Linking Excessive Drinking with Chronic Pain

Today I have documented my painful and failed search to find out what data or reasoning spawned this article further stigmatizing pain patients in a pain-related medical news site:

Excessive Drinking Seen in Some Patients With Chronic Pain – Clinical Pain Advisor – May 28, 2020

Among those reporting alcohol use, patients with certain common medical conditions are more likely to report excessive drinking, according to a study published online May 13 in JAMA Network Open.

There was no further reference to chronic pain as a “medical condition” in the article, only in the headline. This seemed like a completely gratuitous mention of pain, deliberately creating an association of chronic pain with alcohol and leaving the impression that pain patients are a bunch of drunks. So, I decided to investigate. 

Stacy A. Sterling, Dr.P.H., from Kaiser Permanente Northern California in Oakland, and colleagues used electronic health record data to evaluate associations between 26 medical conditions and alcohol consumption levels in 2,720,231 adult primary care patients (52.9 percent female; 32.5 percent aged 18 to 34 years) screened for unhealthy drinking from 2014 through 2017.

Step 1.

I went to look at the study referenced in the article to see if I could verify it.

I only had access to the abstract, but it was quite detailed with other interesting information. There too, chronic pain wasn’t even mentioned.

Associations Between Medical Conditions and Alcohol Consumption Levels in an Adult Primary Care Population | Substance Use and Addiction | JAMA Network Open | JAMA Network – May 2020

Question:

What are the associations between medical conditions and alcohol drinking levels in primary care patients?

Findings:

In this cross-sectional study of more than 2.7 million adult primary care patients screened for unhealthy alcohol use, 269 379 patients (9.9%) reported unhealthy drinking habits, and patients with medical conditions were less likely to drink compared with those without.

However, among those reporting alcohol use, patients with

  • diabetes, 
  • hypertension, 
  • chronic obstructive pulmonary disease, 
  • atrial fibrillation, 
  • cancer, 
  • chronic liver disease, or 
  • injury or poisoning 

were more likely to report drinking above recommended guidelines.

Meaning

Health systems and clinicians should take a more targeted approach to help patients with certain medical conditions reduce unhealthy alcohol consumption and health risks.

Abstract:

Importance:

Excessive alcohol consumption is associated with increased incidence of several medical conditions, but few nonveteran, population-based studies have assessed levels of alcohol use across medical conditions.

Objective:

To examine associations between medical conditions and alcohol consumption levels in a population-based sample of primary care patients using electronic health record data.

Design, Setting, and Participants:

This cross-sectional study used separate multinomial logistic regression models to estimate adjusted associations between 26 medical conditions and alcohol consumption levels in a sample of 2 720 231 adult primary care patients screened for unhealthy drinking between January 1, 2014, and December 31, 2017, then only among those reporting alcohol use.

The study was conducted at Kaiser Permanente Northern California, a large, integrated health care delivery system that incorporated alcohol screening into its adult primary care workflow. Data were analyzed from June 29, 2018, to February 7, 2020.

Main Outcomes and Measures:

The main outcome was level of alcohol use, classified as 

  • no reported use, 
  • low-risk use, 
  • exceeding daily limits only, 
  • exceeding weekly limits only, or 
  • exceeding daily and weekly limits, 

per National Institute on Alcohol Abuse and Alcoholism guidelines. 

Other measures included 

  • sociodemographic,
  • body mass index,
  • smoking, 
  • inpatient and emergency department use, and
  • a dichotomous indicator

for the presence of 26 medical conditions in the year prior to the alcohol screening identified.

Results  

Among the 2 720 231 included patients, 

  • 1 439 361 (52.9%) were female, 
  • 1 308 659 (48.1%) were white, and 
  • 883 276 (32.5%) were aged 18 to 34 years. 

Patients with any of the conditions (except injury or poisoning) had lower odds of drinking at low-risk and unhealthy levels relative to no reported use compared with those without the condition. 

Among 861 427 patients reporting alcohol use, patients with 

  • diabetes (odds ratio [OR], 1.11; 95% CI, 1.08-1.15), 
  • hypertension (OR, 1.11; 95% CI, 1.09-1.13), 
  • chronic obstructive pulmonary disease (COPD; OR, 1.16; 95% CI, 1.10-1.22), or 
  • injury or poisoning (OR, 1.06; 95% CI, 1.04-1.07) 

had higher odds of exceeding daily limits only; 

Notice there is no mention of chronic pain or even any painful conditions.

those with 

  • atrial fibrillation (OR, 1.12; 95% CI, 1.06-1.18), 
  • cancer (OR, 1.06; 95% CI, 1.03-1.10), 
  • COPD (OR, 1.15; 95% CI, 1.09-1.20), or 
  • hypertension (OR, 1.37; 95% CI, 1.34-1.40) 

had higher odds of exceeding weekly limits only; and 

those with 

  • COPD (OR, 1.15; 95% CI, 1.07-1.23), 
  • chronic liver disease (OR, 1.42; 95% CI, 1.32-1.53), or
  • hypertension (OR, 1.48; 95% CI, 1.44-1.52) 

had higher odds of exceeding both daily and weekly limits.

Conclusions and Relevance:

Findings suggest that patients with certain medical conditions are more likely to have elevated levels of alcohol use.

But not chronic pain.

Health systems and clinicians may want to consider approaches to help targeted patient subgroups limit unhealthy alcohol use and reduce health risks.

I could not find “chronic pain” mentioned anywhere in the study. It doesn’t seem to have been one of the 26 medical conditions they screened for.

Yet, the article in Clinical Pain Advisor had twisted it around to make it sound like the study was about pain and drinking. It sure seems like the intention was to hint that pain patients are excessive drinkers.

Step 2. 

So I decided to investigate the number of deaths attributed to alcohol. From the CDC (nccd.cdc.gov), the alcohol statistics were under the acronym NCCD (National Center for Chronic Disease), which may be an older name no longer used. 

From Alcohol and Public Health: Alcohol-Related Disease Impact (ARDI)

ARDI is an online application that provides national and state estimates of alcohol-related health impacts, including deaths and years of potential life lost (YPLL). These estimates are calculated for 54 acute and chronic causes using alcohol-attributable fractions, and are reported by age and sex for 2006-2010.

ARDI is clearly a duplicate effort when we already have an agency dedicated entirely to “alcohol abuse”: the National Institute on Alcohol Abuse and Alcoholism (and another NIH agency, NIDA, is responsible for “Drug Abuse”).

There is no need for the CDC, which is responsible for infectious diseases, to be spending tax dollars on projects that are outside of its scope – especially when those “extra-curricular” project duplicate work being done in agencies that were designed for these other projects.

Alcohol & Public Health -> Alcohol-Related Disease Impact (ARDI) Home

Average for United States 2006-2010 – Alcohol-Attributable Deaths Due to Excessive Alcohol Use

Overall Males Females
Chronic Causes 38,584 26,783 11,801
Acute Causes 49,544 35,540 14,004
Total for All Causes 88,129 62,323 25,805

Here, the overall annual average of alcohol-related deaths up to 2010 are listed at about 88,000.

Step 3:

I wasn’t satisfied with this number out of context, so I searched more and found a recent article on Medscape:

Sobering Data on Alcohol-Related Deaths in the US – Medscape – by Deborah Brauser – Jan 2020

Sobering data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) show the number of alcohol-related deaths in the United States has risen dramatically over the past 2 decades.

A new report indicates that between 1999 and 2017, almost 1 million individuals died from some type of alcohol-related cause. In addition, the mention of alcohol in death certificates increased from nearly 36,000 per year to more than 72,000 during the same period. In 2017 alone, alcohol played a role in 2.6% of all of US deaths.

72,000 is very different from the approximately 88,000 stated previously – and it’s a more recent figure. How is it possible that alcohol deaths *decreased* between 2010 and 2017?

…a report by the World Health Organization revealed that alcohol use resulted in about 3 million deaths worldwide in 2016 alone and accounted for 5.3% of all deaths that year.

In 2017 alone, there were roughly 2.8 million deaths in the United States. Of these, 2.6% involved an alcohol-attributable cause of death.

The findings were published online January 7 in Alcoholism: Clinical and Experimental Research.

Step 4:

Again, I went to the article’s source at the NIH, and verified that number:

Using Death Certificates to Explore Changes in Alcohol-Related Mortality in the United States, 1999 to 2017 – PubMed – 2020 Jan

Results:

The number of alcohol-related deaths per year among people aged 16+ doubled from 35,914 to 72,558, and the rate increased 50.9% from 16.9 to 25.5 per 100,000.

Here the number is 72,000, not the 88,000 as shown previously.

Nearly 1 million alcohol-related deaths (944,880) were recorded between 1999 and 2017. In 2017, 2.6% of roughly 2.8 million deaths in the United States involved alcohol.

Step 5:

Bang head on desk.

I’m dismayed that after all this, I still don’t know if the average number of Americans dying from alcohol-related causes annually is 88,000 or 72,000. And I was never able to figure out why it was announced in the Clinical Pain Advisor as being related to chronic pain.

3 thoughts on “Linking Excessive Drinking with Chronic Pain

  1. samanthaharris

    Brilliant. Fantastic article. I’ve come across Keiser before in my search for answers within the NHS strategies in the UK. Trying to get to the bottom of some of their advice is very difficult. What we do know is that alcohol was used and is used for pain relief – both mental and physical both historically and nowadays. As alcohol is essentially patent free and is banned in certain religions, I suspect much of the anti drug and anti alcohol mantra is from them – along with the well known common sense fact that too much of anything isn’t good for the human body or the human mind.

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      Alcohol certainly has a medicinal use and it’s 100% natural – and enjoying alcohol is 100% natural too. I’ve watched birds smarting to feast on overripe berries that had become slightly alcoholic and then fly away crooked and sometimes into the window. It was just like people at a party.

      On the other hand, as you mention, alcohol is a pain killer, though I find it far too mild to be useful by itself. But it is also a “mood medicine” and can take the edge off both pain and anxiety. In this way, it sounds better than most prescription drugs!

      Liked by 1 person

      Reply

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