Trajectories of Alcohol Use and Related Harms for Managed Alcohol Program Participants over 12 Months Compared with Local Controls: A Quasi-Experimental Study.

AIM: Investigate changes in alcohol use and related harm using the first multisite, controlled, longitudinal study of Managed Alcohol Programs (MAPs). MAPs provide regular doses of alcohol, accommodation, social supports and healthcare to unstably housed people with alcohol dependence. METHODS: A multisite, quasi-experimental, longitudinal study was conducted in day centres, shelters and residential programs for unstably housed people. There were 59 MAP participants from six Canadian cities and 116 local controls. Self-reported alcohol consumption and harms were assessed at 0-2, 6 and 12 months. Liver function test results were accessed for MAP participants. RESULTS: Both groups had similar reductions in mean drinks per day (MAP: -8.11; controls: -8.54 controls, P < 0.001) and days drinking per month (MAP: -2.51 days, P < 0.05; control: -4.81 days, P = 0.0001) over 6--12 months. Both reduced non-beverage alcohol consumption. MAP participants reported significantly fewer harms at both 0-2 and 6 months than controls. MAP participants had similar total consumption to controls, but spread out over more days (25.41 versus 19.64 days per month, P = 0.001). After leaving a MAP, participants' liver status deteriorated, with increases in both aspartate transaminase and bilirubin levels. MAP sites with effective policies on outside drinking drank less and had fewer harms. CONCLUSION: MAP participants drank less hazardously than controls, especially with effective management of non-MAP drinking. Reductions in alcohol use and harms occurred for both groups, although MAP participants reported fewer harms at 0-6 months. Departing an MAP was associated with deterioration in liver status. Although providing stable housing, MAPs did not worsen health or increase alcohol use.

"There is a Place": impacts of managed alcohol programs for people experiencing severe alcohol dependence and homelessness.

BACKGROUND: The twin problems of severe alcohol dependence and homelessness are associated with precarious living and multiple acute, social and chronic harms. While much attention has been focused on harm reduction services for illicit drug use, there has been less attention to harm reduction for this group. Managed alcohol programs (MAPs) are harm reduction interventions that aim to reduce the harms of severe alcohol use, poverty and homelessness. MAPs typically provide accommodation, health and social supports alongside regularly administered sources of beverage alcohol to stabilize drinking patterns and replace use of non-beverage alcohol (NBA). METHODS: We examined impacts of MAPs in reducing harms and risks associated with substance use and homelessness. Using case study methodology, data were collected from five MAPs in five Canadian cities with each program constituting a case. In total, 53 program participants, 4 past participants and 50 program staff were interviewed. We used situational analysis to produce a series of "messy", "ordered" and "social arenas" maps that provide insight into the social worlds of participants and the impact of MAPs. RESULTS: Prior to entering a MAP, participants were often in a revolving world of cycling through multiple arenas (health, justice, housing and shelters) where abstinence from alcohol is often required in order to receive assistance. Residents described living in a street-based survival world characterized by criminalization, unmet health needs, stigma and unsafe spaces for drinking and a world punctuated by multiple losses and disconnections. MAPs disrupt these patterns by providing a harm reduction world in which obtaining accommodation and supports are not contingent on sobriety. MAPs represent a new arena that focuses on reducing harms through provision of safer spaces and supply of alcohol, with opportunities for reconnection with family and friends and for Indigenous participants, Indigenous traditions and cultures. Thus, MAPs are safer spaces but also potentially spaces for healing. CONCLUSIONS: In a landscape of limited alcohol harm reduction options, MAPs create a new arena for people experiencing severe alcohol dependence and homelessness. While MAPs reduce precarity for participants, programs themselves remain precarious due to ongoing challenges related to lack of understanding of alcohol harm reduction and insecure program funding.

Factors preventing kneeling in a group of pre-educated patients post total knee arthroplasty.

BACKGROUND: Difficulties in kneeling, one of the poorest scoring functional outcomes post total knee arthroplasty (TKA),have been attributed to a lack of patient education. This is the first study to investigate specific factors affecting a patient's perceived ability to kneel post TKA, following exposure to a preoperative kneeling education session. MATERIALS AND METHODS: A cross-sectional study was conducted following TKA with patients who had been educated about kneeling prior to the operation. Patients completed kneeling questionnaires at 6 (n = 115) and 12 (n = 82) months post TKA. In addition to the 12-month kneeling questionnaire, patients also completed the Oxford knee score (OKS) survey. RESULTS: Seventy-two percent of patients perceived they could kneel at 12 months post TKA. Overall, pain and discomfort were the most common factors deterring patients from kneeling. Perceived kneeling ability was the poorest scored outcome on the OKS with patients reporting mild to moderate difficulty with this task. Kneeling scores were strongly correlated with overall knee function scores (R = 0.70), strongly correlated with pain scores (R = 0.45) and weakly correlated with knee stability scores (R = 0.29). When asked about other factors preventing kneeling other than pain or discomfort, 75 % had reasons unrelated to the knee or TKA. The most common reason was 'problems with the other knee' (n = 19). CONCLUSIONS: Patients in this study were provided with education regarding their kneeling ability post TKA, yet still experienced limitations in perceived kneeling ability postoperatively. Contrary to previous research, our study suggests that factors other than patient education affect a patient's perceived kneeling ability post TKA.

Haemagglutinin mutations and glycosylation changes shaped the 2012/13 influenza A(H3N2) epidemic, Houston, Texas.

While the early start and higher intensity of the 2012/13 influenza A virus (IAV) epidemic was not unprecedented, it was the first IAV epidemic season since the 2009 H1N1 influenza pandemic where the H3N2 subtype predominated. We directly sequenced the genomes of 154 H3N2 clinical specimens collected throughout the epidemic to better understand the evolution of H3N2 strains and to inform the H3N2 vaccine selection process. Phylogenetic analyses indicated that multiple co-circulating clades and continual antigenic drift in the haemagglutinin (HA) of clades 5, 3A, and 3C, with the evolution of a new 3C subgroup (3C-2012/13), were the driving causes of the epidemic. Drift variants contained HA substitutions and alterations in the potential N-linked glycosylation sites of HA. Antigenic analysis demonstrated that viruses in the emerging subclade 3C.3 and subgroup 3C-2012/13 were not well inhibited by antisera generated against the 3C.1 vaccine strains used for the 2012/13 (A/Victoria/361/2011) or 2013/14 (A/Texas/50/2012) seasons. Our data support updating the H3N2 vaccine strain to a clade 3C.2 or 3C.3-like strain or a subclade that has drifted further. They also underscore the challenges in vaccine strain selection, particularly regarding HA and neuraminidase substitutions derived during laboratory passage that may alter antigenic testing accuracy.

Interventions to reduce harm associated with adolescent substance use.

A major proportion of the disease burden and deaths for young people in developed nations is attributable to misuse of alcohol and illicit drugs. Patterns of substance use established in adolescence are quite stable and predict chronic patterns of use, mortality, and morbidity later in life. We integrated findings of systematic reviews to summarise evidence for interventions aimed at prevention and reduction of harms related to adolescent substance use. Evidence of efficacy was available for developmental prevention interventions that aim to prevent onset of harmful patterns in settings such as vulnerable families, schools, and communities, and universal strategies to reduce attractiveness of substance use. Regulatory interventions aim to increase perceived costs and reduce availability and accessibility of substances. Increasing price, restricting settings of use, and raising legal purchase age are effective in reducing use of alcohol and tobacco and related harms. Screening and brief intervention are efficacious, but efficacy of a range of treatment approaches has not been reliably established. Harm-reduction interventions are effective in young people involved in risky and injecting substance use.

Supply and demand for alcohol in Australia: relationships between industry structures, regulation and the marketplace.

Aspects of alcohol supply and demand relationships are examined in relation to the two main beverage varieties in Australia, wine and beer. It is argued that this case study illustrates how the 'supply side' is able to create and protect demand for alcohol through both taking advantage of and influencing government regulation of the market for alcohol. In relation to low alcohol beer the impact on public health and safety has been extremely positive. In relation to the creation of cask wine in the late 1960s there have been demonstrably deleterious effects. Preferential taxation arrangements for the Australian wine industry have dramatically increased both exports and home consumption. One unintended consequence has been the creation of a major new market for cheap bulk wines that have had a devastating public health impact, particularly on Aboriginal communities, and also the invention of 'alco-pops'. Two-thirds of all table wine consumed in Australia now comes in a cask and 90% of this product is manufactured by three multi-national companies that wield enormous power and political influence to maintain the status quo. The Australian beer industry is well known internationally for its export of 'full strength' (around 5% by volume) beers. What is less well known is its commercial success in the development of low and mid-strength varieties for home consumption. In some States these now comprise 40% by volume of the beer market. This development can largely be attributed to State taxation arrangements, to drink-driving law enforcement, marketing strategies and to a decade of intense competition between several major brewers. This case study indicates how alcohol taxation policy can have major impacts on public health (both positive and negative) but that in a modern market economy it is difficult for governments to act in the public interest due to pressures from vested interest groups.

Mortality and life-years lost due to alcohol: a comparison of acute and chronic causes.

OBJECTIVES: (i) To estimate the numbers of deaths and person-years of life lost (PYLL) due to high-risk alcohol consumption in Australia during 1997, using current estimates of consumption. (ii) To compare the number of deaths and PYLL due to acute conditions associated with bouts of intoxication and chronic conditions associated with long-term misuse of alcohol. METHODS: All Australian deaths during 1997 related to conditions considered to be partially or wholly caused by high-risk alcohol consumption were extracted from the Australian Bureau of Statistics Mortality Datafile and adjusted by alcohol aetiologic fractions calculated for Australia in 1997. A life-table method was used to estimate the PYLL for deaths from alcohol-caused conditions. MAIN OUTCOME MEASURES: Numbers of all deaths and PYLL due to chronic and acute alcohol-related conditions. RESULTS: Of the 3290 estimated alcohol-caused deaths in 1997, chronic conditions (eg, alcoholic liver cirrhosis and alcohol dependence) accounted for 42%, acute conditions (eg, alcohol-related road injuries and assaults) for 28% and mixed (chronic and acute) for 30%. Of the 62914 estimated potential life years lost, acute conditions were responsible for 46%, chronic for 33% and mixed for 21%. The average number of years of life lost through deaths from acute conditions was more than twice that from chronic conditions, because the former mostly involved younger people. CONCLUSIONS: In view of the societal burdens imposed by premature deaths, more effective public health strategies are needed to reduce the harm associated with occasional high-risk drinking (as well as sustained high-risk drinking), especially among young people.

The role of social and health statistics in measuring harm from alcohol.

Since excess use of alcohol contributes to so many varieties of health and social harms, in most countries, there are many potential sources of data indicative of alcohol-related harms. In few instances, compilation and interpretation of these data are straightforward, but, mostly, they are open to various sources of measurement error, which need to be taken into account if they are to be applied for research purposes. Police and health statistics are the major source of such information, but the underlying systems are not usually set up with the purpose of monitoring alcohol-related events. In both of these domains, types of events can be identified, which are wholly attributable to excess alcohol use, i.e. drunk-driving, alcoholic liver cirrhosis. Specific alcohol-related events are particularly prone to variations in, respectively, police enforcement practices, medical diagnostic fashion and sensitivity to prejudices about alcohol-related problems. A case will be made in this paper for the use of multiple surrogate measures of alcohol-related harm drawn from several sources in order to measure and track local, regional and national trends. For health statistics on mortality and morbidity, the aetiologic fraction (AF) method will be recommended for such monitoring purposes. It will also be recommended that these data be categorised by the degree to which cases are attributable to alcohol and also by whether the underlying hazardous drinking pattern is a brief drinking bout or a sustained pattern of heavy intake over a number of years. Nighttime occurrences of road crashes, public violence from both police and emergency room attendance data will also be recommended. It will be argued that routine recording of alcohol relatedness of events is usually unreliable, and the above surrogate measures are preferable. Recommendations will also be made for utilising national surveys of drinking behaviour to improve the calculation of alcohol-related morbidity and mortality, as well as refine estimates of per capita alcohol consumption, another major 'surrogate' measure of alcohol-related harm. The arguments will be illustrated with reference to Australia's National Alcohol Indicators Project and related research projects.

Beverage sales and drinking and driving: the role of on-premise drinking places.

OBJECTIVE: The relationships between on-premise drinking places, beverage specific alcohol sales and drinking and driving were examined in a time series cross-sectional study of place-of-last-drink data from Perth, Western Australia. METHOD: At arrest, 2,411 drinking drivers reported their last location of consumption. Tabulated by 57 premises over 4 years, the rates at which individual premises were referenced as the place-of-last-drink were taken to reflect the relative distributions of numbers of drinking drivers coming from different premise types (hotels, taverns and nightclubs). The data were then statistically related to measures of premise types and characteristics and beverage specific alcohol sales. RESULTS: Significant cross-sectional relationships were obtained between measures of premise types, alcohol sales and drinking and driving. Greatest numbers of drinking drivers came from taverns and from places selling greater amounts of beer and spirits. Significant longitudinal effects were obtained for sales of beer, proportions of high alcohol beer sold and sales of spirits. CONCLUSIONS: As a whole, the results suggest that, at least for Western Australia, outlets selling greater amounts of beer and spirits, and greater amounts of high alcohol beer, will produce larger numbers of drinking drivers.

The relationship between alcohol consumption patterns and injury.

AIMS AND DESIGN: A case-control design was employed to quantify the risk of injury after the recent consumption of alcohol. PARTICIPANTS AND SETTING: A total of 797 cases and 797 controls were interviewed throughout 1997. A response rate of 82% was calculated for eligible cases who were approached by an interviewer. The rate for interviews conducted of all people presenting with an injury during the study period was 67%. Cases were injured patients from a hospital emergency unit. Controls were matched on suburb and were interviewed at home regarding activities leading up to the time of their matched case's injury. MEASUREMENTS: Cases and controls were questioned about the injury event and alcohol and other drug use consumed in the 6 hours prior to the injury. They were also breath-tested and medical records were checked for validation purposes. FINDINGS: Logistic regression analysis produced an odds ratio of 3.4 (95% CI: 1.8-6.4) for the risk of sustaining an injury after consuming more than 60 g of alcohol in a 6-hour period, after controlling for demographic variables. The risk of injury at different levels of alcohol use was substantially higher for females with a significant odds ration of 9.6 at greater than 60 g of alcohol compared to 2.1 for men. CONCLUSIONS: These results need to be interpreted cautiously, but provide additional support that the risk of injury increases with the quantity of alcohol consumed and that the risk of injury is significantly higher for women.

The Northern Territory's cask wine levy: health and taxation policy implications.

OBJECTIVE: To examine the effect of the application, and removal, in the Northern Territory of a levy on the sale of cask wine--a beverage shown to contribute disproportionately to alcohol-related harm. METHOD: Using data on licensee purchases of alcoholic beverages and ABS population data, estimates were made of per capita consumption of pure alcohol by beverage type. Time series variables were analysed using multiple linear regression analysis. RESULTS: Prior to the introduction of the levy, quarterly per capita consumption of cask wine among persons aged > or = 15 years was 0.73 litres. During the levy period, this fell to 0.49 litres and following removal of the levy rose to 0.58 litres. Imposition of the levy had no significant effect on the consumption of other beverages. CONCLUSIONS: Taxation is an effective means of reducing excessive alcohol consumption and related harm. IMPLICATIONS: In the interests of public health, support should be given to the introduction of a tiered tax based on alcohol content.

Consumption of different alcoholic beverages as predictors of local rates of night-time assault and acute alcohol-related morbidity.

OBJECTIVE: To determine whether population levels of consumption of some alcoholic beverages are more closely associated with levels of harm than others, particularly if consumption of cask wine is more strongly related to rates of acute alcohol problems than consumption of bottled wine as a consequence of the extremely low rates of federal tax levied on the former. METHOD: A database of alcohol consumption and related problems was established for 130 areas of Western Australia. Demographic and economic data for these areas were included from the 1991 census. Empirically derived assumptions regarding the mean wholesale price of cask and bottled wine were utilised. Regression analyses examined the extent to which the consumption of different alcoholic beverages predicted levels of major varieties of harm. RESULTS: Only cask wine and high-strength beer consumption were significantly associated with rates of night-time assault; consumption of all beverage varieties except bottled wine was significantly associated with rates of acute alcohol-related morbidity. Further analyses, which included controls for an effect of total alcohol consumption, confirmed the pronounced contributions of cask wine and high-strength beer to rates of night assaults and acute alcohol-related morbidity. The proportion of all alcohol consumed as low-alcohol beer was significantly negatively associated with these harms. CONCLUSIONS: The beverages most associated with rates of night-time assaults and acute alcohol-related morbidity are those with the lowest federal taxation per standard drink, i.e. cask not bottled wine and regular-strength not low-alcohol beer.