Confronting the hidden toll of alcohol use disorders

Over the past two years, many of my patients have been drinking more alcohol than in the past, reflecting a troubling national response to COVID-19 pandemic-related stress. Two recently published studies assessed the increased death toll of unhealthy drinking habits. Alcohol-related deaths occur due to direct effects of alcohol on the body, such as alcoholic hepatitis (severe cases have a 16-30% mortality rate at 28 days and 56% at one year) or via indirect contributions to fatal traffic and nontraffic injuries (e.g., drowning, falls, aspiration, hypothermia, firearm injuries).

The first study used death certificate data from the National Center for Health Statistics to compare numbers and rates of alcohol-related deaths among individuals 16 years or older in 2019 and 2020. Both the absolute number and age-adjusted rate of deaths involving alcohol increased by about 25%, greater than the 16-18% increases in all-cause deaths and death rate during this period. The largest increases (37-40%) were observed in adults aged 25 to 44 years. A second study used data from the National Vital Statistics System to evaluate mortality trends in adults with the diagnosis of alcohol use disorder (AUD) before (2012-2019) and during (2020-2021) the pandemic. Similarly, deaths with AUD listed as a primary or contributing cause during 2020 and 2021 exceeded projected deaths based on pre-pandemic data by 25% and 22%, respectively, with the 25 to 44 year-old age group demonstrating the largest increases (40% and 34%).

For patients who survive alcoholic hepatitis and other alcohol-related life-threatening injuries, it is critical for physicians to offer evidence-based medical therapy for AUD, outlined in a 2020 American Family Physician article. Since the effects of risky drinking and AUD may not be clinically evident, the U.S. Preventive Services Task Force recommends screening and brief behavioral counseling interventions in adolescents and adults to reduce unhealthy alcohol use. Managing alcohol withdrawal syndrome and referring patients to Alcoholics Anonymous and other 12-step facilitation programs for AUD are also important mitigation strategies.

What about patients who have long been told that having a glass of wine with dinner is good for the heart? Setting aside the question of whether patients underestimate personal alcohol consumption, a large (n=371,463) United Kingdom cohort study recently challenged the theory that light alcohol use lowers cardiovascular risk. Investigators found that after adjustment for healthier lifestyles, light alcohol use (up to 1 drink per day) was associated with increased risk for hypertension and coronary artery disease compared to no use, and heavy use (more than 2 drinks per day) was associated with exponentially increasing cardiovascular risks.

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This post first appeared on the AFP Community Blog.

Making schools safe for students and staff during the pandemic

Since fall 2020, I have served as a medical and public health consultant for a private K-12 school system in the Washington, DC area. At that time, many schools were trying to figure out how to safely reopen for in-person instruction after having taught students online after the COVID-19 pandemic began with unacceptable results. With vaccines for adults and children still in development, schools were implementing a variety of interventions in the hope that some would mitigate viral spread: spacing students six feet apart, universal masking, temperature and symptom screening, regular testing, frequent sanitizing, improving ventilation, hybrid scheduling, cohorting, and quarantines. New studies appeared constantly, and it was my job to sift through the imperfect data to advise the best course of action in the context of changing community infection rates and parents who either felt that the school system wasn't doing enough to protect their children or was doing "too much" and unnecessarily restricting classroom or extracurricular activities.

When effective and safe vaccines became available, first for adults, then adolescents, then for children aged 5 or older, we strongly encouraged everyone to receive them, and I personally hosted virtual and in-person question and answer sessions for employees. The schools I advised required that students and staff wear masks until February 2022, after the vast majority had been vaccinated and boosted, if eligible. Given the increasing frequency of (mostly mild) infections in vaccinated persons and continued skepticism about the value of masks in preventing viral spread, though, I have continued to keep up with the literature on these topics. Two recent large observational studies are worth highlighting.

During the 2021-22 school year, schools could require that everyone wear masks (universal masking), that some grades wear masks or that masks be required at a community infection threshold (partial masking), or make masks optional. A study of more than 1 million students and 150,000 staff across 61 school districts in 9 states found a clear benefit of universal compared to optional masking: "Districts that optionally masked throughout the study period had 3.6 times the rate of secondary transmission as universally masked districts; and for every 100 community-acquired cases, universally masked districts had 7.3 predicted secondary infections, whereas optionally masked districts had 26.4." This finding was consistent with a prior study that compared COVID-19 incidence in school districts in Arkansas during the tail end of the delta wave (August-October 2021) and found that "districts with universal mask requirements had a 23% lower incidence of COVID-19 among staff members and students compared with districts without mask requirements."

Masks are not perfect, and some types of masks work better than others. But they do work!

An online survey of more than 1 million respondents living with school-aged children in all 50 states and Washington, DC examined the COVID-19 risk associated with in-person schooling during spring 2021, when most adults were vaccine-eligible but most students were not.  By June, about 75% of respondents had received at least one COVID-19 vaccine dose, a slightly higher proportion than the general population at that time. As expected, living in a household with a child in full-time in-person schooling was associated with an increased odds of experiencing COVID-19-like illness (adjusted odds ratio, 1.32). However, as the number of school-based mitigation measures increased, the risk decreased: "By May to June, risks of all COVID-19 related outcomes disappeared when four or more mitigation measures were reported." Among more than 116,000 teachers included in the survey, those who taught students in person had a higher risk of testing positive (aOR, 2.04) and losing one's taste or smell (aOR, 1.37). However, being vaccinated lowered this risk, to the point where "vaccinated teachers working outside the home were less likely to report COVID-19-related outcomes than unvaccinated teachers reporting no work outside the home."

Vaccines are not perfect, and they are more protective against some viral variants than others. But they do work!

We have reached the point where reinstituting community mask mandates is politically impossible in most parts of the U.S. and mandatory vaccination policies have limited by the courts to employees of the federal government (including active military) and health care organizations. Closing schools and businesses early in the pandemic did buy time to develop vaccines and antiviral drugs, but the societal and economic costs were devastating. By comparison, masks are uncomfortable and vaccines have rare adverse effects that are many orders of magnitude lower than the risks associated with COVID-19. Keeping schools open without facilitating community transmission will continue to remain a challenge as variants continue to evolve. It's been a humbling experience for me, as it has been for all professionals doing our best to protect the public's health.

Does advance care planning improve decision-making in serious illness?

Since 2008, April 16 has been designated National Healthcare Decisions Day, a day that "exists to inspire, educate and empower the public and providers about the importance of advance care planning," according to The Conversation Project. Advance care planning makes sense for everyone because despite modern medicine's best efforts to prolong life, death will eventually come for us all. And although most Americans imagine a "good death" as taking place at home, peacefully passing away surrounded by grieving loved ones, the reality is that acute clinical deterioration may be unpredictable; signs of the end of life are not always well defined; and challenging decisions about medical interventions may need to be made precisely when the patient is least capable of making them.

Most doctors receive little formal training in advance care planning. To the extent that I was aware of advance directives in medical school and residency, it was their relationship to the "DNR/DNI" (do not resuscitate, do not intubate) order that my attending physicians urged discussing with critically ill patients with little chance of survival if their hearts stopped beating or they required invasive respiratory support. And then, these directives often made little sense, as documents that expressed life sustaining treatment wishes at an earlier stage of life often conflicted with the patient's best interests as judged by their spouse or surrogate decision maker and the medical team. Indeed, it's possible that traditional advance directives can undermine advance care planning, since in the words of one older adult, "if you have it [the advance directive] in writing, you do not have to worry about it [having uncomfortable serious illness conversations]."

In a 2021 JAMA Viewpoint, three national palliative care leaders observed that our current model of advance care planning has failed to achieve its goals of promoting goal-concordant end-of-life care and reducing heroic end-of-life interventions with little or no value. Citing two reviews of more than 1600 research studies, they concluded that advance care planning had essentially no effect on health care use, quality of life, or the likelihood of patients receiving care consistent with their expressed goals and values. Noting the complicated series of steps that are essential to the success of advance care planning, they argue that trying harder and providing more incentives for patients and physicians to have serious illness conversations in advance of serious illness is unlikely to yield better results and may cause unintended consequences by causing health care organizations to neglect other areas of clinical care. Instead, they suggested that efforts focus on improving communication and shared decision making between clinicians and health care proxies / surrogate decision makers designated by patients to carry out their wishes at the end of life.

To be sure, not everyone agrees that advance care planning is broken beyond repair. Dr. J. Randall Curtis, a palliative care physician who was diagnosed last year with amyotrophic lateral sclerosis (ALS; "Lou Gehrig's disease"), wrote a related piece in JAMA that offered three personal examples of the process working as it should: his mother-in-law, his mother, and his own soon-to-be-fatal diagnosis. He admitted that these anecdotes do not "prove" the effectiveness of advance care planning or override the rigorous research performed by others in his field, but are "examples of the diverse ways that advance care planning can support resilience, understanding, feelings of peace, and recovery from grief even in circumstances where this advance care planning doesn't change the care received or other measurable outcomes." To those who debate whether advance care planning is inherently ineffective or could be made more effective, his view was that "both sides are right."

Unfortunately, like every sector of health care in the U.S., end-of-life care is inequitable. A recent editorial in American Family Physician discussed racial disparities at the end of life, noting that compared to white patients, "Black patients receive more aggressive and nonbeneficial medical care at the end of life," whether for terminal cancer, trauma, or accessing hospice and palliative care services. Ironically, one of the authors' proposed strategies to mitigate these disparities is "making advance care planning a standard for every adult patient." For some it is the problem, to others it is the solution. And relatively few doctors and patients are doing it, even though Medicare has paid clinicians for having this conversation since 2016. For me, the bottom line is that a static document that a patient can fill out and forget is unlikely to be useful in the future, while a prolonged series of discussions with trusted clinicians and family members - particularly one's spouse or life partner - may be more helpful in guiding end-of-life care, though there are no guarantees.

In patients with heart failure, a low-sodium diet does not improve outcomes

Anecdotally, a common contributor to acute exacerbations of chronic heart failure is having one or more high-sodium meals prior to the onset of symptoms. It seems reasonable, then, to recommend that patients with heart failure adhere to a low-sodium diet to reduce readmissions and mortality and improve quality of life. But until recently, there was limited evidence to support or refute this line of thinking. In a 2014 editorial, my colleague Barry Weiss, MD discussed several studies showing that a low-sodium (less than 1,800 mg per day) diet produced no benefits and increased the risk of death compared to a normal diet in heart failure patients in outpatient and inpatient settings. Consequently, he advised that "based on current evidence and until further studies are completed, patients with heart failure should probably be discouraged from reducing their sodium consumption to less than 2,300 mg per day."

Two subsequent systematic reviews of studies of dietary sodium restriction in heart failure also questioned the low-sodium diet dogma. A 2018 review of 9 randomized trials with 479 participants with heart failure found insufficient data on cardiovascular-associated and all-cause mortality, stroke, and myocardial infarction and conflicting evidence on changes in New York Heart Association functional class. Similarly, a 2021 systematic review and meta-analysis of 10 trials (1011 participants) found that low-sodium diets did not improve quality of life and possibly increased readmission rates and mortality. However, most trials included fewer to 100 participants, leaving open the possibility that a larger trial powered to detect differences in clinical outcomes could still show benefits.

Last month, the Study of Dietary Intervention under 100 mmol in Heart Failure (SODIUM-HF) trial, with 806 participants from 26 sites in Australia, Canada, Chile, Colombia, Mexico, and New Zealand reported its primary findings. All participants in this pragmatic randomized trial were receiving optimally tolerated guideline-directed medical treatment for chronic heart failure. Participants were randomly assigned to usual care or a low sodium diet of <100 mmol/day (<1,500 mg/day). The primary outcome was a composite of cardiovascular-related hospitalization, emergency department visit, and all-cause mortality within 12 months. Median sodium intake decreased in the low-sodium group from 2,286 mg to 1,658 mg/day and in the usual care group from 2,119 mg to 2,073 mg/day by the end of the trial. However, researchers found no statistical differences between the groups in the composite outcome or in each of the individual outcomes.

As Dr. Weiss cautioned in his editorial, "the possibility that aggressive sodium restriction may lead to unfavorable outcomes in patients with heart failure should not ... be misconstrued as meaning that we should lose our focus on reducing sodium intake in the general population." Indeed, there is good evidence that population-level interventions are effective in preventing cardiovascular disease, including a large Chinese randomized trial of a salt substitute that Dr. Jennifer Middleton discussed in a previous AFP Community Blog post. That's why recent guidance for industry from the U.S. Food and Drug Administration that aims to reduce the average American's daily sodium intake from 3,400 mg to 3,000 mg/day over the next few years could have a positive public health impact.

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This post first appeared on the AFP Community Blog.