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...on Clinical Issues
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www.ProjectCork.org
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Spring 2004
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Treating distressed couples with coexisting mental and physical disorders: Directions for clinical training and practice.
Snyder DK; Whisman MA. Journal of Marital and Family Therapy 30(1): 1-12, 2004. (61 refs.)
Relationship difficulties frequently coexist with significant emotional, behavioral, and physical health problems in one or both partners. Moreover couple therapists report individual emotional and behavioral disorders as among the most difficult problems that they encounter in clinical practice. In this article, we summarize empirical evidence regarding the association between relationship distress and the onset, course, and treatment of mental and physical health problems. Based on these findings, we propose five critical implications for clinical training and the practice of couple therapy. Copyright 2004, American Association of Marriage and Family Therapy.
Alcohol relapses associated with September 11, 2001: A case report. .
Zywiak WH; Stout RL; Trefry WB; LaGrutta JE; Lawson CC; Khan N et al. . Substance Abuse 24(2): 123-128, 2003. (8 refs.)
The timing of the terrible events of September 11, 2001 (9-11), and an ongoing randomized clinical trial of case monitoring have allowed a prospective examination of the effects of trauma upon the relapse rates of a group of clients following alcohol detoxification. The clients studied in this report were enrolled in case monitoring prior to 9-11. Case monitoring consists of telephone contacts on a tapering schedule designed to help clients avoid relapses, reduce the severity of relapses that do occur, and get clients back into treatment, at less intense levels, than would occur without case monitoring. For those clients completing a telephone contact before and a telephone contact after 9-11, none of the clients drank between detox discharge and 9-11, while 42% drank by the first telephone contact after 9-11. Data from another study were analyzed and results counter the rival hypothesis that the case monitoring study results reflect an annual seasonal effect. Results suggest that terrorist events may lead to a greater likelihood of relapse for those in alcohol recovery. These effects may be ameliorated by public education and outreach. Copyright 2003, Association for Medical Education & Research in Substance Abuse.
Pleasure drugs and classical virtues: Temperance and abstinence in U.S. religious thought. .
Bischke PN. . International Journal of Drug Policy 14(3): 273-278, 2003. (29 refs.)
This essay considers U.S. Christian attitudes toward psychoactive substances. It presents classical Christian thought and the opinions of major historical church figures about pleasure drugs (especially alcohol) for comparison with contemporary attitudes about licit and especially illicit pleasure drugs (cannabis, cocaine, etc.). The Four Cardinal Virtues of Thomas Aquinas are the primary analytic rubric but selected Protestant denominational leaders are also cited. U.S. drug policies are critiqued in light of each virtue. The active moral character of the virtues is contrasted with the authoritarian and conformist aspects of abstinence ideology. The rhetoric and diverse viewpoints of the so-called Temperance Era are also considered. Copyright 2003, Elsevier Science, Ltd.
Alcoholism and seasonal affective disorder. .
Sher L. . Comprehensive Psychiatry 45(1): 51-56, 2004. (72 refs.)
Seasonal changes in mood and behavior (seasonality) may be closely related to alcoholism. Some patients with alcoholism have a seasonal pattern to their alcohol misuse. They may be self-medicating an underlying seasonal affective disorder (SAD) with alcohol or manifesting a seasonal pattern to alcohol-induced depression. Both genetic and environmental factors play a role in the etiology and pathogenesis of alcoholism and SAD, operating, at least in part, through the brain serotonergic system. Family and molecular genetic studies suggest that there may be a genetic link between seasonality and alcoholism. Certain environmental and social factors may contribute to the development of seasonality in patients with alcoholism. The fact that SAD and alcoholism may be comorbid shows the importance of a thorough diagnostic interview. Both mental health and drug and alcohol professionals should be provided with education to assist with appropriate identification, management, and referral of patients presenting with comorbid alcoholism and SAD. Copyright 2004, W.B. Saunders Co.
Between a rock and a hard place: The role of relatives in protecting children from the effects of parental drug problems. .
Barnard M. . Child & Family Social Work 8(4): 291-299, 2003. (21 refs.)
Using qualitative data gathered from 62 problem drug using parents in Glasgow, Scotland, this paper explores the role played by the extended family in protecting children from some of the negative effects of parental drug use. However, the data also indicated that the intervention of the extended family, whilst often critical, was not without its tensions and difficulties for parents, for the extended family and for the children too. What seemed to obtain in most cases was a complex and volatile mix of practical and emotional concerns over children's appropriate care and issues of responsibility and obligation to the child. These in turn were overlaid by expressions of anxiety, worry, anger and disappointment over both the parent's drug problem and its profound effect on the family. In a worst case scenario it can lead to a breakdown of these care arrangements, leaving these already vulnerable children exposed to further rupture, emotional damage and instability. If we are to avoid such outcomes it is crucial that we first identify and then work to rectify those factors that compromise the abilities of extended family carers to look after these children both in the short and the longer term. Copyright 2003, Blackwell Publishing.
Dose related risk of motor vehicle crashes after cannabis use. (review). .
Ramaekers JG; Berghaus G; van Laar M; Drummer OH. . Drug and Alcohol Dependence 73(2): 109-119, 2004. (53 refs.)
The role of Delta(9)-tetrahydrocannabinol (THC) in driver impairment and motor vehicle crashes has traditionally been established in experimental and epidemiological studies. Experimental studies have repeatedly shown that THC impairs cognition, psychomotor function and actual driving performance in a dose related manner. The degree of performance impairment observed in experimental studies after doses up to 300 mug/kg THC were equivalent to the impairing effect of an alcohol dose producing a blood alcohol concentration (BAC) greater than or equal to0.05 g/dl, the legal limit for driving under the influence in most European countries. Higher doses of THC, i.e. >300 mug/kg THC have not been systematically studied but can be predicted to produce even larger impairment. Detrimental effects of THC were more prominent in certain driving tasks than others. Highly automated behaviors, such as road tracking control, were more affected by THC as compared to more complex driving tasks requiring conscious control. Epidemiological findings on the role of THC in vehicle crashes have sometimes contrasted findings from experimental research. Case-control studies generally confirmed experimental data, but culpability surveys showed little evidence that crashed drivers who only used cannabis are more likely to cause accidents than drug free drivers. However, most culpability surveys have established cannabis use among crashed drivers by determining the presence
of an inactive metabolite of THC in blood or urine that can be detected for days after smoking and can only be taken as evidence for past use of cannabis. Surveys that established recent use of cannabis by directly measuring THC in blood showed that THC positives, particularly at higher doses, are about three to seven times more likely to be responsible for their crash as compared to drivers that had not used drugs or alcohol. Together these epidemiological data suggests that recent use of cannabis may increase crash risk, whereas past use of cannabis does not. Experimental and epidemiological research provided similar findings concerning the combined use of THC and alcohol in traffic. Combined use of THC and alcohol produced severe impairment of cognitive, psychomotor, and actual driving performance in experimental studies and sharply increased the crash risk in epidemiological analyses. Copyright 2004, Elsevier Science Ltd.
Down your drink: A web-baed intervention for people with excessive alcohol consumption.
Linke S; Brown A; Wallace P. . Alcohol and Alcoholism 39(1): 29-32, 2004. (18 refs.)
Aims: To conduct a pilot study of the usefulness of Down Your Drink (DYD), a web-based intervention to encourage excessive drinkers to adopt a healthy pattern of drinking and reduce alcohol-associated harm. The DYD website was structured as a 6-week programme, derived from a manual which included elements of motivational approaches and cognitive behavioural therapy. Methods: Visitors whose responses to the Fast Alcohol Screening Test were positive, and those indicating excessive alcohol consumption, were encouraged to register. Users completed alcohol dependence and mental health questionnaires before the programme, and a drinking diary at each of the weekly sessions. Follow-up questionnaires were sent electronically to those who completed the programme, or who missed three or more sessions. Results: During the 6-month study there were 7581 visits to the site and 1319 registrations. Of the registrants, 61.8% completed week 1, and 6.0% stayed with the programme until the end. The 6% who stayed for 6 weeks provided encouraging feedback about the value of the site. Little information was obtained from those who dropped out, but some reported that the programme was too time-consuming. Conclusions: Web site interventions for excessive drinkers are feasible and merit evaluation of their effectiveness. Copyright 2004, Oxford University Press.
Driving impairment due to sleepiness is exacerbated by low alcohol intake.
Horne JA; Reyner LA; Barrett PR. . Occupational and Environmental Medicine 60(9): 689-692, 2003. (16 refs.)
To assess whether low blood alcohol concentrations (BACs), at around half the legal driving limit in the United Kingdom, and undetectable by police roadside breath analyzers, further impair driving already affected by sleepiness, particularly in young men, who are the most at-risk group of drivers for having sleep-related crashes. Twelve healthy young men drove for 2 hours in the afternoon, in an instrumented car on a simulated motorway. In a repeated measures, counterbalanced design, they were given alcohol or placebo under conditions of normal sleep or prior sleep restriction. Measurements were driving impairment (lane drifting), subjective sleepiness, and electroencephalogram (EEG) measures of sleepiness. Whereas sleep restriction and alcohol each caused a significant deterioration in all indices, the combined alcohol and sleep restriction further and significantly worsened lane drifting (which is typical in sleep-related crashes). This combined effect was also reflected to a significant extent in the EEG, but not with subjective sleepiness. That is, alcohol did not significantly increase subjective sleepiness in combination with sleep loss when compared with sleep loss alone. It was concluded that modest, and apparently "safe" levels of alcohol intake exacerbate driving impairment due to sleepiness. The sleepy drivers seemed not to have realized that alcohol had increased their sleepiness to an extent that was clearly reflected by a greater
driving impairment and in the EEG. Copyright 2003, BMJ Publishing Group.
Effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting: systematic review.
Emmen MJ; Schippers GM; Bleijenberg G; Wollersheim H. . British Medical Journal 328(7435): 318-320B, 2004. (25 refs.)
Objective To determine the effectiveness of opportunistic brief interventions for problem drinking in a general hospital setting. Design Systematic review. Data sources Medline, PsychInfo, Cochrane Library, reference lists from identified studies and review articles, and contact with experts. Main outcome measure: Change in alcohol consumption. Results: Eight studies were retrieved. Most had methodological weaknesses. Only one study, with a relatively intensive intervention and a short follow up period, showed a significantly large reduction in alcohol consumption in the intervention group. Conclusion: Evidence for the effectiveness of opportunistic brief interventions in a general hospital setting for problem drinkers is still inconclusive. Copyright 2004, British Medical Journal Publishing Group.
Evidence-based practices for substance use disorders. (review).
McGovern MP; Carroll KM. . Psychiatric Clinics of North America 26(4): 991+, 2003. (136 refs.)
There are inherent complexities in evaluating evidence-based practices for substance use disorders: the heterogeneity of the disorder itself, the variability in people who suffer from them, the range of settings in which services are provided, and multiple lines of research development. This article outlines four models for evaluating the evidence for interventions for substance use disorders, and presents brief descriptions of pharmacological, behavioral/psychosocial, and treatment services that have a clearly defined intervention (chemical agent or manual-guided therapy) and a documented record of objective evaluation. Although substantial work is underway to evaluate effectiveness in the real world, clinicians and individuals with substance use disorders and their families should be cognizant of the burgeoning array of effective treatment alternatives that are available. Copyright 2003, W.B. Saunders Inc.
Insomnia, alcoholism and relapse. (review).
Brower KJ. Sleep Medicine Review 7(6): 523-539, 2003. (77 refs.)
Insomnia and alcoholism are significantly associated in community surveys and patient samples. Insomnia occurs in 36-72% of alcoholic patients and may last for weeks to months after initiating abstinence from alcohol. Some correlates of insomnia in alcoholic patients are identical to those observed in non-alcoholic insomniacs, including anxiety and depression, tobacco smoking, and the use of alcohol to aid sleep. Other studies suggest that as the severity of alcoholism increases, so does the likelihood of insomnia in alcoholic patients. In the sleep laboratory, alcoholic patients who complain of insomnia have disrupted sleep continuity when compared to alcoholic patients without insomnia complaints. Recently sober alcoholics are also more likely than non-alcoholics to have sleep-disordered breathing and increased periodic leg movements, which might contribute to insomnia in some alcoholic patients. The co-occurrence of insomnia and alcoholism is clinically significant because alcoholism can exacerbate the adverse consequences of insomnia (e.,. mood changes and performance decrements) and because insomnia among patients entering treatment for alcoholism has been significantly associated with subsequent alcoholic relapse. Baseline polysomnographic correlates of subsequent relapse include prolonged sleep latency, decreased sleep efficiency and total sleep time, increased rapid eye movement sleep pressure, and decreased slow wave sleep.
Whether treatment of insomnia in alcoholic patients reduces relapse rates is unknown, but preliminary treatment guidelines that accommodate the special characteristics of alcoholic patients are provided, with a goal to reduce daytime impairment and psychological distress. Copyright 2003, W. B. Saunders.
Intoxicated weekends: Young adults' work hard-play hard lifestyles, public health and public disorder.
Parker H; Williams L. Drugs: Education, Prevention and Policy 10(4): 345-267, 2003. (17 refs.)
Going out at the weekends binge drinking is a leisure priority of the majority of young English adults. This going-out sector is described via a cohort (n = 465) of 22 year olds who have been tracked by the North West Longitudinal Study (1991-2001) since they were 13. This cohort is made up of conventional, educated and employed young people. However, over half are regular heavy drinkers and occasional recreational drug users. They often mix alcohol and illicit drugs on nights out. Their motives for intoxicated weekends relate to maintaining successful work hard-play hard lifestyles. Most nights out are perceived as functional and enjoyable but some go wrong leading to arguments, fights and assaults (the public disorder agenda) and impaired judgement, illness and accidents (the public health agenda). These negative outcomes are probably inevitable given the scale and functions of nights out. Better management of nightlife requires an integrative strategy which recognizes the added value of focusing on the care and welfare of the overall going-out population rather than targeting 'trouble makers' and reacting to ad hoc disorder and mishap. Copyright 2003, Carfax.
Long-term Influence of duration and frequency of participation in Alcoholics Anonymous on individuals with alcohol use disorders.
Moos RH; Moos BS. Journal of Consulting and Clinical Psychology 72(1): 81-90, 2004. (46 refs.)
This study examined the influence of the duration and frequency of a baseline episode of participation in Alcoholics Anonymous (AA) among 473 individuals with alcohol use disorders on 1-year and 8-year outcomes and the effect of additional participation and delayed participation on outcomes. Compared with individuals who did not participate, individuals who affiliated with AA relatively quickly, and who participated longer, had better 1-year and 8-year alcohol-related outcomes. Individuals who continued to participate, and those who continued longer, had better alcohol-related outcomes than did individuals who discontinued participation, but individuals who delayed participation in AA had no better outcomes than those who never participated. In general, the frequency of participation was independently associated only with a higher likelihood of abstinence Copyright 2004, American Psychological Association.
Marijuana and tobacco: A major connection?
Tullis LM; DuPont R; Frost-Pineda K; Gold MS. Journal of Addictive Diseases 22(3): 51-62, 2003. (21 refs.)
Smoking among teens and college students is a significant public health challenge. Tobacco, marijuana, and alcohol continue to be the most commonly abused drugs by teens and young adults. Educational efforts have resulted in increased awareness of the mortality and morbidity attributed to smoking, second-hand smoke, and prenatal exposure to tobacco. Short- and long-term consequences of marijuana use are well documented in the literature, but they have received less wide spread attention. Even less well known is the relationship between these substances. Does use of one lead to use of the other? Are there synergistic and/or antagonistic effects when these substances are used together? We need answers to these questions to understand the prevalence of use and the impact of these drugs on our nations youth and young adults. The gateway theory of drug use is often used to describe the progression from using alcohol or tobacco, to marijuana, and later use of other drugs like MDMA, cocaine, and heroin. While tobacco use does commonly precede marijuana use, we propose that marijuana may be a "gateway drug" to tobacco smoking. Our research with university students is suggesting that cigarette-smoking initiation often follows or coincides with marijuana use. Copyright 2003, The Haworth Press, Inc.
Pathology or modernity? Rethinking risk factor analyses of young drug users.
Parker H. Addiction Research & Theory 11(3): 141-144, 2003. (7 refs.)
The author argues that there is a need to revise the way risk and protective factors are defined in relation to youthful heavy drinking and now extensive 'recreational' drug use certainly in respect of the UK and Western Europe. The Risk Matrix Paradigm (RMP) which has been been a potent driver of anti-crime and social inclusion programs and has been central to the development of 'preventing' drug 'abuse' is discussed. This paradigm remains robust and practically useful when we apply its methodologies to the UK's young problem drug users. The author concludes that the RMP remains an important conceptual and technical tool but it must become subject to modernization lest it pathologizes young people who as model post-modern consumers are living their lives in a world they did not design. Copyright 2004, Harwood Academic Publishing GMBH.
Pharmacological treatments for heroin and cocaine addiction. (review).
van den Brink W; van Ree JM. European Neuropsychopharmacology 13(6): 476-487, 2003. (133 refs.)
Aims: To provide an overview of the pharmacological options for the treatment of heroin- and cocaine-dependent patients based on known biochemical pathways to addiction and the chronic disease model as a starting point for treatment planning. Results: Recent pre-clinical and clinical studies indicate that different brain structures and different neurotransmitters are involved in different stages of the addiction process. In addition, clinical experience shows that heroin and cocaine addiction can best be conceptualised and treated as a chronic, relapsing disorder with the following treatment goals: crisis intervention, cure or recovery (detoxification, relapse prevention) and care or partial remission (stabilization and harm reduction). The various high-quality studies, systematic literature reviews and formal meta-analyses clearly demonstrate that today many proven effective interventions are available for crisis intervention, detoxification, stabilization and harm reduction for hero in-dependent patients. Interventions directed at relapse prevention are still problematic and only effective in a minority of motivated patients in stable living conditions and adequate social support. In contrast, no proven effective pharmacological interventions are available for the treatment of cocaine-dependent patients, maybe with the exception of some patient groups that seem to benefit from treatment with disulfiram or amantadine.
Treatment innovations are primarily based on experimental animal studies. Newly developed cannabinoid receptor antagonists and cortisol synthesis inhibitors show great promise. Conclusion: Heroin addiction is a chronic relapsing disease that is difficult to cure, but stabilization and harm reduction can greatly increase the life time expectancy and the quality of life of the patient, his direct environment and society as a whole. Currently, no proven effective pharmacological interventions are available for cocaine addiction, and treatment has to rely on existing cognitive behaviour therapies combined with contingency management strategies. Copyright 2003, Elsevier Science BV.
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