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2005/summer/html/Clinical.htmlTEXTR*chgy®¾º6l¾ºË`mBINz… CORK Library Watch Clinical Aspects

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...on Clinical Issues

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Summer 2005

Sources of informal pressure on problematic drinkers to cut down or seek treatment.

Room R; Matzger H; Weisner C. Journal of Substance Abuse Treatment9(6): 280-295, 2004. (43 refs.)
Objective: To examine how patterns of expressions of concern about drinking from family members and friends differ according to the demographic characteristics of the drinker. Method: A probability sample of adult treated (n=926) and untreated (n=672) problem-drinking individuals from a Northern California county. Logistic regression analysis was used to predict having received pressure about drinking from a specific family member or friend. Results: Spouses and significant others were the most common relations to have said anything about the respondent's drinking, suggested they cut down or given an ultimatum to enter treatment. When controlling for severity, the respondent's degree of dependence and number of social consequences strongly predicted pressure from all sources. Having a higher income remained a strong predictor of pressure by a spouse, while having a lower income was significant in receiving pressure from siblings and other relatives and friends. Younger respondents were more likely to be pressed by a father or mother, while older respondents were more likely to be pressed by sons and daughters. Conclusions: Results show the importance of family relationships other than that with a spouse or significant other, in the efforts at informal control of drinking and efforts to seek treatment.

The effects of a prison smoking ban on smoking behavior and withdrawal symptoms.

Cropsey KL; Kristeller JL. Addictive Behaviors 30(3): 589-594, 2005. (12 refs.)
This study investigated symptoms of distress and nicotine dependence as predictors of nicotine withdrawal symptoms among 188 incarcerated male smokers during a mandated smoking ban. Participants completed a smoking history questionnaire and measures of nicotine dependence, withdrawal, cravings, and distress before the ban and two follow-up times. The majority of smokers (76%) continued to smoke following the smoking ban. Smokers after the ban were more nicotine dependent than were the participants who reported quitting. Smokers also reported more withdrawal symptoms than did participants who quit, even when accounting for nicotine dependence and baseline withdrawal scores. An interaction was found such that distressed smokers had the highest level of nicotine withdrawal. These results have implications for how smoking bans are instituted in prison settings.

The role of the therapeutic alliance in the treatment of substance misuse: A critical review of the literature. (review).

Meier PS; Barrowclough C; Donmall MC. Addiction100(3): 304-316, 2005. (57 refs.)
Background: In the past two decades, a number of studies investigating the role of the therapeutic alliance in drug treatment have been published and it is timely that their findings are brought together in a comprehensive review. Aims: This paper has two principal aims: (1) to assess the degree to which the relationship between drug user and counsellor predicts treatment outcome and (2) to examine critically the evidence on determinants of the quality of the alliance. Methods: Peer-reviewed research located through the literature databases Medline, PsycInfo and Ovid Full Text Mental Health Journals using predefined search-terms and published in the past 20 years is considered. Further papers were identified from the bibliographies of relevant publications. Findings: A key finding is that the early therapeutic alliance appears to be a consistent predictor of engagement and retention in drug treatment. With regard to other treatment outcomes, the early alliance appears to influence early improvements during treatment, but it is an inconsistent predictor of post-treatment outcomes. There is relatively little research on the determinants of the alliance. In studies that are available, clients' demographic or diagnostic pre-treatment characteristics did not appear to predict the therapeutic alliance, whereas modest but consistent relationships were reported for motivation, treatment readiness and positive previous treatment experiences. Conclusion: The therapeutic alliance plays an important role in predicting drug treatment process outcomes, but too little is known about what determines the quality of the relationship between drug users and counsellors.

Therapist satisfaction with four manual-based treatments on a national multisite trial: An exploratory study.

Najavits LM; VAN Horn A; Siqueland L; Thase ME; Ghinassi F; Weiss RD. Psychotherapy 41(1): 26-37, 2004. (17 refs.)
Ratings by 44 therapists in 4 modalities (cognitive, supportive-expressive, individual drug counseling, and group drug counseling) were obtained during one of the largest outcome trials ever conducted, the National Collaborative Cocaine Treatment Study. Views of the treatments, desired changes, and influences on implementation were studied. Therapists were highly positive about the treatments. However, their likelihood of using them in the future without modification was low, and they viewed them as too short. Supervision was perceived as more important than manuals and taping of sessions as more important than adherence scales. It took therapists an average of 8 months to feel comfortable with the treatments. New learning was therapists' primary motivation, more than extrinsic factors such as pay. Supportive-expressive therapists reported the most negative views, among modalities.

Less directiveness by therapists improves drinking outcomes of reactant clients in alcoholism treatment.

Karno MP; Longabaugh R. Journal of Consulting and Clinical Psychology 73(2): 262-267, 2005. (16 refs.)
In this study, the authors examined the impact of the interaction between clients' trait reactance and therapists' directiveness on the effectiveness of psychotherapy treatment for alcoholism. Ratings of videotaped treatment sessions were used to measure clients' reactance (N = 141) and therapists' directiveness. Models tested for the interaction as a predictor of 1-year posttreatment drinking quantity and frequency. Results indicate that directiveness had a negative impact on outcomes for clients at medium and high levels of reactance but did not affect drinking among clients low in reactance. Increased therapist use of interpretation, confrontation, and introduction of topics was most predictive of more frequent and larger quantities of drinking among reactant clients. This study suggests that research on treatment process can yield significant theoretical and clinical benefits.

Management of opiate detoxification in jails.

Fiscella K; Moore A; Engerman J; Meldrum S. Journal of Addictive Diseases 24(1): 61-71, 2005. (27 refs.)
Little is known about how jails manage opiate withdrawal among arrestees and inmates. We conducted a national Survey of 500 jails in the United States. We specifically asked about assessment and management opiate dependency among arrestees and use of standardized protocols. Among the 245 jails that responded, more than half (56 %) reported they routinely assessed arrestees for opiate dependency and most (59 %) reported using standardized detoxification protocols. Fifty percent of jails used clonidine for detoxification. Very few jails (1%) used methadone or other opiates (2 %) for detoxification. Half of all jails (49 %) failed to use clonidine, methadone or other opiates for detoxification. These results show that many jails fail to use recommended opiate detoxification procedures and highlight the need for uniform national standards for jail management of opiate dependence.

Natural and complementary therapies for substance use disorders.

Dean AJ. Current Opinion in Psychiatry 18(3): 271-276, 2005. (54 refs.)
Purpose of review: To review recent studies that have examined the efficacy of natural and complementary therapies as treatments for substance use disorders and their complications. Recent findings Despite increasing interest in natural and complementary therapies for substance use disorders, rigorous clinical studies in this area are few in number. Recent clinical studies, although preliminary, have reported potential therapeutic effects for hypericum in the treatment of smoking cessation, for prickly pear extract in the prevention of alcohol hangover and magnesium supplementation as an adjunct to methadone treatment. Other clinical studies have reported negative findings for ginkgo as an adjunctive treatment for cocaine dependence, for artichoke in prevention of alcohol hangover, and acupuncture for alcohol withdrawal. Relevant findings from animal studies are also discussed. Neither vitamin E nor Liv 52 had a useful effect in alcohol-related liver disease. A study of silymarin in baboons, which was undertaken in an attempt to untangle the conflicting findings of human studies, reported a potential for this compound to prevent liver injury. There is increasing awareness of safety issues associated with complementary therapies. Safety issues pertinent to substance use treatment are discussed in this review. Summary: Several pharmacological and psychosocial treatments for substance use disorders are solidly evidence-based and improve both individual and public health outcomes. At this stage, there remains insufficient evidence to support the use of natural and complementary therapies as a primary intervention for substance use disorders. Further clinical trials are required to clarify the potential role of particular agents.

Risk factors for relapse in health care professionals with substance use disorders.

Domino KB; Hornbein TF; Polissar NL; Renner G; Johnson J; Alberti S. Journal of the American Medical Association 293(12): 1453-1460, 2005. (23 refs.)
Context: Substance use disorders among physicians are important and persistent problems. Considerable debate exists over whether use of major opioids, especially among anesthesiologists, is associated with a higher relapse rate compared with alcohol and nonopioids. Moreover, the risk factors for relapse with current treatment and monitoring strategies are unknown. Objective: To test the hypothesis that chemically dependent healthcare professionals using a major opioid (eg, fentanyl, sufentanil, morphine, meperidine) as drug of choice are at higher risk of relapse. Design, Setting, and Participants: Retrospective cohort study of 292 health care professionals enrolled in the Washington Physicians Health Program, an independent posttreatment monitoring program, followed up between January 1, 1991, and December 31, 2001. Main Outcome Measure: Factors associated with relapse, defined as the resumption of substance use after initial diagnosis and completion of primary treatment for chemical dependency. Results: Twenty-five percent (74 of 292 individuals) had at least 1 relapse. A family history of a substance use disorder increased the risk of relapse (hazard ratio [HR], 2.29; 95% confidence interval [CI], 1.44-3.64). The use of a major opioid increased the risk of relapse significantly in the presence of a coexisting psychiatric disorder (HR, 5.79; 95% Cl, 2.89-11.42) but not in the absence of a coexisting psychiatric disorder (HR, 0.85; 95% Cl, 0.33-2.17). The presence of all 3 factors major opioid use, dual diagnosis, and family history markedly increased the risk of relapse (HR, 13.25; 95% Cl, 5.22-33.59). The risk of subsequent relapses increased after the first relapse (HR, 1.69; 95% Cl, 1.13-2.53). Conclusions: The risk of relapse with substance use was increased in health care professionals who used a major opioid or had a coexisting psychiatric illness or a family history of a substance use disorder. The presence of more than 1 of these risk factors and previous relapse further increased the likelihood of relapse. These observations should be considered in monitoring the recovery of health care professionals.

Screening for hazardous or harmful drinking using one or two quantity-frequency questions.

Canagasaby A; Vinson DC. Alcohol and Alcoholism 40(3): 208-213, 2005. (33 refs.)
Aims: To address the accuracy of quantity-frequency (QF) questions in screening for hazardous or harmful drinking. Methods: Three groups were interviewed: patients presenting to emergency departments for care of an acute injury (n = 1537) or a medical illness (n = 1151), and community controls interviewed by telephone (n = 1112). The first question about alcohol was a single alcohol screening question (SASQ), 'When was the last time you had more than X drinks in one day?', where X = 4 for women and 5 for men, with any time in the past 3 months considered a positive screen (1 drink = 14 g ethanol). The subsequent alcohol questions were a calendar-based review of recent drinking and the alcohol questions from the diagnostic interview schedule (DIS), which included questions about usual frequency and average quantity. Hazardous drinking was defined as drinking > 4 drinks in 1 day or > 14 drinks in 1 week for men (women 3 and 7) (Guidelines of the US National Institute on Alcohol Abuse and Alcoholism). Current alcohol use disorders were defined using DSM-IV criteria. The areas under the receiver operating characteristic (ROC) curves in identifying hazardous drinking or current alcohol use disorder were compared. Results: The area under the ROC curves in the three samples combined were 0.81 for SASQ (95% confidence interval (CI) 0.79-0.82), 0.80 for a question about average quantity alone (0.79-0.82) and 0.85 for the product of usual frequency times average quantity (0.84-0.86). The QF product and the question about average quantity performed consistently across the three groups. Conclusions: In clinical settings, one way to put these findings into practice is to screen first with a single question, such as the SASQ, a single question about typical quantity, or a question about the frequency of heavy drinking such as the third item of the alcohol use disorders test (AUDIT).

Substance abuse: Medical and slang terminology. (review).

Hamid H; El-Mallakh RS; Vandeveir K. Southern Medical Journal 98(3): 350-362, 2005. (7 refs.)
Substance abuse is among one of the major problems plaguing our society. It has come to the attention of several healthcare professionals that a communication gap exists between themselves and substance abusers. Most of the time the substance abusers are only familiar with the slang terms of abused substances, a terminology that medical professionals are usually unaware of. This paper is an attempt to close that communication gap, allowing health care professionals to understand the slang terminology that their patients use, thus enabling them to make appropriate treatment decisions. In addition, the article presents some key features (including active ingredient, pharmacological classification, medical use, abuse form, usage method, combinations used, effects sought, long-term possible effects, and detectability in urine) of the most commonly abused substances.

The diagnosis and management of benzodiazepine dependence.

Ashton H. Current Opinion in Psychiatry 18(3): 249-255, 2005. (79 refs.)
Purpose of review: Despite repeated recommendations to limit benzodiazepines to short-term use (2-4 weeks), doctors worldwide are still prescribing them for months or years. This over-prescribing has resulted in large populations of long-term users who have become dependent on benzodiazepines and has also led to leakage of benzodiazepines into the illicit drug market. This review outlines the risks of long-term benzodiazepine use, gives guidelines on the management of benzodiazepine withdrawal and suggests ways in which dependence can be prevented. Recent findings: Recent literature shows that benzodiazepines have all the characteristics of drugs of dependence and that they are inappropriately prescribed for many patients, including those with physical and psychiatric problems, elderly residents of care homes and those with comorbid alcohol and substance abuse. Many trials have investigated methods of benzodiazepine withdrawal, of which the keystones are gradual dosage tapering and psychological support when necessary. Several studies have shown that mental and physical health and cognitive performance improve after withdrawal, especially in elderly patients taking benzodiazepine hypnotics, who comprise a large proportion of the dependent population. Summary: Benzodiazepine dependence could be prevented by adherence to recommendations for short-term prescribing (2-4 weeks only when possible). Withdrawal of benzodiazepines from dependent patients is feasible and need not be traumatic if judiciously, and often individually, managed.

The drug-seeking patient in the emergency room.

Hansen GR. Emergency Medicine Clinics of North America 23(2): 349-+, 2005. (92 refs.)
It has been estimated that an emergency department with 75,000 patients per year can expect up to 262 monthly visits from fabricating drug-seeking patients. Distinguishing drug seekers from patients who have a legitimate therapeutic need is not always possible in the acute care setting, yet physicians have the dual obligation to relieve pain and to protect susceptible patients from the consequences of abusing or becoming addicted to drugs. Problems associated with frequent opioid use, for either recreational abuse or for pain control, make it imperative that physicians understand and appropriately manage patients who request psychoactive drugs. In this article, the psychoactive properties of opioids, abuse, addiction, and pseudoaddiction are discussed, and various strategies for managing them are reviewed.

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