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...on Clinical Aspects of Substance Use

www.ProjectCork.org

Fall 2002

A comparison of alcohol-positive and alcohol-negative trauma patients.

Blondell RD; Looney SW; Krieg CL; Spain DA. Journal of Studies on Alcohol 63(3): 380-383, 2002. (17 refs.)
Objective: Hospital admission for an alcohol-related traumatic injury may offer a "teachable moment" to address a patients alcohol problem. Although trauma teams provide a number of other health-related services, there may be characteristics of alcohol-positive victims that act as barriers toward providing alcohol counseling. The purpose of this study was to compare the characteristics and hospital outcomes of trauma patients who tested positive for alcohol at the time of hospital admission with those who did not. This information is useful for planning interventions and referrals for treatment. Method: The study was a retrospective comparison of alcohol-positive and alcohol-negative patients who were admitted for at least 48 hours to a Level-I trauma center. Data from 1,049 trauma victims (736 male. 742 alcohol-negative) were abstracted from clinical records. Results: Several characteristics were found to be associated with alcohol- related injuries: being male, aged 40 years or less. having a toxicology screen positive for illicit drugs, lacking health insurance, being indigent and sustaining an injury related to violence. Alcohol-positive patients were also found to spend fewer days in a critical care unit, to be less likely to die and to be less likely to be transferred to another hospital than alcohol-negative patients, despite having similar injury severity. Conclusions: Patient characteristics suggest that there are obstacles to providing interventions and referrals by healthcare professionals for victims of alcohol-related injuries. Less expensive options that consider the demographic features of this patient population need to be developed as an alternative to expensive, professional interventions.

A Dutch treat: Randomized controlled experimentation and the case of heroin-maintenance in the Netherlands.

Dehue T. History of the Human Sciences 15(2): 75-98, 2002. (82 refs.)
In 1995, the Dutch Minister of Health proposed that a randomized clinical trial (RCT) with heroin-maintenance for severe abusers be conducted. It took nearly four years of lengthy debates before the Dutch Parliament consented to the plan. Apart from the idea of prescribing heroin, the minister and her scientific advisers had to defend the quite high material and non-material costs that would arise from employing the randomized controlled design. They argued that the RCT represented the truly scientific approach and was the royal way to unambiguous results. In the present article, I question this common dual justification of RCTs. First, I situate the historical origins and the basic assumptions of the ideal experiment in 20th-century economic liberalism. Secondly, using the Dutch heroin experiment as an example, I discuss human-science experimentation as an attempt to create reality rather than merely record it. Finally, I discuss some surprising responses by heroin users. These responses display the assumptions of RCTs discussed in the historical section, and underline the importance of the culture of heroin use. In the epilogue, 1 suggest that cultural aspects of heroin consumption can best be studied by thorough ethnographic research.

A prospective study of the factors influencing entry to alcohol and drug treatment.

Weisner C; Matzger H. Journal of Behavioral Health Services & Research 29(2): 126-137, 2002. (43 refs.)
Much is known about factors related to entering alcohol and drug treatment, but most research comprises cross-sectional "snapshots" in time. It is not known whether the reasons for entering treatment endure when problem drinkers are studied over time. This study contrasts characteristics predicting treatment entry in a cross- sectional analysis at baseline with a longitudinal perspective at 1- and 3-year follow-up interviews. Sociodemographic characteristics were less important in the longitudinal analysis. In contrast to the social conesquences important at the baseline interview, physiologic symptoms of alcohol dependence and interventions by medical professionals were prominent at later interview points. The findings have implications for interventions by health professionals, both for the development of early interventions targeting individuals to treatment and for a continuing care service model.

A four-year follow-up study of male alcoholics: Factors affecting the risk of readmission.

Ponzer S; Johansson SE; Bergman B. Alcohol 27(2): 83-88, 2002. (30 refs.)
This study is based on a consecutive series of 52 male alcoholics who have been followed up for 4 years after inpatient detoxification. The aim was to identify risk factors for readmission for alcohol detoxification. Information was collected individually, and psychiatric status, physiologic conditions at admission, personality profile, platelet monoamine oxidase (MAO) activity level, current psychosocial living conditions, as well as those during childhood/adolescence, and a history of alcohol and drug abuse were comprised. This information was supplemented by register data on hospital admissions covering the period of 4 years before the admission in question to 4 years after it. The main findings of this follow-up study revealed five risk factors for readmission; namely, heavy drinking before admission, a high gamma-glutamyltransferase level at admission, previous somatic care, and a sensation-seeking behavior in combination with a low platelet MAO activity level (odds ratios ranging from 4.2 to 10.2). The second year after admission seemed to be the most critical time for readmission.

Association between the engagement of relatives in a behavioural group intervention for smoking cessation and higher quit rates at 6- ,12-and 24-month follow-ups.

Picardi A; Bertoldi S; Morosini P. European Addiction Research 8(3): 109-117, 2002. (30 refs.)
Objective: To assess the effectiveness of a behavioural group intervention for smoking cessation, which included as its most original feature the recommendation to participate with a relative or close friend. Methods: A total of 1,060 subjects entered the programme, which consisted of 9 group sessions over a period of 5 weeks. The intervention consisted of a modified version of the Five- Day Plan, the main differences being the use of behavioural therapy techniques and small group work, and the addition of 4 weekly booster sessions. About two thirds of the participants came with a relative or close friend. Long-term abstinence from smoking was assessed with follow-up telephone interviews. Results: Very few subjects were lost to follow-ups (9.2% at 6 months, 9.7% at 1 year, 10.8% at 2 years). The observed quit rates were 42.6% at 6 months, 35.5% at 1 year and 32% at 2 years. When considering as smokers all subjects who were lost to follow-ups, quit rates were also satisfactory (38.7% at 6 months, 32.1% at 1 year and 28.6% at 2 years). The main predictors of a good outcome were being male, smoking less than 20 cigarettes per day, having started smoking after 18 years of age, having made previous quitting attempts, not having a history of unsuccessful participation to smoking cessation interventions and attending the sessions with a relative or close friend. Discussion: Although some limitations inherent in the design of our study suggest caution in interpreting the results and in making comparisons, the long-term effectiveness of the intervention was satisfactory. The inclusion of a relative or close friend appeared useful. This simple and inexpensive strategy may deserve recommendation, though in the future it should be tested in controlled trials.

Alcohol's role in domestic violence: A contributing cause or an excuse?

Leonard KE. Acta Psychiatrica Scandinavica 106(Supplement 2): 9-14, 2002. (35 refs.)
Objective: This paper reviews evidence regarding the deviance disavowal approach to alcohol-related violence. It focuses on whether alcohol intoxication is used to excuse domestic violence, and whether this can explain alcohol/violence association. Method: Four hypotheses derived from the deviance disavowal approach were identified, including (i) people accept alcohol as a cause of violence; (ii) people attribute less blame and punishment to intoxicated aggressors than to sober aggressors; (iii) the belief that alcohol causes or excuses violence should be associated with and predict the occurrence of alcohol-related domestic violence; and (iv) the administration of a placebo should increase aggressive behaviour. Results: The review suggested that some people do accept alcohol as a cause of violence, but that alcohol does not appear to mitigate blame, and this belief is not longitudinally predictive of violence. Conclusion: The evidence for a deviance disavowal model of alcohol and domestic violence appears quite weak.

A review of temporal effects and outcome predictors in substance abuse treatment studies with long-term follow-ups: Preliminary results and methodological issues. (review).

McKay JR; Weiss RV. Evaluation Review 25(2): 113-161, 2001. (127 refs.)
This article is an initial report from a review of alcohol and drug treatment studies with follow-ups of 2 years or more. The goals of the review are to examine the stability of substance use outcomes and the factors that moderate or mediate these outcomes. Results from 12 studies that generated multiple research reports are presented, and methodological problems encountered in the review are discussed. Substance use outcomes at the group level were generally stable, although moderate within-subject variation in substance use status over time was observed. Of factors assessed at baseline, psychiatric severity was a significant predictor of outcome in the highest percentage of reports, although the nature of the relationship varied. Stronger motivation and coping at baseline also consistently predicted better drinking outcomes. Better progress while in treatment, and the performance of prorecovery behaviors and low problem severity in associated areas following treatment, consistently predicted better substance use outcomes.

Coping, functioning, and adjustment of rescue workers after the Oklahoma City bombing.

North CS; Tivis L; McMillen JC; Pfefferbaum B; Cox J; Spitznagel EL et al. Journal of Traumatic Stress 15(3): 171-175, 2002. (19 refs.)
Studies have not previously considered postdisaster adjustment in the context of psychiatric disorders. After the Oklahoma City bombing, a volunteer sample of 181 firefighters who served as rescue and recovery workers was assessed with a structured diagnostic interview. The firefighters had relatively low rates of posttraumatic stress disorder (PTSD) and described little functional impairment, positive social adjustment, and high job satisfaction. PTSD was associated with reduced job satisfaction and functional impairment, providing diagnostic validity. Turning to social supports, seeking mental health treatment, and taking medication were not widely prevalent coping responses. Postdisaster alcohol use disorders and drinking to cope were significantly associated with indicators of poorer functioning. Surveillance for problem drinking after disaster exposure may identify useful directions for intervention.

Correlates of received and expressed violence persistence following substance abuse treatment.

Walton MA; Chermack ST; Blow FC. Drug and Alcohol Dependence 67(1): 1-12, 2002. (46 refs.)
This study examined different types of violence (i.e. 'expressed' towards others and 'received' from others) across different relationship types (i.e. 'partners' and 'non-partners') among men and women in substance abuse treatment, and during a 2-year follow-up period. For received violence, participants were divided into three groups: no-violence before or after treatment, violence before treatment only, and violence both before and after treatment. Similarly, participants also were divided into three groups based on expressed violence: no-violence before or after treatment, violence before treatment only, and violence both before and after treatment. Both expressed and received violence (either before or after treatment) was associated with younger age. Unique demographic markers of received violence included being female, reporting less income and greater unemployment. For both received and expressed violence, several problem severity indicators (e.g. drug consequences, psychological distress) and psychosocial relapse risk indicators (e.g. resource needs, substance-using leisure activities) differentiated those who reported violence (either before or after treatment) and those who did not report violence. In addition. received violence was related to greater exposure to substances whereas expressed violence was related to greater cocaine use and craving. Continued received and expressed violence post-treatment was related to substance use during the follow-up, recruitment from inpatient treatment. and baseline psychological distress (expressed violence only). The results are consistent with contemporary models of violence specifying the impact of substance use, social/contextual and individual difference factors, and highlight risk factors that could be targeted during treatment to potentially reduce post-treatment substance use and violence.

Decreased alcohol consumption in outpatient drinkers is associated with improved quality of life and fewer alcohol-related consequences.

Kraemer KL; Maisto SA; Conigliaro J; McNeil M; Gordon AJ; Kelley ME. Journal of General Internal Medicine 17(5): 382-386, 2002. (20 refs.)
This study's objective was to determine whether changes in alcohol consumption are associated with changes in quality of life and alcohol-related consequences in an out-patient sample of drinkers. Two hundred thirteen subjects completed the Short Form 36-item (SF-36) Health Survey and the Short Inventory of Problems at baseline, 6 months, and 12 months. Subjects who sustained a 30% or greater decrease in drinks per month reported Improvement in SF-36 Physical Component Summary (P = .058) and Mental Component Summary (P = .037) scores and had fewer alcohol-related consequences (P < .001) when compared to those with a <30% decrease. These findings suggest another benefit of alcohol screening and intervention in the primary care setting.

Does religiousness explain regional differences in alcohol use in Finland?

Winter T; Karvonen S; Rose RJ. Alcohol and Alcoholism 37(4): 330-339, 2002. (60 refs.)
Aims: Because religiousness, a protective factor for alcohol use, is much more prevalent in rural regions, we examined its importance in explaining the differences in adolescent alcohol use found in the rural and the urban regions. In rural Ostrobothnia (hereafter referred to as the rural region), alcohol use is at the lowest level in all of Finland, whereas in Uusimaa, the urban region that surrounds Helsinki (hereafter referred to as the urban region), alcohol use is at the highest level. Methods: We analysed cross- sectional questionnaire data collected from Finnish adolescents and their mothers, during 1991-1995. Results: Abstinence was more prevalent, drinking less frequent, and religiousness higher in the rural region. In the urban region, there was but a negligible correlation between alcohol use and religiousness, whereas in the rural region, the correlation was clear, especially when abstainers were included. In modelling the relationship between region and adolescent abstinence, we found an interaction between mothers' religiousness and region: high religiousness among mothers was more protective of abstinence in the rural region. Conclusions: Our results show the importance of religiousness in explaining differences in adolescent alcohol use in regions with different religious traditions, but further studies will be required to explain why mothers' religiousness affects rates of adolescent abstinence differently in the two regions.

Drugged druggists: The convergence of two criminal career trajectories.

Dabney DA; Hollinger RC. Justice Quarterly 19(1): 181-213, 2001. (46 refs.)
In-depth interviews with 50 recovering, drug-addicted pharmacists reveal two distinct paths of entry into drug use. One group (N = 23), termed "recreational abusers," was drawn into the euphoric effects of prescription drugs. The other group (N = 27), termed "therapeutic self-medicators," began using prescription drugs for medicinal reasons. These two distinct modes of entry eventually converged into a single, common criminal career trajectory with common themes observable among all mature deviants. Early differentiation, followed by subsequent convergence of behaviors and motivations, suggests that some theorists and practitioners alike may have erroneously concluded that they have discovered multiple, static types of crime and criminals when they in fact have examined a single criminal-deviant career at different points along its dynamic trajectory.

Into the world of illegal drug use: Exposure opportunity and other mechanisms linking the use of alcohol, tobacco, marijuana, and cocaine.

Wagner FA; Anthony JC. American Journal of Epidemiology 155(10): 918-925, 2002. (33 refs.)
Drawing upon an "exposure opportunity" concept described by Wade Hampton Frost, the authors studied two mechanisms to help account for prior observations about the "stepping-stone" or "gateway" sequences that link the use of alcohol, tobacco, marijuana, and cocaine. Data were obtained from four nationally representative and independent cross-sectional samples of US household residents (n = 44,624 persons aged 12-25 years). Data were gathered using standardized self-report methods and were analyzed via survival methods. Results indicated that users of tobacco and alcohol were more likely than nonusers to have an opportunity to try marijuana and were more likely to actually use marijuana once a marijuana opportunity had occurred. Opportunity to use cocaine was associated with prior marijuana smoking. Among young people with a cocaine opportunity those who had used marijuana were more likely to use cocaine than were those with no history of marijuana use. The observed associations did not seem to arise solely as a result of young drug users' seeking out opportunities to use drugs. Applying Frost's epidemiologic concept of exposure opportunity, the authors offer new epidemiologic evidence on the sequences that link earlier use of alcohol and tobacco to later illegal drug involvement.

Predictors of family functioning within alcoholic families.

Johnson P. Contemporary Family Therapy 24(2): 371-384, 2002. (33 refs.)
This study assessed the effects of various predictor variables on dimensions of functioning within alcoholic families. Participants were 173 college student volunteers from alcoholic families who completed a measure of family functioning, demographic questions, and questions related to experiences in their families of origin. Child abuse, spousal violence, parental divorce, length of time living with an alcoholic parent, parental marital status, and parental availability and predictability significantly affected family functioning, whereas frequency of parental drinking did not. Results suggest that quality of parental interactions with children is more important for functioning in alcoholic families than frequency of parental drinking.

Promoting self-change with alcohol abusers A community-level mail intervention based on natural recovery studies.

Sobell LC; Sobell MB; Leo GI; Agrawal S; Johnson-Young L; Cunningham JA. Alcoholism: Clinical and Experimental Research 26(6): 936-948, 2002. (99 refs.)
Background: By using a public health approach to the treatment of alcohol problems, this study analyzed the efficacy and cost analysis of two versions of a community-level mail intervention to promote self-change among alcohol abusers who had never sought help or treatment. Methods: A total of 825 participants who responded to media solicitations were randomly assigned to one of two interventions: (a) for bibliotherapy/drinking guidelines (n=411), they were given two pamphlets with information about the effects of alcohol and guidelines for low-risk drinking and self-monitoring, and (b) for motivational enhancement/personalized feedback (n=414), personalized advice/feedback was provided on the basis of the participants' assessment of their drinking and related behaviors. Results: Although both groups exhibited significant reductions in drinking from 1 year before to 1 year after intervention, there were no significant differences between the two interventions for any variable. This suggests that the materials, irrespective of whether they were personalized, facilitated the reduction of drinking. Cost analysis revealed that a brief mail intervention could reduce drinking at a very low cost per participant (US$46 to US$97). Conclusions: A brief community-level mail intervention for problem drinkers who had never sought treatment resulted in sizable reductions in alcohol use over the year after the intervention compared with the year before. Furthermore, many of those with poorer outcomes engaged in a natural stepped-care process by seeking help. These results, coupled with the low cost to deliver the intervention, suggest that public health campaigns could have a substantial effect on reducing alcohol problems and associated costs as well as getting some individuals into treatment. Such an approach would represent a shift from the alcohol field's long-standing clinical focus to a broader public health perspective.

Feasibility of matching alcohol patients to ASAM levels of care.

Kosanke N; Magura S; Staines G; Foote J; DeLuca A. American Journal on Addictions 11(2): 124-134, 2002. (14 refs.
The study examined the feasibility of implementing treatment recommendations derived from the American Society of Addiction Medicine (ASAM) Patient Placement Criteria in an urban addiction treatment program that offered a continuum of levels of care (LOC). A cohort of 281 applicants for alcoholism treatment were evaluated and the reasons for observed differences ("mismatches") between recommended and actual LOC placements were determined. Overall, 88% of the applicants entered treatment, and 72% of these were matched to LOC vs. 28% who were mismatched. Presumptive overtreatment (59%) was more common than undertreatment (41%) among the mismatched patients. The reasons for overtreatment were availability of Medicaid coverage for inpatient rehabilitation (93%), referral sources' treatment philosophy of gradually "stepping down" from inpatient detoxifycation (59%), social pressures on patients (28%), and mandated treatment (8%). The reasons for presumptive undertreatment were work schedule conflicts (72%), patient reluctance (48%), insurance coverage (15%), and interference with family or personal responsibilities (9%). These results indicate multiple barriers that need to be overcome to enable full implementation of the ASAM Criteria in real world program settings, even when a continuum of care is available.

Social networks as mediators of the effect of Alcoholics Anonymous.

Kaskutas LA; Bond J; Humphreys K. Addiction 97(7): 891-900, 2002. (41 refs.)
Aims: This study tested the hypothesis that the relationship between Alcoholics Anonymous (AA) involvement and reduced substance use is partially explained (or 'mediated') by changes in social networks. Design: This is a naturalistic longitudinal study of the course of alcohol problems. Setting: Study sites were the 10 largest public and private alcohol treatment programs in a northern California county. Participants Three hundred and seventy-seven men and 277 women were recruited upon seeking treatment at study sites. Measurements: At baseline and 1-year follow-up, we assessed alcohol consequences and dependence symptoms, consumption, social support for abstinence, pro-drinking social influences and AA involvement. Findings In the structural equation model, AA involvement was a significant predictor of lower alcohol consumption and fewer related problems. The size of this effect decreased by 36%, when network size and support for drinking were included as mediators. In logistic regression models predicting abstinence at follow-up, AA remained highly significant after including social network variables but was again reduced in magnitude. Thirty-day abstinence was predicted by AA involvement (OR = 2.9), not having pro-drinking influences in one's network (OR = 0.7) and having support for reducing consumption from people met in AA (versus no support; OR = 3.4). In contrast. having support from non-AA members was not a significant predictor of abstinence. For alcohol-related outcomes other than abstinence, significant relationships were found for both AA-based and non-AA- based support. Conclusions: The type of social support specifically given by AA members, such as 24-hour availability, role modeling and experientially based advice for staying sober, may help to explain AA's mechanism of action. Results highlight the value of focusing on outcomes reflective of AAs goals (such as abstinence) when studying how AA works.

The long-term effectiveness of brief interventions for unsafe alcohol consumption: a 10-year follow-up.

Wutzke SE; Conigrave KM; Saunders JB; Hall WD. Addiction 97(6): 665-675, 2002. (50 refs.)
Aims: To examine the long-term impact of brief and early interventions for hazardous and harmful alcohol consumption. Design: A 9-month and 10-year follow-up of subjects recruited into a randomized controlled trial of a range of alcohol-related brief interventions. Setting General practices, the outpatient or acute care services of a major city hospital, and a privately run health screening programme. Participants The cohort of 554 (non-dependent) hazardous and harmful drinkers recruited into the Australian arm of the Phase II World Health Organization collaborative project on identification and treatment of persons with harmful alcohol consumption. Intervention The effectiveness of three forms of intervention, ranging from 5 to 60 minutes in duration, were compared with a no-treatment control condition. Measurements: Included drinking behaviour and biological markers of alcohol use. In addition, at 10 years subjects were asked about symptoms of diagnosable alcohol use disorders and their experience of alcohol-related psychological, social and physical harm. Mortality was also assessed. Findings: Results provide further evidence for the short-term effectiveness of alcohol-related brief interventions. In comparison to controls, subjects offered intervention: (1) report significantly lower consumption: and (2) less unsafe drinking at 9-month follow-up. The intensity of intervention was not related to the amount of change in drinking behaviour. Analysis at 10 years failed to find any differences in outcomes between intervention and control groups in median consumption, mean reduction in consumption from baseline to follow-up, mortality and ICD-10 diagnoses of alcohol dependence or harmful alcohol use. Conclusions: This study failed to find evidence that brief advice and counselling without regular follow-up and reinforcement can sustain significant long-term reductions in drinking behaviour at 10-year follow-up.

Addiction careers and criminal specialization.

Farabee D; Joshi V; Anglin MD. Crime & Delinquency 47(2): 196-220, 2001. (35 refs.)
For many drug users, the initiation of drug use and the subsequent transition to an addiction career is accompanied by criminal activities. However, the use of general crime and drug use categories often obscures important features of their relationship. In the present study, data from the national Drug Abuse Treatment Outcome Studies sample of 7,189 clients in substance abuse treatment were analyzed to explore the relationships between several addiction career variables and the likelihood of lifetime participation in predatory, victimless, and nonspecialized criminal behaviors. The order of initiation of addiction and criminal careers was significantly related to participation in certain types of crimes, with those beginning criminal careers after beginning their addiction careers being more likely to engage exclusively in victimless than in predatory crimes. Likewise, dependence on cocaine, heroin, or both, relative to alcohol, was associated with greater criminal diversity but a reduced likelihood of participating specifically in predatory crimes.

The relation between alcohol consumption and smoking abstinence: Results from the Working Well Trial.

McClure JB; Wetter DW; de Moor C; Cinciripini PM; Gritz ER. Addictive Behaviors 27(3): 367-379, 2002. (25 refs.)
The current study examined the relation between drinking and smoking abstinence in a community-based sample from the Working Well Trial (WWT). At baseline, drinking level was related to smoking history (never, former, or current smoker; P<.0001) and abstinence history. Mean monthly alcohol consumption increased linearly with decreases in duration of recent abstinence (i.e., longest period quit in the past year among current smokers; P<.05) and current abstinence (i.e., time since quitting among former smokers; P<.0001), even controlling for relevant demographic factors. Among baseline smokers, lower beer consumption predicted smoking abstinence at 4-year follow-up (P<.01). A trend towards significance was found for total alcohol consumption (P=.06). The results suggest (a) a dose-response relation between baseline drinking and duration of smoking abstinence, and (b) that heavier drinkers are less likely to quit smoking over a 4-year period.