alcohol use 6 months later.Results: Of 312 patients, 240 visited faculty physicians, 301 (97%) completed the outcome assessment after the office visit, and 236 (76%) were followed for 6 months. Faculty physicians in the intervention group tended to be more likely than faculty physicians in the control group to give patients advice about drinking (adjusted proportion, 64% [95% CI, 47% to 79%] vs. 42% [CI, 33% to 53%]) and to discuss problems associated with alcohol use (74% [CI, 59% to 85%] vs. 51% [CI, 39% to 62%]). Resident physicians' advice and discussions did not differ between groups. Six months later, patients who saw resident physicians in the intervention group had fewer drinks per drinking day (adjusted mean number of drinks, 3.8 [CI, 1.9 to 5.7] versus 11.6 [CI, 5.4 to 17.7]).Conclusions: Although effects seem to differ by physician level of training, prompting physicians with alcohol screening results and recommendations for action can modestly increase discussions about alcohol use and advice to patients and may decrease alcohol consumption. [ABSTRACT FROM AUTHOR]

BACKGROUND: Little information exists about serious injury in alcohol or drug abusers who seek detoxification. This study examined injury prevalence, and the impact of alcohol use on injury, among alcohol- and drug-dependent persons. METHOD: We enrolled patients at a detoxification unit into a prospective cohort study and performed follow-up interviews to determine the prevalence of injury. Baseline and follow-up (6, 12, 18, and 24 month) data were examined separately by using multivariate logistic regression to determine factors associated with self-reported episodes of serious injury. The main independent variable was self-reported first and second substances of choice at admission: alcohol only, drug only, or both. RESULTS: Overall, 24% of the 470 subjects reported at least one instance of serious injury over the 6-month period before detoxification. Similarly, approximately 20% of subjects had serious injury during each 6-month follow-up period. Injury in the past 6 months was highest among the 63% of subjects who reported alcohol as a drug of choice (28-29% vs. 16% for drug only), even after we controlled for potential confounders. Analysis of 2-year follow-up data revealed a similar association, after we controlled for baseline injury and alcohol consumption. CONCLUSIONS: Injury is a serious problem for a substantial proportion of patients who undergo detoxification, particularly those with alcohol dependence. This marked risk for serious injury persisted for 24 months after detoxification. Patients at detoxification, particularly those with alcohol problems, represent a high-risk population for injury that may benefit from interventions to reduce these preventable complications. [ABSTRACT FROM AUTHOR]

Although the detrimental effects of excessive alcohol use are well-known, moderate drinking is now correlated with beneficial health effects in certain patient populations. Think twice, however, before telling patients that light alcohol use may be helpful. [ABSTRACT FROM AUTHOR]

Although the detrimental effects of excessive alcohol use are well-known, moderate drinking is now correlated with beneficial health effects in certain patient populations. Think twice, however, before telling patients that light alcohol use may be helpful. [ABSTRACT FROM AUTHOR]

Objective: To describe adult primary care physicians' and psychiatrists' approach to alcohol screening and treatment, and to identify correlates of more optimal practices.Design: Cross-sectional mailed survey.Participants: A national systematic sample of 2,000 physicians practicing general internal medicine, family medicine, obstetrics-gynecology, and psychiatry.Measurements: Self-reported frequency of screening new outpatients, and treatment recommendations in patients with diagnosed alcohol problems, on 5-point Likert-type scales.Main Results: Of the 853 respondent physicians (adjusted response rate, 57%), 88% usually or always ask new outpatients about alcohol use. When evaluating patients who drink, 47% regularly inquire about maximum amounts on an occasion, and 13% use formal alcohol screening tools. Only 82% routinely offer intervention to diagnosed problem drinkers. Psychiatrists had the most optimal practices; more consistent screening and intervention was also associated with greater confidence in alcohol history taking, familiarity with expert guidelines, and less concern that patients will object.Conclusions: Most primary care physicians and psychiatrists ask patients about alcohol use, but fewer use recommended screening protocols or offer formal treatment. A substantial minority of physicians miss the opportunity to intervene in alcohol problems. Efforts to improve physicians' screening and intervention for alcohol problems should address their confidence in their skills, familiarity with expert recommendations, and beliefs that patients object to their involvement [ABSTRACT FROM AUTHOR]

Objective: To assess the effect of hospital discharge against medical advice (AMA) on the interpretation of charges and length of stay attributable to alcoholism.Design: Retrospective cohort. Three analytic strategies assessed the effect of having an alcohol-related diagnosis (ARD) on risk-adjusted utilization in multivariate regressions. Strategy 1 did not adjust for leaving AMA, strategy 2 adjusted for leaving AMA, and strategy 3 restricted the sample by excluding AMA discharges.Setting: Acute care hospitals.Patients: We studied 23,198 pneumonia hospitalizations in a statewide administrative database.Measurements and Main Results: Among these admissions, 3.6% had an ARD, and 1.2% left AMA. In strategy 1 an ARD accounted for a $1,293 increase in risk-adjusted charges for a hospitalization compared with cases without an ARD ( p =.012). ARD-attributable increases of $1,659 ( p =.002) and $1,664 ( p =. 002) in strategies 2 and 3 respectively, represent significant 28% and 29% increases compared with strategy 1. Similarly, using strategy 1 an ARD accounted for a 0.6-day increase in risk-adjusted length of stay over cases without an ARD ( p =.188). An increase of 1 day was seen using both strategies 2 and 3 ( p =.044 and p =.027, respectively), representing significant 67% increases attributable to ARDs compared with strategy 1.Conclusions: Discharge AMA affects the interpretation of the relation between alcoholism and utilization. The ARD-attributable utilization was greater when analyses adjusted for or excluded AMA cases. Not accounting for leaving AMA resulted in an underestimation of the impact of alcoholism on resource utilization. [ABSTRACT FROM AUTHOR]

A study examining records from U.S. veterans receiving opioids for pain management between 2004 and 2009 has found an increased risk of death from opioid overdose in patients who took opioids and benzodiazepines concurrently. Risk of death increased at higher daily benzodiazepine doses, study authors reported. Results were published online June 10 in the BMJ. INSET: précis. [ABSTRACT FROM AUTHOR]

The alcohol withdrawal syndrome is common in elderly individuals who are alcohol dependent and who decrease or stop their alcohol intake. While there have been few clinical studies to directly support or refute the hypothesis that withdrawal symptom severity, delirium and seizures increase with advancing age, several observational studies suggest that adverse functional and cognitive complications during alcohol withdrawal do occur more frequently in elderly patients. Most elderly patients with alcohol withdrawal symptoms should be considered for admission to an inpatient setting for supportive care and management. However, elderly patients with adequate social support and without significant withdrawal symptoms at presentation, comorbid illness or past history of complicated withdrawal may be suitable for outpatient management. Although over 100 drugs have been described for alcohol withdrawal treatment, there have been no studies assessing the efficacy of these drugs specifically in elderly patients. Studies in younger patients support benzodiazepines as the most efficacious therapy for reducing withdrawal symptoms and the incidence of delirium and seizure. While short-acting benzodiazepines, such as oxazepam and lorazepam, may be appropriate for elderly patients given the risk for excessive sedation from long-acting benzodiazepines, they may be less effective in preventing seizures and more prone to produce discontinuation symptoms if not tapered properly. To ensure appropriate benzodiazepine treatment, dose and frequency should be individualised with frequent monitoring, and based on validated alcohol withdrawal severity measures. Selected patients who have a history of severe or complicated withdrawal symptoms may benefit from a fixed schedule of benzodiazepine provided that medication is held for sedation. β-Blockers, clonidine, carbamazepine and haloperidol may be used as adjunctive agents to treat symptoms not controlled by benzodiazepines. Lastly, the age of the patient should not deter clinicians from helping the patient achieve successful alcohol treatment and rehabilitation. [ABSTRACT FROM AUTHOR]

Objective: To describe current practices employed in the inpatient treatment for alcohol withdrawal.Design: Survey.Setting: Inpatient alcoholism treatment programs in the United States.Participants: Medical directors of 176 (69%) of 257 eligible programs randomly selected from a national listing.Results: The medical directors estimated that of all inpatients treated for alcohol withdrawal at the programs, 68% received one of the following medications. Benzodiazepines, including the long-acting chlordiazepoxide (33%) and diazepam (16%), and less frequently the short-acting oxazepam (7%) and lorazepam (4%), were the most commonly used agents. Barbiturates (11%), phenytoin (10%), clonidine (7%), beta-blockers (3%), carbamazepine (1%), and antipsychotics (1%) were less frequently given. Drug was most often given on a fixed dosing schedule with additional medication "as needed" (52% of the programs). Only 31% of the programs routinely used a standardized withdrawal severity scale to monitor patients. Mean duration of sedative treatment was three days; inpatient treatment, four days. Use of fixed-schedule regimens was associated with longer sedative treatment (mean four vs three days, p < 0.01). Northeast census region location and psychiatrist program director were significantly associated with longer sedative and inpatient treatment duration.Conclusions: The most commonly reported regimen for alcohol withdrawal included three days of long-acting benzodiazepines on a fixed schedule with additional medication "as needed." Standardized monitoring of the severity of withdrawal was not common practice. The directors reported using a variety of other regimens, some not known to prevent the major complications of withdrawal. Although geographic location and director specialty were significantly associated with treatment duration, much of the variation in treatment for alcohol withdrawal remains unexplained. [ABSTRACT FROM AUTHOR]

The article focuses on hospitalized patients with unhealthy alcohol use. The unhealthy use of alcohol damages health, hurts relationship, increases risk for accidents and causes problems with liver, brain and heart. Brief counseling by doctors in outpatient settings can help people reduce or stop drinking too much. Moreover, it also provides findings about alcohol-dependent patients who receive brief counseling in the hospital reduced alcohol intake and did not receive alcohol-related care.

Do general practice screening programmes effectively identify people with excessive alcohol use who could benefit from brief interventions?METHODSDesign: Systematic review with meta-analysis.Data sources: MEDLINE, Embase, PsycINFO, Cochrane, and ETOH databases; hand searches of reference lists and discussion with European experts.Study selection and analysis: Randomised controlled trials (RCTs) using screening to identify people with excessive alcohol use, but not a specific disease or alcohol dependency. RCTs comparing brief interventions (lasting <1 hour) in general practice with no intervention or a reduced intervention were selected. Only RCTs published in English and reporting the number of people screened, with at least one discrete outcome measure relating to a clinically significant change: in alcohol consumption, were included. Results were pooled using the fixed effect Mantel-Haenszel method.Outcomes: Prevalence of excessive drinking determined by screening; proportion qualifying for brief interventions; numbers needed to treat (NNT) and effect of screening.MAIN RESULTSNineteen RCTs were included in the review; seven of these RCTs were included in the meta-analysis. Overall, 9% of people were positive for excessive alcohol use on initial screening. 2.5% qualified for brief interventions after further assessment. Brief interventions significantly reduced the likelihood of continued excessive drinking compared with no intervention (absolute risk reduction 10.5%, 95% CI 7.1% to 13.9%; NNT 10, 95% CI 7 to 14). After one year, two to three people per 1000 people screened would reduce their alcohol consumption to recommended levels (pooled screening effect size per 1000 people after one year, 2.6 people, 95% CI 1.7 to 3.4).CONCLUSIONSBrief interventions are effective for reducing excessive drinking. However, universal screening in general practice is an inefficient and labour intensive way of identifying people for these brief interventions.NOTESIncluded studies varied in their definitions of excessive drinking, treatment goals, and in their follow up times. Some studies set their treatment goal at a maximum level of drinking higher than that used in their inclusion criteria--that is, people could be considered a treatment success even if their drinking had remained the same. [ABSTRACT FROM AUTHOR]

Summarizes salient points of a study undertaken to determine whether identifying patients with alcohol problems and then giving their doctors advice about how to manage the problems would help patients stop drinking. Faculty and resident doctors in an academic primary care clinic and patients with drinking problem; Details of study design.