Special article
Early screening and brief intervention in alcohol misuse to improve the treatment of hypertension in primary care
Cribado precoz e intervención breve en el consumo perjudicial de alcohol para mejorar el tratamiento de la hipertensión arterial en atención primaria
Antoni Guala,
, José Zarcob, Joan Colom Farranc, Jürgen Rehmd,e, on behalf of the Group for the Study of Hypertension and Alcohol Use Disorder ◊
Corresponding author
a Unidad de Alcohología, Servicio de Psiquiatría, Instituto de Neurociencias, Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
b Centro de Salud Ibiza, Servicio Madrilen¿o de Salud, Madrid, Spain
c Subdirección General de Drogodependencias, Agencia de Salud Pública de Cataluña, Departamento de Salud, Generalitat de Cataluña, Barcelona, Spain
d Unidad de Investigación Epidemiológica, Psicología Clínica y Psicoterapia, Universidad Tecnológica de Dresde, Dresde, Germany
e Centre for Addiction and Mental Health, Toronto, Canada
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MTC: medullary thyroid carcinoma; PTC: papillary thyroid carcinoma; MEN: multiple endocrine neoplasm; FNA: fine-needle aspiration.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">a</span> Classification system of the British Thyroid Association (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">9</span></a></p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">b</span> Microcalcifications, hypoechogenicity, irregular margins, absence of halo, solid content, intranodular vascularization and anteroposterior diameter<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>transverse diameter.<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">12</span></a></p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">c</span> C1-C6, Bethesda system (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">6,15,16</span></a></p> <p id="spar0025" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleSup">d</span> Mutation panel, gene expression classifier and miRNA expression.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan J. 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Hospital Clínic, Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Centro de Salud Ibiza, Servicio Madrilen¿o de Salud, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Subdirección General de Drogodependencias, Agencia de Salud Pública de Cataluña, Departamento de Salud, Generalitat de Cataluña, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Investigación Epidemiológica, Psicología Clínica y Psicoterapia, Universidad Tecnológica de Dresde, Dresde, Germany" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Centre for Addiction and Mental Health, Toronto, Canada" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Cribado precoz e intervención breve en el consumo perjudicial de alcohol para mejorar el tratamiento de la hipertensión arterial en atención primaria" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 998 "Ancho" => 1538 "Tamanyo" => 83886 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Baseline data of Catalonia. Distribution of the screening rates of hazardous drinking and harmful drinking and brief advice obtained from ODHIN project.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The World Health Organization (WHO) has defined an international framework to monitor progress in prevention and control of major noncommunicable diseases (NCDs cardiovascular diseases, cancer, chronic respiratory diseases and diabetes) and their risk factors, such as smoking, physical inactivity, unhealthy diets or alcohol abuse.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> At the Assembly in 2012, WHO set for year 2025 the global goal of reducing NCD-associated mortality by 25%.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The voluntary global goals included the relative reduction of at least 10% of alcohol harmful consumption and 25% in hypertension (HT) prevalence.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It is estimated that one third of Spanish adults suffer from hypertension and in 75% of them HT control is inadequate.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Moreover, 4.1% of the Spanish adult population (4.5% in men and 3.5% in women) are high-risk drinkers,<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and less than 15% of the population requiring intervention for alcohol use disorders receive treatment.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The implementation of screening for alcohol use among patients with hypertension in primary care (PC) followed by a brief intervention to address harmful use of alcohol is one of the major strategies that the Spanish Ministry of Health, Social Services and Equality has established to comply with this goal.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> The joint approach of harmful alcohol use in PC in people with hypertension through a common strategy might also contribute to comply with WHO's goal.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Relationship between alcohol use and hypertension</span><p id="par0020" class="elsevierStylePara elsevierViewall">There exists a significant overlap between alcohol use disorders and hypertension in patients treated in PC (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) 20.6% of hypertensive men and 7.2% of hypertensive women aged from 40 to 64 have an alcohol use disorder, and 16.7% of men and 5.8% of women with hypertension are alcohol-dependent. It is also estimated that patients with an alcohol use disorder have, depending on the quantities consumed, 1.5–4 times higher risk of HT.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Most studies show a hypertensive effect of chronic alcohol consumption when 60<span class="elsevierStyleHsp" style=""></span>g are exceeded daily.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11–13</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Also, harmful alcohol use has been proven to be one of the most common causes of reversible hypertension and contributes to the emergence of other cardiovascular diseases.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Eventually, alcohol, along with non-adherence to treatment is one of the most common causes of resistant hypertension.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Alcohol and hypertension from a clinical perspective</span><p id="par0030" class="elsevierStylePara elsevierViewall">While hypertension is a risk factor associated primarily with cardiovascular disease, alcohol consumption is linked to over 200 diseases mentioned in the tenth version of the International Classification of Diseases.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The increased use of antihypertensive drugs in the last 10 years in Spain has enabled great advances in the control of blood pressure (BP).<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> However, this control is still far from being the optimal.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> About one third of the Spanish population aged over 18 suffers from hypertension (BP<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>140/90<span class="elsevierStyleHsp" style=""></span>mmHg) or is currently under treatment with antihypertensive drugs, but only 22.7% have a well controlled BP.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand, alcohol is deeply rooted in the Mediterranean culture. Alcohol consumption below 10<span class="elsevierStyleHsp" style=""></span>g daily (equivalent to a standard drink unit) in women and up to 20<span class="elsevierStyleHsp" style=""></span>g in men<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> is associated with a reduction in overall mortality, heart disease, diabetes mellitus, congestive heart failure and stroke.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> However, the line between the beneficial and harmful effects of alcohol consumption is very diffuse,<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> since the risk of causing cardiovascular disease increases depending on the dose. Therefore, above one or two standard drink units per day, each additional beverage increases BP by approximately 1.5<span class="elsevierStyleHsp" style=""></span>mmHg.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In addition, alcohol misuse may be key to detect an uncontrolled hypertension. Hypertensive patients misusing alcohol (>4 units per day in men or >3 in women) had 1.52 times higher risk of uncontrolled BP compared to abstemious.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a> Furthermore, it has been shown that regular consumption of alcohol increases BP in treated hypertensive patients,<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,22,23</span></a> and alcohol-induced hypertension diminishes 2–4 weeks after withdrawal or after significant reduction of consumption.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24,25</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Data from the Spanish Ambulatory Blood Pressure Monitoring Registry reveal that the prevalence of resistant hypertension in treated hypertensive Spanish population is approximately 12–14%.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> Based on these data, the clinical practice guidelines of the European Society of Hypertension and the European Society of Cardiology recommend that the finding of high BP should always lead your doctor to investigate the causes, including consumption of substances increasing BP, such as alcohol.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,27</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Barriers to early detection and brief intervention for alcohol misuse in Spain</span><p id="par0055" class="elsevierStylePara elsevierViewall">The prevalence of alcohol use disorders in Spain is 1.4% in men and 0.3% in women, involving 320,112 individuals.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> The organization of the Spanish health system, with a network of well-trained professionals specializing in the treatment of addictions and with access to information and methods necessary to carry out interventions on alcohol consumption (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>) is relatively good. However, it is estimated that less than 15% of patients requiring intervention due to prolonged alcohol consumption are treated.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In addition, in the field of BP screening programs, brief intervention and referral of patients with alcohol use disorders to therapy have not been systematically implemented. Even in regions with the highest rates of screening, such as Catalonia, significant disparities have been reported in clinical practice: approximately one third of primary care physicians do not refer their patients to this screening, while 40% screen more than 75% of them (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">For patients it is difficult to admit publicly the need to change their habits of alcohol use. The results of the EUROPREVIEW study showed that approximately 24% of men and 9% of women were high-risk drinkers (defined as those with episodes of heavy consumption [≥5 alcoholic beverages per day] high-risk drinkers [≥20 alcoholic beverages per day per week] or dependent [score on the CAGE questionnaire >1]).<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> It was also noted that one third of men (33%) and more than a quarter of women (28%) had been diagnosed with hypertension. 22% of men and 6% of women suffered from hypertension with alcohol misuse. When asked about the need to change their lifestyle, only 30.5% of high-risk drinkers admitted they had to, as opposed to 64% of smokers, 73.5% of patients with unhealthy eating habits and 73% of sedentary people. High-risk drinkers also stated that their general practitioner talked to them less often about alcohol (42%) than about smoking (63%), eating habits (59%) or physical exercise (55%).<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In accordance with the AMPHORA European study–Alliance of Research on Public Health and Alcohol–, the main barriers to screening and treatment of alcohol use disorders involve the lack of time and economic incentives.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> In Spain, in accordance with the Odhin study, the most important barrier to overcome is primary care physicians, who are more focused on treating the disease than in its prevention.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Some of the factors that encourage higher alcohol early intervention are economic incentives and continuing medical training (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). A randomized clinical trial conducted in 120 PC centers in 5 European countries showed that rates of screening and brief intervention for alcohol were increased significantly in the groups receiving continuing medical training and in those receiving a modest economic incentive. There is also a clear synergistic effect between incentives and training (Anderson et al., unpublished data).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Primary care: the best scenario</span><p id="par0070" class="elsevierStylePara elsevierViewall">PC health professionals are best suited to treat both hypertension and alcohol use disorders. HT is detected and treated in PC, and taking into account the high prevalence of alcohol use disorders and its significant impact on health,<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> it is likely that many of the patients attending health centers for any other reason may also suffer from a previous alcohol use disorder.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The Spanish guidelines for the treatment of hypertension recommend behavioral interventions before implementing pharmacological strategies.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,33</span></a> Therefore, limiting alcohol consumption is one of the measures that have been proven effective in reducing BP.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> This BP reduction, along with its reduced risks, leads to a lower use of antihypertensive drugs and its associated costs.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> The higher alcohol use, the more need for interventions (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">Except for the most serious cases, all patients misusing alcohol can be treated successfully in PC (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). In current clinical practice guidelines it is recommend that treatment for alcohol misuse take place in PC.<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The Program of Preventive Activities and Health Promotion, sponsored by the Spanish Society of Family and Community Medicine, identified three areas of activity (tobacco use, alcohol intake and hypertension) and recommended screening strategies for healthy population.<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Since having been provided with clear recommendations for screening for hypertension and alcohol misuse, screening rates for both problems increased significantly,<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38,39</span></a> as well as the diagnosis rates of hypertension and alcohol use disorders, identifying cases that used to go unnoticed.<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Catalonia implemented in 2002 the “Drink Less” program with the aim of providing the PC health professionals with the knowledge, skills and tools necessary for the early identification and brief interventions in high-risk drinkers.<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> This training increased the satisfaction of health professionals working with high-risk drinkers, feeling more prepared and experienced, and considering their interventions more adequate.<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> Since the launch of the program, alcohol screening levels increased from 22% in 2000 to 48% in 2012. The referrals of the most severe cases by PC professionals to the Drug Addiction Care Network were also higher, trying to maintain mild-dependent patients in PC. This program also includes activities to sensitize the general population, such as the organization of the “Screening Week” to commemorate the “Alcohol-free day”.<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Modeling the impact of screening and intervention in alcohol use disorder on hypertension in Spain</span><p id="par0095" class="elsevierStylePara elsevierViewall">Several meta-analyses have shown that intervention to reduce alcohol consumption significantly decreases BP in both hypertensive and normotensive patients.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,20,35</span></a> Thus, it was estimated that systolic BP was reduced by 3.3<span class="elsevierStyleHsp" style=""></span>mmHg and diastolic BP by 2.0<span class="elsevierStyleHsp" style=""></span>mmHg on net average.<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> Based on these data it has been estimated, using a model, that implementation of a program of this type might reduce the number of cases of hypertension by 9.2% in men and 6.5% in women.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> In addition, this entails reducing the costs associated with diseases caused by hypertension. It has also been estimated that 14.1–16.1% of women and 14.2–19.8% of men assisted in PC need at least a brief intervention for alcohol misuse. This percentage increases when including patients who need formal treatment (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">To significantly limit the costs of public health system, detection of hypertension should be improved in PC, such as early screening and brief interventions in case of alcohol misuse and harmful consumption. When both interventions are applied simultaneously, cardiovascular diseases are reduced and morbidity, mortality and health care costs are significantly reduced.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Closing thoughts</span><p id="par0105" class="elsevierStylePara elsevierViewall">This group of experts, having analyzed the Spanish situation, believes that with the exception of the aforementioned local programs, it is necessary to improve early detection and brief intervention in the hazardous and harmful alcohol consumption in PC, as well as treatment or referral to another care level of hypertensive alcohol-dependent patients where appropriate.</p><p id="par0110" class="elsevierStylePara elsevierViewall">To comply with these goals it is necessary to determine the extent of the problem through studies of prevalence of comorbidity between hypertension and alcohol use disorders, and information campaigns for the general population to raise awareness about the importance of drinking alcohol in hypertension and the benefits of reducing consumption. It is also necessary that alcohol consumption be recorded in medical records as a mandatory indicator of health. These records should be standardized with operational definitions of what is considered hazardous and harmful alcohol consumption in men and women. It is important that PC professionals expand their training on alcohol screening and application of brief interventions to reduce it. Government should include economic incentives in the contract of service to record alcohol consumption as a health indicator and so that PC professionals perform said brief interventions. Finally, screening programs and brief intervention for alcohol consumption should be part of the promotion plans for health and care of chronic diseases, both nationally and locally.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interests</span><p id="par0115" class="elsevierStylePara elsevierViewall">All authors are experts in public health, alcohol or high blood pressure. They had a meeting in Barcelona on 6 May, 2014 to review the current situation regarding the treatment of hypertension and alcohol use disorders in Spain and establish a pragmatic route to move forward on how to address these issues. The meeting was supported by Lundbeck and, with the exception of Dr. Joan Colom, the members of the working group received fees for attending the meeting. No member of the working group received remuneration for the preparation of this manuscript.</p><p id="par0120" class="elsevierStylePara elsevierViewall">Dr. Gual has received consulting and teaching fees, and research funding from Lundbeck; consulting fees from D & Pharma; and teaching fees from AbbiVie outside the scope of this paper.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Dr. Colom reports no conflict of interest in relation to the issue addressed in this manuscript.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Dr. Bastida, Brotons, Nevado, Marcos, Zarco and Sierra have received consulting fees from Lundbeck.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Dr. Rehm has received consulting and teaching fees, and research funding from Lundbeck.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Relationship between alcohol use and hypertension" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Alcohol and hypertension from a clinical perspective" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Barriers to early detection and brief intervention for alcohol misuse in Spain" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Primary care: the best scenario" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Modeling the impact of screening and intervention in alcohol use disorder on hypertension in Spain" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Closing thoughts" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interests" ] 8 => array:2 [ "identificador" => "xack218287" "titulo" => "Acknowledgements" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-05-26" "fechaAceptado" => "2015-07-16" "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "◊" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">The names of the members of the Group for the Study of Hypertension and Alcohol Use Disorder are listed in <a class="elsevierStyleCrossRef" href="#sec0045">Appendix</a>.</p>" "identificador" => "fn0005" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Gual A, Zarco J, Colom Farran J, Rehm J, en representación del Grupo para el Estudio de la Hipertensión y Trastorno por Consumo de Alcohol. Cribado precoz e intervención breve en el consumo perjudicial de alcohol para mejorar el tratamiento de la hipertensión arterial en atención primaria. Med Clin (Barc). 2016;146:81–85.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:3 [ "apendice" => "<p id="par0145" class="elsevierStylePara elsevierViewall">The Group for the Study of Hypertension and Alcohol Use Disorder consists of the following members: Núria Bastida Bastús, Carlos Brotons, Joan Colom Farran, Antoni Gual, Miguel Marcos Martín, Armando Nevado, Jürgen Rehm, Cristina Sierra and José Zarco.</p>" "etiqueta" => "Appendix" "identificador" => "sec0045" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 906 "Ancho" => 1319 "Tamanyo" => 52531 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Overlap between hazardous consumption of alcohol, alcohol use disorder and hypertension in primary care patients (Venn chart based on the data of the APC study).<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">EC: excessive consumption; HT: hypertension; AUD: alcohol use disorder.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 998 "Ancho" => 1538 "Tamanyo" => 83886 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Baseline data of Catalonia. Distribution of the screening rates of hazardous drinking and harmful drinking and brief advice obtained from ODHIN project.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a></p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 999 "Ancho" => 1645 "Tamanyo" => 60280 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Interventions in hazardous alcohol consumption. PC: primary care.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Are they available in Spain? \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Materials, methods, screening tools \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Interventions: used and promoted in practice \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Number of service providers that perform interventions in alcohol (governmental/non-governmental) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Drugs: authorized and available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Psychological interventions available \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Training of service providers \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Promotion of protocols or tools to perform effective alcohol interventions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">National review of the effectiveness of treatment, or national standards of care published \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Internet interventions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Professional resources available through Internet \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1062196.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Materials and methods for conducting interventions in alcohol use.</p>" ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The higher score, the greater degree of agreement with the statement.</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Source: ODHIN project factorial analysis.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Reasons for low intervention</th><th class="td" title="table-head " colspan="2" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">What would encourage greater involvement?</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Model focused on the disease rather than prevention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Not considering that prevention is a medical liability \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Be provided with materials and training \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Economic incentives \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spain, mean (standard deviation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.1 (1.8)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.1 (1.7)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.8 (1.9)<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.9 (2.3)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1062198.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">The scores vary from 3 to 12, the neutral value being 7.5.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">The scores vary from 4 to 16, the neutral value being 10.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Elements that hinder and facilitate early intervention in alcohol according to primary care physicians.</p>" ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">ICD-10: tenth version of the International Classification of Diseases; PCT: primary care team; SDU: standard drink unit (corresponds to 10<span class="elsevierStyleHsp" style=""></span>g of pure alcohol).</p><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Source: Anderson et al.<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a></p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of consumption \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Criteria \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Intervention \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Role of PCT \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low-risk consumption \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≤28<span class="elsevierStyleHsp" style=""></span>SDU/week (males)<br><17<span class="elsevierStyleHsp" style=""></span>SDU/week (females) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Primary prevention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Training, support and modeling \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High-risk consumption \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">>28<span class="elsevierStyleHsp" style=""></span>SDU/week (males)<br>≥17<span class="elsevierStyleHsp" style=""></span>SDU/week (females) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Brief intervention \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Identification, assessment, brief advice and follow-up \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Harmful use \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Physical or mental harm related to alcohol use \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Alcohol dependence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">ICD-10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Specialized treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Identification, assessment, referral and follow-up \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1062195.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Intervention depending on the type of consumption.</p>" ] ] 6 => array:9 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "fuente" => "Source: Rehm et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>" "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Males \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Females \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Abstinent, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Need for a brief intervention for high-risk drinking, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.2–19.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.1–16.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Need formal treatment, % \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.1–16.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.9–5.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1062197.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Indicators of alcohol consumption in primary care in hypertensive patients 40–65 years of age.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Draft Political Declaration of the High-level Meeting on the prevention and control of non-communicable diseases" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "United Nations" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2015" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.S. 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