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...on Clinical Issues

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Summer 2004

Addiction and spirituality.

Cook CCH. Addiction 99(5): 539-551, 2004. (31 refs.)
Background: Spirituality is a topic of increasing interest to clinicians and researchers interested in addiction. Aims: To clarify the way(s) in which the concept of spirituality is understood and employed in practice by clinicians and researchers who publish papers on addiction and spirituality, and to develop a definition or description of spirituality which might receive widespread assent within the field. Design: A descriptive study of 265 published books and papers on spirituality and addiction. Findings: The study revealed a diversity and lack of clarity of understanding of the concept of spirituality. However, it was possible to identify 13 conceptual components of spirituality which recurred within the literature. Among these conceptual components of spirituality, 'relatedness' and 'transcendence' were encountered most frequently. 'Meaning/purpose', 'wholeness (non-)religiousness' and 'consciousness' were encountered less frequently in the papers on addiction and spirituality than in an unsystematically ascertained sample of papers concerned with spirituality in relation to other areas of psychology and medicine. However, biases in the literature are notable. For example, the great majority of publications are from North America and the field is dominated by interest in Twelve-Step and Christian spirituality. Conclusion: Spirituality, as understood within the addiction field, is currently poorly defined. Thirteen conceptual components of spirituality which are employed in this field are identified provisionally and a working definition is proposed as a basis for future research.

Adherence to court-ordered disulfiram at fifteen months: A naturalistic study.

Martin BK; Clapp, L.; Alfers J; Beresford TP. Journal of Substance Abuse Treatment 26(3): 233-236, 2004. (13 refs.) .)
Previously, we observed that the presence of a court-mandate doubled adherence to supervised disulfiram treatment over voluntary supervised disulfiram treatment during the initial twelve weeks. To assess persistence, we conducted a naturalistic followup study of adherence at 15 months in 19 voluntary and 17 court-ordered patients from the original groups. Treatment adherence, measured by the percentage of completed disulfiram clinic visits during the study period, was significantly higher in court-ordered subjects: 61.0% vs. 18.2% in the voluntary group (p< .0001). The data suggest that court assistance can exert a significant effect in maintaining adherence. Factors mediating adherence, as well as the effects of adherence on behavior change and abstinence, must be determined through prospective, controlled study.

Brief interventions: Good in theory but weak in practice.

Roche A; Freeman T. Drug and Alcohol Review 23(1): 11-18, 2004
A substantial body of research evidence has accumulated in support of the efficacy of brief interventions for a number of alcohol and drug-related problem areas, most notably alcohol and tobacco. This evidence has been used to exhort a range of professional groups such as general practitioners (GPs), and more recently emergency department hospital staff to engage in brief interventions. Internationally, however, these secondary prevention efforts have largely failed. Why have these proven interventions not been embraced by frontline workers? This is a little-asked question as efforts to press-gang unwilling professionals to take up the cudgel continue. This paper examines the characteristics of brief interventions and their principal delivery agents and explores reasons for the failure to move from efficacy to effectiveness. Given the prevention potential that rests with brief intervention, these are crucial questions to address. A key feature of brief intervention delivery also examined is the role of GPs versus the less well-explored option of the practice nurse. It will be proposed that perhaps we have the right vehicle but the wrong driver and that until closer scrutiny is made of this issue efforts in this key prevention area will continue to fail to achieve optimum results.

Binge drinking and health-related quality of life: Do popular perceptions match reality?

Okoro CA; Brewer RD; Naimi TS; Moriarty DG; Giles WH; Mokdad AH. American Journal of Preventive Medicine 26(3): 230-233, 2004. (57 refs.) .)
Background: Popular culture (movies, television shows, advertising) often portrays drinking to the point of intoxication as either humorous or associated with enjoyable social activities that enhance quality of life. This study examined the association between binge drinking (consuming five or more alcoholic drinks on one occasion) and health-related quality of life (HRQOL) among U.S. adults. Methods: Data are from the Behavioral Risk Factor Surveillance System, a continuous random-digit-dial telephone survey of adults aged >18 years conducted in all states. This survey included questions about alcohol consumption and HRQOL. Results: In 2001, 52% of U.S. adults were current drinkers (one or more drinks in the past 30 days). Of current drinkers, 11% were frequent binge drinkers (three or more episodes in past month) and 14% were infrequent binge drinkers (one to two episodes in past month). After adjusting for confounding factors, frequent binge drinkers were more likely than non-binge drinkers to experience greater than or equal to14 unhealthy days (physical or mental) in the past month (adjusted odds ratio [AOR]-1.39, 95% confidence interval [CI]=1.24-1.56), primarily because they had more mentally unhealthy days than non-binge drinkers (AOR=1.52, 95% CI 1.32-1.75).Conclusions: Frequent binge drinking is associated with significantly worse HRQOL and mental distress, including stress, depression, and emotional problems. Effective interventions to prevent binge drinking should be widely adopted and may help improve quality of life.

Controlled drinking: More than just a controversy.

Saladin ME; Santa Ana EJ. Current Opinion in Psychiatry 17(3): 175-187, 2004. (96 refs.)
Purpose of review: We intend to provide clinicians and clinical scientists with an overview of developments in the controlled-drinking literature, primarily since 2000. A brief description of the controversy surrounding controlled drinking provides a context for a discussion of various approaches to controlled drinking intervention as well as relevant clinical research.Recent findings Consistent with previous research, behavioral self-control training continues to be the most empirically validated controlled-drinking intervention. Recent research has focused on increasing both the accessibility/availability and efficacy of behavioral self-control training. Moderation-oriented cue exposure is a recent development in behaviorally oriented controlled drinking that yields treatment outcomes comparable to behavioral self-control training. The relative efficacy of mode ration-oriented cue exposure versus behavioral self-control training may vary depending on the format of treatment delivery (group versus individual) and level of drinking severity. In general, the efficacy of both techniques does not appear to vary as a function of drinking severity but may vary as a function of drinking-related self-efficacy. Guided-self change is a relatively new and brief cognitive-behavioral intervention that has demonstrated efficacy with problem drinkers. Interventions based on harm reduction principles have decreased alcohol use in various student populations. Finally, Moderation Management is the only self-help program that supports non-abstinence goals, a feature that makes it popular with problem drinkers who are avoidant of traditional treatment services. Summary: The controversial past of controlled drinking is slowly giving way to a hopeful future in which individuals are less likely to be forced into an abstinence-only treatment scenario. The enhanced accessibility of effective controlled-drinking interventions should significantly expand the treatment options of individuals within the full spectrum of alcohol-related problems.

Detection of alcohol use disorders in general hospital admissions in the United States.

Smothers BA; Yahr HT; Ruhl CE. Archives of Internal Medicine 164(7): 749-756, 2004. (40 refs.)
Background: Previous studies in which research-based assessment for alcohol problems at admission was compared with physician diagnoses indicated that many alcohol diagnoses in hospitalized patients were missed. We estimated the extent to which hospital records documented detection of alcohol abuse or dependence and other alcohol-related problems in a national sample of hospital admissions having a research-based diagnosis of alcohol use disorder ("interview-positive admissions"). We also estimated rates of inpatient alcohol intervention and referral for treatment. Methods: A complex, multistage, probability sample was designed to represent nonmaternity, acute-care admissions to nonfederal, short-stay, general hospitals in the contiguous United States. The study included 2040 admissions, 1613 male and 427 female. Research-based diagnoses of current (ie, past 12 months) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition alcohol use disorder were derived from a structured, computer-assisted, personal interview containing the Alcohol Use Disorders and Associated Disabilities Interview Schedule. Information on detection, inpatient intervention, and treatment referral were obtained via retrospective analysis of closed hospital records covering the index visit. Results: Record-documented diagnoses of alcohol-related problems were found in 40% to 42% of interview-positive admissions. Inpatient intervention rate was estimated at 21% for interview-positive admissions, and treatment referral rate, 24%. For detected interview-positive admissions, estimated rates of intervention and referral were 50% and 53%, respectively. Conclusions: Estimated rates of detection, inpatient intervention, and treatment referral of alcohol use disorders in hospital admissions were low. Current-drinking hospital admissions should be screened for alcohol problems as part of the admission routine, with further professional evaluation, intervention, and treatment referral as indicated.

Effects of drug treatment for heroin sniffers: A protective factor against moving to injection?

Kelley MS; Chitwood DD. Social Science & Medicine 58(10): 2083-2092, 2004. (42 refs.)
We explore the relationship between contact with treatment and transition to injection for heroin sniffers. Our primary research question is, does contact with treatment delay onset of injection for heroin sniffers? A stratified network-based sample was recruited from multiple communities in South Florida which were known for high drug use. Three categories of respondents were recruited based on injection outcome: long-term injectors, short-term injectors, and sniffers (n = 900). We answer our research question in two steps. First, we investigate the prevalence of drug treatment for heroin sniffers and injectors using case-control methods. The preliminary findings indicate a positive relationship between contact with treatment and injection status outcome. Second, we further examine the relationship by attempting to identify the causal factors that delay initial injection for a subgroup of current injectors using survival regression procedures. Delaying or preventing transition to injection could significantly decrease risk of HIV transmission by reducing or eliminating risky injecting behaviors. We conclude with a discussion of policy implications and suggestions for future research.

Eliciting patients' preferences for cigarette and alcohol cessation: An application of conjoint analysis [rapid communication].

Flach SD; Diener A. Addictive Behavior 29(4): 791-799, 2004. (12 refs.)
The strength and stability of preferences for quitting cigarettes versus alcohol in a population of dual users undergoing treatment was examined using conjoint analysis. Patients at a Veteran's Administration substance abuse treatment center ranked nine vignettes from most to least preferred at baseline and 4 weeks later. The vignettes, using a full factorial design, described health states associated with three levels of substance use. We regressed vignette rankings on the levels of smoking and drinking. A larger regression coefficient indicated a stronger preference for quitting. At baseline and follow-up, the group placed more preference on quitting alcohol than cigarettes (coefficients of 2.23 and 2.35 for alcohol cessation and .51 and .73 for smoking cessation). Some subjects preferred smoking to quitting at baseline (23.9%) and follow-up (23.5%). Over time, 29.4% and 35.3% increased their preference for tobacco and alcohol cessation, while 41.2% and 17.6% decreased their preference for cigarette and alcohol cessation. Preferences for stopping alcohol were stronger than for stopping cigarettes, and many preferences changed after a treatment program

Medicine and morals, craving and compulsion.

Morse SJ. Substance Use & Misuse 39(3): 437-460, 2004. (26 refs.)
Thinking about addictions has been dominated by two models: the medical model, which treats addiction as a disease and related behaviors as signs and symptoms, and the moral model, which views addiction and related behaviors as indication's of moral failure. This article describes both models and their implications, with special emphasis on the moral model. The meaning of compulsion or coercion caused by internal psychological states, such as craving, is explored to determine if addicts may fairly be held morally and legally responsible for their behavior, such as seeking and using substances. It is argued that diminished rationality better explains than compulsion why addicts might be excused for their behavior, but it is concluded that most addicts can be held responsible for most addiction-related behavior. Nonetheless, both models have desirable characteristics, and sound public policy should not be based solely on either. The implications for criminal justice of employing both models to guide policy are explored.

Partner violence before and after couples-based alcoholism treatment for male alcoholic patients: The role of treatment involvement and abstinence.

O'Farrell TJ; Murphy CM; Stephan SH; Fals-Stewart W; Murphy M. Journal of Consulting and Clinical Psychology 72(2): 202-217, 2004. (54 refs.) .)
This study examined partner violence before and after behavioral couples therapy (BCT) for 303 married or cohabiting male alcoholic patients and used a demographically matched nonalcoholic comparison sample. In the year before BCT, 60% of alcoholic patients had been violent toward their female partner, 5 times the comparison sample rate of 12%. In the 1st and 2nd year after BCT, violence decreased significantly from the year before BCT, and clinically significant violence reductions occurred for patients whose alcoholism was remitted after BCT. Structural equation modeling indicated that greater treatment involvement (attending BCT sessions and using BCT-targeted behaviors) was related to lower violence after BCT and that this association was mediated by reduced problem drinking and enhanced relationship functioning.

Sustained increased consumption of cigarettes, alcohol, and marijuana among Manhattan residents after September 11, 2001.

Vlahov D; Galea S; Ahern J; Resnick H; Kilpatrick D. American Journal of Public Health 94(2): 253-254, 2004. (11 refs.) .)
We compared reports of increased substance use in Manhattan 1 and 6 months after the September 11, 2001, terrorist attacks. Data from 2 random-digit-dial surveys conducted 1 and 6 months after September 11 showed that 30.8% and 27.3% of respondents, respectively, reported increased use of cigarettes, alcohol, or marijuana. These sustained increases in substance use following the September 11 terrorist attacks suggest potential long-term health consequences as a result of disasters.

Sublingual cocaine: Novel recurrence of an ancient practice. (review).

Clapp L; Martin B; Beresford TP. Clinical Neuropharmacology 27(2): 93-94, 2004. (7 refs.)
Present knowledge suggests that cocaine is almost always used by snorting, injecting, or smoking. During a recent treatment study, we encountered 2 cases who reported active cocaine use by the sublingual route exclusively. We describe here 1) the method of sublingual use, 2) its attraction for cocaine dependent individuals, especially those who wish to conceal use, and 3) concerns regarding the medical consequences of sublingual cocaine use. Sublingual cocaine use may cause unique medical symptoms and may easily evade detection by medical personnel.

Role induction: A method for enhancing early retention in outpatient drug-free treatment.

Katz EC; Brown BS; Schwartz RP; Weintraub E; Barksdale W; Robinson R. Journal of Consulting and Clinical Psychology 72(2): 227-234, 2004. (36 refs.) .)
Retention in outpatient drug-free treatment is poor, with many clients terminating prior to receiving therapeutic benefit. This randomized clinical trial compared the impact on retention and drug use of an individual role induction session conducted at intake with the standard group orientation offered at the clinic. Results of interim analyses indicated that participants assigned to role induction (n = 180) were retained for more days, more likely to attend at least one postorientation session, and more satisfied with the treatment program than were those assigned to standard treatment (n = 87). Preliminary results suggest that role induction is a brief technique that shows promise for retaining clients through the critical first 3 months of treatment.

Using technical innovations in clinical practice: The Drinker's Check-Up software program.

Squires DD; Hester RK. Journal of Clinical Psychology 60(2): 159-169, 2004. (18 refs.)
Interest in assessing and treating a variety of psychological conditions with software programs is increasing rapidly. This article reviews a software program for problem drinkers entitled the Drinker's Check-Up (DCU) and illustrates its use with three patients. The DCU is based on the principles of brief motivational interventions and can be used as a stand-alone intervention by therapists without expertise in substance abuse or as a prelude to alcohol treatment services. It is the first software program to provide integrated assessment, feedback, and assistance with decision making for individuals experiencing problems with alcohol. Preliminary data from an ongoing clinical trial of the DCU as a stand-alone intervention indicate that it is an effective intervention for a wide range of problem drinkers.

Readiness and stages of change in addiction treatment. (review).

DiClemente CC; Schlundt D; Gemmell L. American Journal on Addictions 13(2): 103-119, 2004. (110 refs.)
Understanding the role of personal motivation in addiction treatment changed with the advent of the Transtheoretical Model of intentional behavior change, a better understanding of relapse, and a shift in focus from denial to readiness. Motivation is a complex concept that covers many diverse aspects of the process of intentional behavior change. This review examines current perspectives on readiness and the stages of change, criticisms and measurement issues, and clinical applications and future research in this area. Although significant challenges remain, properly incorporating the concepts of readiness and the stages of change into addiction treatment enables providers to address the diverse needs of substance abusers and treatment seekers, supports more proactive interventions, creates a concentration on motivational enhancement, and helps researchers understand the larger process of change where addict and treatment provider meet. Better measurement, more frequent assessments, and a better understanding of the stage subtasks and how they relate to readiness and successful change are needed to deepen our understanding of motivation and its role in the treatment of addiction.

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