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..on clinical aspects
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www.ProjectCork.org
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Fall 2003
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A 60-year follow-up of alcoholic men.
Vaillant GE. Addiction 98(8): 1043-1051, 2003. (28 refs.)
Aims To study the course of male alcohol abuse from age 20 to age 70-80 years.
Design A prospective multi-disciplinary follow-up of two community cohorts of
adolescent males from 1940 until the present. Setting and participants Two hundred
and sixty-eight former Harvard undergraduates (college sample) and 456 non-delinquent,
socially disadvantaged Boston adolescents (core city sample).Measurements Since
adolescence these cohorts have been followed by repeated interview, questionnaires
and physical examination. The college cohort has been followed until age 80 and
the younger core city cohort until age 70. DSM-III criteria were used to ascertain
alcohol abuse and alcohol dependence. At some point during their lives, 54 (20%)
of the college men and 140 (31%) of the core city men met criteria for alcohol
abuse. Outcome categories were mortality, continued alcohol abuse and stable
remission. Findings and conclusions These socially divergent cohorts resembled
each other in four respects. First, by age 70 chronic alcohol dependence was
rare; this was due both to death and to stable abstinence. By age 70, 54% of
the 72 successfully followed alcohol-dependent core city men had died, 32% were
abstinent, 1% were controlled drinkers and only 12% were known to be still abusing
alcohol. By age 70, 58%, of the 19 successfully followed college alcohol-dependent
men had died, 21% were abstinent, 10.5% were controlled drinkers and only 10.5%
were known to be still abusing alcohol. Secondly, in both samples alcohol abuse
could persist for decades without remission, death or progression to dependence.
Thirdly, among both samples prior alcohol dependence and AA attendance were the
two best predictors of sustained abstinence. Fourthly, few life-time symptoms
of alcohol abuse were the best predictor of sustained return to controlled-drinking.
Copyright 2003, Society for the Study of Addiction to Alcohol
and Other Drugs.
A population study of low-rate smokers: Quitting history and instability
over time.
Zhu SH; Sun JC; Hawkins S; Pierce J; Cummins S. Health Psychology22(3):
245-252, 2003. (31 refs.)
This study used 1 longitudinal and 2 cross-sectional population surveys to compare
stability of low-rate daily smokers (less than 5 cigarettes per day) with other
daily smokers and occasional smokers. Few low-rate smokers maintained consumption
level; 36% retained smoking status after 20 months, compared with 82% and 44%
for regular daily and occasional smokers, respectively. In a dynamic process,
established smokers quit smoking and/or modified (decreased or increased) consumption.
Low-rate and occasional smokers quit at higher rates than regular daily smokers
(odds ratios 3: 1) but were replenished by new members, many converted from regular
daily smokers. The overall trend is an increasing proportion of low-consumption
smokers while smoking prevalence declines. The dynamic process his implications
for tobacco control efforts and for addiction theory.
Copyright 2003, American Psychological Association, Inc. and
Division of Health Psychology.
Alcoholic men endorse more DSM-IV withdrawal symptoms than alcoholic women
matched in drinking history.
Deshmukh A; Rosenbloom MJ; Sassoon S; O'Reilly A; Pfefferbaum A; Sullivan EV. Journal
of Studies on Alcohol 64(3): 375-379, 2003. (23 refs.)
Objective: Given gender differences in alcohol metabolism, drinking patterns
and alcohol-related problems, we asked whether men and women recruited for research
protocols from treatment programs would meet different subsets of alcohol dependence
or withdrawal criteria or differ in current level of functioning. Method: The
subjects were 66 men and 62 women meeting DSM-III-R or DSM-IV criteria for alcohol
dependence. Gender differences were tested in frequency counts of criteria endorsed
and Global Assessment of Functioning (GAF) scores. Results: All seven alcohol
dependence criteria were endorsed by 50% of the sample. There were no significant
gender differences in frequency of individual criteria endorsed. However, more
men than women tended to endorse the withdrawal criterion for alcohol dependence
and the tremor criterion for alcohol withdrawal, whereas women had higher GAF
scores. When subgroups of men and women were matched on alcohol consumption variables,
significantly more men than women endorsed the withdrawal criterion for alcohol
dependence and the anxiety criterion for alcohol withdrawal, and women still
had significantly higher GAF scores than men. Conclusions: DSM criteria provide
a similar characterization of alcohol dependence in male and female research
volunteers. Despite this similarity, the DSM criteria were sensitive to gender
differences, which can now be challenged with rigorous testing.
Copyright 2003, Alcohol Research Documentation, Inc.
An examination of the process of relapse prevention therapy designed to aid
smoking cessation.
Stoffelmayr B; Wadland WC; Pan W. Addictive Behaviors 28(7): 1351-1358,
2003. (15 refs.)
The process of relapse prevention (RP) therapy is examined. Patients' responses
were recorded primarily during telephonic, RP counseling designed to facilitate
smoking cessation. A computer program that prompted counselor initiatives and
provided a framework for the recording of patient responses guided counselor
interaction with patients. A total of 437 patients took part in 1650 counseling
sessions and reported 2882 urge/lapse situations. The 2531 situations, for which
complete data were available, and 4879 coping responses were analyzed. The main
findings are (1) the descriptions of urge/lapse situations provided by patients
in treatment are similar to those derived by research that aimed to discover
the determinants of relapse without specific treatment, (2) number of coping
responses rather than number of situations is related to treatment outcome, and
(3) the more coping responses discussed during treatment, the better the treatment
outcome.
Copyright 2003, Elsevier Science Ltd.
Efficacy of nicotine patch in smokers with a history of alcoholism.
Hughes JR; Novy P; Hatsukami DK; Jensen J; Callas PW. Alcoholism: Clinical
and Experimental Research 27(6): 946-954, 2003. (49 refs.)
Background: Smokers with a history of alcohol dependence may have more difficulty
quitting, might relapse to alcohol use, and might especially benefit from nicotine
replacement therapy for smoking cessation. Methods: One hundred fifteen smokers
with a history of alcohol dependence (median of 5 years previously) were randomly
assigned to either a 21-mg nicotine patch or placebo in a trial designed to be
as, similar as possible to a prior study that examined smokers with no history
of alcoholism. Both studies were of heavy smokers with similar levels of nicotine
dependence; thus, any differences in trials would be due to a history of alcohol
problems per se. Results: In the current trial, adjusted prolonged smoking abstinence
in those with a history of alcohol dependence was higher in the active than the
placebo group at end-of-treatment (28% vs. 11%; odds ratio, 3.2; p = 0.04) and
at 6-month follow-up (24% vs. 6%; odds ratio, 4.9; p = 0.02). Among subjects
not lost to follow-up, none reported drinking problems or increases in craving
for alcohol. Smoking abstinence was not lower and the odds ratio for nicotine
patch therapy was not greater in smokers with a history of alcohol dependence
than in smokers with no such history. Conclusions: Heavy smokers with a history
of alcoholism benefit from nicotine patch treatment. A history of alcohol problems
after a period of stable sobriety does not appear to influence smoking outcomes
or response to nicotine replacement. Although no smokers relapsed to alcohol
use, a trial that follows up all subjects is needed to verify this.
Copyright 2003, Research Society on Alcoholism.
Naltrexone implants can completely prevent early (1-month) relapse after
opiate detoxification: a pilot study of two cohorts totalling 101 patients
with a note on naltrexone blood levels.
Foster J; Brewer C; Steele T. Addiction Biology 8(2): 211-217, 2003. (26
refs.)
Early relapse is common after opiate withdrawal and deprives addicts of important
opportunities to develop new, opiate-free cognitive-behavioural habits. The oral
opiate antagonist naltrexone (NTX) significantly reduces relapse only when rigorously
supervised and/or probation-linked. Simple but effective NTX implants, containing
1G NTX and giving an average blockade of 6-7 weeks, have been available since
1997. We present outcome data for two cohorts. Group 1 were the first 55 consecutive
implanted British patients (76% male, 51% unemployed, 64% in social classes III-V).
Group 2 were a second consecutive group of 46. Implants were inserted subcutaneously
mainly during rapid opiate detoxification under general anaesthesia or sedation.
The follow-up rate for group 1 was 100%. At 12 weeks after first implantation,
21% of group 1 patients and 26% of group 2 patients had apparently resumed opiate
use. Thirty per cent of patients tested-out the blockade in the first week. None
reported any opiate effects at less than 5 weeks after insertion. In other patients,
typical blood NTX levels 4-5 weeks post-insertion were in the range 3-5 ng/ml,
which is evidently enough to block 500 mg of pure diamorphine. NTX implants provide
considerable protection against early relapse and may increase the likelihood
of therapeutically useful periods of abstinence after opiate withdrawal. Troublesome
tissue reactions were infrequent. Improvements in implant technology and duration
are already occurring. We stress that implants strengthen rather than replace
the therapeutic alliance.
Copyright 2003, Carfax, Ltd.
Outcome predictors in substance use disorders. (review).
Ciraulo DA; Piechniczek-Buczek J; Iscan EN. Psychiatric Clinics of North America 26(2):
381+, 2003. (208 refs.)
Identifying predictors of treatment response in substance abuse is complicated
not only by the heterogeneity of substance use disorders, but also by the various
treatments available and the research community's choice of which predictor variables
to study. Research in the area reflects the contrasting approaches of those who
look for unifying principles underlying certain illnesses, and those who seek
finer delineation of subgroups for whom specific treatments may be individualized.
As a consequence, the search for predictors serves both purposes, by describing
shared factors associated with recovery across different substance use disorders,
while also characterizing clinically relevant patient subgroups. Also complicating
studies of predictors is the large number of effective treatment options available
in substance abuse. A characteristic associated with a positive response to a
psychosocial treatment may not have the same relationship to a medication therapy,
and predictors vary even among various psychosocial interventions and different
pharmacotherapies. The selection of predictors in studies influences the interpretation
of data and the clinical relevance of findings. To some degree, investigators
are slaves to their technology and expertise. As a consequence, very few truly
integrative biopsychosocial studies exist. The field is then left to interpret
whether different predictors are linked, whether some are merely epiphenomena,
and whether they have practical or heuristic value. Does a specific biologic
marker that is associated with poor response merely reflect greater use of the
substance, or does it provide insights into the underlying process of disease
development or response to a specific therapy? Is low self-efficacy a consequence
of poor coping mechanisms, or the logical conclusion of a person who has a relatively
intractable form of addiction? The following overview should be read with these
limitations in mind. For simplicity it is organized by drug class, although some
of the studies address additional drug and psychiatric comorbidities. For each
drug of abuse biologic and psychosocial factors are discussed; however, there
are few studies examining the interaction. Given the practical limitations on
the length of this article, alcohol dependence is focused on in greatest detail,
and other substances in less detail.
Copyright 2003, W.B. Saunders Co.
Parents' disclosure of HIV to their children.
Lee MB; Rotheram-Borus MJ. AIDS 16(16): 2201- 2207, 2002. (42 refs.)
Examined parents' disclosure over time of their HIV serostatus to all of their
children, and the effects of disclosure on adolescent children. 301 parents (mean
age 30 yrs) living with HIV and their 395 adolescent children (aged 12-17 yrs)
were assessed every 6 mo during a 5-yr period. Collected data included disclosure
trends to all children, associated factors with disclosure, and the effects of
disclosure on adolescent children. Results show that parents were more likely
to disclose to older than to younger children. Mothers were more likely to disclose
earlier than were fathers, and they disclosed more often to their daughters than
to their sons. Parents were more likely to disclose over time to children of
all ages; disclosure did not vary according to parents' ethnicity, socioeconomic
status, self-esteem, or mental health symptoms. Disclosure was significantly
more common among parents with poor health, more stressful life events, larger
social networks, and those who perceived their children experiencing more HIV-related
stigma. Over time, poor health status and a self-destructive coping style were
associated with higher rates of disclosure. It is concluded that parental disclosure
of HIV status is similar to disclosures by parents with other illnesses. 2002,
Lippincott Williams & Wilkins.
Post-prison mortality: Unnatural death among people released from Victorian
prisons between January 1990 and December 1999.
Graham A. Australian and New Zealand Journal of Criminology 36(1): 94-108,
2003. (29 refs.)
The extent and nature of unnatural death among people who were released from
Victorian prisons between January 1990 and December 1999 were examined. A total
of 820 men and women released during that period were identified as having died
unnatural deaths while not imprisoned prior to July 2000. The rate of unnatural
deaths among Victorian ex-prisoners was double the 1996/1997 Victorian rate of
deaths in prison custody. The unnatural death rate of ex-prisoners was 10 times
that found in the general Victorian population. Risk of unnatural death was greatest
during the weeks immediately following release and greater among those who had
previous imprisonments. Over half of the unnatural deaths were heroin-related
deaths. Ex-prisoner heroin-related deaths accounted for at least 25% of all the
Victorian heroin-related deaths.
Copyright 2003, The Australian & New Zealand Society of Criminology.
Predictors of the psychosocial adjustment of children living in households
of parents in which fathers abuse drugs: The effects of postnatal parental
exposure.
Fals-Stewart W; Kelley ML; Cooke CG; Golden JC. Addictive Behaviors 28(6):
1013-1031, 2003. (64 refs.)
The purpose of this study was to examine the relationship between the psychosocial
adjustment of children living in households of parents (N=112) in which fathers
were entering treatment for substance abuse and the following sets of variables:
(a) parents' sociodemographic characteristics, (b) parents' dyadic adjustment,
(c) fathers' substance use severity, and (d) parents' psychological adjustment.
Mothers did not meet current criteria for a psychoactive substance use disorder
on alcohol or other drugs; moreover, based on reports by parents, none of the
children was not exposed prenatally to illicit drugs. Results of hierarchical-by-blocks
regression analyses revealed that each of the variable sets made a significant
unique contribution to the prediction of children's psychosocial adjustment.
Furthermore, the following variables within the sets were also found to be significant:
(a) parents' age, (b) weekly family income, (c) frequency of male-to-female physical
aggression between the parents, (d) frequency of fathers' substance use during
the previous year, (e) diagnosis of antisocial personality disorder of fathers,
and (f) mothers' level of psychological distress.
Copyright 2003, Elsevier Science.
The impact of smoking cessation on drug abuse treatment outcome.
Lemon SC; Friedmann PD; Stein MD. Addictive Behaviors 28(7): 1323-1331,
2003. (25 refs.)
Although cigarette smoking is endemic among illicit drug users, drug abuse treatment
programs rarely encourage smoking cessation and often discourage it. The purpose
of this study was to determine whether smoking cessation after entering drug
abuse treatment influenced drug use 12 months after drug abuse treatment. We
analyzed 2316 cigarette smokers in the Drug Abuse Treatment Outcome Study (DATOS),
a national, longitudinal study of drug abuse treatment. Heckman probit selection
models assessed the association of self-reported smoking cessation while in drug
abuse treatment on self-reported drug abstinence in the year after treatment
completion, while simultaneously accounting for possible nonparticipation bias.
Controlling for multiple factors, smoking cessation was associated with greater
abstinence from drug use after completion of drug abuse treatment (P=.04). Despite
drug abuse treatment programs' hesitance to encourage smokers to quit, smoking
cessation does not negatively impact drug use outcomes.
Copyright 2003, Elsevier Science Ltd.
Treating adolescent heroin use.
Hopfer CJ; Khuri E; Crowley TJ. Journal of the American Academy of Child and
Adolescent Psychiatry 42(5): 609-611, 2003. (11 refs.)
Heroin use among young people has been increasing over the past decade. Given
this increase and the relative paucity of treatment literature, we present a
clinical perspective on the treatment of adolescent heroin use and dependence.
A key clinical issue is whether the patient meets criteria for dependence on
heroin, including whether he or she has developed tolerance to opiates, exhibits
withdrawal signs upon discontinuing use, spends a substantial amount of time
and effort obtaining the substance or recovering from its effects, or gives up
substantial other activities to continue using. An algorithm is presented to
determine detox versus maintenance. The authors then describe a model program,
the Adolescent Development Program, affiliated with Weill Cornell Medical College
in Manhattan, which offers methadone treatment specifically for adolescents and
young adults. For programs such as the Adolescent Development Program about 50%
of the patients will continue on methadone maintenance, some after several unsuccessful
dose reduction attempts. The usual duration of stay in treatment is 1 to 6 years.
Of greater importance, however, in defining "success" is the status of patients
who are in treatment at any given moment. After 3 months of treatment, 50% are
working, 15% in school, 10% full-time homemakers, 10% on disability for medical
or psychiatric reasons, and 15% in an "other" status. the same factors that have
been shown to influence treatment retention in adult patients apply to adolescent
treatment as well -- well-trained staff, firm and nonambiguous policies and procedures,
and low staff turnover.
Copyright 2003, American Academy of Child and Adolescent Psychiatry.
Behavioral family counseling and naltrexone for male opioid-dependent patients.
Fals-Stewart W; O'Farrell TJ. Journal of Consulting and Clinical Psychology 71(3):
432-442, 2003. (40 refs.)
Men (N = 124) entering treatment for opioid dependence who were living with a
family member were randomly assigned to one of two 24-week treatments: (a) behavioral
family counseling (BFC) plus individual treatment (patients had both individual
and family sessions and took naltrexone daily in presence of family member) or
(b) individual-based treatment only (IBT; patients were given naltrexone and
were asked in counseling sessions about their compliance, but there was no family
involvement). BFC patients, compared with their IBT counterparts, ingested more
doses of naltrexone, attended more scheduled treatment sessions, had more days
abstinent from opioids and other drugs during treatment and during the year after
treatment, and had fewer drug-related, legal, and family problems at 1-year follow-up.
Copyright 2003, American Psychological Association, Inc.
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