CORK Newsletter. Clinical Issues. Winter 2003

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...on Substance Abuse and Clinical Issues

www.ProjectCork.org

Winter 2002/03

A brief telephone intervention targeting treatment engagement from a substance abuse program wait list.

Parker JD; Turk CL; Busby LA. . Journal of Behavioral Health Services & Research 29(3): 288-303, 2002. (32 refs.)
This study compares three brief participant-initiated telephone interventions aimed at enhancing treatment engagement of individuals on a substance abuse treatment wait list. Policies requiring that wait list members call at least every other week in order to remain eligible for treatment remained in place for the standard and enhanced conditions but not for the voluntary condition. The standard condition was a minimal intervention, providing information on the program. The enhanced condition focused on client motivation for treatment and recovery. If individuals in the voluntary condition called, they were provided information about current wait list number and approximate remaining wait time. The rate of treatment engagement was the same among treatment conditions. The best predictor of engagement was the number of calls placed to the program while waiting. Treatment condition was a positive predictor of call frequency; presence of a comorbid psychiatric diagnosis was a negative predictor. The article also discusses future directions.

Bystander resuscitation attempts at heroin overdose: Does it improve outcomes?

Dietze P; Cantwell K; Burgess S. . Drug and Alcohol Dependenc 67(2): 213-218, 2002. (24 refs.)
Study objective: To document the characteristics and effectiveness of cardiopulmonary resuscitation (CPR) at non-fatal heroin overdose events in Melbourne, Australia. Methods: A retrospective analysis of a computerised database of ambulance attendance records at non-fatal heroin overdose cases for the period 1/12/1998 to 31/7/2000 was undertaken. Main outcome measures: The main outcome measure was the rate of patient hospitalis-ation. The rate of CPR administration at heroin overdose cases was also examined, along with characteristics of the attendance, such as the age and sex of the overdose case, the relationship of person providing CPR to the overdose case as well as the location, time and date of the event. Results: CPR was administered prior to ambulance arrival in 579 heroin overdose cases (9.4% of total heroin overdose cases attended) between 1/12/98 and 31/7/2000. A greater proportion of female overdose cases were administered CPR than males and CPR administrations were evenly distributed across attendances occurring in private and public locations. Bystander administration of CPR prior to ambulance attendance resulted in a significantly lower rate of heroin user hospitalisation (14.5%) compared to cases where bystander CPR was not administered (18.8%). Conclusions: While CPR administration prior to ambulance attendance at heroin overdose events is relatively uncommon (especially compared to out-of-hospital cardiac arrest), such administration was associated with a statistically signif-icant improvement in clinical outcomes in cases of non-fatal heroin overdose. These findings suggest that the provision of CPR training to people likely to come into contact with heroin overdose events may be an effective strategy at minimising consequent overdose-related harm.

A vulnerable population in a time of crisis: Drug users and the attacks on the World Trade Center.

Weiss L; Fabri A; McCoy K; Coffin P; Netherland J; Finkelstein R. . Journal of Urban Healt 79(3): 392-403, 2002. (27 refs.)
In this article, we present preliminary findings from a qualitative study focused on the impact of the World Trade Center attacks on New York City residents who are current or former users of heroin, crack, and other forms of co-caine. In it, we present data describing their responses to and feelings about the attacks, changes in drug use after the attacks, and factors affecting changes in use. Our analysis is based on 57 open-ended interviews conducted between October 2001 and February 2002. The majority of study participants reported that the attacks had a signifcant emotional impact on them, causing anxiety, sadness, and anger. Several described practical impacts as well, include-ing significant reductions in income. On September 11th and the weeks and months that followed, several partici-pants who had been actively using did increase their use of heroin, crack, and/or other forms of cocaine. Reductions in use were, however, as common over time as were increases. There was some relapse among former users, but this was limited to those who bad stopped using drugs within the 6 months immediately preceding the attacks. A diverse set of factors interacted to control use. For some participants, these factors were internal, relating to their individual motivations and drug use experiences. Other participants were essentially forced to limit use by marked reductions in income. For others, access to health and social service professionals, as well as drug treatment, proved to be key.

A randomized trial of two methods for engaging treatment-refusing drug users through concerned significant others.

Meyers RJ; Miller WR; Smith JE; Tonigan JS. . Journal of Consulting and Clinical Psychology 70(5): 1182-1185, 2002. (21 refs.)
In a randomized clinical trial, 90 concerned significant others (CSOs) of treatment-refusing illicit drug users were assigned to either (a) community reinforcement and family training (CRAFT), which teaches behavior change skills; (b) CRAFT with additional group aftercare sessions after the completion of the individual sessions; or (c) Al-Anon and Nar-Anon facilitation therapy (Al-Nar FT), All protocols received 12 hr of manual-guided individual treatment. Follow-up rates for the CSOs were consistently at least 96%. The CRAFT conditions were significantly more effective than Al-Nar FT in engaging initially unmotivated drug users into treatment. CRAFT alone engaged 58.6%, CRAFT + aftercare engaged 76.7%, and Al-Nar FT engaged 29.0%. No CSO engaged a treatment-refusing loved one once individual sessions had been completed.

Abuse liability in opioid therapy for pain treatment in patients with an addiction history.

Weaver M; Schnoll S. . Clinical Journal of Pain 18(4 Supplement): S61-S69, 2002. (19 refs.)Patients may present to physicians with complaints of acute or chronic pain. Some of these patients will have a history of addiction to drugs or alcohol, and a few will have active addiction. Controlled- substance prescriptions, especially opioid pain medications, can be very beneficial for treatment of pain in patients. There are clear differ-ences between physical dependence on medication, active addiction, addiction in remission, and pseudo-addiction. A search of the medical literature revealed different rates of addiction in patients with chronic pain because different criteria were used to define addiction and the types of chronic pain. It appears that rates of addiction in patient populations with chronic pain are no different than rates of addiction in the general population, according to some recent studies. "Drug-seeking behavior" may be seen with either active addiction or pseudo-addiction. A way to dis-tinguish between these conditions is by giving the patient more pain medication and observing the patient's pattern of behavior. Some patients may be at higher risk to abuse prescription opioids, and some types of drug-seeking behavior may be more predictive of active addiction than pseudo-addiction. General guidelines can improve physicians' comfort level in prescribing opioids for patients with chronic pain, even those with a history of addiction. These include using a medication agreement or contract, setting appropriate goals with the patient, giving appropriate amounts of pain medication, monitoring with drug screens and pill counts, and documenting the case carefully. Even patients with a history of addiction can benefit from opioid pain medications if the patients are monitored appropriately.

An information-processing analysis of mindfulness: Implications for relapse prevention in the treatment of substance abuse. (review).

Breslin FC; Zack M; McMain S. . Clinical Psychology: Science and Practice 9(3): 275-299, 2002. (154 refs.)
This article provides a cognitive framework for integrating mindfulness meditation into substance abuse treatment. We review recent developments in cognitive theory and treatment research that point toward mindfulness medita-tion as a useful additional strategy for reducing relapse. Although the idea of using meditation to reduce substance use is not new, there are several reasons for further exploring the relevance of mindfulness for addiction treatment. This article reviews the cognitive-behavioral formulation of relapse, evaluations of mindfulness meditation as a component of the treatment of psycho-pathology, and the role of information processes in relapse. We also present an information-processing analysis of how mindfulness can help prevent relapse and discuss its utility and clinical implications.

Assessment for addiction in pain-treatment settings.

Savage SR. . Clinical Journal of Pain 18(4 Supplement): S28-S38, 2002. (31 refs.)
The identification of the disease of addiction is important to safe and effective clinical management of pain in persons with addictive disorders. The disease of addiction affects approximately 10% of the general population, and its prevalence may be higher in subpopulations of patients with pain. The presence of active addiction may facilitate the experience of pain. Both active and recovering addiction may complicate the use of medications, such as opioids, important to the management of pain. There is, further, persistent misunderstanding among health care providers, regulators, and the general population regarding the nature and manifestations of addiction that may result in under treatment of pain and stigmatization of patients using opioids for pain control. The author seeks to clarify understanding of addiction, to underscore the importance of identifying addiction in the context of pain treatment, and to provide a rational approach to assessment for addiction in patients with pain. Current scientific under-standing of addiction as a chronic illness is briefly reviewed. Recent definitions related to addiction are presented. The impact of addictive disorders on pain and pain treatment are explored. The roles of medical interview, physical examination, laboratory studies, and standard addiction screening tools in assessing for addiction are outlined. Differential considerations in distinguishing therapeutic use of opioids for analgesia from addictive or other nontherapeutic use of opioids are discussed. In summary, the article provides salient background and a detailed approach to assessment for addictive disorders in the context of pain treatment.

Cannabis use and psychosis: A longitudinal population-based study.

van Os J; Bak M; Hanssen M; Bijl RV; de Graaf R; Verdoux H. . American Journal of Epidemiology 156(4): 319-327, 2002. (41 refs.)
Cannabis use may increase the risk of psychotic disorders and result in a poor prognosis for those with an established vulnerability to psychosis. A 3-year follow-up (1997-1999) is reported of a general population of 4,045 psychosis-free persons and of 59 subjects in the Nether-lands with a baseline diagnosis of psychotic disorder. Substance use was assessed at baseline, 1-year follow-up, and 3-year follow-up. Baseline cannabis use predicted the presence at follow-up of any level of psychotic symptoms (adjusted odds ratio (OR) = 2 76, 95% confidence interval (Cl): 1.18, 6.47), as well as a severe level of psychotic symptoms (OR = 24.17, 95% Cl: 5.44, 107.46), and clin-ician assessment of the need for care for psychotic symp-toms (OR = 12.01, 95% Cl: 2.24, 64.34). The effect of baseline cannabis use was stronger than the effect at 1-year and 3-year follow-up, and more than 50% of the psychosis diagnoses could be attributed to cannabis use. On the additive scale, the effect of cannabis use was much stronger in those with a baseline diagnosis of psychotic disorder (risk difference, 54.7%) than in those without (risk difference, 2.2%; p for interaction = 0.001). Results confirm previous suggestions that cannabis use increases the risk of both the incidence of psychosis in psychosis-free persons and a poor prognosis for those with an established vulnerability to psychotic disorder.

Atheists, agnostics and Alcoholics Anonymous.

Tonigan JS; Miller WR; Schermer C. . Journal of Studies on Alcoho 63(5): 534-541, 2002. (35 refs.)
Objective: In spite of the strong emphasis in AA on spiritual beliefs and practices, findings are mixed about the importance of such beliefs in predicting AA affiliation. This study of the Project MATCH outpatient (N = 952) and aftercare (N = 774) samples tested three hypotheses about the role of client God belief and subsequent AA attendance and benefit, taking into account that some individuals may, in fact, deny the existence of a God. Method: Longitudinal analyses were conducted (N = 1,526) investigating client God beliefs, AA attendance, patterns of AA attendance and alcohol use. Assessments were conducted at intake and in 3-month intervals using the Form 90, Religious Behaviors and Background, and the Alcoholics Anonymous Inventory. Results: 12-Step treatment was significantly more likely to promote pre-post shifts in client God beliefs, and atheist and agnostic clients attended AA significantly less often throughout follow-up relative to clients self-labeled as spiritual and religious. AA attendance, however, was significantly associated with increased abstinence and reductions in drinking intensity regardless of God belief. Finally, no differences in percent days abstinence and drinking intensity were found between atheist and agnostic versus spiritual and religious clients, but clients unsure about their God belief reported significantly higher drinking frequency relative to the other groups. Conclusions: God belief appears to be relatively unimportant in deriving AA-related benefit, but atheist and agnostic clients are less likely to initiate and sustain AA attendance relative to spiritual and religious clients. This apparent reticence to affiliate with AA ought to be clinically recognized when encouraging AA participation.

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 posttreatment. At 6 months, four significant matches were uncovered. Females and individuals with a multiple substance abuse profile reported better alcohol outcomes with TSF aftercare than their cohorts exposed to R-P 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 random assignment to aftercare was consistent with participant preference. Overall, an Alcoholics Anonymous approach to aftercare appears to provide the most favorable substance use outcomes for most groups of substance abusers. RP may be most suitable for clients whose psychological distress is low, especially where maintenance of abstinence is targeted. Where choice in aftercare program is possible, matching client preference with type of aftercare program can improve outcome.

Mood and anxiety symptoms among 140 children from alcoholic and control families.

Preuss UW; Schuckit MA; Smith TL; Barnow S; Danko GP. . Drug and Alcohol Dependence 67(3): 235-242, 2002. (27 refs.)
Objective: Children of alcoholics have been reported to have elevated levels of internalizing symptoms, including anxiety and depression. However, many studies have not adequately controlled for the influence of independent (i.e. not substance-induced) parental mood or anxiety disorders and other factors. The present evaluations assess the relationships of the family histories of alcohol use disorders and independent mood and anxiety disorders to internalizing symptoms in children of alcoholic and nonalcoholic subjects. Method: A behavioral checklist and a structured interview were administered to the parents of 140 children aged 7-18 years. The fathers of these offspring had been recruited 15 years previously from a university population to participate in a prospective study of 453 men from alcoholic and nonalcoholic families. Results: While a higher score for one of four measures of internalizing symptoms in the children was found to relate to a higher density of alcoholic relatives, this pattern was more robust in children of parents with mood or anxiety disorders. In a hierarchical regression, the family history of alcohol use disorders did not add significantly to the prediction of any of the four internalizing scores in the children after considering the impact of a family history of independent mood and anxiety disorders. Conclusions: The results indicate that internalizing symptoms in children of alcoholics were more strongly influenced by a positive family history of mood and anxiety disorders than the family history of alcohol use disorders.

Clients with substance abuse and mental health concerns: A guide for conducting intake interviews.

Brems C; Johnson ME; Namyniuk LL. . Journal of Behavioral Health Services & Research 29(3): 327-334, 2002. (32 refs.)
Although comorbidity (co-occurrence of a psychiatric and substance use disorder) is a common phenomenon at both mental health and substance abuse treatment agencies, rarely do such agencies thoroughly assess for both types of diagnoses during their standard intake interview. This article describes the development of an intake from designed to guide a comprehensive assessment of both mental health and substance abuse concerns. The form guides intake interviewers toward documenting administrative and demographic information, substance use and mental health concerns, and variables needed for compliance with grant funding sources. Use of the protocol can provide a clinical foundation for treatment planning and continuity of care for clients, while also providing error-free agency data that can be used for administrative, program planning, outcome assessment, and research purposes.

The behavioral and cognitive effects of two benzodiazepines associated with drug-facilitated sexual assault.

Dowd SM; Strong MJ; Janicak PG; Negrusz A. . Journal of Forensic Sciences 47(5): 1101-1107, 2002. (23 refs.)
Recently, sexual assaults have included the use of benzodiazepines to impair the victim. Our aim was to examine the physiological, cognitive, and behavioral effects of flunitrazepam (FN) and clonazepam (CLO). In the first study, ten healthy volunteers received a single oral dose of 2 mg of FN. Mini Mental State Examination (MMSE), behavioral reports and staff observations were then collected. In the second study, ten healthy volunteers received a single oral dose of 3 mg of CLO Vitals signs, performance on the MMSE and Digit Symbol Substitution Test, and behavioral changes were examined. FN significantly decreased systolic and diastolic blood pressure 4 h post drug ingestion with diastolic remaining low at 6 h. CLO was associated with changes in temperature and decreased systolic pressure. FN affected memory and attention 4 h following ingestion. CLO affected memory and attention throughout the study (6 h), and psychomotor performance was decreased 2 h post ingestion. In both studies, subjects were disinhibited and did not perceive their own impairment.

The five-year predictive validity of each of the seven DSM-IV items for alcohol dependence among alcoholics.

Schuckit MA; Danko GP; Smith TL; Buckman KR. . Alcoholism: Clinical and Experimental Research 26(7): 980-987, 2002. (46 refs.)
Background: Information about the prognostic impli-cations of a DSM-IV diagnosis of alcohol dependence is important to both clinicians and researchers. In this regard, only limited data are available on the performance of specific diagnostic items. Methods: This study reports data gathered with a structured, validated interview with 642 alcohol-dependent men and women from the Collaborative Study of the Genetics of Alcoholism (COGA). The goals were to evaluate the ability of each of the DSM-IV dependence items to predict the occurrence over the next 5 years of a broad pattern of 27 alcohol-related problems. For comparison, similar data are reported regarding the performance of abuse criteria for 516 additional subjects. Results: The results revealed that dependence item 3 (use of alcohol in larger amounts) was the only criterion that did not relate significantly to outcome, and indicated that the dependence criteria related relatively similarly to different types of outcomes among alcoholics. No specific combination of diagnostic items stood out in predicting outcome but, rather, the span of items generally performed well. Conclusions: These data support the potential usefulness of the DSM- IV dependence criteria.

Voucher-based incentives: A substance abuse treatment innovation.

Higgins ST; Alessi SM; Dantona RL. . Addictive Behavior s 27(6): 887-910, 2002. (58 refs.)
In this report we provide an overview of research on the voucher- based incentives approach to substance abuse treatment. This approach was originally developed as a novel method for improving retention and increasing cocaine abstinence among cocaine-dependent outpatients. The efficacy of vouchers for those purposes is now well established, and plans are underway to move the intervention into effectiveness testing in community clinics. The use of vouchers also has been extended to the treatment of alcohol, marijuana, nicotine, and opioid dependence. Particularly noteworthy is that vouchers hold promise as an efficacious intervention with special populations of substance abusers, including pregnant and recently postpartum women, adolescents, and those with serious mental illness. Overall, voucher-based incentives hold promise as an innovative treatment intervention that has efficacy across a wide range of substance abuse problems and populations.

Women who marry men with alcohol-use disorders.

Schuckit MA; Smith TL; Eng MY; Kunovac J. . Alcoholism: Clinical and Experimental Research 26(9): 1336-1343, 2002. (46 refs.)
Background: Women who marry men with alcohol-use disorders (AUDs) might have unique characteristics that could affect the clinical course of their partner's AUD and the risk for problems in the offspring. Most data available on spouses of such men come from subjects in treatment, which might bias results to more severely impaired individuals. Our data were gathered as part of a prospec-tive study of an original sample of 453 sons of alcoholics and controls who were originally selected as students or nonacademic staff at a university. Methods: Personal interviews were performed with 327 women who were married to men who had been personally evaluated on multiple occasions over the prior 15 years. The data compare characteristics of the 235 women (71.9%) whose husbands had never developed alcohol abuse and dependence with the 92 (28.1%) for whom these disorders had been documented. Results: The women who married men with an AUD were less likely to be homemakers, were more likely to meet criteria for alcoholism (especially abuse) themselves, were more likely to report use of illicit substances, and to be current smokers. However, spouses of men with AUDs in this highly functional sample had no higher risk for other major psychiatric disorders and did not report a higher rate of alcohol abuse or dependence or psychiatric conditions in their parents. Conclusions: The results demonstrate increased risks for the use of illicit substances and for AUDs in women married to alcoholics, despite the overall high level of functioning of the sample. This information may be relevant to enhancing our understanding of the environment in which their offspring are being raised. The descriptive aspects of the work might also help researchers and clinicians working with alcoholic families.

How is excessive drinking maintained? Untreated heavy drinkers' experiences of the personal benefits and drawbacks of their drinking.

Orford J; Dalton S; Hartney E; Ferrins-Brown M; Kerr C; Maslin J. . Addiction Research & Theory 10(4): 347-372, 2002. (34 refs.)
>The present paper reports results from a larger study of 500 heavy drinkers (men drinking more than 50 units of alcohol per week, women more than 35 units), untreated for their drinking within the last ten years, recruited by advertising and snowballing in the English West Midlands. Data on participants' perceived benefits and drawbacks of their own drinking were obtained by 1) a computer-administered set of ratings of benefits and drawbacks in thirteen life domains, and 2) open-ended interviewing with a sub-sample of 50 participants leading to qualitative analysis of post-interview reports and transcripts. The main findings were: perceived benefits outweighed drawbacks in both forced-choice ratings and open-ended interview; there was a small but significant correlation between drinking large quantities in a day and perceived drawbacks; social benefits and drawbacks were dominant in open-ended interview; enhancement and coping benefits were linked by the concept of 'relaxation' and were difficult to distinguish; becoming argumentative and aggressive with friends and family was the dominant drawback in open-ended interview; in the health domain, toxic and short-term drawbacks were more salient than longer-term illness effects. These findings suggest a model of the perceived benefits and drawbacks of heavy drinking which challenges both conventional health promotion efforts and motivational balance models of alcohol consumption.

Personal drinking and sociocultural drinking norms: A representative population study.

Wild TC. Journal of Studies on Alcohol 63(4): 469-475, 2002. (30 refs.)
>Objective: This study examined relationships between personal drinking and perceived social norms for alcohol use. It was hypothesized that frequent heavy drinkers (i.e., those consuming five or more drinks at least once a week or greater in the last 12 months) would exhibit biases in sociocultural expectations for alcohol use. Method: A representative sample of Ontario residents who had consumed alcohol in the previous 12 months (N = 937, 51.8% women, mean [SD] age = 42.7 [15.2] years) compared their own alcohol use with the drinking habits of friends, coworkers and the general public, Respondents rated the importance of seven psychosocial factors that might define "problem drinking" and estimated the number of drinks social and problem drinkers are likely to have in different contexts. Results: Compared with lighter drinkers, frequent heavy drinkers (1) believed that heavy alcohol use is more normative in social reference groups, (2) overestimated the amount of alcohol that social and problem drinkers consume in different contexts, (3) rated several criteria (e,g., frequency of intoxication) as less definitive of problem drinking and (4) did not exhibit pluralistic ignorance (i.e., they shifted private approval of the drinking habits of others to match [mistaken] social norms of reference groups). Conclusions: Frequent heavy drinkers calibrate their beliefs about drinking in reference groups in order to view their drinking as normative. Results are discussed in relation to the development of brief public health interventions.