To examine comorbidities in a privately insured substance abuse population, Mertens et al compared the prevalence of 32 medical conditions among 747 substance-abuse treatment patients with 3690 matched controls from the same health maintenance organization (HMO). One third of the conditions were of heightened prevalence in patients with alcohol and/or drug problems relative to controls, and several (eg, injuries, asthma, and hypertension) are particularly costly. Prevalence was also higher for pain diagnoses. These findings suggest the need for improved linkages between primary care and substance abuse treatment. Coordination of care with patients' medical providers may enhance substance abuse treatment outcomes and suggests more appropriate medical therapies. Screening for alcohol or drug problems in medical settings is important, especially where prevalence is high. Optimal treatment of many common medical disorders may require identification, intervention, and treatment of an underlying substance use disorder.
Suffering, or spiritual pain, receives little attention in medical education, research, or practice. Institutional standards for pain management often address only physical pain, the inadequate treatment of which is widespread and well documented. While we may not be able to alleviate suffering in the same manner or to the same degree as we can physical pain, the simple recognition of suffering in the patient is the first step in a truly holistic approach, allowing the patient to feel the therapeutic power of compassion and begin healing.
The search for ways to prevent cognitive impairment continues with this work by Mitchell et al. Although postmenopausal hormones may no longer be appropriate for preventing heart disease, postmenopausal hormones may have a role in cognitive function. The authors administered the Mini-Mental State Examination and assessed reports of physician diagnosed Alzheimer disease in a population-based cohort of nearly 1500 women aged 53 to 97 years. There was no significant association between cognitive impairment and current postmenopausal hormone use, past use, or duration of use. Similarly, rates of cognitive impairment did not differ according to estrogen vs estrogen-progestin use. The strongest predictors of cognitive impairment were age and educational status.
Because depression and painful symptoms commonly occur together, Bair et al conducted a literature review to determine the prevalence of both conditions and the effects of comorbidity on diagnosis, clinical outcomes, and treatment. The prevalences of pain in depressed cohorts and depression in pain cohorts are higher than when these conditions are individually examined. The presence of pain negatively affects the recognition and treatment of depression. When pain is moderate to severe, impairs function, and/or is refractory to treatment, it is associated with more depressive symptoms and worse depression outcomes (eg, lower quality of life, decreased work function, and increased health care utilization). Similarly, depression in patients with pain is associated with more pain complaints and greater impairment. Depression and pain share biological pathways and neurotransmitters, which has implications for the treatment of both concurrently. A model that incorporates assessment and treatment of depression and pain simultaneously is necessary for improved outcomes.
Previous population-based studies have not examined the differential impact of patient sex on long-term mortality between unstable angina (UA) and acute myocardial infarction (AMI). Chang et al examined 5-year mortality in more than 30 000 patients with acute coronary syndrome discharged from acute care hospitals in Alberta, Edmonton, between 1993 and 2000. After adjustment for various factors, women fared better than men in the UA cohort and only women younger than 65 years were at higher risk than men after AMI (Figure 1). Revascularization within 6 months of the index admission did not have a significant impact on the risk of mortality. Broadening the understanding of these findings may have important implications for prevention and treatment strategies.
In This Issue of Archives of Internal Medicine. Arch Intern Med. 2003;163(20):2411. doi:10.1001/archinte.163.20.2411