1. www.aodhealth.org1 Journal Club Alcohol, Other Drugs, and Health: Current Evidence July–August 2008

2. www.aodhealth.org2 Featured Article A Prospective Study of Risk Drinking: At Risk for What? Dawson DA, et al. Drug Alcohol Depend. 2008;95(1–2):62–72.

3. www.aodhealth.org3 Study Objective To determine… The association between risky drinking and various adverse outcomes.

4. www.aodhealth.org4 Study Design Observational cohort Researchers analyzed data from a subgroup (n=22,122) of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a longitudinal sample of US adults. Criteria for inclusion in the subgroup were… –consumption of at least 1 drink in the year immediately preceding the baseline interview. –participation in the 3-year follow-up interview. –nonmissing frequencies of risky drinking at baseline.

5. www.aodhealth.org5 Frequency of Risky Drinking In men, frequency was defined as the larger of… –drinking 5 or more alcoholic drinks in a single day, or –drinking ≥2.7 ounces (≥4.5 standard drinks) of ethanol in a single day of coolers, beer, wine, or spirits, where beverage-specific ounces of ethanol intake per day were calculated based on number of drinks, size of drink, and ethanol content of main brand consumed. In women, frequency was defined as the larger of… –drinking 4 or more alcoholic drinks in a single day, or –drinking ≥2.1 ounces (≥3.5 standard drinks) of ethanol in a single day of coolers, beer, wine or spirits.

6. www.aodhealth.org6 Assessing Validity of an Article About Harm Are the results valid? What are the results? How can I apply the results to patient care?

7. www.aodhealth.org7 Are the Results Valid? Did the investigators demonstrate similarity in all known determinants of outcomes? Did they adjust for differences in the analysis? Were exposed patients equally likely to be identified in the two groups? Were the outcomes measured in the same way in the groups being compared? Was follow-up sufficiently complete?

8. www.aodhealth.org8 Did the investigators demonstrate similarity in all known determinants of outcomes? Did they adjust for differences in the analysis? Baseline characteristics differed by drinking group. Analyses were adjusted for the following factors (which include the differing baseline characteristics): age sex race/ethnicity marital status employment attended/completed college health status body mass index tobacco use drug use any mood or anxiety disorder any personality disorder family history of alcoholism volume of ethanol consumed on days with no risky drinking mean quantity of drinks consumed on risky drinking days years since first drink

9. www.aodhealth.org9 Were exposed patients equally likely to be identified in the various groups? The cohort consisted of 22,122 who participated in the 3- year follow-up interview and provided information about their level of drinking at baseline. The cohort was derived from the 43,093 US adults that participated in the 2001–2002 NESARC survey. The NESARC survey consists of individuals 18 years of age and older, sampled to be representative of the population residing in households and noninstitutional group settings in all 50 states and the District of Columbia. No information is provided regarding the drinking (exposure) categories of those who did not complete the 3-year follow-up interview.

10. www.aodhealth.org10 Were the outcomes measured in the same way in the groups being compared?  Interviewers were trained by the US Bureau of the Census.  Standardized instruments were used to measure outcomes.  Limitations: –Alcohol or drug dependence may have been misclassified. Investigators considered individuals as meeting criteria for alcohol or drug dependence if they report only 1 or more of 7 DSM-IV dependence criteria. Standard criteria requires individuals to meet at least 3 of 7 DSM-IV dependence criteria. –Blinding of interviewers to baseline data was not specifically stated.

11. www.aodhealth.org11 Was follow-up sufficiently complete? Follow-up surveys were completed approximately 3 years after the baseline survey. This is a brief period of time for the development of most of the outcomes.

12. www.aodhealth.org12 What Are the Results? How strong is the association between exposure and outcomes? How precise is the estimate of the risk?

13. www.aodhealth.org13 What Are the Results? Amount% of Subjects no risky drinking60 <1 time per month17 1 to 3 times per month9 1 to 2 times per week8 3 to 4 times per week3 daily or near-daily3 Frequency of risky drinking* at baseline (n=22,122) *In this study, defined as 5+ standard drinks in a day for men and 4+ standard drinks in a day for women.

14. www.aodhealth.org14 What Are the Results? (cont’d) At 3-year follow-up, subjects who reported risky drinking 1 to 2 times per week were more likely than subjects who reported no risky drinking to have… –alcohol abuse– nicotine dependence –alcohol dependence– liver disease –drug use– divorced or separated –drug dependence – lost their driver’s licenses –tobacco use

15. www.aodhealth.org15 What Are the Results? (cont’d) Subjects who reported daily or near-daily risky drinking were more likely than subjects who reported no risky drinking to have… –alcohol abuse– liver disease –alcohol dependence– divorced or separated –tobacco use– exhibited violent behavior –nicotine dependence– lost their driver’s licenses

16. www.aodhealth.org 16 How strong is the association between exposure and outcomes? How precise is the estimate of risk? Occurrence of Adverse Outcomes Odds Ratios (95% CI) Frequency of risky drinking: 1–2 times per weekdaily or near-daily alcohol abuse (n=13,894)3.29 (2.47–4.38)3.93 (2.40–6.44) alcohol dependence (n=18,114)2.69 (2.00–3.62)7.23 (4.75–11.00) drug use (n=15,018)1.63 (1.19–2.24)1.87 (1.21–2.88) drug dependence (n=20,669)2.32 (1.30–4.14)2.13 (0.99–4.59) tobacco use (n=10,418)2.71 (1.75–4.18)4.67 (2.16–10.10) nicotine dependence (n=17,061)1.77 (1.26–2.48)3.03 (1.92–4.79) any liver disease (n=21,200)2.78 (1.32–5.85)4.76 (2.29–9.88) divorce/separation (n=11,665)1.34 (0.88–2.02)2.54 (1.50–4.28) violent behavior (n=21,313)1.09 (0.78–1.54)1.61 (1.05–2.47) driver’s license revoked (n=21,313)1.81 (1.30–2.54)2.11 (1.38–3.22) abuse of spouse (n=11,665)1.27 (0.87–1.85)2.06 (1.22–3.46)

17. www.aodhealth.org17 How strong is the association between exposure and outcomes? How precise is the estimate of risk? (cont’d) The large sample size allowed adjustment for a wide array of potential confounders. Analyses were adjusted for the aforementioned factors. The large sample size also led to relatively narrow CIs and precise estimates of risk, although the intervals were wide and less precise for some rarer outcomes (see table).

18. www.aodhealth.org18 How Can I Apply the Results to Patient Care? Were the study patients similar to the patients in my practice? Was the duration of follow-up adequate? What was the magnitude of the risk? Should I attempt to stop the exposure?

19. www.aodhealth.org19 Were the study patients similar to the patients in my practice? The sample (n=22,122) was drawn from a random, representative survey of adults age 18 years and older residing in households and noninstitutional group quarters in all 50 states. As such, they are intended to represent housed individuals in the US but may differ from medical treatment seeking individuals.

20. www.aodhealth.org20 Was the duration of follow-up adequate? Follow-up surveys were completed approximately 3 years after the baseline survey. This may be a short period of time for the development of: –chronic and rarer health conditions such as specific cancers. –divorce or separation (although an effect was found).

21. www.aodhealth.org 21 What was the magnitude of the risk? The odds of developing each conse- quence associated with risky drinking were 2–3 times greater than in those who drank less than risky amounts.

22. www.aodhealth.org22 Should I attempt to stop the exposure? Yes. In addition to other risks, there is good evidence, in this paper as well as in other studies, that risky drinking is associated with adverse outcomes such as… –alcohol abuse– liver disease –alcohol dependence– being divorced or separated –tobacco use– exhibiting violent behavior –nicotine dependence– losing a driver’s license