Unhealthy Alcohol Use
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In his review of unhealthy alcohol use (Feb. 10 issue),1 Dr. Saitz does not address the important role that biomarkers can play in identifying and treating alcohol-use disorders. At least some patients with alcohol-use disorders are unable or unwilling to provide accurate information on their drinking habits to clinicians. There are, of course, several excellent self-report measures available. The concurrent use of biomarkers can augment their accuracy.2,3
Although we firmly believe that treatment for alcohol-use disorders is often ultimately effective, a return to some level of drinking, especially in the first three months of recovery, is quite common. Often the markers of alcohol consumption, especially carbohydrate-deficient transferrin, will be elevated before the patient voluntarily acknowledges a return to drinking.4 The results of biomarker tests can alert the clinician to a recent relapse and thereby allow the treatment regimen to be modified. Finally, feedback given to patients on the basis of the biomarker levels may reinforce recovery efforts or demonstrate the need for the patients to reduce consumption substantially or totally cease drinking.5
Raymund Schwan, M.D., Ph.D.
University Hospital Clermont-Ferrand
F-63003 Clermont-Ferrand, France
rschwan@chu-clermontferrand.fr
John P. Allen, Ph.D.
Pacific Institute for Research and Evaluation
Calverton, MD 20705-3102
References
Saitz R. Unhealthy alcohol use. N Engl J Med 2005;352:596-607.
Schwan R, Loiseaux MN, Schellenberg F, et al. Multicenter validation study of the %CDT TIA kit in alcohol abuse and alcohol dependence. Alcohol Clin Exp Res 2004;28:1331-1337.
Litten RZ, Allen JP, Fertig JB. Gamma-glutamyltranspeptidase and carbohydrate-deficient transferrin: alternative measures of excessive alcohol consumption. Alcohol Clin Exp Res 1995;19:1541-1546.
Allen JP, Anton R. Biomarkers as aids to identification of relapse in alcoholic patients. Recent Dev Alcohol 2003;16:25-38.
Miller WR, Zweben A, DiClemente CC, Rychtarik RG. Motivational enhancement therapy manual: a clinical research guide for therapists treating individuals with alcohol abuse and dependence. Project MATCH monograph series. Vol. 2. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, 1995. (NIH publication no. 94-3723.)
Dr. Saitz replies: As stated in my review, biomarkers — particularly when elevated initially — can be useful in brief intervention. I also agree that evidence supports their use as one of several ways to identify early relapse during treatment for alcoholism. However, in accordance with practice guidelines, I do not recommend biomarkers for screening (which is addressed in Table 2 of my article) because few studies have validated them for identifying the spectrum of unhealthy alcohol use in patients in general health care settings. Many studies of biomarkers have included subjects from specialty treatment centers,1,2 and the few that have been conducted exclusively in medical settings have found the tests to be inadequate.3,4,5 In terms of sensitivity and specificity, biomarkers are either not better or are worse than validated questionnaires.1,2,3,4,5 Furthermore, the incremental value of biomarkers (the cost per case identified in those with negative questionnaires) is unknown and probably small, since questionnaires detect most cases. For patients who deny drinking, a positive but insufficiently specific test is of uncertain value.
Richard Saitz, M.D., M.P.H.
Boston University Medical Center
Boston, MA 02118
rsaitz@bu.edu
References
Schwan R, Loiseaux MN, Schellenberg F, et al. Multicenter validation study of the %CDT TIA kit in alcohol abuse and alcohol dependence. Alcohol Clin Exp Res 2004;28:1331-1337.
Conigrave KM, Degenhardt LJ, Whitfield JB, et al. CDT, GGT, and AST as markers of alcohol use: the WHO/ISBRA Collaborative Project. Alcohol Clin Exp Res 2002;26:332-339.
Sillanaukee P, Aalto M, Seppa K. Carbohydrate-deficient transferrin and conventional alcohol markers as indicators for brief intervention among heavy drinkers in primary health care. Alcohol Clin Exp Res 1998;22:892-896.
Meerkerk GJ, Njoo KH, Bongers IM, Trienekens P, van Oers JA. Comparing the diagnostic accuracy of carbohydrate-deficient transferrin, gamma-glutamyltransferase, and mean cell volume in a general practice population. Alcohol Clin Exp Res 1999;23:1052-1059.
Bell H, Tallaksen CME, Try K, Haug E. Carbohydrate-deficient transferrin and other markers of high alcohol consumption: a study of 502 patients admitted consecutively to a medical department. Alcohol Clin Exp Res 1994;18:1103-1108.
Although we firmly believe that treatment for alcohol-use disorders is often ultimately effective, a return to some level of drinking, especially in the first three months of recovery, is quite common. Often the markers of alcohol consumption, especially carbohydrate-deficient transferrin, will be elevated before the patient voluntarily acknowledges a return to drinking.4 The results of biomarker tests can alert the clinician to a recent relapse and thereby allow the treatment regimen to be modified. Finally, feedback given to patients on the basis of the biomarker levels may reinforce recovery efforts or demonstrate the need for the patients to reduce consumption substantially or totally cease drinking.5
Raymund Schwan, M.D., Ph.D.
University Hospital Clermont-Ferrand
F-63003 Clermont-Ferrand, France
rschwan@chu-clermontferrand.fr
John P. Allen, Ph.D.
Pacific Institute for Research and Evaluation
Calverton, MD 20705-3102
References
Saitz R. Unhealthy alcohol use. N Engl J Med 2005;352:596-607.
Schwan R, Loiseaux MN, Schellenberg F, et al. Multicenter validation study of the %CDT TIA kit in alcohol abuse and alcohol dependence. Alcohol Clin Exp Res 2004;28:1331-1337.
Litten RZ, Allen JP, Fertig JB. Gamma-glutamyltranspeptidase and carbohydrate-deficient transferrin: alternative measures of excessive alcohol consumption. Alcohol Clin Exp Res 1995;19:1541-1546.
Allen JP, Anton R. Biomarkers as aids to identification of relapse in alcoholic patients. Recent Dev Alcohol 2003;16:25-38.
Miller WR, Zweben A, DiClemente CC, Rychtarik RG. Motivational enhancement therapy manual: a clinical research guide for therapists treating individuals with alcohol abuse and dependence. Project MATCH monograph series. Vol. 2. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, 1995. (NIH publication no. 94-3723.)
Dr. Saitz replies: As stated in my review, biomarkers — particularly when elevated initially — can be useful in brief intervention. I also agree that evidence supports their use as one of several ways to identify early relapse during treatment for alcoholism. However, in accordance with practice guidelines, I do not recommend biomarkers for screening (which is addressed in Table 2 of my article) because few studies have validated them for identifying the spectrum of unhealthy alcohol use in patients in general health care settings. Many studies of biomarkers have included subjects from specialty treatment centers,1,2 and the few that have been conducted exclusively in medical settings have found the tests to be inadequate.3,4,5 In terms of sensitivity and specificity, biomarkers are either not better or are worse than validated questionnaires.1,2,3,4,5 Furthermore, the incremental value of biomarkers (the cost per case identified in those with negative questionnaires) is unknown and probably small, since questionnaires detect most cases. For patients who deny drinking, a positive but insufficiently specific test is of uncertain value.
Richard Saitz, M.D., M.P.H.
Boston University Medical Center
Boston, MA 02118
rsaitz@bu.edu
References
Schwan R, Loiseaux MN, Schellenberg F, et al. Multicenter validation study of the %CDT TIA kit in alcohol abuse and alcohol dependence. Alcohol Clin Exp Res 2004;28:1331-1337.
Conigrave KM, Degenhardt LJ, Whitfield JB, et al. CDT, GGT, and AST as markers of alcohol use: the WHO/ISBRA Collaborative Project. Alcohol Clin Exp Res 2002;26:332-339.
Sillanaukee P, Aalto M, Seppa K. Carbohydrate-deficient transferrin and conventional alcohol markers as indicators for brief intervention among heavy drinkers in primary health care. Alcohol Clin Exp Res 1998;22:892-896.
Meerkerk GJ, Njoo KH, Bongers IM, Trienekens P, van Oers JA. Comparing the diagnostic accuracy of carbohydrate-deficient transferrin, gamma-glutamyltransferase, and mean cell volume in a general practice population. Alcohol Clin Exp Res 1999;23:1052-1059.
Bell H, Tallaksen CME, Try K, Haug E. Carbohydrate-deficient transferrin and other markers of high alcohol consumption: a study of 502 patients admitted consecutively to a medical department. Alcohol Clin Exp Res 1994;18:1103-1108.