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...on Clinical Issues

www.ProjectCork.org

Spring 2003

Absinthe makes the heart grow fonder.

Pates R. Journal of Substance Use 7(2): 63-64, 2002
The recent introduction of the alcoholic beverage absinthe as a trendy drink for young people in Great Britain is discussed. The author notes that the hallucinogenic effects of absinthe appear to have been lost. Absinthe is part of the history of alcohol use in modern times, celebrated in paintings and consumed by poets and writers. In 1905, an agricultural worker killed his wife and two daughters on the same day that he had consumed two large glasses of absinthe. Although he had, on the same day, also consumed a large number of brandies, a creme de menthe, and at least 2 liters of strong local wine, the absinthe was seen as the cause of the murder. The murder led to the call for absinthe to be banned in Switzerland in 1910. In France, absinthe was banned in 1915. It has since been banned in most of Europe but not in Great Britain. However, a Frenchman selling absinthe antiques, which are collectors' items, noted that the absinthe consumed by the young in Britain is mainly imported from Eastern Europe, is very strong, and neither tastes nor looks like the original. Absinthe is still made in Spain, and the Frenchman suggested that this was most like the original absinthe, having the same pale green color and the same taste, although it is not as strong as the original. Despite the changes in the beverage, the drink has become a fashionable thing and with excessive use, a significant number of young people have been taken to emergency rooms because of acute intoxication and deaths have been reported.

Alcoholics Anonymous and church involvement as predictors of sobriety among three ethnic treatment populations.

Roland EJ; Kaskutas LA. Alcoholism Treatment Quarterly 20(1): 61-77, 2002. (23 refs.)
This study examines the impact of spirituality and religiousness, and involvement in Alcoholics Anonymous (AA) on sobriety among three ethnic groups, African Americans, Caucasians, and Hispanics. Participants (African Americans: n = 253; Hispanics: n = 60, and Caucasians: n = 538) completed survey questionnaires upon entry into public, private, and health maintenance treatment pro-grams. Results indicated that among the three groups, African Americans, who described themselves as more religious, were less likely to substitute church attendance for participation in Alcoholics Anonymous. African Americans reporting high AA attendance at the end of one year, in addition to church attendance, were more likely to report sobriety over the past 30 days than were those African Americans reporting only high church attendance. Among Caucasians and Hispanics, participants reporting primarily high AA attendance were more likely to report past 30 day sobriety.

Characteristics, belief, and practices of community clinicians trained to provide manual-guided therapy for substance abusers.

Ball S; Bachrach K; DeCarlo J; Farentinos C; Keen M; McSherry T et al. Journal of Substance Abuse Treatment 23(4): 309-318, 2002. (46 refs.)
The successful dissemination of empirically supported addiction therapies to community providers requires an appreciation. of the characteristics of those practitioners who might be willing participants in this process of technology transfer. Clinicians (N = 66) from 11 community treatment programs associated with six research-clinic partnerships of the National Drug Abuse Clinical Trials Network volunteered to be trained in Motivational Inter-viewing or Motivational Enhancement Therapy (MET/MI) and were assessed prior to training. The clinician sample was heterogeneous in education and credentials, had a, high level of counseling experience, reported using a wide range of counseling techniques and orientations, but had limited prior exposure to MET/MI or to the use of treatment manuals of empirically supported therapies. In general, many of the clinicians reported beliefs and techniques that were consistent with their stated theoretical orientation and recovery status. Relatively few participants reported relying on one dominant orientation or set of techniques.

Do patients' perceptions of their counselors influence outcomes of drug treatment?

Kasarabada ND; Hser YI; Boles SM; Huang YC. Journal of Substance Abuse Treatment 23(4): 327-334, 2002. (31 refs.)
This prospective longitudinal study examined the influence of patients' perceptions of their counselors on their lengths of stay in treatment and subsequent treatment outcomes. Patients (N = 511) were recruited from 19 substance abuse treatment programs in Los Angeles County. While in treat-ment, patients rated their counselors on 14 aspects (e.g., empathy, directiveness); I year later they were interviewed for follow-up outcomes. Multiple regression analyses were conducted using patients' ratings of their counselors to assess the impact of these ratings on treatment retention and follow-up outcomes (i.e., severity of alcohol use, drug use, and psychiatric status as measured by the Addiction Severity Index). Results revealed that patients' positive perceptions of their counselors were significantly associated with a longer length of stay in treatment for the outpatient drug free/day treatment and residential treat-ment sub-samples. Patients' positive perceptions were also significantly associated with better psychiatric-functioning at follow-up, but had a limited relationship to severity of alcohol use and no relation to severity of drug use.

Does the treatment of attention-deficit/hyperactivity disorder with stimulants contribute to drug use/abuse? A 13-year prospective study.

Barkley RA; Fischer M; Smallish L; Fletcher K. Pediatrics 111(1): 97-109, 2003. (74 refs.)
Objective. To examine the impact of stimulant treatment during childhood and high school on risk for substance use, dependence, and abuse by young adulthood. Methods. A total of 147 clinic-referred hyperactive children were followed approximately 13 years into adulthood (mean: 21 years old; range: 19-25). At adolescent (age 15) and adult follow-up, probands were interviewed about their use of various substances and duration of stimulant treatment. Results. Duration of stimulant treatment was not significantly associated with frequency of any form of drug use by young adulthood. Stimulant-treated children had no greater risk of ever trying drugs by adolescence or any significantly greater frequency of drug use by young adulthood. Stimulant treatment in high school also did not influence drug use in adulthood except for greater use of cocaine. This difference was no longer significant after controlling for severity of attention-deficit/hyperactivity disorder and conduct disorder in childhood, adolescence, and adulthood. Stimulant treatment in either childhood or high school was not associated with any greater risk for any formal Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised drug dependence or abuse disorders by adulthood. Treatment with stimulants did not increase the risk of ever having tried most illegal substances by adulthood except for cocaine. Subsequent analyses showed that this elevated risk was primarily mediated by severity of conduct disorder by young adult-hood and not by stimulant treatment in childhood. Con-clusion. This study concurs with 11 previous studies in finding no compelling evidence that stimulant treatment of children with attention-deficit/hyperactivity disorder leads to an increased risk for substance experimentation, use, dependence, or abuse by adulthood.

Clinically useful assessments: Substance use and comorbid psychiatric disorders.

Carey KB. Behaviour Research and Therapy 40(11): 1345-1361, 2002. (70 refs.)
This review addresses the assessment of substance use and related constructs with persons having severe and per-sistent mental illness. The review contains two major sections. The first section focuses on issues particular to the assessment of substance use and abuse in the context of major mental illness; these include the social and motiva-tional context of assessment, the impact of mental status and acute symptoms, limitations associated with acute and chronic cognitive impairment, and the psychosocial relevance of assessment items. The second section highlights a selected set of substance assessment tools for use with. this population; evidence for the reliability, validity, and/or feasibility of these tools is summarized. Each instrument meets the criteria of being: (a) relatively brief; (b) easy to administer and interpret; and (c) useful for treatment planning, motivational feedback, and/or monitoring change.

Factors associated with completion of a drug treatment court diversion program.

Butzin CA; Saum CA; Scarpitti FR. Substance Use & Misuse 37(12/13): 1615-1633, 2002. (30 refs.)
Factors related to successful completion of a first offender diversion program were examined from initial data of a longitudinal study of drug treatment court outcomes in Delaware. The strongest predictors of success were factors associated with social stakeholder values, especially those involving employment. Other factors associated with pro-gram completion included race, education, and frequency of drug use. While the overall success of drug treatment courts continues to be documented, these data suggest success varies with individual characteristics. The continuing study will explore whether these characteristics are also related to subsequent outcomes, especially drug use relapse and criminal recidivism, over a 24-month post-treatment period.

Matching substance abuse aftercare treatments to client characteristics.

Brown TG; Seraganian P; Tremblay J; Annis H. Addictive Behaviors 27(4): 585-604, 2002. (50 refs.)
This study investigated matching client attributes to different aftercare treatments. A naturalistic sample of adults entering substance abuse treatment was randomized into either Structured Relapse Prevention (RP, n=61) or a 12-Step Facilitation (TSF, n=72) aftercare program. Four patient attributes were matched to treatment: age, gender, substance abuse profile, and psychological status. Sub-stance use outcomes were assessed 3 and 6 months post-treatment. At 6 months, four significant matches were uncovered. Females and individuals with a multiple sub-stance abuse profile reported better outcomes with TSF aftercare than their cohorts exposed to RP aftercare. Individuals with high psychological distress at treatment entry were able to maintain longer periods of posttreatment abstinence with TSF aftercare compared to their cohorts exposed to RP. Inversely, RP was found to maintain abstinence significantly longer for individuals reporting low distress compared to those with high distress. Finally, better outcomes were achieved when assignment to aftercare was consistent with participant preference. Over-all, an Alcoholics Anonymous approach to aftercare appears to provide the most favorable substance use out-comes for most groups of substance abusers. RP may be most suitable for clients whose psychological distress is low, especially where maintenance of abstinence is target-ed. Where choice in aftercare program is possible, matching client preference with type of aftercare program can improve outcome.

Development and consequences of cannabis dependence.

Budney AJ; Moore BA. Journal of Clinical Pharmacology 42(11 Supplement): 28S-33S, 2002. (41 refs.)
The past 10 to 15 years of clinical and basic research have produced strong evidence demonstrating that cannabis can and does produce dependence. Clinical and epidemiological studies indicate that cannabis dependence is a relative-ly common phenomenon associated with significant psychosocial impairment. Basic research has identified a neurobiological system specific to the actions of cannabinoids. Human and nonhuman studies have demonstrated a valid withdrawal syndrome that is relatively common among heavy marijuana users. Last, clinical trials evaluating treatments for cannabis dependence suggest that this disorder, like other substance dependence disorders, is responsive to intervention, yet the majority of patients have difficulty achieving and maintaining abstinence. Of concern, treatment seeking for marijuana dependence has increased almost twofold over the past 10 years. This report briefly reviews selected research literature relevant to our current understanding of cannabis dependence, its associated consequences, and treatment efficacy.

Programmes for the children of illicit drug-using parents: Issues and dilemmas. (review).

Banwell C; Denton B; Bammer G. Drug and Alcohol Review 21(4): 381-386, 2002. (31 refs.)
Concern about the health and general well-being of children whose parents use illicit drugs has contributed to an increased interest in intervention programmes, but the number of such services is still limited. We review published papers about residential, home-visiting and non-residential programmes and use these and our experience in studying playgroup-based clinics to outline issues and dilemmas they face. These include balancing trust and acceptance with intervention when problems are identified, harmonizing accessibility and flexibility with the provision of child-focused activities and adult education, finding a location that is both suitable and affordable, appropriately supporting staff, collaborating with other services and securing adequate funding, including for ongoing evaluation and monitoring.

The RAFFT as a screening tool for adult substance use disorders.

Bastiaens L; Riccardi K; Sakhrani D. American Journal of Drug and Alcohol Abuse 28(4): 683-693, 2002. (14 refs.)
The purpose of this study was to evaluate the specificity and sensitivity of the RAFFT, a brief screening tool, in adult patients with substance use disorders (SUD) when presenting to a psychiatric emergency room. A total of 215 patients were evaluated with the RAFFT, the CAGE, the Mini International Neuropsychiatric Interview, and urine drug screens. The RAFFT performed well in adults with SUD and was not influenced by factors such as gender, race, socioeconomic status, or the coexistence of psych-iatric disorders. In alcohol use disorders, the CAGE per-formed better than the RAFFT, due to the lower specificity (or more false positive answers) of the latter.

Nicotine intervention during detoxification and treatment for other substance use.

Gait P; Alterman A; Mulvaney F; Mechanic K; Dhopesh V; Yu E et al. American Journal of Drug and Alcohol Abuse 28(4): 673-681, 2002. (8 refs.)
This preliminary study evaluated the efficacy of a brief smoking cessation intervention (30 controls, 34 intervention groups) on a smoke-free inpatient unit for substance use detoxification. Controls received usual care, including the transdermal nicotine patch and referral to an outpatient smoking program. The intervention group additionally received a structured motivational enhancement program.. Biochemically confirmed smoking cessation rate and abstinence reduction of alcohol or other drug use were the main outcome measures taken 6 months after treatment initiation. The smoking cessation intervention did not result in greater participation in formal outpatient smoking cessation treatment and was not associated with either enhanced smoking cessation (6 vs. 0%) or greater smoking reduction at follow-up. Both groups significantly reduced the number of cigarettes smoked per day (cpd) from about 24 at baseline to 10 cpd. The groups did not differ on abstinence from non-nicotine addictive substances. Smoking cessation treatment in substance users undergoing detoxification resulted in little or no smoking cessation advantage.