Library Watch - On Clinical Aspects

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Last Update: 15.12.03

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...on Clinical Aspects

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Winter 2004

Challenge of fetal alcohol syndrome in adult offender populations.

Boland FJ; Chudley AE; Grant BA. Forum on Corrections Research . 14(3): 61-64, 2002. (19 refs.)
Fetal alcohol effects and syndrome (FAE, FAS) in adult offender populations are discussed, with a focus on a proposed reliable and valid method of identifying adult offenders who suffer from fetal alcohol spectrum disorders (FASD). The authors note that individuals suffering from FASD are at high risk for criminal behavior. Additionally, these individuals represent an important subpopulation, with its own unique needs, within the adult prison system. The characteristics associated with these disorders make it difficult for those with FASD to function effectively in the aggressive and often uncertain environment of a prison. This, in turn, creates issues for institutional staff, program deliverers, parole boards, and those involved with community supervision. The authors propose a research project to develop a potential FASD screening instrument that could be used with adult offenders. The basic premise is to use a preliminary screening tool, based on an empirically derived checklist of known characteristics of those with FAS/FAE, along with historical data to determine who is at "high risk" for FASD. The assessment would take place during the period immediately after sentencing but prior to incarceration. It is hoped that this initiative will lead to a reliable and valid method of identifying adult offenders suffering from FASD and help in developing estimates of the incidence of FASD in the federal offender population. Criteria for an FAS diagnosis are presented in table format.

Development of a computer-based, brief intervention for drinkers: The increasing role for computers in the assessment and treatment of addictive behaviors.

Squires DD; Hester RK. . Behavior Therapist . 25(3): 59-65, 2002. (34 refs.)
The use of personal computers (PCs) in the assessment and treatment of addictive disorders is discussed, with a focus on the development of computer-based brief intervention for drinkers, the Drinker's Checkup (DCU) as well as of the Follow-up Drinker's Checkup (FDCU). The DCU is designed for those ambivalent about change and provides a comprehensive assessment of drinking and drug use. The DCU consists of integrated assessment, feedback, and decision-making modules and comes in a therapist version, a single user version, and a Web application The FDCU permits a provider to conduct follow-ups and to automate data collection at one, two, or three points following treatment. The authors conclude that the use of PCs in the assessment and treatment of various psychological conditions is an exciting development with the potential to aid busy clinicians in the following ways: (1) engagement of clients in a creative, interactive manner; (2) stimulation of earlier self-exploration of salient topics; (3) a mechanism for offering low-cost preliminary treatment options to more clients; (4) minimal training requirements; and (5) more effective and organized data management.

Does stimulant treatment lead to substance use disorders?

Faraone SV; Wilens T. . Journal of Clinical Psychiatry . 64(Supplement): 9-13, 2003. (16 refs.)
The authors examine the relationship between the treatment of attention-deficit/hyperactivity disorder (ADHD) with stimulants and substance use disorders by reviewing their published meta-analysis of 6 studies and adding preliminary data from a seventh study. Despite some discrepancies among the findings of the 7 studies, the meta-analysis demonstrated that exposure to stimulant therapy for ADHD does not increase the risk for develop-ing substance use disorders but is, in fact, protective against it. Stimulant treatment of ADHD appears to reduce the risk for substance use disorders by 50%, thus reducing the risk for substance use disorders in ADHD youth to levels well within the normal population risk. The implica-tion of this finding is unquestionably one with enormous value both clinically and as a matter of public health.

Early reactions to cannabis predict later dependence.

Fergusson DM; Horwood LJ; Lynskey MT; Madden PAF. . Archives of General Psychiatry . 60(10): 1033-1039, 2003. (40 refs.)
Context: While there is a growing literature on the linkages between early subjective responses to nicotine and alcohol and later risks of nicotine or alcohol dependence, to date there has been no study of this issue in relation to cannabis. Objective: To examine the extent to which subjective responses to early (prior to the age of 16 years) cannabis use were associated with subsequent cannabis dependence in a birth cohort studied to the age of 21 years. Design: Data on early (prior to the age of 16 years) subjective reactions to cannabis use and subsequent cannabis dependence were gathered over the course of the Christchurch Health and Development Study, a 21-year longitudinal study of a birth cohort of children born in Christchurch, New Zealand. Setting: General community sample. Participants: Members of a population-based birth cohort (86.5% white, 11.3% New Zealand Maori, and 2.2% Pacific Island).Main Outcome Measure: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition cannabis dependence (for those aged 16-21 years).Results: Of the cohort, 198 (20%) had used cannabis prior to the age of 16 years. Among this high-risk group, rates of dependence were high with 21.7% meeting DSM-IV criteria for cannabis dependence by the age of 21 years. There were clear tendencies for rates of cannabis dependence to increase with increasing reports of positive responses to early cannabis use: those reporting 5 positive responses had odds of cannabis dependence that were 28.5 (95% confidence interval, 6.3-133.8) times higher than those not reporting positive reactions to cannabis. The association held (odds ratio, 23.4; 95% confidence interval, 4.0-135.9) after control for potentially confounding factors including the extent of use of cannabis prior to age 16 years. The extent of early negative reactions to cannabis was unrelated to later cannabis dependence. Conclusions: Early subjective responses to cannabis are prognostic of later cannabis dependence. These findings may suggest the presence of genetically mediated individual differences in early responsiveness to cannabis. Clinicians should be aware that young people who report positive reactions to early use of cannabis are at increased risks of later cannabis dependence.

Family-focused substance abuse treatment: A program evaluation.

McComish JF; Greenberg R; Ager J; Essenmacher L; Orgain LS; Bacik WJ. . Journal of Psychoactive Drugs. 35(3): 321-331, 2003. (54 refs.)
Until recently, few programs were available for children whose mothers are in recovery. A refinement of the gender-specific model of substance abuse treatment, the "family-focused" approach, has placed increased emphasis on the needs of children and other family members. However, because these programs are relatively new, little is known about the effectiveness of this type of treatment for either the mother or her children. This article presents findings from a three-year evaluation of a family-focused residential treatment program for women and their children. Longitudinal assessment of the mothers indicated that their psychosocial status and parenting attitudes improved over time. Additionally, the mothers remained in treatment longer. At intake, as a group, the children who were birth to three years of age did not exhibit developmental delay. However, developmental concerns were identified for some children in the areas of motor and/or language development. The results reported here provide beginning evidence that family-focused treatment improves retention, psychosocial functioning, and parenting attitudes. of pregnant and parenting women. It also provides a mechanism for early identification and intervention for children.

Improving family functioning and child outcome in methadone maintained families: The Parents Under Pressure programme.

Dawe S; Harnett PH; Rendalls V; Staiger P. . Drug and Alcohol Review . 22(3): 299-307, 2003. (36 refs.)
Twelve families responded to posters displayed in a methadone clinic for inclusion in a pilot study assessing the viability and potential utility of an intensive, multi-component family-focused intervention, the Parents Under Pressure programme. The programme was designed to improve child behaviour, decrease parental stress and improve family functioning in methadone-maintained families by targeting affect regulation, mood, views of self as a parent, drug use and parenting skills. Nine of the families completed the programme delivered in their homes; eight were recontacted at 3 months. Each family reported significant improvements in three domains: parental functioning, parent - child relationship and parental substance use and risk behaviour. In addition to the changes in family functioning, the majority of families reported a decrease in concurrent alcohol use, HIV risk-taking behaviour and maintenance dose of methadone. The families reported high levels of satisfaction with the programme. It is recommended that future studies include independent measures (e.g. behavioural observations) of child outcome and parental functioning. The results were optimistic and provided the impetus to evaluate the treatment programme using a randomized controlled trial.

Past alcohol problems do not predict worse smoking cessation outcomes.

Hughes JR; Callas PW; High Dose Study Group. . Drug and Alcohol Dependence. 71(3): 269-273, 2003. (29 refs.)
Whether smokers with a past history of alcohol problems are less able to stop smoking and have a greater need for nicotine replacement therapy than smokers without this history is unclear. We conducted a secondary analysis of a prior study (Nicotine Tobacco Res. 1:169) of 1039 smokers randomized to 0, 21, 35 or 42 mg/day nicotine patch for smoking cessation. Because higher dose patches were being tested, only smokers of 30 cigs/day were included. Although smokers with current alcohol abuse or dependence were excluded, 15% of the smokers had a past (>1 year ago) Short Alcohol Dependence Data (SADD) score of 9 suggesting past alcohol problems. Heavy smokers with a past history of alcohol problems did not relapse sooner, were not less likely to be abstinent and did not benefit more from nicotine treatment or from higher doses than heavy smokers without this history. We conclude that a past history of alcohol problems per se does not predict inability to stop smoking.

Racially related health disparities and alcoholism treatment outcomes.

Brower KJ; Carey TL. . Alcoholism: Clinical and Experimental Research . 27(8): 1365-1367, 2003. (12 refs.)
Published studies comparing the outcomes of black and white patients with alcohol dependence have produced mixed results. We hypothesized that among alcoholic outpatients blacks would have worse outcomes than whites. A sample of 38 blacks and 136 whites were assessed prospectively at baseline and 6-12 months using a naturalistic study design. At baseline, blacks had less education, employment, and income than whites, and they were less likely to be married. They also were more likely to have family histories of substance abuse, previous episodes of treatment, cocaine use disorders, antisocial personality disorder, and poor physical health. Between baseline and follow-up, blacks received less treatment for alcohol dependence than whites. Such differences would seem to favor worse outcomes which were not found. Blacks, however, reported more social support for sobriety than whites. They also had better rates of study retention than whites, suggestive of either higher levels of motivation or stronger alliances with the treatment center. Future studies of racial differences should include measures of social support for sobriety, motivation for treatment, and treatment alliance.

Research-based analysis of the moderation management controversy.

Humphreys K. . Psychiatric Services . 54(5): 621-622, 2003 This column summarizes findings of a study of Moderation Management (MM), a controversial mutual help organization that offers the goal of moderate drinking. MM's supporters argued that this option would attract problem drinkers who were not dependent on alcohol and not interested in abstinence-only organizations such as Alcoholics Anonymous (AA). Prominent figures in treatment and research denounced MM as dangerous and built on the illusion that alcoholics can return to controlled drinking. The study found that MM members scored a full standard deviation below AA members on standardized measures of alcohol dependence symptoms, alcohol-related problems, and frequency of drinking before joining their respective organizations and were more likely than members of abstinence-oriented programs to be female (69%), younger than 35 years (24%), and employed (81%). Thus MM members as a group scored favorably on every variable shown to predict success at attaining controlled drinking. However, a subgroup of MM members (about 15%) had characteristics that would almost certainly meet formal criteria for alcohol dependence. While MM allows members choose either moderation or abstinence, only 3% chose abstinence. However, other research has shown that a significant number of alcoholic patients who entered treatment with a goal of moderation moved to a goal of abstinence after a few weeks and tended to have positive outcomes. Thus MM may be providing an entry route for alcoholics who are not ready for abstinence but may opt for it later.

Risk factors for drug addiction and its outcome. A follow-up study over 25 years.

Gjeruldsen S; Myrvang B; Opjordsmoen S. . Nordic Journal of Psychiatry. 57(5): 373-376, 2003. (17 refs.)
The aim of the study was to investigate factors related to initiation and abandonment of illegal drugs. A follow-up study on 53 drug addicts originally hospitalized because of parenterally acquired hepatitis was performed using questionnaires. The majority stated that curiosity and peer pressure were the main reasons for starting drug use. Family conflicts, school and mental problems were each reported by about 40% of the subjects. Thirty-nine patients (74%) had abandoned addictive drugs during the approximately 25 years that had elapsed since the hospital stay. All of these thought that own efforts had been most important in this achievement. Other important factors were help and support from family and friends, establishing a family or experiencing acute hepatitis or an overdose.

Short-term alcohol and drug treatment outcomes predict long-term outcome.

Weisner CG; Ray T; Mertens JR; Satre DD; Moore C. . Drug and Alcohol Dependence. 71(3): 281-294, 2003. (78 refs.)
Introduction: Although addiction is recognized as a chronic, relapsing condition, few treatment studies, and none in a commercially insured managed care population, have measured long-term outcomes. We examined the relationship of 6-month treatment outcomes to abstinence 5 years post-treatment, and whether the predictors of abstinence at 5 years were different for those who were, and were not, abstinent at 6 months. Methods: The sample (N=784) is from an outpatient (day hospital and traditional outpatient) managed care chemical dependency program. Subjects were interviewed at baseline, 6 months, and 5 years. Logistic regression analysis was used to assess which individual, treatment and extra-treatment characteristics predicted alcohol and drug abstinence at 5 years. Results: Abstinence at 6 months was an important predictor of abstinence at 5 years. Among those abstinent at 6 months, predictors of abstinence at 5 years were older age, being female, 12-step meeting attendance, and recovery-oriented social networks. Among those not abstinent at 6 months, being alcohol dependent rather than drug dependent, 12-step meeting attendance, treatment readmission, and recovery-oriented social networks predicted abstinence at 5 years. Conclusion: Our findings demonstrate a clear association between short-term and long-term treatment success. In addition, these results strongly support the importance of recovery-oriented social networks for those with good short-term outcomes, and the beneficial impact of readmission for those not initially successful in treatment.

The longitudinal relationship between self-help group attendance and course of recovery.

Kissin W; McLeod C; McKay J. . Evaluation and Program Planning. 26(3): 311-323, 2003. (25 refs.)
Most alcohol and other drug (AOD) abuse patients participate in self-help (SH) programs such as Alcoholics Anonymous or Narcotics Anonymous at some time, but few studies investigate longitudinal SH attendance patterns. The present study examines the relationship between longitudinal SH attendance patterns and level of AOD use over 30 months in a large sample of adults seeking public AOD treatment. Continuous SH participation was associated with lowest AOD use at followup, while non-attendance was linked to highest use, even after controlling for length of formal treatment and participants' perceived severity of their AOD problem. Results suggest that both SH and formal substance abuse treatment are independently associated with reduced AOD use, and SH participation is associated with treatment. This study supports the importance of SH attendance and of formal treatment by individuals with AOD abuse disorders.

Who seeks treatment for cannabis-related problems?

Strike CJ; Urbanoski KA; Rush BR. . Canadian Journal of Public Health. 94(5): 351-354, 2003. (17 refs.)
Purpose: To examine the types of presenting problems and symptoms among individuals seeking treatment for cannabis-related problems in a large treatment centre in Ontario. Methods: Data from assessment interviews conducted with clients who identified cannabis as their primary drug problem (n=426) were analyzed using descriptive statistics. Results: The majority of people seeking treatments were male (80%) and single (77%). Cannabis treatment seekers varied in their socio-demographic characteristics, drug consumption, pressure to seek treatment, and adverse consequences of cannabis use. They experienced a broad range of substance-related problems, however, the majority were classified as below the action stage in terms of readiness to change their drug consumption. Daily users were older, more likely to be employed, to be cannabis dependent, to suffer from an anxiety disorder, and to use multiple substances. Discussion: Cannabis treatment seekers are a heterogeneous group. A better understanding of the relationship between client characteristics and different interventions may improve outcomes.

Acceptability and availability of harm-reduction interventions for drug abuse in American substance abuse treatment agencies.

Rosenberg H; Phillips KT. . Psychology of Addictive Behaviors. 17(3): 203-210, 2003. (37 refs.)
This study assessed acceptability,. availability, and reasons for nonavailability of interventions designed to prevent drug use related harm by substituting pharmaceuticals for illicit drugs; facilitating detoxification; and reducing the occurrence of HIV transmission, relapse, and opiate overdose. A survey was mailed to a sample of 500 randomly selected American substance abuse treatment agencies. Of 435 potentially eligible respondents, 222 (51%) returned usable data. A subset of interventions-including harm reduction education, cue exposure therapy, needle exchange, substitute opiate prescribing, various detoxification regimes, and complementary therapies-were rated as somewhat or completely acceptable by 50% or more of the respondents. Regardless of their acceptability, listed interventions were generally not available from responding agencies; respondents typically attributed unavailability to lack of resources and inconsistency of an intervention with agency philosophy.