|
|
|
|
...on Clinical Issues
|
|
www.ProjectCork.org
|
Winter 2005
|
A longitudinal evaluation of treatment engagement and recovery stages.
Simpson DD; Joe GW. Journal of Substance Abuse Treatment 27(2): 89-97, 2004. (61 refs.)
Recent methodological advancements for structural equation modeling were used to test a comprehensive version of the TCU Treatment Model, especially for addressing the hypothesized sequential relationships of early engagement components (participation and therapeutic relationship) and early recovery (psycho-social and behavioral changes) that contribute to retention and posttreatment recovery. Relationships among pretreatment patient motivation, treatment process elements, a cognitive-based treatment strategy, retention, and drug use outcomes were estimated using intake, during treatment, and 1-year followup data for 711 patients in outpatient methadone treatment. Hypothesized sequential elements representing treatment process and patient functioning were supported, and relationships between these com-ponents were estimated also as odds ratios as an aid for translating the findings and increasing their clinical usefulness to treatment settings. Copyright 2004, Elsevier Science
A pilot study of buprenorphine-naloxone combination tablet (Suboxone (R)) in treatment of opioid dependence.
Bell J; Byron G; Gibson A; Morris A. Drug and Alcohol Review 23(3): 311-317, 2004. (17 refs.)
In Australia, maintenance treatment for opioid dependence involves supervised daily administration of a dose of methadone or buprenorphine. A sublingual tablet combining buprenorphine and nalox-one in a 4 : 1 ratio (Suboxone(TM)) has been developed, designed to deter diversion and intravenous misuse, and may be suitable for unsupervised admin-istration. The aim of this study was to investigate the tolerability of Suboxone, and investigate whether unsupervised administration can be effective in stabilized patients. Employed patients on bupren-orphine maintenance, who had ceased heroin use, were switched to Suboxone and provided with weekly supplies of medication to take without supervised administration. Subjects were monitored closely with weekly clinical reviews, and research interviews at baseline, 3 and 6 months. Only 11% of people receiving buprenorphine met eligibility criteria. Seventeen subjects were recruited. Fifteen were retained for the full 6 months. No subject appeared destabilized by unsupervised dosing. Suboxone was well tolerated. The current trial demonstrated that unsupervised administration with regular clinical monitoring can be effective in selected patients. However, using access to unsupervised dosing to promote abstinence from heroin probably limits the potential benefits of unsupervised administration to a very small proportion of patients. Copyright 2004, Australian Medical and Professional Soc Alcohol and Other Drugs.
Alcohol dependence and use of treatment services among women in the community.
Wu LT; Ringwalt CL. American Journal of Psychiatry 161(10): 1790 -1797, 2004. (46 refs.)
Objective: This study examined the extent and charac-teristics of alcohol dependence and the perceived need for and use of alcohol treatment services among women compared with men in a nonclinical sample of adults 18-64 years of age. Method: Data were drawn from the 1999 National Household Survey on Drug Abuse. The authors calculated rates and correlates of alcohol dependence and treatment among adult alcohol users in this sample. Results: About 3% of the women in the survey met criteria for DSM-IV alcohol dependence in the previous year. About 13% of these women received alcohol treatment services in the same period. only 8% of the women who did not receive treatment perceived a need for treatment. Younger women-those who were 18-25 years of age-were more likely to be dependent on alcohol but less likely to perceive a need for treatment or to use treatment services. Among alcohol-dependent women who received no treatment, those with a family income of $75,000 or more, those who had two or more children living with them, and those who were not dependent on psychotherapeutic medications were less likely to perceive a need for help. Conclusions: There were no significant differences between men and women in use of treatment services, location of services received, and perceived need for treatment. However, correlates of treatment service use varied somewhat by gender. These findings suggest that the goal of efforts to reduce barriers
to alcohol treatment services should be to change people's attitudes toward alcohol abuse and seeking professional help. Copyright 2004, American Psychiatric Association.
Alcoholics Anonymous and relapse prevention as maintenance strategies after conjoint behavioral alcohol treatment for men: 18-month outcomes.
McCrady BS; Epstein EE; Kahler CW. Journal of Consulting and Clinical Psychology 72(5): 870 -878, 2004. (40 refs.)
Ninety men with alcohol problems and their female partners were randomly assigned to I of 3 outpatient conjoint treatments: alcohol behavioral couples therapy (ABCT), ABCT with relapse prevention techniques (RP/ABCT), or ABCT with interventions encouraging Alcoholics Anonymous (AA) involvement (AA/ABCT). Couples were followed for 18 months after treatment. Across the 3 treatments, drinkers who provided follow-up data maintained abstinence on almost 80% of days during follow-up, with no differences in drinking or marital happiness outcomes between groups. AA/ABCT participants attended AA meetings more often than ABCT or RP/ABCT participants, and their drinking outcomes were more strongly related to concurrent AA attendance. For the entire sample, AA attendance was positively related to abstinence during follow-up in both concurrent and time-lagged analyses. In the RP/ABCT treatment, attendance at posttreatment booster sessions was related to posttreatment abstinence. Across treatment conditions, marital happiness was related positively to abstinence in concurrent but not time-lagged analyses. Copyright 2004, American Psychological Association.
Can drug injectors be encouraged to adopt non-injecting routes of administration (NIROA) for drugs?
Dolan K; Clement N; Rouen D; Rees V; Shearer J; Wodak A. Drug and Alcohol Review 23(3): 281-286, 2004. (29 refs.)
Drug use by injection can cause problems specific to this form of administration. Problems include an increased risk of drug overdose, drug dependence, the transmission of HIV, hepatitis B and hepatitis C and vein damage. Shifting drug injectors from injecting to another route of administration may minimize these problems. The aims of the study were to develop and trial an intervention to assist willing injecting drug users (IDUs) to shift to non-injecting routes of administration (NIROA) and to explore the acceptability and practicality of facilitating NIROA. IDUs were assessed and suitable subjects entered a cognitive behavioural trial consisting of five 1-hour sessions of individual therapy with a registered psychologist. Forty-two subjects were assessed (22 males and 20 females). Thirty subjects entered treatment. The mean age was 36 years. Twenty-one subjects were followed-up at 3 months and 10 subjects at 6 months. At 3 and 6 months, the proportion of subjects who had commenced using NIROA was 30% and 50%, respectively. This pilot study showed that it was possible to assist a minority of drug injectors to move from injecting to the non-injecting administration of drugs. However, many of these appeared to be already motivated to cease using drugs and adopting NIROA was one way of assisting this. Poor follow-up rate, lack of control group, questions about cost-effectiveness and the impact of market factors which possibly constrain shifting to NIROA suggest that further research is needed before it could be said that NIROA should be recommended as a viable harm reduction strategy in the Australian context. Copyright 2004, Australian Medical and Professional Society on Alcohol and Other Drugs.
Cognitive and psychological correlates of smoking abstinence, and predictors of successful cessation.
Powell JH; Pickering AD; Dawkins L; West R; Powell JF. Addictive Behaviors 29(7 (Special Issue)): 1407-1426, 2004. (56 refs.)
The neural circuitry implicated in addictive drug use, which appears to be down-regulated in early abstinence, corresponds closely with brain reward pathways. A literature review suggests that responses to incentive stimuli and the ability to inhibit reflexive responses, both of which have been associated with normal functioning in these pathways, might be weakened during acute abstinence from chronic drug use. In an ongoing study, 82 smokers, abstinent overnight before two separate testing occasions, have been assessed after administration of nicotine and placebo lozenges (order of sessions counterbalanced). Nicotine administration is associated with a significant reduction in anhedonia, a near-significant increase in response to financial incentive, enhanced ability to inhibit reflexive eye movements, and increased attentional bias to words with appetitive significance. Fifty-nine participants then initiated a quit attempt and 19 reported relapsing within 7 days. Comparing their performance in the two prequit lozenge assessment sessions, relapsers showed a stronger effect of nicotine on enhancing their ability to inhibit reflexive eye movements and a near-significant trend towards greater nicotine-induced increases in attentional bias toward appetitive words. Copyright 2004, Elsevier Science.
Continuity of binge and harmful drinking from late adolescence to early adulthood.
McCarty CA; Ebel BE; Garrison MM; DiGiuseppe DL; Christakis DA; Rivara FP. Pediatrics 114(3): 714-719, 2004. (35 refs.)
Objective. To test the hypothesis that late adolescent drinking behavior (ages 17-20) is associated with harmful and binge drinking in early adulthood (ages 30-31). Methods. We used the National Longitudinal Survey of Youth (NLSY), a nationally representative longitudinal data set. We used harmful and binge drinking at ages 17 to 20 to predict harmful and binge drinking at ages 30 to 31, stratifying for gender and controlling for confounders. Results. Data were available on harmful drinking at both the adolescent and the early adult age period for 3790 individuals and on binge drinking for 2387 individuals. Harmful drinking during adolescence was significantly associated with harmful drinking at ages 30 to 31 for men only. Among male adolescents, 14% of harmful drinkers continued harmful drinking at ages 30 to 31, compared with 4% of nonharmful drinkers who became harmful drinkers. In Poisson regression models, binge drinking during adolescence was associated with binge drinking at ages 30 to 31 for both men and women, generating relative risks of 2.3 (95 %confidence interval: 1.8-3.0) and 3.0 (95% confidence interval: 2.4-4.8), respectively. Half of binge-drinking male adolescents and one third of binge-drinking female adolescents engaged in binge drinking into early adulthood, compared with 19% for non-binge-drinking male adolescents and 8% of non-binge-drinking female adolescents. Conclusions. Problem drinking during adolescence is associated with problem drinking
in early adulthood. Efforts to prevent and treat adolescent problem drinking could have an impact on the progression of alcohol-related disease. Copyright 2004, American Academy of Pediatrics.
Ecstasy: Commodity or disease?
Agar M; Reisinger HS. Journal of Psychoactive Drugs 36(2): 253-264, 2004. (36 refs.)
This article evaluates past work on heroin and crack cocaine epidemics by comparing it with the increase in Ecstasy use in the late 1990s. First of all, the authors make the case that there was, in fact, a dramatic increase in Ecstasy use in the late1990s. Following that is a review of the rise and fall of several different Ecstasy scenes beginning in the 1960s. The most recent rise, in the late 1990s, requires a broadening of the theory of epidemics to include longer historical waves of change, so we do that by reviewing work on post World War H trends in social disconnection and consumerism. We then shift to a marketing rather than a public health framework and look at the nature of the Ecstasy "product," both its good and bad characteristics. Finally, we describe the narrative mechanism, developed in our earlier work, that plausibly explains why use rose when it did, given the needs of the market. The article concludes by discussing the changes this case motivates for our theory, particularly in light of globalized and normalized drug use that at the moment appears to be the current context for illicit drug use. Copyright 2004, Haight-Ashbury Publications.
Intensive therapy: Utilizing hypnosis in the treatment of substance abuse disorders.
Potter G. American Journal of Clinical Hypnosis 47(1): 21-28, 2004. (26 refs.)
Hypnosis was once a viable treatment approach for addictions. Then, due to hypnosis being used for entertainment purposes many professionals lost confidence in it. However, it has now started to make a comeback in the treatment of substance abuse. The approach described here, using hypnosis for treatment, is borrowed from studies effectively treating alcoholism by using intensive daily sessions. Combining the more intense treatment of 20 daily sessions with hypnosis is a successful method to treat addictions. The treatment has been used with 18 clients over the last 7 years and has shown a 77 percent success rate for at least a 1-year follow-up. Copyright 2004, American Society of Clinical Hypnosis.
Mortality risk among new onset injection drug users.
Vlahov D; Wang CL; Galai N; Bareta J; Mehta SH; Strathdee SA et al. Addiction 99(8): 946-954, 2004. (31 refs.)
Aims: To characterize mortality experience among those who only recently started injection. Design: Prospective study. Setting Independent study clinic within high drug use neighborhoods. Participants: In 1988-1989, we enrolled 256 adult injection drug users (IDUs) recruited through street outreach who had initiated injection within the prior 2 years. Measurements Consenting participants underwent venipuncture for HIV antibody testing and interviews. We prospectively ascertained date and cause of death through follow-up contact and registry linkages. Analyses included standardized mortality ratios (SMRs) with local, state and national mortality data, adjusted for age, gender and race. Findings: Baseline median age was 30 years, 70% were male, 95% were African-American and 90% injected within the prior 6 months. We identified 69 deaths through October 2000; mortality rate was 3.3/100 person-years. The adjusted SMR with the USA (and Baltimore) as the reference for IDUs was 4.40 (2.43) for 1991-1992, which increased to 8.12 (4.13) by 1993-1994, decreased to 4.43 (2.13) by 1997-1998 and increased slightly to 5.35 (2.79) during 1999-2000. Excluding HIV-related mortality, SMRs remained elevated. Decline in SMRs was not linked to drug abuse treatment. Conclusions: These data demonstrate excess mortality among new-onset IDUs compared with demographically similar peers in the general population, indicating the need for interventions to prevent premature death among young IDUs. Copyright 2004, Society for the Study Addiction to Alcohol & Other Drugs.
Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects.
Streissguth AP; Bookstein FL; Barr HM; Sampson PD; O'Malley K; et al. Journal of Developmental and Behavioral Pediatrics 25(4): 228-238, 2004. (41 refs.)
Clinical descriptions of patients with Fetal Alcohol Syndrome (FAS) and Fetal Alcohol Effects (FAE) suggest major problems with adaptive behavior. Five operationally defined adverse outcomes and 18 associated risk/protective factors were examined using a Life History Interview with knowledgeable informants of 415 patients with FAS or FAE (median age 14 years, range 6-51; median IQ 86, range 29-126). 80% of these patients were not raised by their biological mothers. For adolescents and adults, the life span prevalence was 61% for Disrupted School Experiences, 60% for Trouble with the Law, 50% for Confinement (in detention, jail, prison, or a psychiatric or alcohol/drug inpatient setting), 49% for Inappro-priate Sexual Behaviors on repeated occasions, and 35% for Alcohol/Drug Problems. The odds of escaping these adverse life outcomes are increased 2- to 4-fold by receiving the diagnosis of FAS or FAE at an earlier age and by being reared in good stable environments. © 2004, Lippincott, Williams and Wilkens.
Smoking abstinence after hospitalization: Predictors of success.
MacKenzie TD; Pereira RI; Mehler PS. Preventive Medicine 39(6): 1087-1092, 2004. (29 refs.)
Background. Our objective was to explore the relationship between baseline characteristics of hospitalized smokers and 6-month to 2-year self-reported quit rates. Methods. We surveyed adult smokers (n = 154) admitted to the Medicine service of an urban public hospital. We used the pharmacy database, a follow-up telephone survey, and medical records to characterize nicotine patch use and post-discharge smoking abstinence. Results. Among the 102 patients for whom smoking status at least 6 months after discharge was known, 18 (18%) were not smoking at last contact (mean follow-up 20 months). Individual factors associated with quitting include confidence to quit within 1 week, stage of change other than precontemplation, filling a nicotine patch prescription after discharge, number of previous quit attempts, and increasing age. With multivariate modeling, only confidence to quit [OR 9.8, confidence interval (CI), 2.8-35.0] and the number of previous quit attempts (OR 1.3 per attempt, 95% CI, 1.0-1.5) remained significantly associated with future abstinence. Conclusions. A high level of confidence to quit and multiple prior quit attempts are strongly associated with future abstinence among hospitalized patients who smoke. Using a simple confidence-to-quit scale to target interventions to patients with high confidence may improve the effectiveness of smoking cessation programs. © 2004, Institute for Cancer Prevention.
The interplay between help-seeking and alcohol-related outcomes: Divergent processes for professional treatment and self-help groups.
Moos RH; Moos BS. Drug and Alcohol Dependence 75(2): 155-164, 2004. (45 refs.)
This study examined the influence of self-selection, as reflected in alcohol-related functioning, on the duration of professional treatment and Alcoholics Anonymous (AA), and the influence of social causation, as reflected in the duration of treatment and AA, on alcohol-related outcomes. A sample of alcoholic individuals was surveyed at baseline and 1, 3, and 8 years later.. There were divergent processes of self-selection and social causation with respect to the duration of participation in professional treatment and AA. Individuals with more severe alcohol-related problems obtained longer episodes of professional treatment, but this self-selection process was much less evident for AA. Longer participation in professional treatment in the first year predicted better alcohol-related outcomes; however, the duration of subsequent treatment was not associated with better subsequent outcomes. In contrast, longer participation in AA consistently predicted better outcomes. These findings are consistent with a need-based model of professional treatment, in which more treatment is selected by and allocated to individuals with more severe problems, and an egalitarian model of self-help, in which need factors play little or no role in continued participation. Copyright 2004, Elsevier Science
|
